As with all research and divulged information, it is important to understand the source of that information and the organization that is paying the writer and researcher.
KFF news established in 1948 by Henry J Kaiser concurrent to the Kaiser Family Foundation in Oakland, California. Although Kaiser Family Foundation deemed to be separate from Kaiser Permanente (integrated managed care consortium based in Oakland, CA), both were directly founded by Henry J Kaiser, an American industrialist. Kaiser Family Foundation was overhauled in 1990 by CEO Drew Altman. Drew Altman completed his postdoctoral work at Harvard before moving on to a lustrous career in public service to include several notable positions such as commissioner of the Department of Human Services for the state of New Jersey and senior position in the Health Care Financing Administration in the Carter administration.
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John Rossheim is a freelance journalist. Per his LinkedIn profile, John reports “...on healthcare delivery, access, and disparities; Medicare and Medicaid…” In his last post four months previously, John writes: “For a story for KFF Health News, I’m interviewing patients whose primary care physicians have transitioned to concierge medicine practice I’m looking both for patients who stayed with their doctor and are paying the concierge membership fee, AND (especially) for patients who decided NOT to stay with their doctor and had to seek a new primary care provider.”
John Rossheim opens the article describing Terri Marroquin of Midland, Texas finding out about the transition of her doctor’s office to Concierge practice while at the office proper. By not being in that practice in Texas, cannot speak to the specifics of the incident. However; do find it surprising and unlikely that patients were not informed via letter or email communication of this transition.
Petersen Concierge Medical like many other concierge practices is upfront and clear about the design and purpose of the practice. We offer a non-committal one hour visit with the doctor to learn about the practice and answer any questions regarding physician’s approach and care. Then, a contract is signed by both parties that is clear, precise, and has options for termination. Questions are welcomed at any time and no client of the practice is unaware of any financial obligation.
“Marroquin finally left to join a practice with no membership fee where she sees a physician assistant rather than a doctor” citing the increase in fees and nice appearance of the office as the reason. This comment deserves some discussion. A development in the market that speaks to the power of innovation and individual choice that is given to all Americans.
Market forces will drive competition and that competition can be based on many factors including price and quality. It is in many instances that we choose to compete on price. For example, we can choose to buy a lesser quality yet cheaper automobile, cell phone, or furniture. In the same instance, market allows for competition in healthcare. One can choose to pay a higher premium for higher trained more qualified provider such as a physician who will not only spend time with you but pull the resources of his or her practice to assist with navigation of healthcare industry, set up referrals, broker consultations, and provide recommendations. Or one can choose the cheaper option that will comprise a fifteen-minute visit with a lesser qualified individual who will perform the minimum required.
“With the national shortage of primary care physicians reaching 17,637 in 2023 and projected to worsen…”
National shortage of primary care physicians is indeed projected to increase. “Physician Thrive” 2023 publication projects a shortfall of 48000 primary care physicians by 2034. This study cites several factors causing shortages including: aging population, retirement, burnout and stress, regional impacts, change in hiring trends and work conditions such as work from home. In fact, physician burnout has been a keystone discussion not only among organizations, public institutions, schools but also amongst physician groups and state medical boards. 2023 American Medical Association Prior Authorization Physician Survey reported that physicians and their staff spend 12 hours each week completing insurance prior authorization paperwork leading to burnout as reported by 95% of the physicians surveyed. Pushing away from traditional private practice into corporatization of medicine where benchmarks and metrics rather than patient relationships are the measures of success is often viewed as the driving force to a change in primary care workforce.
Last five to ten years have seen an ever-increasing trend of consolidation and corporatization of healthcare. More and more physicians are selling private practices due to rising overhead costs and becoming employees. The hospitals; however, are not the largest employer of physicians. “Private equity, physician groups, and health insurers have acquired the vast majority of physician practices in the years 2019-2023” according to American Hospital Association’s analysis of LevinPro HG, Leven Associates 2023. UnitedHealth and its subsidiary Optum is the largest employer of physicians nationwide with over 70,000 employed or affiliated physicians (AAMC recorded 938,966 total active USA physicians in 2019). In 2023, CVS Health acquired Oak Street Health and Signify Health. Physicians Advocacy Institute drafted an open letter to Congress in June of 2021 citing research conducted by Avalere Health for the Physicians Advocacy Institute revealing that at the start of 2021, nearly 70% of US physicians were employed by hospital systems or corporate entities; only 3 out of 10 of the physicians in the USA were practicing in independent medical practices. PAI (Physicians Advocacy Institute) raised concern regarding physicians’ ability to retain clinical autonomy while being directly employed by corporate entities.
