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Concierge Medicine Is Here and Growing!!

      An increasing number of primary care physicians are downsizing to a concierge medical practice (also termed “retainer-based medicine”). In a concierge medical practice, the physician limits the number of patients in his practice and offers exclusive services for an annual fee. The patient pays a surcharge for increased access and additional services from their physician.
      • Press M.J.
      Improvement happens: an interview with Deeb Salem MD and Brian Cohen MD.

      Advantages to Physician

      To maintain income, many primary care physicians are seeing more patients and spending less time with them.
      • Freedman N.
      Is it time for pulmonary concierge practices?.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      This has led to the “burn out” of some primary care physicians.

      The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

      The primary advantage of a concierge practice is that the panel of patients is smaller, ranging from 400 to 600,
      • Freedman N.
      Is it time for pulmonary concierge practices?.
      compared with a panel size of 2000 to 3000 in a typical primary care practice.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      As a result of the smaller panel size, a concierge physician sees 6 to 8 patients per day compared with 20 to 24 patients for the typical primary care physician.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      Association of Mature American Citizens
      Concierge medicine: an alternative to insurance.
      The smaller panel size allows the concierge physician to spend 30 minutes or more for each visit and several hours on executive-type annual physical examinations. The extra time allows the concierge physician to offer a comprehensive assessment and customized treatment plan, including lifestyle and preventive services for optimum health.
      Concierge physicians are able to respond to phone and e-mail messages, and offer same-day or next-day appointments. There is far less time spent on billing and paperwork.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      The decreased billing results in a lower overhead. Most concierge practices have only 1 or 2 employees.
      Association of Mature American Citizens
      Concierge medicine: an alternative to insurance.
      Reimbursement is more assured, and income usually equals or surpasses the income for the typical primary care physicians.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      Association of Mature American Citizens
      Concierge medicine: an alternative to insurance.
      Some report greater work satisfaction and less burnout in concierge practices.
      • Foreman M.
      • Lopez V.
      • Flenaugh E.C.
      Is it time for pulmonary concierge practices? Not yet.

      Advantages to Patient

      Patients in a concierge practice appreciate the immediate access to their physician by cell phone, e-mail, and same-day appointments, and minimal waiting time in private, pleasant waiting rooms.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      Visits are 30 minutes or longer and allow patients to present all their concerns.
      The physician coordinates care with other providers, with follow-up calls after specialist visit or hospitalizations. Their physician may accompany them to specialist visits and makes hospital and home visits when indicated.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      Some laboratory tests and procedures are available at the physician's office.

      Charges

      Concierge practices charge an annual retainer that averages $1500 per year to $1700 per year, approximately $135 per month.
      Association of Mature American Citizens
      Concierge medicine: an alternative to insurance.
      The annual fee has remained stable.

      The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

      Medicare does not cover the annual retainer.
      Some concierge physicians offer reduced retainers of $200 per year for less-extensive access.

      The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

      There is no charge and no co-pay or deductible for office visits, home or hospital visits, or office procedures.
      Association of Mature American Citizens
      Concierge medicine: an alternative to insurance.
      • Eskew P.M.
      • Klink K.
      Direct primary care: practice distribution and cost across the nation.
      Most concierge physicians bill Medicare and other insurance for office visits and procedures.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      Patients are not charged co-pays or deductibles.
      Association of Mature American Citizens
      Concierge medicine: an alternative to insurance.
      Concierge patients still need health insurance for hospitalizations, specialists, and tests performed outside the concierge office.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      Many concierge patients elect high deductible insurance.

      Number of Concierge Practices

      One of the first concierge practices was established by a noted Los Angeles cardiologist, Myron Prinzmetal in the early 1960s.

      Los Angeles Times. January 13, 1987. Obituaries: Myron Prinzmetal; pioneer cardiologist.

      He limited his clinical practice to spend more time in research. Several of his fellows went on to become “Doctors to the Stars in Hollywood.”

      USA Today. October 1, 2013. Rex Kenammer, doctor to the stars dies. Available at: www.usatoday.com/story/life/people/2013/10/01/redford-kennamer-dies/2906219/. Accessed February 20, 2017.

      Beverly Hills Courier.March 4, 2016. Clarence M. Agress, dead at 103. Available at: www.legacy.com/obituaries/newspress/obituary.aspx?pid=1779960334. Accessed February 28, 2017.

      Concierge practices were established in Seattle in the late 1990s.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      By 2010, there were 2400 to 5000 concierge practices in the United States.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      By 2014, the number had increased to 12,000.
      • Freedman N.
      Is it time for pulmonary concierge practices?.
      The increase in concierge practices is due in part to the emergence of organizations that recruit concierge physicians and manage concierge practices. One of the largest, MDVIP, was founded in 2000 and was bought by Proctor & Gamble in 2009. In 2015, they managed practices with more than 800 physicians and 240,000 patients in in 42 states.
      The majority of concierge physicians are general internists; 20% are medical subspecialists
      • Freedman N.
      Is it time for pulmonary concierge practices?.
      and 20% are family practitioners.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      Most concierge practices are in large urban areas on both coasts.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.

