In which I continue my debate with Dr Val

19 Dec
2009

She writes:

The problem with retainer medicine is that it incentivizes smaller patient loads. I understand that this is desirable for doctors, it's not good for the healthcare system as a whole. My point is that direct-pay IS a great option for many people, but I question whether the exclusivity of VIP concierge practices is good for the common person. My model rewards volume while decreasing admin paperwork and decreasing costs. This can be scaled, while concierge practices cannot.

Obviously "panel size" remains important.  What we do not know is the optimal panel size.  What we do not know is the optimal number of patients the primary care physician should see each day.

Hospital medicine has answered the question.  Most hospitalists groups have a goal of 15-18 patients per day, knowing that once you have more patients your care suffers.  Length of stay increases and quality measures decrease.

Outpatient medicine has not addressed this issue properly.  The payment system rewards volume – exactly the wrong incentive.

I believe that the best retainer models will find the optimum panel size.  It probably is somewhere in the 1200-1500 range.

I stand by my argument that moving to a retainer model would attract many physicians back to primary care.  Our problem is not having enough capable physicians, rather we have too many physicians who have reject the inane practice volumes.

I have nothing against cash only practices, but I believe the retainer model will lead to slightly better access.

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5 Responses to In which I continue my debate with Dr Val

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Rocky Balboa, Jr, MD

December 19th, 2009 at 8:39 pm

Lets not lose sight of our goal: empowering primary care and making it a profession again.
It does not have to be a one size fits all model.  Direct care, retainer, and hybrid  models can peacefully coexist and still cover patient volume.  
Individual physicians can customize what type of practice and payment model is best for their patients and themselves.

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Dr. Val

December 19th, 2009 at 10:13 pm

Bob, I think we agree on the fundamentals (let's get primary care physicians off the treadmill and spend more time on medicine rather than paperwork). But I'd like to explain a little further why my model is better at covering more patients than concierge practices.
The ideal patient load depends on how many actually need to be seen in the office.
The reason why I can see so many patients is because I'm not bound by the reimbursement system designed by third party payers. My practice partners have found that about 66% of office visits (for patients well known to us) are unnecessary, and can be handled via phone, email, or webcam visit. This unburdens the waiting room, and is dramatically more convenient for all.
If there is a whif of concern, we ask the patient to come in to see us – or we can make a house call.
Let's keep the dialog going – because we all have the same ultimate goal – outstanding, affordable patient care that's convenient and enjoyable for both physician and patient!

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pcb

December 19th, 2009 at 11:13 pm

you guys are splitting hairs.
The key is eliminating the 3rd party payer from the equation, then you and the patient decide what the value of your services is.  See what volume you're comfortable with.  See patients how you want to see them and how they want to be seen.   All the things you can do when you don't have to follow insurance company and govt checklists and protocols to get paid. 
 

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PalMD

December 19th, 2009 at 11:46 pm

Hmm…this "retainer" in a non-concierge setting, while appealing in some ways, sounds a lot like capitation.  

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Alan Dappen

December 20th, 2009 at 5:39 pm

The fundamental problem of primary care is that 95% of patients are “owned” by the insurance companies. Woe to the doctor who drops their preferred provider status.
 
Our experience at DocTalker (a pay-as-you-go practice.)  shows that most people need 3 contact points a year. Two of the three are done through phones and emails and one at the office. The average time required of the physician is an hour.  Total cost for a “concierge level service”  is $300.00/ year for most people  No one is getting rich, and we work 10-12 hour days to pay our bills. We feel our mission is to gain the respect and trust of our patients while at the same time explaining that patients need to be part of the solution for fixing health care and be aware that time is money too
 
Primary care physicians as a whole have failed to take responsibility for re-inventing
themselves into a “force for the good” and win back the consumers trust at a price that is much cheaper than going through insurance,  Until then, most  patients take comfort  in the protection afforded to them through insurance companies over the perceived  predatory pricing habits of doctors and health care system at large.
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In the end doctors medical services  can’t get around the business formula that time is money.  We are trying to give our patients the best service at a price continues our mission. If someone prefers unlimited access for a fixed amount of money, the more power to them. Re-inventing primary care in the end is nothing more than what it takes to bring patients to use our service and to date, the insurance owned patient continues to have all other models beat 10 to 1 no matter how hard we have tried.
 
No matter what method of payment we choose, try we must if primary care is to have a future separate from the insurance task masters who consistently profit off our work while charging the patient (or employers) excessive amounts of money for the service we provide.

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