However, there are many physicians who yearn to embody the ode of service and giving that is innate to the medical profession of old. Some of these physicians are choosing to step out on their own, take up the financial and personal risk to open a private practice away from the direction and influence of corporate or managed care organizations. These physicians are thus marketing their services to the consumers directly. That is the origin of private medicine, a directive from the physicians to make independent decision in the service of their patients.
“Concierge medicine potentially leads to disproportionately richer people being able to pay …”
Because concierge medicine is innately a private and consumer funded practice, it may lead to those with greater disposable income to seek out this service. When logically applied, one would reasonably say that those who possess more capital spend more on products. For example, a higher earning individual may spend twice as much on a vehicle that powers their daily commute. However; when looked deeper and systematically some other trends may show up. Health Services Research published “Accounting for the burden and redistribution of health care costs: Who uses care and who pays for it.” In April of 2020. The research study objective was to “measure the burden of financing health care costs and quantify redistribution among population groups.” Authors illustrated that higher-income households pay the most to finance health care in dollar amounts, but the burden of payments as a share of income is greater among lower-income households. Because all health care costs are paid by households in some obvious and non-obvious ways. The costs are those through insurance premiums, out-of-pocket costs, or through employer-paid premiums and taxes.
Taking this into consideration, a family may choose to look carefully at their total health expenditure. That same family may choose to take a different view into their health altogether. Is health a replaceable commodity or an investment for the future? When looking down the line into older age, what goals may one wish to accomplish. If and when something happens in the future, how much does one want a dedicated physician in their corner? That family may look at their yearly insurance cost, add average out of pocket expenses and analyze prior trends of insurance approvals for previous expenditures. The family may also look to their relatives and friends and inquire as to what their health costs have been as they migrate through the health industry and system later in life. That family may then make an independent choice to switch to a Concierge Practice and opt to have catastrophic only coverage from insurance thus likely cutting down their true healthcare costs and expenditures.
Adam Levine, lead author of 2023 study on concierge medicine is cited in the KFF Article. This 2023 Study titled: “On resource allocation in health care: The case of concierge medicine” was published in the Journal of Health Economics in July of 2023. The premise of the study was to analyze concierge medicine and whether concierge medicine can serve as a vehicle for improved efficiency and health outcomes. For example, concierge medicine allows for more time and access to a physician and thus will minimize costs associated with emergency room visits or hospital admissions.
Data utilized for the study centered on Medicare insurance claims merged with data from 225 physicians who left traditional practice and transitioned into concierge practice under large concierge medicine company between 2008 and 2013. (The physicians retain primary ownership of their practice but pay a percentage to the company for the administrative support and practice organization. All physicians signed on with the concierge medicine company limit their panel size, provide greater access for patients, perform comprehensive annual screenings and diagnostic tests not often covered by insurance.) The authors then compared the claim data to identify patient health status and income. They compared this data to the patients of physicians who switched to the same concierge company after 2013 and to other Medicare beneficiaries. The study created multi-tiered analysis of selection into concierge medicine and the outcomes. The findings showed that those with higher incomes are more likely to follow their primary care physician into a concierge practice. The study also found that difference in chronic condition spending was not statistically different while the difference in physician spending was different but not of economically large magnitude. No statistically different reduction was noted in inpatient spending.
The conclusion of the study was broad stating that the switch to concierge medicine is largely governed by patient’s choice and income. The authors also made the conclusion that
concierge medicine increases overall “total health care spending by 30-50%” and that there is “no evidence that concierge medicine leads to mortality changes, on average.” However; the authors did comment on the limitations of the study due to small sample size and the lack of observability of true patient income in the study rather an inference based on zip codes. The authors also comment on their lack of longitudinal data as they only used 3-5 years for analysis.
It is difficult to make generalizations based on small data set in one paper. There are plentiful papers that offer differing viewpoints and can be cited as well. Journal of the Association of American Medical Colleges “Academic Medicine” published an article by David Lucier and others “Academic Retainer Medicine: An Innovative Business Model for Cross-Subsidizing Primary-Care” in June of 2010. This article cites the value of enhanced services provided by concierge practices and the success of incorporating such primary care service into academic medicine such as Concierge Primary Care within the Department of Medicine at Tufts Medical Center founded in 2004. Many other large academic and tertiary centers are doing the same. Mayo Clinic advertises Mayo Clinic Medallion Program, highly personalized care with 24/7 delivered in a private setting. The embracing of this model and its growth may speak for itself.
The next paragraph in the article sights 2005 study showing that concierge physicians take care of smaller proportions of patients with diabetes and take care of fewer Black and Hispanic patients.
