Article In Brief
Neurologists who run concierge practices say the business models can be financially risky and require business management skills not acquired in medical school. But they also give neurologists autonomy and a level of patient interaction that they enjoy.
After a decade in academic neurology, Hope O'Brien, MD, MBA, FAAN, wanted a different kind of practice.
“I was not spending as much time as I thought was needed to address the needs of patients,” she said. “When my patients needed ancillary services like massage therapy and IV therapy, I would refer them away. And when you're having a bad headache, the last thing you want to do is hop around from place to place to place.”
In June 2021, she moved toward a concierge model of neurology when she launched Headache Center of Hope in Cincinnati. Her patients pay out-of-pocket for the services they receive.
“We see very good outcomes because I'm able to spend the time and educate my patients,” she said. “They understand their condition, so they have fewer questions when they get home. And they know that they can come back to see me at their convenience because I have a small panel of patients, so they are not waiting months and months for an appointment.”
Neurologists who run concierge practices say the business models can be financially risky and require business management skills not acquired in medical school. But they also give neurologists autonomy and a level of patient interaction that they enjoy. General neurologist Dhrupad Joshi, DO, was employed in an academic practice before starting his concierge neurology practice three years ago, and he appreciates the freedom of self-employment. “I have full control of how I see my patients, how much time I want to spend with them, and what kind of services I can offer,” he said. “It is much more rewarding.”
Concierge Medicine in Brief
While still unusual, concierge practices in medical specialties are becoming more common around the country. Physicians use the term “concierge” in different ways, but all concierge practices share one commonality: patients pay out of pocket for access to neurology care.
How that works depends on the practice. Terry Bauer, CEO of SpecialDocs Consultants, a service provider for concierge practices, describes two types of membership models:
- The concierge model, in which patients pay an annual fee and the physician remains in network with Medicare and other private payers.
- The direct primary care model, in which patients pay for a membership and then out of pocket for the services they receive because the physician does not participate in Medicare or other insurance plans.
Beyond that, some concierge practices do not charge a membership fee; patients pay a la carte for the services they receive.
Bauer estimates about 20,000 physicians are participating in one of the membership models. Membership fees vary, but the average fee across the country is $2,250.
The business model is appropriate for specialists who have an ongoing relationship with their patients over many years, such as internal medicine, family practice, pulmonology, endocrinology and rheumatology, he said. It does not work for surgeons and other physicians who typically treat patients for a discrete period of time.
“In neurology, there are certain medical conditions that would work well in a concierge model—Parkinson's or migraine management, for example—because there is a continuous relationship between the patient and the doctor,” Bauer said. “And the doctor in a traditional fee-for-service model can't spend the time that that patient needs to help them with their condition.”
Other success factors include the physician's location—those working in rural or low-income areas will have difficulty recruiting enough patients to make the business work—and the physician's reputation with patients.
“It's got to be the right doctor in the right market with the right specialty,” Bauer said. “By ‘right doctor,’ I mean a doctor who has the interpersonal skills, emotional intelligence, communication skills, and the like to succeed.”
When a physician asks his company for help, he checks out the individual's online reviews. “If reviews say, ‘This doctor is unqualified, doesn't communicate well, doesn't seem to really care about the patient, doesn't listen,’ those are all red flags,” he said.
Headache Medicine, A La Carte
Dr. O'Brien's was frustrated by the fact that when patients asked how much a recommended treatment would cost, she did not know, had trouble finding out, and found inconsistent price information.
At Headache Center of Hope, patients pay out of pocket for office visits, Botox injections, nerve blocks, IV therapy, acupuncture, and other services, the prices of which are posted on the practice's website. For example, an initial consultation—60 minutes plus one follow-up—costs $575, a nerve block for headache pain costs $295, and a 60-minute acupuncture session costs $110.
Although she does not contract with insurance companies, Dr. O'Brien and her staff still interact with insurers because obtaining prior authorizations—needed if patients choose to file their own insurance claims—is part of the service they offer.
