OP-ED

Doctors Who Take Medicine Into Their Own Hands

Screen Shot 2014-08-01 at 9.42.53 PMMany doctors are frustrated by pressures to practice a faster and more impersonal brand of medicine, but some are actually doing something about it.  I recently spoke with one such doctor, Tom O’Connor, MD, who practices general internal medicine in central Connecticut.  He and his partner, Paul Guardino, MD, believe they were the first US physicians to begin building a fully concierge medical practice the day they completed training.  In the concierge model, their practice collects an annual fee of several thousand dollars from each patient, enabling better access, more personalized care, and even house calls.

But the real story about physicians such as O’Connor is not that they are opting for a different model of financing their practices.  Instead it is the unmistakable sense of excitement with which they talk about the way they care for patients – an attitude that has become noticeably rarer in recent years.  Says O’Connor, “I have been practicing medicine for nearly ten years this way, and I am happier than ever.”  His enthusiasm stems largely from the fact that, unlike most physicians, he is not employed by a hospital or a large practice group.  Instead, he works for himself.  He is his own boss.

Of course, the idea of doctors running their own practice is not a new one.  For much of the 20th century, most physicians were self-employed, and many operated in solo practice.  Today’s trend away from physician self-employment is driven by a number of factors, including increasingly complex and costly regulation of medical practice by government and insurance companies, the failure of medical schools and residencies to prepare physicians to manage their practices, and big financial incentives for hospitals and health systems to buy medical practices in order to capture patient referrals.

Enter a new breed of physician that includes O’Connor.  He did not want someone else telling him who he could care for, what tests and medications he could order, or how long he could spend with each patient.  In his practice, he and his partner – the doctors who actually see the patients every day – make such decisions themselves.  He sees all his own patients, whether in the office, the nursing home, the hospital, or at home – wherever care needs to be provided.  They do not go to walk-in clinics and they are not cared for by teams of hospitalists.  O’Connor is their doctor in every context.

Most primary care physicians have several thousand patients in their practice, and they see dozens in the office every day.  This means that they cannot devote very much time to any individual patient, forcing them to rely on others – nurses, minute clinics, emergency rooms, and hospitalists – to provide much of their patients’ care.  By contrast, O’Connor and his partner each serve hundreds of patients.  A typical day at the office consists 6 to 10 patient visits.   As a result, they can do it all, and they can take their time.

“Seeing such a relatively small number of patients each day enables me to take the time necessary to research their medical issues and discuss their cases with other physicians,” he says.  “I spend two hours a day reading journals.”  He tells story after story of patients whose diagnoses were missed, not because their doctors weren’t highly knowledgeable, but because they did not have the time to dig deeply.  As he puts it, “Good medicine is incompatible with fast medicine.  And every time a patient is handed off from one health professional to another, knowledge is lost.”

O’Connor feels privileged to know his patients so well.  Except when they go to the emergency room or require referral to a specialist physician – both of which are less likely to happen to one of O’Connor’s patients, compared to those of his peers – he is the one taking care of them.  When they need care, he is the one they see, and every time he interacts with them, he gets to know them even better, building still stronger relationships.  As he puts it, “I am able to provide true continuity of care, and this is probably the single most important contribution I make to my patients’ quality of life.”

O’Connor is not making more money than his peers.  He sees patients in a wider variety of contexts, which makes his practice more complex.  And he must be available a greater number of hours than most other primary care doctors.  But to O’Connor, it is all worth it, because it enables him to come as close as possible to realizing his full potential as a physician.  He can provide the kind of care that he would want for himself or a close friend or relative.  In fact, he can provide the kind of care he wishes were available to every patient.

Not coincidentally, a relatively high percentage of O’Connor’s patients are medical specialists and their families.  Another prominent patient group in his practice is hospital administrators.  Why are doctors and the people who run hospitals so over-represented in his practice?  Presumably because they see the value in having a doctor who can devote the time and attention necessary to practice the best medicine – and also, it must be said, because they can afford it and are willing to pay for it.  They are voting with their feet and their dollars.

But not all O’Connor’s patients can afford his services.  He was caring for a well-to-do family, and in particular their elderly mother, who had a live-in attendant.  One day the family asked what else they could do for their mother.  O’Connor pointed to the attendant, a woman from the Caribbean who suffered from diabetes and hypertension.  If they wanted the best care for their mother, he said, they should ensure that their mother’s attendant, on whom she depended so heavily, remained as healthy and fit as possible.  So the family enrolled her in O’Connor’s practice.

