Simone, Joseph V. MD
A few weeks ago, I had an annual check-up by my personal internist. He and his office staff were thorough, efficient, and friendly as usual, but at the end of our medical discussion he said he wanted to notify me that he was changing his practice. After “hyperventilating over this” for months, he decided he would convert it to a “concierge practice.” He said his partners had already made the change and he now would follow.
He said he and his partners felt they no longer could practice the kind of medicine they desired under current conditions. They had taken on more patients and had spent less and less time per patient in the face of declining reimbursement in order to pay the bills. He also didn't like the idea of handing off the after-hours calls to “someone you don't know.”
He said he had 2,500 patients in his personal practice and he found himself rushing through visits just to finish. They had hired two new physicians in the past year but had to let them go because they didn't want to work the same schedule as he did.
He described his new “concierge practice” as follows. He (via a company that arranges these changeovers, MDVIP) would notify all his patients of this pending change and invite them to an explanatory presentation. The gist of the new practice is that he will have only 600 patients who are each willing to pay him an upfront fee of $1500 per year, in addition to his regular fees. He will not pre-select the patients; they will be the first 600 who sign up.
In this model, he will schedule more time for each patient; spend more time on prevention, health promotion, and counseling; become more involved in overseeing care given by subspecialists; and will “always” be available by phone or pager.
My wife and I both are under his care and when I brought the news home, her reaction was instantaneous—“He is an excellent doctor, takes good care of me, keeps me well informed, and I trust him. We fully discuss suggested treatments and he always values my preferences. Also, I don't want to start all over with a new internist. I will be the first to sign up.”
Although I agreed completely with her assessment of his talents, my response was more measured. I trust him, but something about this didn't sit quite right, and I wasn't sure what it was. So I did some thinking.
I was curious about the finances. First, only people able to pay the annual $1500 fee could sign up. Second, his practice is in a relatively affluent area, so it was a safe bet on his part that he would get his 600 patients.
Third, $1500 times 600 equals $900,000. Let's say the transition company takes 30% of the upfront fee (I am guessing), that leaves $600,000. Overhead costs of 60% would leave $240,000 in personal income before the collection of ordinary fees. In addition, reducing the practice by 75% would certainly lead to a similar reduction in staff and other overhead costs (the whole practice would be reduced to 1800 patients from 7500).
Fourth, I don't know what my internist's personal income has been, but a 2005 survey of the annual personal income of busy, mid-career general internists in my area is a median of $176,000 and a 75th percentile of $210,000 after overhead expenses.
I can't say what a “fair” income is for any particular physician and I have no data on other factors that may influence his actual bottom line.
I do believe my doctor made this change for the right reason: so he can deliver better, more satisfying care at a more personal and less hectic pace. And like it or not, we live in a strongly capitalist society with all its strengths and weaknesses.
Economists would say that as long as the playing field is level, the buyers (my wife and I in this case) have reasonable alternative options, and there is no monopoly, there should be no complaint, at least from a business point of view.
And concierge medicine is indeed big business (see www.MDVIP.com). For an annual fee, MDVIP and other companies manage the transition and market the concept. With a whole new source of financing uncovered, can Wall Street be far behind?
Then I stepped back and tried to depersonalize the issue. I realized that my little episode is taking place in the much larger arena of American medicine, which is facing seismic forces that have been developing for some time. Here is a sample of these trends that I believe are linked to one another, and to my episode.
More recent medical graduates don't want to work the long hours that once were the rule. They want a different lifestyle with more leisure and family time, less night call, less hospital rounding.
Furthermore, fewer and fewer medical graduates are going into primary care practice. A study published in the May 2005 issue of Academic Medicine reported that in 2003 only 27% of residents had chosen careers in primary medicine and only 19% of medical school juniors said they would become primary care doctors; both numbers are much lower than in the past.
Patients are being asked to take greater and greater responsibility for their care. Some of this is good, too much is not. It has been a mantra of patients and advocacy groups that patients need more information; doctors, pharmaceutical companies, and the Internet have responded with a tsunami of information.
The problem is that patients not trained in medicine (or even if they are) may have a very difficult time sifting out the chaff or even choosing from among the often confusing “good” choices.
Figure. Joseph V. Si...Image Tools
Referral to sub-specialists (which patients often demand or seek out independently) is far more common today, after which the primary care doctor may become disconnected from his patient. It is often up to the patient to maintain contact with the internist. This trend has, in many cases, put more distance between doctor and patient.
A front-page article in the New York Times last month (Sunday 8/14/05) describes this dilemma in graphic detail. With case studies it points out that patients want more say in their management, but the handoff of decisions from doctor to patient may be clumsy and second opinions may simply confuse matters and put even more pressure on the patient.
As the author, Jan Hoffman, explained when a patient insisted on staying with her doctor despite less than ideal results for her difficult problem, “It is impossible to overestimate the bracing impact of that old-fashioned guide, the doctor who can be a patient's constant, her polestar.”
This shift of responsibility is engrained and growing. Patients test their own blood sugar and take their own blood pressure, and many make difficult decisions without confident advice from their doctor, without an “old-fashioned guide.”
Some blame the risk of litigation for this shift; I think that is a very small part of larger social changes, especially patients morphing into consumers, the changing lifestyle and professional expectations of practicing physicians, and the declining reimbursement for cognitive and psychological services compared with technical procedures.
Although most physicians do quite well financially, the rising cost of health care and the reaction of payers and employers have gradually squeezed their incomes—primary care doctors the most.
They have no lucrative technical services to offer or chemotherapy to resell, so they are almost totally dependent for income on the traditional services of examination, assessment, and management.
From many payers, and especially Medicare and Medicaid, that payment is totally inadequate for the time, angst, and intellectual and emotional capital required to do the job well. This has caused physicians to see more patients to maintain staff and income.
Also, today's Byzantine billing systems require a large staff to manage the paperwork and causes endless frustration in today's practices.
And, frankly, most doctors are poor businesspeople (maybe “disinterested” is a better term), so they are attracted to simplified models like concierge medicine.
Thus far, concierge medicine has been limited mainly to primary care medicine. But there are other examples that have long operated on the same principle of an upfront premium cash payment from patients: cosmetic surgery; VIP suites in famous medical centers; and in some cases, bone marrow and organ transplantation.
The potential scale of the current movement is, however, far greater because the per capita entry fee is within the reach of many more people.
Few Answers, Many Questions
After this long rumination, I am left with few answers and many questions. Who will take care of the 1900 patients my doctor will no longer care for? And the other 3800 patients his partners have already shed?
Was my doctor's “hyperventilating” and apologetic demeanor an indication that he sensed that something wasn't right about it? Were his hesitancy and my own unease arising from the same place? Was it something in our medical training or the quiet nagging of the idealism most of us still have?
“Is this just another adaptation of medical practice, as from horse and buggy to automobile, or office microscope to an efficient and cost-effective for-profit lab? Or is concierge medicine another sign of the increasing industrialization of medical care, the patient becoming like just another consumer buying a car? And if so, is that also a sign of the erosion of a proud and noble professional ethic?”
© 2005 Lippincott Williams & Wilkins, Inc.