Six years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.
After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.
Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.
I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.
Many 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.
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.
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.