We should call it what it is: direct-pay. As in, patients pay their provider directly.
But most of the world, it seems, calls it concierge.
This is a bit of a problem. Clarity of thought, after all, often stems from clarity in language and word choices.
Now that a growing number of providers are choosing to not accept insurance, or are supplementing insurance payments with annual fees (this too, has been called concierge), we need to be able to have clear, serious, and meaningful conversations about what this means and where healthcare, especially primary care, might be going.
(Disclosure: I’m one of those physicians who has decided to not accept insurance, at least for the time being. I have my reasons.)
The term “concierge medicine” interferes with this conversation. It’s overly broad, freighted with overtones, and allows us to conflate all kinds of aspects of healthcare that would be best considered separately. These include:
- How expensive is the care? Concierge has been used to refer to practices that charge primary care subscription fees ranging from $30/month to $25,000/year.
- How does the pay structure correspond to service? Although a “monthly subscription = all the care you want” model is common, we also find fee-for-visit and fee-for-time. And then some practices charge patients both an annual or monthly retainer, plus fee-for-service.
- Is insurance still accepted? According to Wikipedia, concierge medicine includes practices which accept insurance and charge an additional annual fee to cover extra services. Fees at One Medical in SF are $149/yr; at GreenField Health, they range from $120-$756 per year, depending on one’s age. At MDVIP, the membership fee starts at $1500/year.
- What kind of access to the team and to the personal physician is provided? Some practices promise to give patients the doctor’s cell phone number and invite them to call at any hour. Larger practices seem usually offer 24/7 access to the team. Probably few practices are like my consultative practice, which offers good response time during business hours but no after-hours or weekend coverage.
- How individualized is the care? How participatory is it? This is a tricky one, but I think it’s important to at least consider, given everyone’s recent interest in things like personalized care, patient-centered care, person-centered care, and participatory medicine. Just about all the practices labeled “concierge” do offer a more satisfactory patient experience. Whether this equates to individualized care in a way that is meaningful (i.e. correlates to better health outcomes or a better match of care to the patient’s situation/values/preferences) is another story.
In general, it seems to me that the term “concierge medicine” right now is being applied for a few different purposes.
The most concrete purpose is to designate any kind of practice whose fee structure involves something other than solely accepting insurance payments. As noted above, this includes those practices who accept insurance and charge an additional membership fee, as well as practices that don’t accept insurance at all.
Why lump all of this together under one term? Presumably, it’s because there is a presumption of a better “customer service” experience for the patient. After all, the experience in many doctors’ offices remains abysmal: it’s still common to encounter long wait times, rushed visits, and frustrating phone access. Whereas if you are going to ask people to pay you directly, or even pay you an arguably modest $149 annual fee (as One Medical does), you’d better make the experience nice for them.
Still, the diversity of payment models currently encompassed under the term concierge is rather substantial. Which makes the term of little value in describing practices, other than to signal that it’s not “primary-care-as-usual.”
The other purpose of applying the term concierge, as I see it, relates to leveraging the overtones for various purposes. Now, Google’s default dictionary will inform you that concierge is a noun, primary definition being the caretaker of an apartment or small hotel, and secondary definition being “a hotel employee whose job is to assist guests by arranging tours, making theater and restaurant reservations, etc.”
However, I think it’s safe to say that when it comes to medicine, concierge is used as a qualifier that implies luxury, exclusivity, and a focus on catering to the customer’s wants.
For instance, in one of the earliest articles (published in 2002) on PubMed mentioning concierge medicine, the author notes that the media has also described it as “’boutique,’ ‘retainer,’ ‘platinum,’ ‘gold-plated,’ ‘premium,’ ‘old-style,’ ‘Main Street’ and more recently, ‘luxury primary care.'”
These are overtones that presumably are appealing to those patients/customers who are in a position to join the practice. As a patient, who wouldn’t like the idea of getting “extra special care for you!”
