Concierge doctors " the future of Colorado primary care?
A typical day for Littleton’s Dr. Jon Cram involves seeing 28 to 32 patients over the course of nine hours.
“We’re moving so fast that we do not have time to have personal relationships,” Cram said.
“The system asks primary guys to be the patient advocate, but there is so much high tech we don’t have time to explain things. We’re running, running.”
But change is coming.
In June, after 30 years as a family physician, Cram will be one of five Colorado doctors joining MDVIP ” a national network of doctors whose focus is on preventive medicine and wellness planning.
Doctors in the MDVIP network ” VIP stands for Value in Prevention ” use a retainer-fee system to provide what some have dubbed boutique or concierge health care.
The fee system allows Cram to reduce his patient load from 3,000 to 600 and spend more time with each patient.
“We have more time to talk when a patient needs to come in instead of the following week,” he said.
Patients will get same-day or next-day appointments, little or no wait times and 24/7 access to Cram via cell phone or e-mail.
“We become more proactive in our ability to take care of our patients,” Cram said.
“Right now, it’s difficult to be proactive if we’re reacting to the medical problem of the day. We’ll be more on top of their medical care than we would have been.”
For the annual fee of $1,500, Cram’s patients will get a comprehensive physical exam along with a thorough assessment of their health risks and lifestyle, and a wellness plan.
Each patient will also have his or her medical records available on a CD-ROM and an individual Web page to track his or her medical history.
“What we do is much more than what is considered in a concierge practice,” Cram said. “There is more prevention. We partner with them the whole year, and striving to really resolve their personal issues, and continuing that personal relationship.”
For example, he said, one thing he’s targeting is lowering cholesterol levels, which could lead to fewer heart attacks and strokes.
“I think that the long-term benefits will be impressive,” he said.
The idea of a retainer-fee practice is not new, although only a few hundred doctors in the nation practice it, and only a handful in Colorado.
Thomas LaGrelius, president of the Society for Innovative Medical Practice Design, a trade organization for concierge doctors, said the concept was pioneered by two doctors in Seattle who formed MD Squared in 1996.
“They wanted to limit their practice to 50 families and charged $1,000 a month,” he said. “Patients didn’t have what we call medical ‘homes,’ where you can reach and access a doctor directly.”
LaGrelius blames the health insurance companies and other third parties, such as employer health plans and Medicare, for hindering family doctors’ efforts to provide the care their patients need.
“The third parties are demanding that they (doctors) see more patients per hour and making them fill out piles of paperwork through third parties to get paid,” he said. “It’s very disruptive and very unsatisfying. Doctors are running a hamster wheel.”
It’s the reason why many boutique doctors do not accept insurance, including Medicaid and Medicare, he said. MDVIP doctors accept insurance.
LaGrelius said it’s the main reason why so few medical students choose to go into primary care.
“Fifteen to 20 years ago, about half of med students went into primary care, but last year (2008), only 8 percent went into primary care, when it means working inside the insurance system,” he said.
LaGrelius believes that as more patients and doctors see the benefits of concierge care, more will choose it.
“We’re talking about the issue of freedom,” he said.
But there have been a number of controversies about different aspects of retainer-fee medical care.
Concierge care practices have sprung up around the country but are still rather limited.
MDVIP has about 280 doctors in 28 states in its network and SIMPD lists about 270 members, including two in Colorado.
Part of the reason for the slow growth of the field is probably due to the high cost of the retainer fees, said Dr. Mark Earnest, associate professor of medicine at the University of Colorado.
“If you look at median income, which is in the vicinity of $50,000 a year, and the average cost of coverage for a family of four with private insurance is somewhere around $12,000 a year, they’re already spending nearly a quarter of their income on health insurance,” he said.
“Asking them to spend another 5 to 10 percent of their income just to have a doctor ” the people who can afford to do this is a small section of the population.”
Earnest said he understands why some doctors are attracted to concierge care, but “we will not see huge numbers of it ” there are not enough people who can afford it or are willing to pay for it.”
LaGrelius disagreed, saying the average retainer fee ” $1,500 ” is quite affordable, since it translates to about $4 a day.
“This does not cater to the wealthy,” he said.