To prepare to open her own business, Dr. O'Brien completed an executive MBA. She had no referral base, so she networked to get to know other providers. “When I went out on my own, I really had to market myself,” she said. “Patients find neurologists through their internists or other providers and through word-of-mouth. So I have to do a good job taking care of patients so they tell other people about the services they received.”
Two years after striking out on her own, Dr. O'Brien is happy with her decision. “I get to come to work in a place that's very soothing and where the culture is positive,” she said. “I get to hand-pick the people I work with, so I get to create that culture, and my patients feel that positivity.”
General Neurology, Direct Pay
After nearly two decades in a traditional neurology practice, Peter McAllister, MD, FAAN, became fed up with the documentation burden and pay rates he had no control over. “We were seeing more and more patients; the idea was just to row the boat faster and try to bring in income,” he said. “It didn't seem sustainable, and as I saw more patients per day, I had less and less quality time with them.”
In 2014, he co-founded the New England Institute for Neurology and Headache (NEINH) and a sister organization, the New England Institute for Clinical Research, in Stamford, CT.
The clinic now has a staff of 10, including Dr. McAllister and another neurologist; it also works with a network of therapists. “I wanted to have a group of the best professionals that overlap with neurology working with me, so we have physical therapy, occupational and speech therapy,” he said. “We have therapeutic massage, psychologists, a ketamine infusion program, and trauma therapists because (post-traumatic stress disorder) overlaps so much with chronic neurological conditions.”
The majority of his patients pay out of pocket for the services they receive. For example, a standard consult visit costs $645, and follow-up visits are $265. A therapeutic botulinum toxin injection is $195, and a lumbar puncture costs $395. They receive a receipt they can submit to their insurance company.
About 20 percent of his patients prefer to pay a $4,500 annual fee that gives them guaranteed same-day appointments and up to 10 services in a given year. “So they could see me three times, get two massages, see our nutritionist, work with the occupational therapist on something—whatever they want,” he said.
All Dr. McAllister's patients get his work email address—a less frustrating way to communicate than going through a patient portal or leaving a phone message asking for a nurse to call. “Being able to email me in a few days to let me know how a med change is going gives them the confidence to do what I want them to do,” he said.
In fact, he believes the extra time he spends with patients and the fact they are paying out of pocket increases his patients' compliance with treatment regimens. “I have found, since I've been doing this for nine-plus years, my patients listen to me more in this model than an insurance-based model,” he said. “I suspect that when you have skin in the game, you're more likely to say, ‘I paid for this. I'm going do what this guy says.’”
Dr. McAllister typically sees patients three and a half to four days a week, with 10 to 16 appointments per day. While his no-insurance business model has worked out well, Dr. McAllister said it requires a mindset that might be unfamiliar to most neurology subspecialists. He is typically booked out three to four weeks, but getting there requires being highly visible.
“You have to promote yourself,” he said. “Early on, I gave lectures at the local YMCA or library and did radio interviews. For a while, I was the go-to neurologist for a local television station.”
Limiting yourself to a subspecialty means limiting your potential patient base, so Dr. McAllister casts a wider net than when he was in a traditional practice. He practices general neurology and, having had training in pediatric neurology, he sees patients as young as 6 years old. About a third of the clinic's patients are pediatric.
More broadly, starting and running a business requires skills and experience, such as negotiating leases and setting up payment systems, that most neurologists do not have. Dr. McAllister co-founded his practice with a long-time administrative colleague from his previous practice, who now serves as CEO of both NEINH and the clinical research company.
“You have to have either some business sense or partner with someone who has some business sense,” he said.
Movement Disorders, Insurance Plus
When her employer, a research and clinical center for Parkinson's disease, closed during the pandemic, Kristin Andruska, MD, seized the opportunity to reinvent her professional life. In 2020, she opened California Movement Disorders Center, a Bay-area practice with offices in Mountain View and Los Gatos.
Patient appointments are booked for at least an hour. “I never feel rushed, like I'm either buried in the computer or like I've got one hand on the door because there are several patients in the waiting room,” Dr. Andruska said.
Indeed, patients typically will only see one other person other than Dr. Andruska—an office manager who escorts them to the exam room.
