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Ideas and Opinions |

Concierge Medicine: A “Regular” Physician's Perspective

Michael Stillman, MD
[+] Article and Author Information

From Boston University School of Medicine, Brookline, Massachusetts.


Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2107.

Requests for Single Reprints: Michael Stillman, MD, 209 Harvard Street, Suite 407, Brookline, MA 02446; e-mail, michael.stillman@bmc.org.


Ann Intern Med. 2010;152(6):391-392. doi:10.7326/0003-4819-152-6-201003160-00009
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Concierge medical practices, which advertise expanded access to care and individualized attention, collect charges both from insurance companies and directly from their patients. Some bill hundreds of dollars for one-time “executive” physicals, whereas others have patients pay annual retainer fees. Yet, virtually no data are available about these “luxury” practices. It is not known how many physicians have “turned concierge,” whether they have altered their testing and prescribing patterns, or whether their clinical outcomes are superior to those of their colleagues in traditional practices. Although some have voiced concern that concierge physicians create a 2-tiered system and may contribute to the difficulty that many patients have with access to care, the medical community has largely remained silent on the matter. The mere existence of concierge medicine may reflect our need as physicians to do better by our patients. Yet our responsibility as a professional community is to engage in—not run from—that monumental challenge.

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response to Concierge Medicine Article
Posted on March 20, 2010
James Bowers
Primary Care Partners NW
Conflict of Interest: None Declared

Dr. Stillman misses an important point that needs to be called out. I sense that today's primary care physicians, especially those in direct employment with a hospital or health group, have a "shift mentality", that is they work their 8-5 shift and go home. Concierge doctors fill the need for customers seeking time and access. Also, instead of only coming in to see a doctor when a person has a "complaint", a concierge practice fosters wellness through prevention. I admit I do a better job when I am not rushed from patient to patient in an every 15 minute cycle and get to spend time with patients. Lastly, insurance reimbursement is a travesty. How is it that I bill $75.00 for a visit and only receive back $14.00? Insurance reimbursement needs to change and doctors need direct reimbursement, not the obtuse reimbursement structure that currently exists today.

Conflict of Interest:

None declared

Re:response to Concierge Medicine Article
Posted on March 23, 2010
Lodovico Balducci
Moffitt cancer Center, Tampa, Fl
Conflict of Interest: None Declared

I share the concerns of Dr. Stillman toward concierge medicine. I don't share his surprise, however! American medicine is practiced as a business and perceived as a privilege. Everyday, science that was developed with taxpayer money is translated into medications of minimal efficacy and outrageous profit. Palotrexate cost $400000.00 for 8 months treatment and the benefit consist in the prolongation of the median survival of a few months of 28% of patients with cutaneous T cell lymphoma. What is insulting is that fact that this drug has never been proven superior to its congener methotrexate that costs just penny! Thanks to the complicity of physicians who made big bucks by declaring that it would have been malpractice to use estrogen in metastatic prostate cancer, LHRH analogs have become the most common treatment of this condition since 1984. They cost 1000 times more than estrogen and unlike estrogen they cause loss of libido, osteoporosis, diabetes and heart attack. We have enabled to drug and the insurance industry to sell questionable products at enflated price, we have promoted as life saving practices that have cost a lot of lives and whealth and have enriched some specialist, such us PSA screening for prostate cancer. Why should we be surprised if some colleagues decided it was time for us to share the loot?

Conflict of Interest:

speaker for AMGEN, Novartis and Cephalon

Concierge medicine
Posted on March 25, 2010
Mary Zwelling-Aamot
President, American Academy of Private Physicians
Conflict of Interest: None Declared

