Transitioning to a Hybrid Concierge Practice

A few months ago, internist Steven Krems faced a daily struggle many of you will find familiar. He wanted to spend more time with his patients, but he felt pressured to keep pace with declining reimbursement. "Let's face it. Our bills go up and our reimbursement goes down," says Krems. "It's harder to stay afloat."

Krems, who is based in Marina del Rey, Calif., thought about transitioning to a concierge-style practice, in which patients pay an additional flat fee for extra perks, such as improved access to care and longer patient visits, but he wasn't ready for the possible trade-offs. "I was afraid that most of my patients really wouldn't be able to afford it, and I really wasn't looking to be this elite type of a practice," says Krems. "I really wasn't looking to say goodbye to my patients."

About a year ago, Krems found a solution in which he didn't have to say goodbye: hybrid concierge. In this model, which blends traditional fee-for-service reimbursement and concierge practice, Krems continues to accept patients who pay for services through traditional insurance, but he also sees patients who pay an additional fee for concierge services. "When I learned about the hybrid model, I really liked the fact that people who did value what we're offering could take advantage of [concierge services], but people who couldn't afford it, or for whatever reason just didn't see value, they could continue to see me," says Krems. "It was really kind of a shift in my practice as opposed to a complete change."

To help determine if such a shift is right for your practice, we asked Krems to weigh in. Here's how he made the transition and how it is affecting his practice, his patients, and his revenue.

Gauging interest

While shifting to hybrid concierge is not as drastic as a transition to a true concierge practice, it does require some important considerations. A big one: Whether enough of your patients will be attracted to concierge to make it work. To gain this understanding, Krems turned to Concierge Choice Physicians, a company that helps physicians across the country transition to concierge and hybrid concierge practices. "I just kind of walked into this thinking they know how to do what they do," says Krems, "And I know how to do what I do, and I don't need to recreate the wheel."

To get things rolling, Concierge Choice Physicians sent a survey to all of his patients to gauge their level of interest. The survey results were promising, so Krems held a presentation to explain to his patients how the concierge part of the practice would work. "One of the things we really stressed was that if it wasn't for them, that there was no pressure to do it," he says. "If they didn't participate, they could still be my patient and things would hopefully not be much different."

Rolling it out

Ultimately, about 70 patients decided to go concierge. Each pays $1,900 annually for longer visits with Krems; improved access to care, including same-day and next-day appointments; after-hours access to Krems via phone and e-mail; and an extensive annual physical.

To ensure he's meeting his concierge patients' expectations, Krems sets aside two mornings and two afternoons each week for concierge appointments and requests. He also provides concierge patients with a separate office number so his front-office staffer Keisha Sardin is able to prioritize their calls and requests. "I have to stay in tune to make sure I'm always checking that I don't miss any calls," says Sardin. "I need to make sure [concierge patients are] catered to right away, which is what they expect from the program."

Finding balance

Despite the steps Krems is taking to better accommodate his concierge patients, he says his non-concierge patients continue to receive adequate access to care. Though they may experience longer wait times for non-urgent appointments, Krems makes no distinction between concierge and non-concierge if patients need to be seen right away. "Ultimately medical condition trumps everything, so my front office is trained so that we triage things," says Krems. "If I have a non-concierge patient that's having a problem that's urgent - whether they have a really bad headache, or chest pains, or who knows, maybe they just have a really bad cold - I'll still be able to get them in today or tomorrow."

Krems acknowledges that if his concierge patient population grows (currently it makes up less than 10 percent of his total patient population), non-concierge patients may experience more difficulty securing non-urgent appointments. "Some patients are going to get upset and they're going to move on and that's OK," he says. "I'm going to still try as hard as I can for everybody. If I'm the right guy for them that's great, if I'm not, I'm not."

Concierge perks

In addition to improved access to care, Krems' concierge patients receive an annual "executive" physical. This in-depth exam is a great way to gauge each patient's overall health and wellness, and it's a great value to patients because much of what's evaluated is not covered by traditional insurance, says Krems.

Prior to the physical, patients fill out health and wellness-related questionnaires and they undergo various tests and procedures including an EKG, body fat analysis, and blood work.

"When they come in for that evaluation we have basically an hour or more set aside where we literally can just have a conversation about all that information [and] any other issues they want," says Krems, adding that specific health problems, nutrition and exercise, and stress are frequent conversation topics. "Before I was doing this I was always under the gun of having that [next] patient waiting, so sometimes there would be topics and things that we would just have to defer to another time and, quite frankly, sometimes never get to."

The payoff

So how are all of these changes affecting Krems' finances? Since he spends more time with his concierge patients, he conducts fewer patient visits each week. That of course, translates to lower reimbursement from payers. Krems also pays Concierge Choice Physicians $500 of the $1,900 annual fee he receives from each of his concierge patients. Still, Krems says he is retaining enough of that fee to see his overall compensation grow.

But that's not the biggest perk of making the shift to hybrid concierge, he says. "No. 1 would definitely be an improved doctor-patient communication/relationship," he says. "No. 2 is that it has actually made most of my days mellower - not busier."

The hybrid physician

Internist Steven Krems recently transitioned to hybrid concierge practice, in which a small portion of patients pay an additional flat fee for concierge services, while the majority of patients continue to receive traditional services. While the hybrid concierge model might work for any physician, Krems says it's helpful if you:

1. Prefer a more in-depth approach to care. A successful hybrid physician enjoys spending a lot of time with patients, says Krems, whose concierge patients receive access to him after hours and experience longer patient visits.

2. Are a generalist. "My patients can come in and they have time to ask me about anything and everything," says Krems, adding that specialists may not be as equipped to provide the wide-range of services he offers his concierge patients. "As an internist my practice is suited for that."

Making the case for concierge

On the fence about whether shifting to hybrid concierge is the right move for your practice? Visit http://bit.ly/hybrid-concierge for a podcast with Wayne Lipton, founder of Concierge Choice Physicians, which helps physicians transition to concierge practices. In the podcast, Lipton addresses some of the top criticisms voiced against hybrid concierge and concierge practices.

Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the October 2013 issue of Physicians Practice.