After some years elapsed, the elderly mother died.  The family ceased employing her attendant and making payments for medical care on her behalf.  Did O’Connor strike her from the rolls of his patients?  No he did not, and he still cares for her today.  In part, he does it out of a sense of loyalty to his patient.  But he also does it as a celebration of his professional autonomy.  When he weighs such a decision, he relishes the fact that he doesn’t need to seek his employer’s permission.  He can do it, because he is his own boss.

To repeat, O’Connor’s style of practice is not cutting edge.  In fact, it is rather old school, in the sense that most primary care physicians were once self-employed.  The underlying motivation is one of the oldest and soundest imaginable – physicians designing their practices around optimal patient care.  As O’Connor puts it, “Just imagine what kind of doctor you could be – and how rewarding it would be to practice medicine – if you could be your patient’s doctor all the time, in every context, and you knew that no one else was preventing you from doing your very best for them.”

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28 replies »

  1. Point taken Jill.

    not trying to be TOO snarky, just a little bit snarky. After all, this is an online blog and not really a “real” debate, but you are correct, rudeness is not ever much of a virtue!

    Maybe I shoulda just stuck to driving that dump truck.

    But I am either free to practice “concierge” medicine or I’m not, and if I’m not, then that’s a pretty dangerous premise, wouldn’t you agree?

  2. Lawyerdoctor- You are an educated individual, arguably sufficiently trained in civil discourse to be above snarkiness in a debate context. While you are certainly free to take your dump truck anywhere you’d like, you are not above state regulation. Let me know if you are able to have a healthy discussion without accusing me of being unamerican and I’ll happily share my perspective.

  3. Kate Hoekstra- Where precisely do you take from my comment that I advocate preventing people of means from buying whatever care model they wish and can afford? I neither stated nor implied anything like that. As someone with 20 years of work with consumers and health plan design, I understand the system and reposting your explanation that “we already have a multi-tier system” doesn’t improve the dialogue. My comment provides a valid perspective regarding a downside risk of concierge. It is not an evaluation of whether the concierge model will ‘solve all the problems of inefficient, unequal and unsatisfying healthcare’ or a demand for ‘one size fits all’. I asked myself “what does concierge service solve for in our U.S. system” and my perspective is important in this dialogue.

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  5. Very nice to see this activty. Concierge medical practices like mine are in insurance net works. So everything I order, eg, labs, xrays, medicines and all my work in the hospital is fully covered as any other proving doctor in network would.

    Only my annual fee is not covered by your insurance. It’s very simple, the fee goes for amenities that are not in anyway covered by your insurance, eg, limited patient panel- I take 10% of the patients in a regular practice!

    That says it all. I have time to really care for my patients. After 10 years, I’m keeping things simple.

    Concierge medicine is here to stay and I’m proud to be one of the first in America to have made it successful.

    I’m looking for investors.

    I can be contacted at tom@toconnormd.com

    My new website Will be live 2/24/15 http://www.thomasoconnormd.com

    Stay healthy,

    Dr. O

  6. This is not surprising! We practice concierge medicine in Los Angeles and we have noticed how more and more patients are seeking to be part of a medical practice that allows them to have more control over the care they receive. Most patients realize the changes happening within medicine and value the time spend with their healthcare providers. They rather be able to spend more time with their doctors and less time waiting in a waiting room.

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  8. I’m trying to imagine any other profession which would tolerate such dictates about how, when, where they practice—after having invested their own time and money into their own training. It’s happening now to teachers, with Common Core touted as the UniAnswer to the nation’s education/inequality woes. Let’s see if they give more push back than doctors have done for themselves.

  9. Did I miss something or do we still live (at least for a little while longer) in a free society? Can’t doctors take their “plastic dump trucks” (i.e., their substantial skills acquired from 17 yrs of school & training which cost them around $200,000) and practice where they wish?

    It sounds as if you much prefer a system wherein someone (preferably in the all-wise, all-powerful government) decides WHERE I will practice, WHO I will practice upon, WHAT type of practice I might pursue, HOW I shall perform (judged by various AHRQ and CMS stnds), and WHEN I might be allowed to do so.

    The latter appears to be consistent with Cuba, or Iran, or maybe on a good day, China. As for me, I’m taking my expensive, hard-fought, and very valuable dump truck and driving it how and where I want.

