An interview with Christopher Ewin, MD, President and Founder of 121MD in Fort Worth, Texas, Elmer G. Pinzon, MD, MPH, Medical Director at University Spine & Sports Specialists, Knoxville, Tennessee, and Michael Tetreault, Editor-in-Chief of Concierge Medicine Today _and T_he Direct Primary Care Journal.
Q: What is concierge medicine and what are the varying types of concierge medicine business models that are in use?
Dr. Pinzon: Concierge medicine is an emerging form of practice in which private health professionals are expanding out beyond the fixed insurance model of medicine. Because of the restrictive nature of insurance companies, these companies are not always able to cover newer, more novel approaches that are not considered mainstream medicine. It can take a long time for research to be recognized and covered by health insurance companies; some patients don’t want to wait that long.
Concierge medicine models allow patients to pursue other options that their insurance plans will not cover—such as regenerative medicine, prolotherapy, acupuncture, and nutritional approaches.
I practice musculoskeletal medicine and physical medicine and rehabilitation, and have patients who are willing to pay for certain procedures not covered by their insurance, such as interventional spine procedures and ultrasound-guided musculoskeletal injections in the knee, shoulder, and other joints. I am able to incorporate these interventions into my practice using concierge medicine.
In addition to physician-based models, psychological, nutritional, and exercise-based models of concierge medicine exist. Or you can have a practice that offers a continuum of models.
Mr. Tetreault: Although concierge medicine started out as a concept for the affluent nearly 20 years ago, over time, the movement has taken a clearly middle-class turn. Today, we can see impressions of old-fashioned medical care, in which a doctor will see you the same day you make an appointment, no questions asked, or carries a medical bag into your home, or even visits you when you’re in the hospital because … it’s simply the best way to provide care for the patient at that time.
Moreover, there are more people searching for these types of doctors every day. From the mid 1990s to present day, concierge medicine has matured into countless service variations within our local communities. Annual fees today reflect the level of personal attention and service that a doctor provides, and patients are deciding to make a personal investment in their own health care.
The overwhelming benefits of concierge medicine can be summed up in 2 words: time and transparency. Concierge medicine typically is understood to be a transparent, cost-
effective relationship between a patient and physician in which the patient pays an annual fee or retainer. All concierge doctors generally claim to be accessible via telephone or email at any time of day or night or offer some other service above and beyond customary care. While all concierge medicine practices share similarities, they vary widely in their service offerings, payment requirements, costs and forms of operation.
It is estimated that there are between 6,000 and 12,000 concierge medicine doctors operating in primary care, family medicine, and specialty practices across the country, according to surveys conducted by Concierge Medicine Today. Their surveys show that annual fees at most concierge medicine practices vary nationally from $101 to $225 per month, but fees usually are billed annually.
Although many concierge doctors also accept and/or participate in insurance and/or Medicare, concierge medicine fees are for services that are not covered by Medicare or patients’ insurance. What also is fundamental to the various clinics operating a concierge medicine practice across the country is that patients decide to make a personal investment in their own health care. This is a relationship-based service, not a transactional service.
Q: Which patients are best served under the concierge medicine model of care?
Dr. Pinzon: It really depends. The majority of patients in my practice under the concierge medicine plan tend to be more demanding in terms of their type of care. They understand that their private insurance companies are not going to cover the services they want, and they are tired of fighting their insurance companies to obtain services.
It may take weeks, and in some cases months, to get a response from insurance companies on whether a service is covered. And in some cases, we know that an insurance company is not going to approve coverage because the service is not included in evidence-based guidelines. So we offer patients another way to receive those non-covered services.
Mr. Tetreault: Concierge medicine patients tend to skew upper middle class, with typical household earnings between $125,000 and $250,000 per year (Table). They also tend to be Baby Boomers, generally in their 50s to 80s. From a psychology perspective, this age group makes buying decisions based on brand loyalty and brand enhancement. They want to know that that doctor is up-to-date on the current research and current tests, and strives to help his or her patients be healthier.
Q: When did you start offering concierge medicine and how has it benefitted your practice?
Dr. Ewin: I do not consider my practice a concierge practice. I consider it a direct primary care (DPC) practice, whereby I work for my patients and not for the insurance companies. I started my DPC practice in January 2003. Previously, I had more than 4,000 patients—today that number has dropped to 400 patients. The benefit has been being able to spend more time with my patients and really listening. I consider my patients to be like family and I have more time to care for their needs. I am practicing old-school family medicine, which is why I became a physician. More importantly, it’s all about the patient. They benefit by having timely access to care with their trusted physician.
