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Why I ‘Went Concierge’ – a Personal Statement
by Dr. David Schroeder
“Going concierge” was not an easy decision. I have been practicing medicine for over thirty years, initially in an academic setting, and for twenty-two years in private practice. By training and inclination I feel extremely responsible for my patients’ health. My relationship with them is a true covenant. However, I also feel that there had to be a better practice model. The past three decades have dramatically transformed the practice of medicine. Internists are now grouped with Family Practitioners, Nurse Practitioners and Physician Assistants as ‘Primary Care providers.’ This group of very different individuals is now responsible for almost all outpatient general medical care. In the hospitals, employed physicians called “Hospitalists” are responsible for much of the in-patient care. This means that the old model of the family doctor managing his or her patients in the hospital is rapidly ending.
Meanwhile, health care costs have risen rapidly. This has been driven in part by advances in medicine — new technologies, major developments in genetics and other areas of basic science and new highly sophisticated drugs. The other drivers, however, are an ever-growing health insurance infrastructure and government health care bureaucracy.
As a result, care models must take into account cost-savings. Physicians, physician groups and hospitals are being given incentives by insurance companies and the government to provide less expensive, but still “high quality” care. Reimbursement is becoming ever more tied to “Population Medicine.” Rates and forms of reimbursement are determined by large studies that statistically demonstrate the cost-effectiveness of treatments, procedures and preventive actions. If individuals require treatments or procedures that do not fall into the “preferred” categories, exceptions are allowed only with extensive justification.
So Why Concierge?
I believe that Concierge Medicine may offer a patient an opportunity to partake of the best medicine has to offer. I also believe that as concierge medicine evolves, it will prove to be a cost effective alternative. These are bold statements, and may not immediately be obvious, but they are not unreasoned.
Patient volume, the time spent with patients, the extent and type of communication all are going to influence outcome. Unfortunately, in most practices, the norm is one to two patients every fifteen minutes. That is simply too busy. There can only be limited communication during the office visit, and the physician cannot reflect adequately and formulate the hypotheses and plans necessary to ensure optimal outcomes. Consequently the office visit is by necessity more formulaic than personal and thoughtful.
The main drivers of increased patient volume are reimbursement from private insurers and Medicare and Medicaid. The reimbursements have not kept up with costs, forcing doctors to take on more patients.
In addition to traditional fee-for-service reimbursement, today’s physicians are also rewarded if achieve certain quality and efficiency measures. The basic problem, however, remains: reimbursement is still volume dependent. The amount of payments received by physicians who perform successfully with respect to quality and efficiency is still based on total numbers of patients.
I am not opposed to cost-effective analysis, and I am a strong believer in evidence-based medicine and support any effort to effectively improve the health of our population. But it seems to me that the actual, day-to-day practice of outpatient medicine is at odds, in many cases, with how we might best become more cost-effective, more informed about what really works, and how we can effectively improve the health of our population.
Concierge Practices, on the other hand, have a limited number of patients. Depending on the amount of the fee concierge patients pay annually, concierge practices range from fifty to six-hundred patients. These practices offer many additional services to those offered in traditional primary care practices, but I think that the most important differences are time spent with patients and more physician access. Extended office visits, more comprehensive and thoughtful annual exams, and telephone and email access “ twenty-four-seven” can make the difference between barely adequate and truly excellent care. Of course, concierge physicians must also have ability, experience and dedication.
Unlike traditional practices where reimbursement is highly dependent on patient volume, in concierge practices, quality determines financial stability. Patients pay a fee directly to the physician, and accordingly expect high level of care in return. That is a powerful incentive.
Because concierge practices limit their number of patients, and because the care they provide must be excellent in order to succeed, concierge practices are uniquely positioned to consistently provide “the best that medicine has to offer.” There are differences in individual practice approaches: some are more holistic, and others offer extra non-medical services, but unless the medicine practiced in these practices is based on good science, it is doubtful they will succeed.
Concierge medicine changes the traditional model. Because patients assume responsibility for direct payment for concierge services, they have new expectations. Quality service is therefore paramount. There is little room for error, but lots of room for making a difference.