  10. Well said, Perry. Just as the word “socialism” frightened people about single payer healthcare or ACA, the word “concierge” may be off putting to anyone who fears catering to the wealthy at their expense. Vested interests who would like to manipulate the population one way or another depend on such loaded words to discourage exploration. The day when people look deeply into the systems which affect them is the day they take control of these.

  11. oh crap, I completely forgot about the VA folks . . . I don’t even want to THINK about what Tier they are on . . .

  12. Just to be completely clear, we have a MULTI-tiered system of care already in this country.

    Tier 1) We have super-rich folks who may or may not have health insurance, or may just own a health insurance company. They don’t care how much health care costs because, well, they don’t care how much anything else costs. When the time comes to pay the doctor and hospital, they just drop off a briefcase full of $$. (unfortunately for those of us who are actually in the healthcare delivery system, this truly capitalist process is incredibly rare, and seems to be limited only to arab sheiks and people who invent software programs, i.e. > 0.000001% of the population.)

    TIer 2) We have HIGH COST, generally high quality healthcare for people with insurance. Note these are NOT necessarily people who are “rich,” but conversely, have the luxury of belonging to a union, or work for the federal govt, or otherwise have “good” health insurance. They probably don’t have a need for concierge medical care since their deductlbles are low, and out of pocket costs are low, and they are happy with the current point-of-care, consumer-driven healthcare delivery system. (this previously prevalent population is fast going the way of the do-do bird)

    Tier 3) we have HIGH COST, low reimbursement, generally “moderate” quality coverage which is absolutely FREE to indigent patients and the disabled, known as Medicaid. This population is exploding. Contrary to popular myth, Medicaid also allows patients access to care almost everywhere, especially for primary care. I doubt concierge providers will be interested in taking on Medicaid patients, but since I frequently see patients with expensive cars, gold jewelry, new i-pads, fancy hairdos, designer purses, and the like who surprisingly produce a Medicaid card in the ER, maybe they WOULD like to use some of their disposable income to purchase high-touch healthcare. Or maybe not, since they can always continue to simply use the ED as their totally free 24/day walk in clinic.

    Tier 4) We have people who work, pay bills, pay taxes, but don’t have insurance through their job. These people are the ones who truly lack access to care since they cannot pay out of pocket for medical services at the “sticker price.” Depending on your politics, the Affordable Care Act either cured this problem or made it dramatically worse. Since every person in the United States is now required, by penalty of law, to purchase health insurance, I am frankly amazed at the stream of uninsured patients I continue to see (on a daily basis) in my emergency department. HOWEVER, after just one look at the sky-high deductibles in these so called “affordable” care act plans, I think these folks might also be interested in having concierge care also!!!!

    Tier 5) We have “non-citizens” who may or may not be receiving Medicaid. They will continue to use any local ER as their clinic, whether they have a payor source or not.

    Tier 6) Medicare. Once the dream of many a person hoping to retire, and the cash cow for a whole generation or more of physicians, apparently no doctors now are interested in dealing with this unfortunate group of patients, UNLESS they have managed to also produce a “SUPPLEMENTAL” Medicare insurance policy, which, of course, is sold to the senior by one of the super-large health insurers. My advice to the elderly: get poor really quick, so you can be eligible for Medicaid. Or maybe you can get pregnant, since that’s the quickest way in my state to become Medicaid eligible.

  13. I think” concierge ” may be an inadequate term for some of these practices and this is what makes people like Jill uncomfortable with the concept.
    Many family practitioners are doing what is called “direct care” which means direct payment without all the rigamarole of health insurance plans.
    Many of these practices are serving all kinds of people in all walks of life, not just the wealthy. I believe they are acting within the confines of the ACA.
    What I think many lay people fail to understand is the tremendous frustration that primary care doctors are facing with all the changes in health care, and constant bombardment with new rules and requirements for practicing within the Medicare/Medicaid systems and insurance.
    Most doctors want to practice good medicine and be able to experience
    quality interactions with their patients, much of which is hindered by extraneous requirements.
    I agree with Kate, I think we need to continue looking at different ways of providing care to patients within or without the “system”.
    Believe me, the government and the insurance companyies don’t care near enough about your health as your doctor.

