What should we call it, when doctors decide to not accept with insurance and instead require patients to pay them directly for a healthcare service?
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.
It is good to know that there are more than insurance out there for health care. I am curious for oversea patients who are interested in coming to US for their medical needs, is there any option other than insurance system? for normal health care, treatment, and more cutting edge clinical trials? Is there a database one can search and find out different doctors information? by disease, therapeutic area, and location?
Let’s go back a bit. HMOs and other like programs came about because physicians wanted out of the service business, see the patient, charge for services, collect from patients. They opted, stupidly for someone else doing it for them. Hence the helped this whole fiasco evolve. Now physicians want to set their fees for services and charge and collect directly from patients. So we will see how that goes!
We have used the term “proactive primary care” to direct pay or concierge.
I’m not a fan of “insurance free” because ideally, your insurance would pay for this, like some of the programs offered by ReDirect Health in Phoenix and Physicians Care Direct in Seattle.
Agree that the word “concierge” is a horrible word for the practice of medicine
Below news might help medicine get back to its former professional status?
Great post Leslie. Direct primary care (DPC) sponsored by the employer also requires better terminology. Companies such as Qliance, Paladina Health, Iora Health, R-Health practice directly contract with employer to provide these services at no cost to their members, employees and dependents fees are paid by the employer. Is this really direct?
The weakness with the consumer direct pay model is the financial incentive. Fee for Service resulted in volume incentives and 8 min. A consumer direct pay model will result significant increase in patient satisfaction, but also likely are an increase in total costs with uncertain quality improvements. The employer model works well because their is an accountability for costs and outcomes, not just access, the principle benefit of traditional concierge models.
I like the concept of “low-cost concierge”. More appealing is “no-cost primary care.” Primary care that is covered by insurance/employers and paid directly out of premiums.
“The over utilization of primary care is driving the increase costs of healthcare in America” – said no one.
Your point about DPC paid for by employers is very interesting! Hadn’t thought about that twist.
Primary care is generally underfunded and to get overall better health and lower cost, we need to invest more in primary care (and reduce spending on hospitals/procedures/etc). So yes, primary care costs should go up, but who pays and how is complicated; who should pay what and how is even more complicated!
We should certainly try to make it easy for people to get care that’s good for them.
Agreed. There are others service in healthcare that exist because primary care has failed, such as telemedicine, wellness programs, walk in clinics, urgent care.
Who should pay? Typically the answer is whoever is at risk for the payments to the spending on hospitals/procedures/etc., usually self insured employers or payers.
I don’t see how this couldn’t be a favorable option for both physicians and patients. Too many docs today are so burdened by fulfilling the ridiculous “quality meaures” and EHR mandates, patient care becomes secondary. Docs are now facing likely lower reimbursements for the exchange plans, and they are told to “just see more patients”.
This way the docs and patients can get back to a reasonable relationship, without interference from a third party.
We congratulate Dr. Kernisan on highlighting important facts facing healthcare providers today. As healthcare becomes more industrialized and less personalized, an avenue exists for patients to receive more consistent and individualized care. There may be several levels and different price points for this service. This is consistent with the way the rest of society functions. You pay more for a first class airline ticket than for coach; more for a Bentley than for a Pinto; more for caviar than for chicken eggs. Yet, a doctor who is regarded as the best in the world for a certain surgery or medical service is paid by most governmental or in network third party insurance payers the same as a doctor who has just finished residency and is performing the same service. The medical profession has ceded control to third party payers, which has has a carrot and a stick to it. The carrot was see by physicians decades ago, with guaranteed payments of billed charges. The stick is seen today, with complete loss of control by medical providers,of the control over the access to and delivery of healthcare. http://www.ratehospitals.com/blog/who-benefits-the-most-from-privatized-healthcare/ further discusses the effects that privatized healthcare has on individualized patients’ freedom to choose.
We thank Dr. Kermisan for this thought provoking and informative article.
Thanks Leslie… you are correct. I should have clarified that this is a hybrid model that is becoming popular.