This 2005 study is a “Physicians in Retainer (“Concierge”) Practice: A National Survey of Physician, Patient, and Practice Characteristics” by Caleb Alexander, MD et al. This study was a mail survey of 144 retainer physicians (58% response rate – 83.52) and 463 nonretainer physicians (50% response rate – 231.5). The responses were assorted and reported. Retainer physicians reported seeing fewer patients as had much smaller patient panels (mean 898 vs 2303). They did see statistically fewer African-American patients, had noted to make house calls, accompany their members to specialist visits, provided 24-hour access, and offered many other services. The article also noted that most retainer physicians converted their practice into a concierge model but kept few of the former patients and most (84%) provided charity care seeing patients who did not pay retainer fees. The conclusion drawn from the study was that there are differences and there is overlap in services between two different models of practices and further questions regarding ethics and legality exist.
This is an interesting survey and does deserve some merit and delving into. The study highlights some of the key features of the concierge practice such as 24-hour access to a physician, extra services, house-calls, specialist referrals and accompaniment, smaller patient panels allowing for detailed review and time with the doctor. It is difficult to statistically compare 83 small concierge practices that averaged 898 patients to 231 nonretainer practices averaging 2303, thus comparing 74,534 to 531,993, and make an inference about broad population spectrum based on demographics and diagnoses. The paper does confirm this as well. But in defense of the study’s efforts, it may be so that there are concierge practices that statistically do not represent the demographics of the area. Ultimately, retainer or concierge practices work on free market, catering to individual choice and thus are self-selecting of personal characteristics rather than demographic data.
The market research firm sighted is the “US Concierge Medicine Market Size, Share & Trends Analysis Report by Specialty” using data from 2018-2022 to forecast 2024-2030. According to the report the US Concierge medicine market size was estimated to be at 6.7 billion in 2023 and is projected to grow by 10.4% annually. The reasons for this growth and rising popularity were sighted to be round-the-clock access to the physicians, lab tests, house calls, care while traveling, no wait times, regular health assessments, preventative care. As a general comparison, the total health expenditure in the USA has reached 4.5 trillion in 2022 according to CMS (Centers for Medicare and Medicaid Services). US Concierge Market is less then 0.15% of the total health expenditure, still a drop in the total health care bucket but significant enough to show a market trend.
The next two paragraphs in the article describe the premise and base of the concierge practice: more time with the doctor, access, care at your fingertips on your time and individualized to you. This is contrasted to the regular primary care doctor who cares for thousands on their panel with appointments of 15 minutes or less. The article then confirms that there is variability among concierge practices in terms of fees and services offered.
The reasons for choosing a retainer or concierge service are clear from the patient perspective. At its base, each concierge practice will offer: immediate and flexible physician access 24/7, home visits if needed, longer and more frequent office visits, convenient scheduling, administrative support, clear communication. Superimposed onto those basic offerings, each concierge practice may choose to augment their services. Petersen Concierge Medical has chosen to bring advanced diagnostic testing, personalization on every level of diagnosis and treatment, longevity and human optimization, body mechanics and fitness, urgent care, preventative care, complete white glove wrap-around service for all members of all ages.
One needs to also mention the reasons why a physician would choose to select such a practice, a concierge model. Concierge model is an ode to time past where a family doctor intimately knew each member of the family, was available and made house calls. That relationship gives understanding and direction in the care that cannot be matched by urgent care, 15-minute visit with a midlevel provider, or an ER. Doctors understand this and harken for the time past, where they had meaning and purpose in every minute of their life, to a time where they made decisions unilaterally in the care of their patients that they know well. Doctors want the autonomy to provide the best care possible to each and every one of their patients without third party rules based on revenue, production, and metrics. Doctors want to spend time in front of the patient not in front of the computer. They want to spend time improving their knowledge in patient care rather than billing skills. Concierge model of care allows for all of that. A single retainer fee paid monthly or yearly relieves the physician from the ever-churning hamster wheel where a doctor needs to see 25 patients a day in rapid-fire fashion to cover over-head or meet the revenue demand of the corporate entity. The doctor then is also relieved of the ever-present pressure to document extensively for the billing department and the ever-evolving box checking for insurance.
The article quotes Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation siting Affordable Care Act and the need for insurance to cover preventative services: “Your annual physical should be free.”
National Patient Advocate Foundation describes its mission to amplify the voices of patients and advocating for better access to care and to make personalized and informed decisions. The need for such an organization is in itself the reason for a concierge practice. Concierge or retainer model practices are there to serve their members, their patients. The physicians will provide the information, advocate for the patient, and directly coordinate complex care. The market created this need and many forward and innovative physicians answered it. The reasons for this need are extensive and are not related to concierge practices themselves. The faults of the system that does not support patients and creates a need for patient advocacy can be discussed elsewhere.