“Then I come in, take their blood pressure, talk about any changes in medication, and continue with the appointment,” she said. “We like to think of our practice as an old-fashioned model where you just see the doctor and there's not a lot of levels in between.”
Her work is supported by a nurse, who often works remotely triaging patient questions, and arranges appointments with physical, speech, or other therapists, which patients pay for separately.
Dr. Andruska refers to her practice as a concierge/personalized care practice. She contracts with many insurance companies, and her patients pay an annual membership fee. That allows her to have fewer patients, which makes it easier for her patients to schedule appointments; to provide longer appointments than insurers will pay for; and to provide educational programs on topics ranging from sleep and exercise to updates on movement disorders, emerging therapeutics, and clinical research. “For some, I bring in experts like other physicians or physical therapists, and some I provide personally,” she said.
Her practice participates in Medicare and commercial insurance plans. “It can be onerous for patients to submit their own claims for covered services because insurers deny so many claims out of hand, especially when patients submit them,” she said. “By submitting claims on the patient's behalf, we can streamline the process and hopefully make it easier for patients while still providing really good care.”
Dr. Andruska declined to reveal the annual concierge fee, but she set it after speaking with other specialty concierge physicians in Silicon Valley. “I wanted the clinic to be as accessible to as many patients as possible,” she said. “My fee might be different than someone in a different part of the country, but it's very commensurate with subspecialists in my area and less than many.”
She believes patients are willing to pay the membership fee because they value the amount of time she spends with them.
“They can come back and see me as often as they want whether insurance deems it necessary or not, and I'm available to pick up the phone to answer their questions,” she said.
Because of that, patients in a concierge practice typically have fewer trips to urgent care clinics and emergency departments. But the biggest benefit to her patients is also what Dr. Andruska likes most about her practice model: an ongoing relationship that supports them as their disease progresses. Patients who join her practice often express frustration at having been treated by multiple neurologists in the past.
“They want a consistent, knowledgeable, supportive presence in their journey,” she said. “When I get to know patients and their families really well, it helps me guide our medical decision-making over time because I know what their values and their preferences are.
“Anticipatory guidance is really important in conditions that evolve over time, and with longer visits, I have time to educate them about what to expect, what to be watching for, and when to let me know about something. Patients really want to trust their doctor, and that trust is built on a relationship that is built over time.”
Dr. Andruska encourages neurologists intrigued by the concierge practice model do a thorough feasibility study. Simply being an excellent neurologist is insufficient for a successful practice.
“The success of any clinic depends on the location and the patient population,” she said.
Most patients and family members are unfamiliar with concierge medicine, so she must educate them about how it works. She schedules an introductory meeting with potential patients so she can describe her experience and how the clinic works as well as answer questions.
Being a business owner with total responsibility for all facets of the business is a sharp contrast to working as an employee of a university or other practice setting. Dr. Andruska likes the entrepreneurial aspect of building her business, but after starting the practice on her own, she engaged Specialdocs Consultants to handle non-clinical functions, such as accounting and membership management, patient outreach, and marketing. “Having done it both ways, I really appreciate the value of having an expert team,” she said.
She believes concierge medicine in neurology and many specialties will continue to grow, but it's not for everybody. “It is risky, and it must fit with the vision, the skill set, and the unique interests of the neurologist,” she said. “The biggest benefit personally is that I'm able to sustain good work-life balance and good work-work balance. For me, that means the ability to participate in clinical research, which is something that is important to me.”
Jennifer Buczyner, MD, is trained in neurophysiology and practiced with an emphasis on neuromuscular diseases, but when she went solo a few years ago, she broadened her practice to focus on the general neurologic needs in her community.
Comprehensive Neurology of the Palm Beaches in Florida is one of more than 50 practices in physician owned First Choice Neurology, the nation's largest neurology group. Dr. Buczyner operated as a traditional practice, treating patients covered by various insurance companies until 2022, when she added membership-based concierge service as an option for her patients.
Patients who pay a $2,500 annual membership fee receive longer comprehensive visits, 24/7 phone access to Dr. Buczyner and her clinical team, and a customized wellness plan. “We provide initial consultations with a nutritionist, social worker, or therapists, and they provide disease-specific information we integrate into the patient's plan,” she said.