Dr. Pinzon: I have been in private practice since 2008. The practice I worked for prior to that was an orthopedic multispecialty-type practice, where some of the younger orthopedists started offering concierge medicine options. I got the idea from these orthopedists, and over the past 5 years started dabbling into the concierge medicine option in my own private practice.
Q: How does payment provided under concierge medicine plans work in your office?
Dr. Ewin: I use a fee-for-care model—no private insurance. I am on retainer and have regular office hours like any family practice. For a monthly fee, patients are given prompt access to office-based services and telephone conferences. After hours, people can contact me if their needs are urgent.
There is no copay for in-office services, and we do not bill health insurance companies or Medicare. There is no charge for in-office lab work, but out-of-office charges provided by laboratories, radiology, specialists, or during hospitalizations are the responsibility of the patient.
Since my practice is smaller, I have more time to care for patients with opioid addictions. DPC practices are in a unique position to care for these patients.
About 5 years ago, after getting my certification to prescribe Suboxone (buprenorphine), I started an addiction clinic, focusing only on patients who wanted to get off opioids, buprenorphine, and methadone. Initially, I took care of patients with chronic pain who were stable on buprenorphine. However, it was difficult to focus only on their opioid addiction, particularly if I took them into my DPC practice as their family physician.
Now, I only take patients who are serious about getting off opioids. I start them on the lowest dose tolerated, so they can function and work. We have small group meetings every 2 weeks (with drug screening) at which time they tell me what dose they would like to be on. Patients wean themselves off buprenorphine and set their own sober date. It puts control in their hands. I give them a 2-week supply of medication at a time and medicines to help with the withdrawal symptoms. After they have weaned off buprenorphine (sober date), if they choose, they continue attending group meetings, and we consider treating with naltrexone to decrease their urge of relapsing.
This is a fee-for-service model that works well for this clinic. These patients are not part of my regular DPC practice and are requested to seek another health care provider for primary care services and other health care needs. This clinic is less expensive than a rehabilitation facility and allows patients to receive care without having to leave their jobs or families.
For those interested in treating opioid addiction, DPC models offer a great way to care for a population in real need.
Dr. Pinzon: My model of concierge medicine has not completely matured. Less than 5% of my practice is involved in the concierge medicine plan, under which patients are given access to care 24 hours per day, 7 days per week. A triage nurse is available to take more routine calls and patients with more complicated questions can call me directly.
Under this model of care, patients pay a certain fee, depending on the services they are looking for. In my format, payment is either semi-annual or annual. Other practitioners may take payments on a monthly basis.
For patients who pay upfront, perhaps using money from a settlement they received through a workers’ compensation case, I offer a 20% discount and charge what Medicare would typically pay for a similar service.
Q: What would you say to critics who might consider concierge medicine as a model that favors the wealthy? Or that concierge physicians see fewer patients and this further compounds the issue of doctor shortages now and in the future?
Dr. Pinzon: I still take insurance in my practice, including Medicare. But there is a select population of physicians who only practice using concierge medicine, and they cater to patients who want certain services and more time with their health care provider. This doesn’t mean that physicians who practice concierge medicine are excluding patients. Instead, they are providing a higher level of service to patients whose conditions demand more time or who need more expertise.
I think concierge medicine has spun off as a result of how insurance companies have started to dictate how physicians and medical providers are able to practice medicine. My father was a physician, and when he first got into medicine, he spent as much time as he could with a patient. Everybody knew him, and he became a member of the family and provided great service. As times have changed, patients sometimes have felt that there is a deficit of medical care, and some are willing to pay for extra time with their physician or for extra services not covered by health insurance.
Mr. Tetreault: That is a common misconception. Anything new to the marketplace is expensive at first. Whereas concierge medicine was expensive 20 years ago, it has evolved and is now much more affordable. Most annual fees range, on average, between $1,200 and $2,500 per year. Couple that with a health savings account or high deductible health plan, and some patients are seeing anywhere from a 13% to a 17% savings compared to what they paid for general health care insurance in the year prior.
In addition, 54% of concierge medicine physicians who participated in our survey accept health insurance and/or Medicare. Insurance acceptance (most), transparent cost savings features, and a relationship-driven business model removes much of the skepticism many people have about concierge medicine.
Q: How can health care providers obtain more information about offering concierge medicine?
Dr. Ewin: Direct Primary Care (www.dpcare.org) is the organization of direct primary care practices. They give great information on active legislative reforms being proposed nationally. Concierge Medicine Today (www.conciergemedicinetoday.org) and the Direct Primary Care Journal (www.directprimarycarejournal) are excellent resources.
The AAPP (American Academy of Private Physicians) is the founding organization for concierge medicine. (www.aapp.org). They are inconclusive of many different innovative practices, including DPC and concierge medicine. They have meetings that are instructional in how to get started, as well as online and print resources.