A good discussion….We are seeing more of these popping up every month across the West Coast. The “Membership” model seems to be the current preferred flavor and some are doing very well. Both in terms of patient satisfaction and physician quality of life.
A good example would be Greenfield Health in Portland, OR and the membership fees look pretty reasonable. http://www.greenfieldhealth.com/
Greenfield (which I mention by name in the post and link to) is esp interesting because they have a very tiered membership fee, based on age.
But you should be specific. They are insurance-takers with extra fee…so their physicians have to handle insurance issues, but they may very well be happier than the usual PCP who is doing payment-as-usual.
I lean toward Unmanaged Unprotected Care (UUC).
Good comments, thanks!
Re EXTRA payments vs completely direct, I think that’s a very useful distinction. And, the range of EXTRA payments is quite something. Recently I heard about a healthy 35 yo man living in my hometown of Tucson AZ: his longtime PCP had just sent him a letter announcing a switch to charging an annual membership fee (along with taking insurance). The fee: $1500/year, which seemed like an awful lot given this young man is healthy.
At the other extreme is One Medical, to whom I’ve transferred a few geriatric consultation patients. They are taking on complex older patients and charging $149/year.
As for direct-pay practices, there is similarly a big range in what’s being charged…I recently talked to a direct-pay doc in SF with a high-end practice who wouldn’t tell me what they charge to invite patients to the practice…and it seems to be “invite-only” too…
I myself modeled my payment approach on Alan Dappen’s Doctalker practice…fee-for-time is easiest given my practice is small and the medical/communication needs of the patients are very variable.
Really, what I’d most like to see change is the use of terms like “low-cost concierge” in the media. Just how to determine what is a fair and/or affordable charge for services rendered vs an expensive charge is a bit tricky, but could probably be worked out by some of the health policy people. (Would make an interesting paper!)
Well said, Leslie. Concierge is an incredibly loaded term. I don’t begrudge MDs who want to go that route but it’s quite different than direct-pay variants whether it’s direct primary care or non primary care alternatives. I think “direct” has a pretty clear understanding in the minds of a consumer. It could be “direct care” or “direct medicine” could work fine (to partially address John’s concern re PAY in the phraseology). I suppose if someone wanted to be provocative, they could say “insurance free”.
I suppose if someone wanted to be provocative, they could say “insurance free”.
Heh heh, I like that one.
Agree that concierge is a frontloaded word. Not entirely sure, but putting on my marketing cap and guessing that a lot of business types are going to hesitate to use a term that highlights the fact that consumers have to PAY. That may seem a bit silly. After all, we all have to pay, eventually. What are we? In denial? Anybody else?
“Concierge” label gets applied to so many different models, it really doesn’t mean anything specific in terms of payment model these days — which is why I don’t describe my practice as such (among other reasons).
Functionally, I think the biggest distinction is between fully “DIRECT” payment model (zero insurance contracts) versus “EXTRA” payment models (still bill insurance but have additional fees).
Most “DIRECT” providers have opted for a membership model, but it doesn’t inherently have to be. There are a few “few-for-service” based “direct” providers (e.g. Leslie, DocTalkr, and http://stfhealth.com/).
I don’t begrudge the “EXTRA” fee models (MDVIP, One Medical), but they aren’t really challenging the status quo as much.
There are many good reasons not to accept insurance any more, you certainly don’t have to convince me of that. As for doctors “staying in the fray”, I think many are too weary and frazzled just taking care of patients and fulfilling all the necessary mandates to get involved. I switched from Family Practice to Occupational Medicine over 20 years ago and am so happy I did that now.
Frankly, I’m not so sure the policy makers want to hear what we have to say.
By the way, I like the term Dirct Pay. I can’t think of any better way to ensure a quality physician-patient relationship the way it should be.
Thanks for your comments.
There are certainly disadvantages to people paying directly for their outpatient care. But an advantage is that it’s easier for the provider to focus on what patients want and need.
Glad your career switched worked out for you.