More on retainer medicine

Friday I had lunch at the retainer practice, and interviewed the original physician (SP) in the practice. As I talked with each of these physicians, I began to better understand why this model has so much importance and is so misunderstood.

I often write about time and reimbursement. Our current reimbursement system drives short appointments. Because we are paid per visit, shorter visits allow more visits each day. While physicians generally strive to provide the highest quality patient care, finances do matter.

As I interviewed the senior partner, I felt his passion. He had practiced in two separate practices over the previous 20+ years. His reputation as an internist is impeccable. The first thing he shared was his burnout. He had guilt about his ability to provide the care that he wanted to provide. He no longer was enjoying being a general internist.

These comments are not unusual. Many physicians leave outpatient internal medicine practice each year. The younger ones opt for a fellowship or a hospitalist position; the older ones either leave practice or become hospitalists.

Economists often stress that everything is money – especially time. I often write about the amount of time that excellent outpatient medicine takes.

So SP, at the urging of others, developed the retainer practice. Now he has 280 patients and has capped his practice, because each day is busy. I asked him about the patients in his practice. While he does have a cadre of “high rollers,” most of his patients are in the well off rather than wealthy group. His patients almost all have multiple medical problems, and that seems to be their motivation for joining the practice. His patients, like many other patients, are looking for a medical experience that enhances communication and education.

As I asked SP about his typical day, he told me that he physically saw 6-8 patients each day. He spent at least as much time on the phone or answering email as physically seeing patients. At least once each week he makes home visits. He often calls his patients preemptively.

Because of his intense outpatient work, his admission rate is very low. He needs less consultants and orders fewer high ticker imaging studies.

Over a 4 year period, one patient has left the practice, and he has “fired” one patient (for demanding to direct their own care.)

Patients pay a sizable retainer, and seem to feel like they are getting 1st class care. They have excellent physicians (both docs in this practice are superb) who can devote enough time to patients. An excellent internist can make a difference, given enough time with each patient.

Neither of these physicians would practice in the standard factory style. They had both already decided to reject the madness that internists face each day. They are both happy and love medicine and their patients. Their patients are happy because they are paying for access and time and they are receiving it.

This movement continues to grow. It grows because patients are willing to pay for service. Unfortunately, the Medicare reimbursement system drives what other insurers pay. This illogical, bureaucratic system is destroying outpatient internal medicine. Retainer medicine and cash based practice may save these practices.

If your gut reaction about retainer medicine is negative, please think carefully about the alternative. I would argue that trying to see patients in inadequate time leads to bad medicine and unhappy physicians and patients.

SP shared his opinion that before he left his former practice, he was delivering a standard of care which troubled him. He was losing his love for medicine and patients.

As you consider retainer medicine, the alternative is not for those physicians to have a practice with 24 patients each day. The alternative is an ever decreasing pool of outpatient internists.