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Concierge Medicine

by: DrAbston

Sun Jul 11, 2010 at 15:37:22 PM CDT


One of my coworkers showed me a letter she had gotten from a local internal medicine physician, who explained that he was converting to what is often called "concierge medicine".  In the letter, he complained that Medicare was not paying him enough for the work he did, and also that he spent long hours into the night doing insurance paperwork instead of being with his family.  His solution is to stop taking Medicare and other insurances, and instead charge patients $100 a month (to be paid every 6 months in advance as $600).  This would not cover any labs, medications or hospital bills, just his personal services.  Furthermore, he is only going to accept the first 350 patients who contract with him-- I guess the others will have to scramble for another doctor.  I don't know how many patients are in his practice now, but many doctors have a few thousand patients-- this could be a big problem in Huntsville with our current shortage of doctors accepting new patients.

My co-worker felt this was a fair thing for him to do, because he deserved to be able to make good money and have time for his family.  I don't dispute his needs-- but I pointed out that this would bring in $420,000 yearly for him, even if these 350 patients didn't need many appointments.  Typically a physician keeps 40% of total income for personal profit, but the percentage would likely be far higher in this case, since none of it would be used to purchase medications or vaccines, and his practice will not have to pay for insurance billing personnel.  Probably not as much for clinical staff either, with such a reduced patient load.  Patients who could afford these up-front fees, I suspect, would likely be wealthy and thus more likely to be healthier.  Even though we might think they would want to come for more appointments, having already paid for them in advance, I doubt that these higher earners would really want to take too much time off from their work and leisure activities when not sick.

I believe this particular form of concierge medicine is unethical and unprofessional.  First of all, regarding income-- the large part of a physician's medical education cost is actually borne by the public, through tax money distributed to medical schools and hospitals.  Our tuition doesn't come close to covering the actual costs.  To me, that means we owe a debt not only in terms of student loans but also to our communities.  I feel quite sure this doctor was not dumpster diving for his groceries, although it is probably true that there were things he wanted that he could not afford (like all of us).  Is the income a person makes really based on what she deserves, on the hours or effort expended?  If this were true, public school teachers would make as much as surgeons-- their work does not end when the school bell rings, either.  The truth is that our incomes are based on what people are willing to pay for our work, not on what we deserve.  And as professionals, we are obliged to consider not only what people are willing to pay but also what they are able to pay.

As physicians, we are held to professional standards which go beyond market economics.  We are to be compassionate towards our patients.  The word compassion comes from the Latin for "to suffer with".  Right now, our patients are suffering from healthcare rationing-- many completely unable to afford medical care, and many more unable to afford sufficient care to meet their needs.  The professional response to this is first to be willing to suffer somewhat ourselves.  I do not propose that we dress in rags, only that we do not attempt to profit at the expense of our patients having decent medical care.  Once we have agreed to that, it is perfectly reasonable to speak out for in favor of fairer and more reliable physician payments-- and even to enlist the grateful help of our patients in doing so.

There are actually ethical methods of refusing to deal with insurance companies.  For instance, there are doctors who work on an affordable fee for service schedule but who have a sliding scale for the poor.  A way to do this on a concierge basis would be to maintain the same number of patients in one's practice, while charging a higher monthly amount to higher income patients and perhaps nothing to those who can't afford it.  And the way I advocate is to convert to a publicly funded national health insurance-- an improved, expanded Medicare for All.  This would also significantly reduce physician paperwork (note the word "improved").  By putting all of us in the same boat, it would push well-off patients to insist on proper physician payment, so that they could continue to have access to quality medical care.

An Alabama physician, Dr. Robert Bentley, is running as a Republican for Governor of Alabama-- one of his campaign promises is that he will not draw a salary until Alabama has sufficient jobs for its citizens.  I do not like Dr. Bentley, who espouses some very regressive ideas.  But would that he had issued a similar call to physicians not to increase their salaries by turning away patients who need care.

DrAbston :: Concierge Medicine
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Concierge Medicine | 20 comments
Concierge medicine... (4.00 / 1)

Never heard of this before...A doctor on retainer getting paid whether you use them or not...just doesn't sound ethical.

Interesting post, DrAbston!



Works for lawyers (0.00 / 0)
Why not doctors.  In fact, Community Supported Agriculture uses the same idea to provide farmers with a decent, predictable income.  Food for thought.

Work harder and work smarter!

[ Parent ]
It is unethical (4.00 / 2)

 The population continues to rise. A doctor is suppose to accept a situation for what it is. Our teachers are not allowed to turn away students. A doctor should not be allowed to turn away patients. If this line of thinking continues, where will it end? Cops allowing crimes to be commited right before their eyes because they already have too much paper work to do? Firemen ignoring fires until the morning movie is over?

