Concierge or retainer medicine – considering the why?
Patients want continuity, comprehensiveness, and access. None of my golf buddies are physicians. They want access at their convenience. Often they’ll call me in the morning and want a problem addressed that day. I try to help them, when I can, but the current system generally lacks that responsiveness. Last year my 25 year old daughter called me on a Sunday night complaining of an acute illness. I was fairly certain that she had influenza and would benefit from medication. I told her to call her internist the next morning to either get a prescription called in or be seen. Her internist’s office said she couldn’t be seen until Tuesday. My understanding of the anti-influenza medications says that those 24 hours were very important – she remained ill for approximately a week.
Patients want time with their physician. One physician that works in my division has a great clinical reputation. Her patients commonly tell me that she spends enough time with them and ‘really listens’. Unfortunately, you don’t often hear physicians described like that.
I remain fascinated with retainer medicine. A search in this blog will find many articles related to retainer medicine.
This week in thinking about retainer medicine I had a minor inspiration. The patient centered medical home (PCMH) model has much in common with retainer medicine.
Many physicians speak against retainer medicine. These physicians object to the financial model. I urge them to get past the money and consider why patients are willing to pay for retainer practices. Patients want access. They want appointments at their convenience; they want phone access; they want email access. They want the physician to spend enough time with them and thinking about them.
Our current model rarely provides any of those things. We need a new model, and perhaps understanding the success of the retainer model would inform true reform.
{ 5 comments… read them below or add one }
Bingo! You’ve hit the nail on the head. I wrote my dissertation on concierge medicine, and I thought of it as Janus-faced–looking both backwards and forward–combining the clinical bells and whishtles of today with the time and empathy of yesterday. Seven minutes with the doc just doesn’t cut it, especially after waiting who-knows-how-long just to get that seven minutes. People who have asked me about concierge medicine said they’d be happy to pay the retainer (granted, they were capable of doing so) and, almost to a person, when the concept was initally described, said: “Just like in the old days!” Patients haven’t forgotten Dr. Welby and they still yearn for him.
Why speak against this? Capitalism is based on the concept that people can pay extra for whatever they consider “better” – witness collectors who pay huge sums of money for things that you and I think are worthless (stamps, coins, cars, whatever).
If there are enough people willing to pay for improved access to physicians, there is no reason why retainer medicine is not a viable option.
My city has buses and a subway – should I not be allowed to pay for and maintain my own car? Retainer medicine is the same thing – an upgrade of the current system that both patient and provider want.
I stay in business because I keep my overhead low. I do many non doctor things in my practice, including billing and coding and sometimes answering the incoming calls. I have seen the primary care salaries from concierge and retainer medicine, and I am doing better financially than those doctors.
That said, the advantages of concierge and retainer medicine include seeing fewer patients, providing longer visits (often a half hour for an established patient), not having to submit claims to insurance companies, and selecting out a middle class to upper class patient base. There is no third party billing with insurance companies out of the picture and no longer controlling the doctors to limit costs.
Most of my insurance contracts require 24 hour access to a physician for my patients, preauthorization for specialty referral or MRIS/CTS, free telephone calls, free paperwork completion, and other free things that the concierge and retainer medicine would either include in the package fees or would charge the patient. The negotiation on cost is directly with the practice and the patient.
During my first 6 months in practice, I was only on 3 insurance plans, while I waited for credentialing contracts to go through, which took 6-12 months. I tried discounted self paying fees, and my area does not support the concierge or retainer medicine idea, as most patients did not want to pay more than their $20 copay to see a doctor. The insurance companies have brainwashed the patients into wanting care for $20, while the patients and business pay thousands per patient for each insured person. Currently doctors are getting the short end of the stick, and HMOs keep reducing fees while doctors have to work harder to maintain their practice overhead.
You got it, finally.
Go to http://simpd.binaryminds.com/UserFiles/SIMPD_Keynote.doc
for my opening remarks to SIMPD’s last meeting explaining just how well you’ve finally got it.
Thomas W. LaGrelius, MD, FAAFP
Chariman of the Board, SIMPD (retainer docs) http://www.simpd.org 877-448-6009
Dr. LaGrelius:
I always “got it;” I just never agreed with your entire proposition, as you know from our long conversation last year. For one thing, your assumption that each doc would have some 650 patients is based on an equal distribution of docs across the country. Obviously, docs tend to distribute more heavily in large metro areas (such as I live in), and are more thinly scattered in what are considered less desireable areas. Immediately, I see a problem. And, in fact, when we look at geographic distribution of docs presently practicing concierge/boutique medicine, that is exactly what we see: heavy distribution on both coasts and a light scattering between.
Do we need a change in health care? Absolutely! Do we need better reimbursement for cognitive care? Absolutely! Do we need more action and less hot air? Absolutely! And last but not least, do we need to do away with both political weight-throwing and lobbying which only place obstacles in the way of real change ? You know it!
P.S. After reading your May 9th presentation, just one comment: I think you may have mixed your metaphors when saying that doctors used to die in the saddle; perhaps you really meant they died with their boots on.