      Criticisms of Concierge Care

      The primary criticism of concierge medicine is that it is elitist, available to the rich but not to low-income patients. Studies have shown that concierge practices have fewer low-income, minority, or Medicaid patients.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      This could lead to a 2-tier health care system: healthy wealthy patients versus chronically ill poor patients.
      • Freedman N.
      Is it time for pulmonary concierge practices?.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      However, most concierge physicians also care for charity patients.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      A second criticism relates to when a primary care practice is downsized to a concierge practice. The primary care physician may “cherry-pick,” inviting the most healthy to join their concierge practice.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      • Stillman M.
      Concierge medicine: a “regular” physician's perspective.
      Some studies have shown that concierge practices include fewer patients with diabetes or hypertension.
      • Alexander G.C.
      • Kurlander J.
      • Wynia M.K.
      Physicians in retainer (“concierge”) practice.
      • Stillman M.
      Concierge medicine: a “regular” physician's perspective.
      Physicians downsizing could face patient abandonment laws.
      • Brennan T.A.
      Luxury primary care-market innovation or threat to access?.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      An additional criticism is that the increasing number of concierge physicians with their reduced patient panels will increase the shortage of primary care physicians.
      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      • Carnahan S.J.
      Concierge medicine: legal and ethical issues.
      However, some primary care physicians report that they were burned out and would have left the practice of medicine if concierge medicine had not been an option.

      The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

      • Doherty R.
      Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
      Others ask if physicians who practice medicine part time are also guilty of decreasing the supply of primary care physicians?
      • Huddle T.S.
      • Centor R.M.
      Retainer medicine: an ethically legitimate form of practice that can improve primary care.

      Does Concierge Care Increase the Quality of Care?

      There are no peer-reviewed comparisons of the quality of concierge care versus standard primary care practices.
      • Stillman M.
      Concierge medicine: a “regular” physician's perspective.
      There are some reports from concierge care organizations, such as MDVIP, that patients in concierge practices have fewer hospitalizations, fewer emergency department visits, and better control of hypertension and diabetes.

      The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

      Conclusions

      Given the obvious advantages of concierge medicine to physicians and their patients, concierge medicine will continue to grow.

      The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

      Primary care physicians must downsize carefully when they establish a concierge practice to avoid cherry-picking the healthiest patients. It is true that an increase in concierge practice will contribute to the shortage of US primary care primary care physicians. The shortage of primary care physicians will continue and may be relieved by new models of primary care that increase the use of nurse practitioners and physician assistants.
      • Dalen J.E.
      • Ryan K.J.
      • Alpert J.S.
      Where have the generalists gone? They became specialists, then subspecialists.

      References

        • Press M.J.
        Improvement happens: an interview with Deeb Salem MD and Brian Cohen MD.
        J Gen Intern Med. 2011; 27: 381-385
        • Freedman N.
        Is it time for pulmonary concierge practices?.
        Yes Chest. 2017; 151: 255-257
        • Brennan T.A.
        Luxury primary care-market innovation or threat to access?.
        N Engl J Med. 2002; 346: 1165-1168
      1. The Wall Street Journal. January 17, 2013. Why concierge medicine will get bigger. Available at: http://www.marketwatch.com/story/why-concierge-medicine-will-get-bigger-2013-01-17. Accessed February 1, 2017.

        • Doherty R.
        Assessing the patient care complications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians.
        Ann Intern Med. 2015; 163: 949-952
        • Alexander G.C.
        • Kurlander J.
        • Wynia M.K.
        Physicians in retainer (“concierge”) practice.
        J Gen Intern Med. 2005; 20: 1079-1083
        • Association of Mature American Citizens
        Concierge medicine: an alternative to insurance.
        (Available at:) (Accessed February 26, 2017)
        • Foreman M.
        • Lopez V.
        • Flenaugh E.C.
        Is it time for pulmonary concierge practices? Not yet.
        Chest. 2017; 151: 257-259
        • Eskew P.M.
        • Klink K.
        Direct primary care: practice distribution and cost across the nation.
        J Am Board Fam Med. 2015; 28: 793-801
      2. Los Angeles Times. January 13, 1987. Obituaries: Myron Prinzmetal; pioneer cardiologist.

      3. USA Today. October 1, 2013. Rex Kenammer, doctor to the stars dies. Available at: www.usatoday.com/story/life/people/2013/10/01/redford-kennamer-dies/2906219/. Accessed February 20, 2017.

      4. Beverly Hills Courier.March 4, 2016. Clarence M. Agress, dead at 103. Available at: www.legacy.com/obituaries/newspress/obituary.aspx?pid=1779960334. Accessed February 28, 2017.

        • MDVIP
        Concierge care for all?.
        (Available at:) (Accessed February 25, 2017)
        • Stillman M.
        Concierge medicine: a “regular” physician's perspective.
        Ann Intern Med. 2010; 152: 391-392
        • Carnahan S.J.
        Concierge medicine: legal and ethical issues.
        J Law Med Ethics. 2007; 17: 121-163
        • Huddle T.S.
        • Centor R.M.
        Retainer medicine: an ethically legitimate form of practice that can improve primary care.
        Ann Intern Med. 2011; 155: 633-635
        • Dalen J.E.
        • Ryan K.J.
        • Alpert J.S.
        Where have the generalists gone? They became specialists, then subspecialists.
        Am J Med. 2017; 130: 766-768