 The insurance companies need to be made to simplify insurance forms. (this guy got sick, I treated him with medicine X and it cost X amount of dollars) And we need to start locking up insurance agents that deny claims with no tangible, just cause.



October 2012 was the 332nd consecutive month with a global temperature above the 20th century average. The last month with below-average temperature was February 1985. - N.O.A.A.

Need More Facts (0.00 / 0)

Dr. Abston,

As a wife of a local physician (and a left-leaning one at that!), I appreciate your shedding light on this issue. I have heard of several internal medicine doctors who are adopting this kind of practice as a response to decreased reimbursements.

My elderly mother recently recieved a letter like the one you describe. In fact, I suspect it is the same doctor. If so, some of your facts are incorrect. The original letter certainly was more persuasive for the doctor in question. Having known this doctor for years, taking into account his community service and sheer time he takes with complicated, aging patients, I am absolutely sure his decision was not motivated by greed. 

Do you have the letter? Can you post it with the relevant names blacked out? If I find my mother's before you do, I will do the same.

Thanks!



Ding! Ding! First time comment here! (0.00 / 0)

Welcome nashnative!

I see that you registered months ago but are just now making a comment.  Great to have you!

You make a good point and I know that you and the diarist can have a great dialogue on this issue.

Unfortunately, when I hear "concierge medicine" all I can think of is the USA "Royal Pains" tv show.  So please, y'all, shed more light on the issue!



"The modern conservative is engaged in one of man's oldest exercises in moral philosophy; that is, the search for a superior moral justification for selfishness."  - John Kenneth Galbraith




[ Parent ]
Cocierge Medicine (0.00 / 0)
The term "concierge medicine" was not used by my doctor in his letter, but rather applied by others. I am clear on the origin of this term but I'll check on it.

[ Parent ]
letter (0.00 / 0)
I don't have the letter--but I would recognize it if you posted it.  If the decision was not motivated by greed, it still has that effect-- putting care out of reach for many patients to his benefit.  I would have to see his tax form before I could have my mind changed on that!

[ Parent ]
left-leaning doctor (0.00 / 0)
Oh, and would your husband be interested in helping with our local chapter of Physicians for a National Health Program?  We would really be happy if he did!  Actually, anyone can join-- does not need to be a physician.

[ Parent ]
Leftie Dr. (0.00 / 0)
He already belongs.

[ Parent ]
Interesting. (4.00 / 1)

With Medicare and a Medicare Supplement (plan J) I pay about $250 now.  If that doctor just charged me a hundred a month and I could drop Medicare premium, I'd just pay a hundred a month for medical care.  Even paying the Medicare payment, I'd save fifty dollars. I could get a separate drug plan.

But I like what I have now; it covers me during travel. No deductible, no copays, and just two dollars and half for generic drugs. 

His plan would not cover me for travel.

 

 



Qui bibit, dormit; qui dormit, non peccat; qui non peccat, sanctus est; ergo qui bibit sanctus est.

Until... (0.00 / 0)
You need surgery for something.  If anything crops up-- even so much as a freaking blood clot-- the equipment charges and hospital fees will pile up rather quickly.

[ Parent ]
Medicare supplement vs concierge (0.00 / 0)
Another problem is that this $100 a month only covers the one doctor-- if you need to go to any other specialists, you would still need to pay them.  Most older patients who would need to see a primary care doctor enough times a month to justify $100 are also needing to see at least one specialist if not several.

[ Parent ]
Medicine in Rural Areas (0.00 / 0)

I am an advocate for Universal Single Payer health care here in the US.  I lived in Australia and can attest to how well a socialized health care system can benefit you.  

However, living in a Rural area I can understand how concierge medicine would be attractive for a physician.  There are two Pediatric practices in the place I live, yet on more than one occasion I have had to sit for appointments onwards of 4-5 hours.  Many of my visits with my children were routine kinds of things, things that in the office took 2-3 minutes to assess and diagnose, we could have the Doctor stop by the house to do.  In order to not have to wait in a Doctors office half a day, I might pay $600 every six months to have someone a phone call away.

 



9.13, 4.82, Just left of Gandhi.

Wait times here... ugh! (0.00 / 0)

Yeah, we live close to at least three different hospitals (more that that, actually, but the three are the first that come to mind) and several pediatrics offices.  Yet, when I take my daughter to the doctor, we've waited an average of four hours for a scheduled appointment with her doctor for a regular checkup unless it's the first appointment of the day, which will yield a one hour wait.  The visits themselves will usually take around 10 minutes total-- including maybe two minutes with the doctor while a nurse does the actual checking of various things and administers vaccinations.

I've said time and again that I was going to change practices, but it seems like the story from the other practices is that they're similar.