But in many arenas, the term seems to be somewhat pejorative. The presumption is often that physicians are restricting their practices in order to improve their income and focus on wealthier patients. Some are troubled by the prospect of worsened inequalities in access to care. Others are alarmed by the thought of physicians having smaller panels and being “less productive,” which could exacerbate the primary care shortage. And many conclude that physicians with “concierge” practices are, in some way, betraying their responsibilities to society.
Consider this excerpt from a 2010 Annals of Internal Medicine commentary, titled “Concierge Medicine: A ‘Regular’ Physician’s Perspective”:
“This being said, physicians who opt out of the current system by expending their energies catering to “patron patients” rather than helping reform a deeply flawed health care system or energizing a beleaguered professional community should reenter the fray. There are patients to be cared for, both wealthy and underprivileged; ideas to be proposed and exchanged; and policymakers to be educated and persuaded. These difficult times call for engagement, not isolation and retreat.”
Now, it’s certainly true that many practices currently described as “concierge” do cater primarily to wealthier patients, and I’m sure that for some physicians, protecting one’s income is an important consideration. (Note: this was not the case for me; my priorities were having a small part-time practice in which I could emphasize phone and email follow-up, and have the freedom to try different technologies and approaches to care. Basically impossible without opting-out; taking Medicare means chasing face-to-face visits and sinking a lot of time into dealing with billing.)
However, as this Business Week article points out, we now have “low-cost concierge medicine” practices charging as little as $30/month for primary care. This is interesting! This is affordable! This is making that reduction in insurance hassle really benefit patients, and policy-makers should be thinking about this.
Also, direct-pay medicine is definitely growing and diversifying (see WSJ article here), in part because the Affordable Care Act allows direct-pay primary to count as ACA-compliant, provided it’s combined with a policy covering catastrophic expenses.
Clearly, if we are to speak meaningfully about the pros and cons of the new practice models that are emerging — and of the reasons that physicians and patients gravitate towards them — the time has come to move beyond the term “concierge.”
Developing new terms for a new era in medicine
How to develop new ways to describe what we might call “non-traditional” models of physician practice (for lack of the new terms we need)?
Although I think it’s fairly straightforward to refer to practices that don’t take insurance as “direct-pay,” we’ll still need to develop additional terms and qualifiers to describe the other factors that I listed earlier in this post. The challenge will be to do so in a way that doesn’t saddle us with unbearably clunky terms.
For instance, should we keep calling direct-pay primary care practices with monthly subscriptions “direct primary care,” as Dave Chase does? Or do we need a term that specifies the monthly subscription, to distinguish them from this primary care practice’s direct-pay fee-for-visit structure?
And how exactly to go about developing a new terminology? Should this be done under the auspices of a professional society? Or will an academic who has developed some expertise in studying these new models step forth with a nice taxonomy?
Last but not least: even if we develop new terms, what to do about the fuzzy terms that are likely to persist in the media and blogosphere?
Although I’d love to see us stop using the term “concierge medicine,” I suspect it will likely stick just the way “Alzheimer’s” remains the term of choice for what should really be called dementia.
Why? Because “concierge medicine” is the term people know, that’s the term that catches their eye. I suspect some writers even like that it might give people a little emotional feeling, such as “extra-special care for you” if you’re trying to appeal to patients, or “those docs who forget their vows and go serve rich people” if you’re in a hand-wringing state of mind.
Furthermore, “concierge medicine” is quite probably the term people Google for and by golly SEO is important because what good is it to write something if no one can find it when they Google?
So. Those of us who would like to speak in terms that are more specific and less freighted have our work cut out for us.
But let’s get to it.
Just because I’ve opted-out of Medicare doesn’t mean I’ve left the fray.
Leslie Kernisan, MD MPH, is a practicing geriatrician, cautious techno-optimist, and enthusiastic caregiver educator. She hopes to someday be surrounded by cool tools and innovations that will make great geriatric care totally doable for all, especially primary care providers and family caregivers. She is a regular THCB contributor, and blogs at Geritech.org and at drkernisan.net.