The membership fee also includes programming on topics like Parkinson's-specific physical therapy and alternative music classes appropriate for people with Parkinson's, provided by presenters that Dr. Buczyner recruits.
“The concierge aspect isn't for everybody—I'm not going to suggest it for a migraine patient who comes twice a year—but most of my patients who have dementia or Parkinson's need more time because they have a lot of concerns,” she said. “There's a lot of caregiver burden, and caregivers may want a lot more time to help understand things. Those are the types of patients this works really effectively for.”
Certain days on her schedule are left open just for concierge patients, who also are given expedited access to appointments on other days, when needed. Each concierge visit is double the time of a standard patient visit.
“In my traditional practice, a patient who needs dementia follow-up care may not come for four to six months, but in my concierge practice, the patient can say, ‘I would like to see you every month,’” she said.
For Dr. Buczyner, the extra time with concierge patients has reminded her about the aspects of neurology that she loves the most. “This affords me the opportunity to get to know the patients on a very different level,” she said. “I enjoy knowing my patients and their families well enough so that I know how to be helpful to them.”
Although her concierge patients receive a phone number that lets them call at any time, she is not inundated with calls. She finds the vast majority of patients are respectful of her personal time and other responsibilities. “They want to know that if they need you, you're there—that's what it is,” she said.
General Neurology, Concierge, and More
As he was finishing a fellowship in clinical neurophysiology at New York Presbyterian/Weill Cornell Medical Center in 2021, Ashwin Malhotra, MD, was preparing to launch his private practice.
Today, he sees patients in 12 office locations—typically in each office one or two days a month—across New York City plus one in New Jersey. Supported by a back-office staff that operates remotely and a “traveling team” of assistants that accompany him to each office, Dr. Malhotra has a diversified practice that includes both face-to-face and telehealth visits.
His concierge service is for patients seeking a diagnosis and treatment plan or those who need a second opinion and are willing to pay out of pocket. “For the second-opinion cases, usually it's neuromuscular disease or traumatic brain injury-related, where I'm the subspecialist for those,” he said. “Sometimes it's other disease states like Parkinson's disease or multiple sclerosis, where I always refer out. With or without the diagnosis, the fees are for the consultation and review of usually extensive medical records and an exam.”
When necessary, he provides home visits and round-the-clock phone access for his patients. His practice also provides expert opinions to insurance companies evaluating disability or personal-injury claims and treats professional athletes whose injuries are covered by workers' compensation insurance.
When the pandemic hit in 2020, Dhrupad Joshi, DO, launched We-Care Neurology, a cash-only general neurology practice in Riverside, CA. Since then, the practice has evolved so that he treats patients across California as well as Florida, New York, and New Jersey.
“It's 90 percent telemedicine except for patients who live locally—I see them in person,” he said.
Along the way, Dr. Joshi contracted with five insurance companies, so he now sees both insured patients and those who pay out of pocket. Dr. Joshi does not participate in Medicare or Medi-Cal, California's Medicaid program. Rather, he focuses his practice on patients who can afford a membership fee—$50 per month for those who have insurance, and $75 per month for those who pay out of pocket—for unlimited office or virtual visits. The concierge fee also entitles patients to a 15 percent discount on services he provides al a carte, such as electroencephalogram for $350 and Holter monitor for seven days for $225.
“I'm not tailoring to super-rich people,” he said. “I want anyone to be able to afford these services.”
The concierge service provides 24/7 telephone access to Dr. Joshi; same-day or next-day appointments, including on evenings or weekends, if necessary; and visits that last between 30 and 60 minutes.
“We also do handholding for our patients,” Dr. Joshi said. “Yesterday, I had an elderly patient who did not know how to go about finding an MRI center, so my assistant found a place for him and, if needs a referral to a different doctor for another issue, we will make an appointment for him.”
Dr. Joshi has no referral base, but patients find him online.
“I ask for testimonials or reviews from my patients after every appointment, and most of them do write reviews,” he said. “Because of that, I get a lot of patients. All my patients find me by word-of-mouth or online.”