Thank you to Dr. Michael Stillman, for a reasoned article about concierge medicine. His questions about validating that those of us who enjoy the opportunity to work more directly for our patients actually results in better quality care at a lower overall cost are just and appropriate. We believe that that is correct. There is some literature to suggest that that is the case. Back in 2006, Wasson, Johnson, et al. published in the Journal of Ambulatory Care Management, that collaborative care, a centerpiece of direct care, was associated with better blood pressure management, blood glucose level, serum cholesterol level as well as better pain control and better control of emotional issues. The American Academy of Private Physicians are in the process of initiating a study that will prove conclusively that spending more time with our patients and being available 24/7 does make a difference in the quality of care we offer. That said, I do want to make a single criticism of the valid challenge that Dr. Stillman has set up. He assumes (as do many) that quality care is about meeting a set of established best practices. I believe that quality of care is about providing our patients with that better, more productive day. Sometimes, that means understanding your patients real question, his or her level of anxiety and worry, or the fact that they value their time very highly. Dr. Stillman has established that he takes good care of his patients and he cares about them deeply. But, patients, as humans, have other ill-defined needs that must be addressed in order for them to be productive and in control of their lives. Direct practice physicians are better able to meet that need because they have established the time to make that happen. It has already been proven that P4P and other paper based controls and initiatives are time consuming and do not offer the value based opportunity government and other administrative authorities had hoped for. Quality of care analyses belong to our patients not to administrators. Direct practice physicians hope to take back the profession by re-establishing that the patient-doctor relationship is the cornerstone of quality and affordable care. Finally, please do NOT assume that our patients are wealthy. They are not all wealthy. Those choosing to pay for their care directly make a value based decision about their healthcare. Some of my patients have chosen to purchase my time and dedication in lieu of vacations or new cars; 10% of my patients do not pay me one dime. They receive care in exchange for offering their time at a charitable organization in the community. America's patients have the right of self determination regardless of the size of their bank account. That, after all, is the American opportunity. This is not an insurance issue, or a government obligation. America's doctors should seize the moment to work directly for their patients. The self-respect that it offers both patients and doctors could be the substance the country is looking for to climb out of the doldrums and distrust we have found ourselves in over the last decade.

Conflict of Interest:

None declared

A "Regular" Physician's Perspective
Posted on March 30, 2010
Harry M. Walen
No Affiliation
Conflict of Interest: None Declared

Dear Editor: I read Dr. Stillmans perspective article cited above with concern. He asserted that very little is known about such "luxury" practices and cites "well written" articles that question the ethics of those who provide such services (1). An investigation of the subject reveals data that demands a very different opinion.

A statistical analysis by Applied Quantitative Sciences has shown that Medicare beneficiaries in such practices experience only 56.4% as many hospitalizations as matched non-participating Medicare beneficiaries, and commercially insured patients aged 25 to 65 experienced 61.5% fewer hospitalizations. The total savings to the country if all 36 million Medicare patients were in such a program would be about $54 billion. Add to this the savings from the 25 to 65 year old population, and the savings would be vast. Such savings repay the public moneys spent on training internists many times over.

In addition, Dr. Stillman confused practices which provide for pre- paid preventive care evaluations with practices that use retainers. Personalized care contracts provide for preventive care screening and health maintenance planning that is not covered by Medicare or most commercial contracts. The improved physician availability found in perosnalized care practices is a byproduct of contracting physicians electing to keep their practices small so that they can do their job well.

Dr. Stillman is correct in asserting that "Patients deserve and desire our fullest attention and consideration." And it is worth remembering that Sir William Osler declared that a physician could only see four patients a day if their work was to be done well. "Regular" physicians currently allocate 10 to 12 minutes per visit. This is certainly not what Osler had in mind.

Finally, Dr. Stillman asserts that the patients in such practices are rich. In fact, the tax adjusted cost of membership is about the same as maintaining a cell phone, about $85.00 a month. In my practice few are rich. Some are retired school teachers, others office clerks, some are bus drivers. When the facts of this matter are well reviewed, the conclusions drawn by Dr. Stillman must change.

Reference

1. Michael Stillman Concierge Medicine: A "Regular" Physician's Perspective Ann Intern Med 2010; 152: 391-392

Conflict of Interest:

None declared

What patients want vs. what we think they need
Posted on April 1, 2010
Robert A. Swerlick
Emory University
Conflict of Interest: None Declared

I too want to thank Dr. Stillman for his thoughtful piece on concierge medicine. However, I too believe that his perspective on this phenomena is colored by assumptions and biases which may not be valid. The first assumption is that it is his role as a physician to deliver to patients what he or some other third party deems what that particular patient needs as opposed to what the patient wants. While these different goals ideally are in alignment, more often than not they diverge. It is unfortunate that the present payment system has created bizarre incentives which foster overconsumption of often useless or even dangerous medical interventions and actions. This can used as a justification for inserting physicians as gatekeepers to prevent patients from obtaining what they want. However, we should not forget we are basically in a service industry and ideally our focus should be to facilitate patients reaching their, not our goals.