Further, to follow basic treatise of economics “there is no free lunch.” One pays for every medical service rendered in every system, but it may not be a direct financial exchange. In single payor systems, one pays for medical care through taxation. With commercial and government insurance, one pays the insurance company through insurance premiums or government through taxation. These entities then bear the privilege and power to make direct medical decisions for individuals. This is done through multi-tiered system and governed through payment to the physicians or the companies who hire physicians. One may still bear some additional direct cost through out-of-pocket expenses to meet deductibles. Concierge practices eliminate all the tiers and deal with the clients directly. In a true business sense, this makes for a clear financial transaction. Why pay another entity who then pays a third-party company to choose a car for you? Why not just go to the dealer and buy the car yourself?
Liz Glatzer is mentioned in the article who chose to pursue MDVIP service after three physical exam experiences where a doctor was rushed, unable to cater to her needs and did not recognize that she had a double mastectomy. She chose another solution and “in the first couple of visits, Glatzer’s new physician took hours to get to know her.”
Liz Glatzer’s concierge physician took the time to get to know her, gave Liz the needed attention and subsequently was able to cater to her individual needs. This is a perfect example of the many reasons why one would choose a concierge physician and why the market forces are growing this service opportunity. Long-range studies are not yet available to fully evaluate the effect on individual and population healthcare to have such close physician relationships and needed time for medical service. Logically, the odds are in the concierge practice patients’ favor.
Yalda Jabbarpour, director of Robert Graham Center is quoted to critique the transition of primary care practices to the concierge model as a break in the continuity of care for patients.
Robert Graham Center “exists to improve individual and population healthcare delivery through the generation of evidence that brings a primary care perspective to health policy.” The Robert Graham Center focuses on research and policy focused on primary care both nationally and internationally. Dr Yalda Jabbarpour focuses her research on workforce issues such as provider burnout and delivery and financing of primary health care. Dr Jabbarpour is not wrong that a patient may choose to not follow their physician into a concierge practice thus facing the often-difficult search for another provider. The decision for a physician to transition to a concierge model may be multi-faceted. It may be to avoid burnout and to become autonomous in the delivery of quality care to their patients. It may be to achieve a better work-life balance and ability to dictate own scheduling. Ultimately, this leaves the patient to make individual choice not only in the selection of their physician but perhaps in the allocation of the monies and household budget. If multiple patients make different choices in budget and money allocation, this may in the future impact health direction and policy.
The author then quotes Abbie Leibowitz, chief medical officer at Health Advocate who comments on the consequences in the primary care disruption for patients.
Abbie Leibowitz is correct that care disruptions should be minimal. Health Advocate, a company for which she works, markets their health advocacy services to patients and organizations. Health Advocate advertises digital navigation of benefits, advice regarding enrollment, tailored reminders and data for benefit adjustment to its members. Health Advocates main focus is to ease the complex world of insurance and benefit navigation, something that concierge practices completely bypass by dealing directly with their clients who then may elect a different approach to benefit selection altogether.
The article then discusses that many who lose their primary care physicians may choose to use urgent care centers and hospitals for their needs, the difficulties of finding an in-network provider, and the lack of support from insurance plans.
This highlights some of the reasons for the existence of the Concierge Model in itself. If the need was not there, the market would not create this niche for the primary care service.
The author then highlights Russell Phillips, director of the Harvard Medical School for Primary Care commenting on the paucity of primary care physicians and transition to midlevel providers in primary care, which may compromise some of the complex care delivery.
Indeed, the author is correct in his assertions and the best-case scenario would be for primary care to be managed by a board-certified physician. It would be prudent to look at the multiple reasons and forces within the healthcare industry that is creating this situation. For physicians, it may be the high rates of physician burnout, the lack of autonomy in decision making, the lack of relationship with patients, or simply a market opportunity for a better or different situation. For patients, this creates opportunities and challenges that may drive differing decisions.
In conclusion, the concierge or retainer model for primary care has evolved through market forces and speaks to individual choice of the patient. As concierge or private medicine presence in the healthcare space is still evolving and relatively new, it would be interesting to follow the trend and the concierge patients for long-term study. We can’t quantify the impact of the personalized care concierge practices offer yet. But we can speak to the idea of the model and the driving principle of that type of care.
In principle, concierge model leans on individual choice and caters to individual investment in health. Through the premise itself, it drives individual involvement and introspection into own health and automatically makes concierge practice members advocates for their own health and wellbeing. All of us will “pay the piper” somehow and sometime. The question is when one is 95 years old and looking back, what does one want to see over the previous 25 years? Does one want to look back at dinners with the grandkids, time in the garden, walking in the woods or hospital admissions, frustrated medical office visits, and limited mobility at home. We cannot predict the future but we can stack the odds in our favor. By futuristic thinking and planning ahead, some individuals are selecting to pay forward for their health and invest in their future. This created opportunity for concierge practices who focus on high-level prevention, optimization, and health.
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