Oddly enough, the local "doc-in-a-box" is a 10 minute wait and is open on the weekend.  So when she actually gets sick, that's where we go.

No way am I sitting with a sick child in a doctor's office for four hours, and these people REFUSE to call in so much as eye drops for pink eye, won't give a blue form for school without an office visit (or a $10 charge), are horrible at actually picking up the phone for an appointment (much less if I need to leave a message for the nurse), and charge for non-emergent calls!

Thankfully they've just figure out how to use the Internet, so I can at least email my question that I'll be charged for later as to how much Benadryl is safe to give my 4-year-old (since it says to ask a physician and the pharmacist isn't going to tell me) after a bee sting without having to sit on hold for a good hour to get the nurse's voice mail.



[ Parent ]
wait times (4.00 / 1)

That sounds terrible-- I don't think it is very common in Huntsville, although I have heard of a couple of practices with that problem.  Wait times like that are totally unnecessary-- that means there is some consistent problem with the way they run their schedules.  There are different reasons docs can justifiably be late without expecting it ahead of time.  There can be hospital or office emergencies, for instance, although you wouldn't expect those every time.  A common problem for us is that a parent schedules an appointment for something simple, maybe swimmer's ear, but when I get in the room it turns out he has had headaches every day for a month-- obviously that takes a lot longer!  Or a teenager comes for a routine sports physical and turns out to be suicidal. And there just isn't any way to know when that is going to happen.  We also have parents who try to slip in "extra" kids ("can you just look at his ear?"-- "Mrs. Smith, his ear is attached to the rest of his body, so I will need to actually do a regular visit").  I try and get them to wait and be worked in after I'm finished seeing the folks who are on time, although you'd be surprised that some of them get angry about that.

But on average, a patient in my practice gets seen within about 10 to 15 minutes of arriving if they are on time. This is mainly because it takes the nurse a few minutes to work them up and enter them into the computer. Because we are teaching, that first person might be a student or a resident, but I come in as soon as they are finished.  My wait time when I was in private practice was usually less than 10 minutes.  Instead of double booking, I just worked later in the evening if I had more sick kids call in.  I am always trying not to keep people waiting, because I hate waiting myself.  On the flip side, I have to admit to being really ticked off when patients are late themselves! I am sorry you are having so much trouble in your community with this!



[ Parent ]
Thank you! (0.00 / 0)

I think people who are late are usually those people who will throw that "extra" kid in there, and are those who are going to get angry about having to wait.  All I want is to be able to be seen in a timely manner.  If I'm not late, then every effort should be made to see me and others who are on time in a timely manner.

I can imagine that physicians in larger towns aren't going to have this same issue.  Its a function of fewer and fewer physicians going into Family or General Practice and even fewer of those choosing to practice in rural areas.  Medical students should have an opportunity to have their loans forgiven if they choose to practice in a high need area. 



9.13, 4.82, Just left of Gandhi.

[ Parent ]
More Facts to Consider in support of "Concierge" Doc (0.00 / 0)

I'm sorry I haven't gotten a copy of the letter up yet. I really intend to.

The Doc in question (I'll call him Dr. B) has been taking medicare patients for years now, while other practices have been rejecting them. This happens because privately insured patients are more profitable than medicare patients. Dr. B. has never turned down medicare. He states in his letter that his practice is now 90% medicare. I am sure he would like a better patient "mix" -- insured v. medicare, young v. old, working v. really sick. This is an attempt to adjust that mix, for himself, and his practice partners who share his overhead and call. 

BTW, the $100/month fee would be good for coverage by his call partners who would care for his patients when he is not available. He is the only one in his practice making this change. If his motives were really greed above and beyond his more traditional business partners, I would imagine they would be parting ways. 

Another doc in town, Jack Moody, has another approach to this. Since he has publicized this change on a website, I'll include it here: http://www.physicians-mdvip.com/JonMoodyMD/Pages/default.aspx. He is charging each patient a yearly fee ( $1500, I have heard) whether or not they have private insurance or medicare. His would seem to me a more "concierge" approach than Dr. B's, in my opinion. However, I have not seen the letter he sent to his existing patients. 

Whether you like this way of doing business or not, it seems to me the wave of the future. Other single payer systems, such as England, have gradually developed two tier systems where the wealthier patients pay more to receive shorter waits.  The less well off are assured care, but not necessarily convenience. 

Another thought on all this... BC/BS has been reducing reimbursements for several years. Medicare is threatening to reduce payments by 21%. For physicians in mid-career with family expenses rising, this is a startling change. Not many of us would take a 21% cut in income without a complaint. For people just entering the profession, they can make their own choices about hours worked and the trade-offs they want to make for less money. I for one, would choose a 9-5 life with a vastly reduced salary (like docs in England), but this generation of US docs was not permitted that choice at the outset and they can't exactly make it now. Accepting less money doesn't even reduce your workload -- it just means you work harder for less.

