I had lunch with a retainer doc yesterday. He works at my university, and is a former resident. He has worked as a full time primary care internist and as a teaching internist at a community hospital. He joined the retainer practice in the past year. His practice includes 10% “scholarship” patients.
I am still digesting our chat, and plan to chat with his partner also. I will make some observations.
Retainer physicians provide better care. The key to their care is time. We all know that time is important. Some critics of retainer medicine complain that these physicians are unethical, but could practicing internal medicine in 15 minute visits be the true unethical style of practice.
My friend suggested these observations:
1. Because he has enough time with his patients, he orders less imaging studies and less consultations.
2. He now enjoys practicing medicine.
3. His patients are very happy.
4. He and his partner admit fewer patients because they can see patients longer and do more in the office.
Perhaps this style of medicine, framed as a luxury by many, is really cost-effective. Perhaps we should invest in these practices because they would decrease overall health care costs. If this became the standard style of practice then might not many more students and residents choose family medicine and internal medicine. Expanding this style of practice might improve overall health care.
Our current practices are substandard. Seeing patients too quickly leads to missed diagnoses, reliance on excess imaging, and too frequent consultations. Some data suggest that retainer practices markedly decrease admission rates – these data are not yet published, so they have not passed the test of peer review.
So I am thinking about retainer medicine as a potential alternative to our current outpatient medicine, which must necessarily cut corners and lead to dissatisfied patients and physicians.
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{ 7 comments… read them below or add one }
I support retainer, and similar styles of medicine. I think that is the way I will attempt to specialize–so I can practice in that style. However, it does make me think that if physicians see this as a more viable option–won’t we need more physicians? How will physician education change? How will an increased need in physicians be met?
From a patient perspective it quickly becomes cheaper to pay a fee for prompt service than the current hurry up and wait system. Add to this the seemingly unending test and subscribing to a retainer practice becomes an attractive economic alternative.
Under the current system doctors are paid for office visits and test, so we get office visits and test. Remove this incentive and we will see doctors practicing better medicine.
Steve Lucas
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How convenient. These are the things that I have been blogging about for two months.
Give the primary care doc the time to cogitate and you will watch a shifting of the cost curve downward that will trickle through out the whole system Part A, Part B and Part D
The Medicare National Bank’s idea of cost control is to cut reimbursement. The only response a physician has is to increase volume to remain revenue neutral. When you spend less time with the patient, you get what you pay for. More referrals, more tests, more hospital admissions. More expensive health care.
To hear this from a doc who is actually practicing retainer medicine is so comforting to know that my ideas and reflections are not just theories but have applicable real world effects.
In a previous blog entry “My 125 billion dollar experiment” I proposed a dollar for dollar tax credit to every man woman and child of $30 a month, or $360 a year to be used towards the purchase of primary care services. My idea was a market decided “access”/retainer fee. In return, primary care gets out of the insurance business, forever. They bill the patient the equivalent of a copay ($30-50) for an office visit, cash. Insurance in primary care is no longer a factor.
I figured a primary care doc with a panel of 1000 patients (much smaller than todays panels), could see every patient 4 times a year at an average visit length of $27 minutes, take 6 weeks off vacation and work 40 hours of patient contact time a week, with 50% over head, and charging about $30 per office visit, cash, and take home almost $250,000 a year.
Now that would save primary care in just about every part of this country you can imagine. And the market will determine the price.
And the cost savings would be immediate, and the cost would be no where near $125 billion dollars, as primary care would get out of the insurance business, forever, would have nothing to do with Medicare Part B
I call it my National Primary Health Care Initiative.
http://thehappyhospitalist.blogspot.com/2007/11/my-125-billion-dollar-experiment.html
Retainer medicine characteristics should be the standard of care for primary care, not the exception.
I am quite sure I do not follow your math. A physician in your plan would have a panel of 1000 patients each of which he sees 4 times a year. That is 4000 office visits per year at $30 per visit is $120,000 per year gross. With your 50% overhead the take home pay is $60,000 not $250,000.
I left a busy group practice in Fort Myers, Florida in 2005 to start my house-call based concierge practice. Originally I tried to deal with insurances but since none pay for house-calls, and Medicare only reimburses minimally, I couldn’t make it viable. In our area it’s not uncommon for me to drive 30-45min between visits and I typically spend 45-60min with a patient. Hence I was drawn to the concierge business model. I am still the ONLY concierge physician in South-West Florida exclusively making house-calls in Lee and Collier counties.
No mistake, my services are a luxury item and convenience for most of my patients. I charge $2000-$6000 a year per person, depending on age, size of family, and location.
I know it’s not the answer to our health care crisis, but I certainly love my job again! Besides I get to see my kids more.
Two other key points for the lay-person to understand. Just because I charge above what insurance pays, doesn’t make me rich. I actually made less than our city pays bus drivers for the past 2 years, although admittedly the potential is significant. Also, even though most of my patients are the “rich and famous” of our area, doesn’t absolve me or any concierge physician of our responsibility to the community. In fact this is a responsibility of each of my patients as well.
I continue to be an active office in the US Army Reserve, chair the Health Advisory Committee of the Lee County School District, volunteer as a Guardian ad Litem serving abused and neglected kids, teach Head Start program moms about child care, etc…
No, concierge medicine isn’t for everyone, but it certainly has worked for me and my patients.
Andrew Oakes-Lottridge, MD
Personalized Health Care, Inc.
(239)694-6246
http://www.DrAndy.us
Wayne M. Burr, MD, PL
(239) 333-DR4U(3748)
9407 Cypress Lake Drive, Ste. C
Fort Myers, FL 33919
http://www.concierge-physician.com
The concierge medical practice model is not for everyone. People have to decide what is important in regards to their time and their healthcare. The person that has been attracted to my practice is the one who is frustrated with the typical medical office of long waits, hurried visits and phone calls that do not seem to get returned.
My practice also offers ancillary services such as visits with a Registered Dietitian, personal fitness trainers, and massage therapist – all for less than the typical concierge fee charged by other physicians in this area. In fact, my office is the only one in Southwest Florida providing this comprehensive care as part of the concierge fee.
We offer a choice for the client on when and where they can receive his/her medical care – my office or their home/office. We can also provide laboratory services in the office as well that would not be available in a house call situation. It is all about what the client needs.
Concierge medicine is not going to replace the typical practice model of medicine, but instead provides the public another choice in their medical care.
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