  14. I don’t think it improves the dialogue to evaluate any one model on the basis of whether it will solve all the problems of inefficient, unequal and unsatisfying healthcare. We already have, and will have going forward, ACA or not, a multi-tiered system. Each of these can be made more effective while not erring on the side of reducing our sytem to a one size fits all, and losing the richness of diversity and of designing systems within the system which best meet the needs of differing populations. For example, Medicare is well suited to seniors who need assurance that their medical needs will always be covered, regardless of other changes in their lives; similarly, busy professionals for whom time is literally money, benefit from the turnaround responsiveness of concierge medicine, as do patients with chronic and complex conditions and who rely on a close reliable relationship with their physician. The poor benefit from Medicaid which covers many more services than private insurance covers, e.g., dentistry. And private insurance can provide a range of products to fit individual pocketbooks. It seems already clear that concierge medicine comes in many forms….some which integrate private insurance; some which don’t. Announcements I’ve seen for these are quite clear about these limitations as well as the benefits. Perhaps we should be encouraging innovation rather than seeing any attempts at it as too little. There is no down side to concierge as far as I can see, and there is , among other benefits, the strong possibility that such practices may be exactly what the profession has been seeking in order to attract new docs to general medicine.

  15. Athough I thoroughly revel in the thought of going back to home visits, etc of the 60’s that concierge care promises, I am troubled by the failure of these doctors to consider the layperson’s experience and reaity of 2014.
    Under ACA, individuals will be required by law to have health insurance that includes hospital care and concierge care will not deliver that.

    Concierge service is really a buy up service for the very rich. It doesn’t help address heath care fraud and abuse, it doesn’t move care to the best outcome/least invasive options, and it doesn’t keep doctors within a system where they can influence and improve the system. Instead, these doctors have taken their plastic dump trucks, pails and shovels and moved to a newly constructed sandbox.

    The rich will enjoy this model, but God help the misguided regular guy who brings his family to one of these options. Unlike physician family’s who have always received preferential pricing within the healthcare system, the lay person will find at some point that his new child’s birth or child’s strabismus surgery is not covered by the annual concierge fees required by Doctors First and other elite sandbox players.

    To protect the other 99%, I certainly hope Congress passes legislation asap that requires these providers to disclose in user friendly clarity that participating in the concierge approach will not satisfy health insurance as defined by ACA and will not cover hospitalization, specialists, and outside lab work.

    We are in the U.S. so I shouldn’t be surprised by these wild west tactics that really are about: I can’t be bothered with integrated systems, so I’m just not playing.

  16. Great article. What Dr. O’Connor has done is nothing new at all. This type of practice has been around since “little house on the prairie” days. This type of model has juts gotten a new spin on it. Dr. Josh Umbehr (Atlas.MD) is the top expert in the country on this type of model and is interviewed on all of the national news programs on a regular basis. Dr. Josh is actually very unique. Any physician who associates directly with him can get their patients savings on labs, medications, and imaging 90% or more. Nobody else in the FFS or concierge/DPC models does that. The savings that Dr. Josh and his colleagues create are real. These are savings that ACOs and others only dream of but can not accomplish at all (due to being tied to insurance companies). I highly recommend taking a look at what Dr. Josh Umbehr has accomplished.

  17. Where precisely do you take from my comment that I advocate preventing people of means from buying whatever care model they wish and can afford? I neither stated nor implied anything like that. As someone who has spent more than two decades working within the systems an analyst and health IT consultant, I understand quite well how it operates.

    Perhaps as we move more and more toward a system with much more prevalent high OOP outlays, concierge/direct pay/subscription will scale and become economically viable writ large. I would not oppose that. I am simply a bit skeptical.

    Time will tell.

    Just don’t put words in my mouth.

  18. The argument against concierge medicine that sees it as creating a two tiered medical syste is a straw man: We already have a multi-tiered system…Medicaid for the poor; variable care dependent on the kind of private insurance one has;charity care (where available) for anyone who has neither of the above; and no care for anyone who lives in an underserved, e.g, rural area. Depriving people who can afford and believe they need concierge care is neither fair nor effective. It is a lack of understanding about how healthcare is already provided, and is likely to be provided for a long time to come. The surest way to provide sufficient numbers of primary care doctors is to provide financial incentives, including concierge practice, to encourage medical students to select this area of medicine.
    As many have pointed out already, the surest way to improve access to primary care providers is to provide financial incentives to medical students to enter this area of medicine.