Dr. B., Dr. Moody, and others are just responding to mid-career surprises from the medical system, the government, and the insurance companies. Sure they have self-interest, but who doesn't? Are any of the other players acting selflessly? It's just another step in the evolving changes for the next generation of American patients and doctors.

Sorry for rambling....

 

 

 

 

 

 

 



workloads, etc (4.00 / 1)

Well, I understand what you are saying.  But I still don't think the letter in question reaches a middle ground, when I look at the huge amount (to me) he would be taking home in salary for such a small number of patients-- and I admit to comparing these  numbers to my personal ratio.  I'm not sure I would even have time to spend that much money!  Why does he feel like he needs so much?  I guess, even though I am only 46, I went into medicine before there were hourly limits on resident work schedules, and I knew ahead of time I was committing myself to a profession that would require the large majority of my waking hours (and many of the hours most people spend sleeping).  So it was a conscious choice on my part-- and I do see that changing.  Which may be ok, but it will require us to probably double or even triple the number of docs we train (in addition to more nurse practitioners).  And we should really get that going immediately, preferably with free medical education, which would not be a large expenditure, considering that taxpayers already fund the bulk of it.

I have some inside info on these continually threatened Medicare cuts.  For those of you who don't know, there was legislation passed many years ago which was supposed to ensure a "sustainable growth rate" (SGR).  Because payments have risen much faster than the SGR allowed for, there is an increasingly large gap every year, which is supposed to result in a cut to the level originally specified.  But it never happens-- in fact, after it supposedly took effect this year, the "fix" was passed shortly afterwards and retroactive payments are being made.  There was actually a 2.2% increase in provider payments-- which hasn't happened to my knowledge with private insurers.

I went with a group of docs in Feb 2009 to DC for a legislative affairs conference, and we met with our senators.  When Shelby was asked why we can't get this SGR situation fixed permanently, he laughed and said very bluntly that there would never be a permanent fix.  The reason he gave was that is had become a "must pass" item every year, and it was being used as a tool to get other legislation passed that was included in each bill.  The other legislation isn't even related to medicine-- this year it had something to do with pension amortizations that I couldn't figure out.  Shelby said not to worry, that the SGR would continue to be fixed yearly.  I don't know whether that will be true or not, but it certainly is an interesting twist.

I am beginning to have a concern that maybe conservatives are also doing this kind of thing to actively sabotage any health care reform that would involve government financing.  When cuts are made to Medicare, it gives the appearance that the Tea Partiers are correct and govt "can't do anything right."  If Medicare is continually threatened, why would people support a vision of an improved, expanded Medicare for All?  The truth is that the US CAN afford universal single payer financing, and it would be less expensive than our current situation-- but if we don't convince conservatives of that, perhaps they will wind up throwing so many wrenches into things that even a good single payer law would go south.  If that is the case, maybe we will have to "hit bottom" with private insurers-- and when none of us can afford adequate health care/ insurance anymore (because that $100 a month isn't going to cover your meds, hospital charges, etc), even conservatives might change their tune.



[ Parent ]
Dr. Brian Roberts responds (0.00 / 0)

So it looks like it is public knowledge that the doctor we've been talking about is Brian Roberts. 

He wrote the following letter, published in the Huntsville Times, Sunday July 27, 2010.

 

 

Doctor's Medicare
I would like to respond to the statement by Mrs. Rigsby on July 19 to doctors who do not take Medicare payments.

I am a primary care internal medicine physician. I have been in practice in Huntsville for 20 years.

 Ninety percent of my patients have Medicare. To provide them with quality care I must work 80 hours each week.

Due to pay cuts and payment delays, my income is down 30 percent compared to this time last year.

Therefore, I have three choices. Perhaps Mrs. Rigsby can tell me the best choice. I understand her frustration. I have no complaint against her.

Option #1. Quit

Option #2. Get rid of 80 percent of my Medicare patients. Most practices limit it to 20 percent.

Option #3. Drop out of Medicare. I will get no money from Medicare. I have to ask my patients to pay an extra $100 a month for their health care.

Of course, like always, we treat some truly poor people free. For the majority it costs $100 per month. Maybe that is not fair.

However, it is my only reasonable choice, and the patients still have a doctor.

I do get one great benefit. I do not have to spend about three hours doing useless paperwork that is required by Medicare each day.

I am not threatened by criminal penalties. The extra time helps me take care of my patients better.

Most importantly, my children will be awake when I get home!

R. Brian Roberts, M.D.
Huntsville, 35801



Concierge Medicine | 20 comments

 

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