Dr. Stillman may not understand that concierge medicine is growing because it serves to deliver what amounts to be a service not covered by insurance, time and access to physicians when patients want time and access, not necessarily when they need time and access. Who are we to say that those with financial resources should not be able to contract with physicians to purchase what insurance will not pay for?

Conflict of Interest:

None declared

Response to Dr. Stillman, a "regular" physician
Posted on April 5, 2010
Robert P. Fields, M.D., FACP
None
Conflict of Interest: None Declared

As a general internist who practiced in a "regular" group practice for 15 years, and since 2003 in an independently-designed retainer practice, I feel both qualified and compelled to respond to Dr. Michael Stillman's Perspective essay.

I do not collect or accept any money from any insurance company or the government. This simple decision removes ethical or contractual concerns about "double dipping", eliminates the immense complexities and headaches of billing, and eliminates most of my paperwork. While I voluntarily surrender that insurance money, I am also freed of their rules and restrictions, thus simplifying my life immeasurably.

By taking an hour or more with most of my patient visits, and accepting their phone calls and e-mails, I am confident that I actually order fewer of the expensive tests Dr. Stillman refers to than do physicians who just have a few minutes with each patient. Also, each patient I see at their home (about 100 per year)instead of in a costly and over-burdened E.R. keeps patients and their families from waiting hours to see a doctor they don't know, and may order costly tests they may not need.

Contrary to the most common criticism, retainer practices need not only select for wealthy patients. I have patients from every walk of life who have chosen my practice, and 99% of them renew each year. At $29 per week, they are people who value our relationship and their medical care as much as they value their cable TV service and their cell phone contract. I reserve 15% of my spaces for patients whom I charge a reduced fee or none at all, based on their ability to pay. I also have the time now to volunteer at a community clinic several times a month, which I could not do before.

General internal medicine is critically ill, but I believe that lower salaries aren't the only reason. It is time-consuming and demoralizing to fight insurance companies every day for our patients' welfare. And, from an ethical standpoint, I would remind that money is not purified by first passing through an insurance company.

Dr. Stillman suggests that doctors who leave the current "system" are abandoning their patients. But unhappy internists will leave clinical medicine or retire early, and are doing so in record numbers. The future of internal medicine does not lie in an ever-dwindling number of increasingly dissatisfied doctors. It is only by transforming our field to one that medical students see as enjoyable that we will attract sufficient quantities of the best students to keep our specialty viable and in that way continue to serve our patients.

Conflict of Interest:

None declared

Critique of "Concierge" Medicine
Posted on April 14, 2010
Christine Harter
Internal Medicine and Headache Care
Conflict of Interest: None Declared

In response to Dr. Stillman's critique of "concierge" medicine:

I, too, am still a "regular" physician, in full-time primary care medicine and part-time focus on a time-consuming area of medicine, namely headache medicine. Yet I do not presume to decide for other physicians how they should run their practices, and I am glad that there is still a "neutrality" in the medical community about these practices. What are we to do, legislate them out of existence? Shall we then also legislate how many physicians can or cannot go into a lucrative field such as cosmetic surgery or cosmetic dermatology?

And there is a whole breadth of practices that could be referred to as "concierge" practices, some charging thousands of dollars, but others just charging a $50 annual fee to help cover their uncompensated administrative costs. This kind of fee may be the difference between a primary care physician remaining in primary care, or sometimes quitting medicine and going into a different business altogether. Some of these physicians may be earning enough to do a fair amount of volunteer or pro bono work, that the lawyers often do but maybe that's because they don't always have third parties and government deciding what their pay should be. And many of the patient may not be wealthy; they may just be wanting to pay extra for what they perceive as value added. Certainly if there are longer appointment times, that is value added. Again, who has the right to decide what the patients should or shouldn't do?

Let's live and let live, and continue the neutrality which Dr. Stillman derides.

Conflict of Interest:

None declared

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