  19. Excellent questions lawyerdoctor. Do the authors have to employ an army of staff to manage claims with insureres/Medicare?….or perhaps they don’t take Medicare/Medicaid?

  20. Yeah. Maybe. There may, however, be a limited market for this in the aggregate. It might saturate rather quickly. Seems like a great model while it’s a sparse proportion of the primary care market. But it may not scale. And, people by and large will have to continue to insure against the non-routine big ticket stuff. Add that in, and, well, we’re right back close to current per capita.

    Not that I disagree with the principle, not at all. Half to 2/3 of primary care encounters have more to do with keeping the doors open than they do addressing pressing clinical need.

  21. I have practiced as a PA for 18 years, even though it is in a little bitty underserved rural area, I still see the deterioration of the patient-doctor relationship. Insurance and government regulations are becoming more and more cumbersome. I honestly think this type of practice is going to become more dominant as more regulations take place. I know if I lived in a metro area, I would definitely opt for this type of practice.

  22. I have recently written a Kindle book “Direct Pay Independent Practice: Medicine and Surgery,” which features 12 interviews with doctors like Dr. O’Connor. Several of the doctors I interviewed thought direct pay.concierge medicine would be the dominant form of primary care practice within 5 years. One of them, Dr. Josh Umbehr of Wichita, Ks, entered concierge medicine straight out of medical school. Most of those I interviewed said ObamaCare, which has produced high premiums and deductibles, is their best salesman. From responses to my blog, which is getting up to 7600 page views a day, I believe direct pay/concierge medicine could be the wave of the future for primary care and for direct pay ambulatory surgery centers.

    Richard L. Reece, MD, 1-860-395-1501, Old Saybrook, CT

  23. I have long been fascinated with the concept of concierge medicine – I am assuming that most of Dr. O’Conner’s patients have “good” health insurance (save for the Caribbean lady in the article) – how does Dr. O’Conner and his partner deal with ordering lab, X-ray, and EKG’s?

    What about prescriptions and drug benefits for his patients?
    It appears they follow their patients as attending MD in the hospital – if so, do they round in the mornings, or the evenings, or both?
    Does he use an EMR? If so, is it “interoperable” with his hospitals EMR?

  24. ““Good medicine is incompatible with fast medicine.”
    __

    Indeed. Everyone ought read “God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine.”

    “San Francisco’s Laguna Honda Hospital is the last almshouse in the country, a descendant of the Hôtel-Dieu (God’s hotel) that cared for the sick in the Middle Ages. Ballet dancers and rock musicians, professors and thieves—“anyone who had fallen, or, often, leapt, onto hard times” and needed extended medical care—ended up here. So did Victoria Sweet, who came for two months and stayed for twenty years.

    Laguna Honda, relatively low-tech but human-paced, gave Sweet the opportunity to practice a kind of attentive medicine that has almost vanished. Gradually, the place transformed the way she understood her work. Alongside the modern view of the body as a machine to be fixed, her extraordinary patients evoked an older idea, of the body as a garden to be tended. God’s Hotel tells their story and the story of the hospital itself, which, as efficiency experts, politicians, and architects descended, determined to turn it into a modern “health care facility,” revealed its own surprising truths about the essence, cost, and value of caring for the body and the soul.”

    I bought this book and had to put the world on ‘pause’ while I read it from cover to cover.

    http://www.amazon.com/Gods-Hotel-Hospital-Pilgrimage-Medicine-ebook/dp/B005GSZHYU/ref=tmm_kin_title_0?ie=UTF8&qid=1406992703&sr=8-1

  25. Yesterday, I was at the Hospital for Special Surgery in NYC, and it was clear why their reputation as a consistently top ranking hospital, year after year, is well deserved. What they provided–and which is missing in too many other hospitals and medical practices–is attention to detail and adequate time given to patients at EVERY step of the experience. This is concierge medical care at the hospital level. What practices like Dr. O’Connor’s and hospitals like HSS provide may not be possible throughout medicine, it is certainly a standard to aspire to. There are many areas in which physicians can make changes in their own practices, as Dr. O’Connor has in his, to push back at the downgrading of the patient/doctor experience which too many have accepted as inevitable.

  26. Thank you Dr Gunderman. My partner and I are into our 10th year of this type of practice and have never seen the kind of growth we are seeing now!! The future of American medicine will offer this top tier of service for sure. I’m happy to be one of the “fathers” of this type of old school medical practice.

    Dr. O

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