“How much does a smoker spend on cigarettes a day? They spend twice as much. You can spend $4 for a burger at McDonald’s. These are very affordable numbers if people would just get it out of their heads that their health care should be paid by third parties.”
Erik, 39, an Erie database administrator who did not want his last name used, said he was more than willing to pay for easy and direct access to his Louisville doctor, Erik Mondrow.
“I’m not a millionaire,” he said. “I’m of the mindset that time is money. That’s the benefit for me ” he’s only a phone call away. Making an appointment, getting yourself there, waiting there, seeing the doctor and going home takes hours. When you calculate that, I’m losing money.”
While Erik readily admits that concierge care is not for everyone, he said he considers it an investment in his health.
“Why would I not spend whatever for a year ” if I have to drop HBO ” to keep my doctor?” he said. “I know that it’s not something that you have to have, but my health is very important to me. I can adjust my lifestyle to address the need.”
When the country is in a recession and people are losing jobs and benefits, some might question the timing of doctors who switch to a retainer-fee practice.
But Darin Engelhardt, president of MDVIP, said there has been an increase in patients choosing concierge care.
“We have more patients joining these practices now than last year,” he said. “We have not seen any adverse impact from the economy.”
If anything, the recession has forced people to look at health care in a new light.
“Being able to go to work and be healthy is an important priority,” Engelhardt said.
He added that the retainer fees for MDVIP doctors have not changed in the past eight years.
“We want to make it affordable for most people at $1,500 a year,” he said. “That’s not a significant amount at $125 a month. It’s what many people would choose to spend on cable or cell phone service.”
Engelhardt also notes that 92 percent of MDVIP patients in the past five years have stayed with their doctor and renewed their annual retainer fee.
“Ninety-four percent of the patients responding to a 30-point satisfaction questionnaire responded ‘excellent’ or ‘very good’ to all aspects of the program,” he said.
“They are deriving a very high-quality service. This is not an easy time for people, but patients are embracing it (concierge care) as a real value.”
LaGrelius points to MDVIP studies that show retainer-fee patients have a much lower rate of hospitalization (53 percent) compared with the average patient.
“It’s an indication of doctor quality care,” he said. “That’s the bottom line.”
Engelhardt said the MDVIP studies showed even more impressive results when their patients were compared with Medicare and commercially insured patients.
The MDVIP studies surveyed 20,000 patients in five states ” California, Nevada, New York, Virginia and Arizona ” between 2004 and 2006.
He said there was a 56 percent to 65 percent reduction in hospitalization for MDVIP patients compared with Medicare patients, and a 61 percent to 66 percent reduction in hospital visits compared with patients using commercial insurance.
“The numbers are consistent across Medicare and the commercially insured,” he said. “It’s a pretty strong validation of the consistency of care.”
Engelhardt also disputed the notion that MDVIP patients are generally healthier than the average patient.
“The information on MDVIP patients is that they’re slightly sicker and have slightly more severe illness at hospitalization,” he said. “That leads to the possible conclusion that the program is not dramatically self-selecting, when our patients are slightly sicker at hospitalization.”
But not all doctors agree.
G. Caleb Alexander, an assistant professor with the Department of Medicine at the University of Chicago who has surveyed practices that use retainer fees versus those that don’t, is skeptical of the findings of the MDVIP studies.
“There has not been a randomized study of retainer versus non-retainer practices,” he said.
“Patients aren’t randomly allocated between them. There may be important differences in the health status of those who enroll (in concierge practices) and those who don’t. One has to be skeptical about claims of superiority of one practice model over another.”
He said retainer practices are also more likely to “attract people who are wealthier or could afford to spend the extra money” and “people who have a number of illnesses and believe that the retainer system would provide them with a higher standard of care.”
Engelhardt said MDVIP patients who were surveyed were representative of the general population.
“Generally, the practice looked like what it was like prior to joining MDVIP,” he said. “We may have a slightly older patient population, but we’re looking at a pretty wide distribution on the age continuum.”
Alexander is the co-author of a 2005 University of Chicago study that seems to show concierge care is not accessible to everyone.
Researchers found that while concierge doctors had fewer patients overall than physicians not on retainer, they also had fewer black, Hispanic and Medicare patients.
The survey also found that while most boutique doctors had converted from a regular practice, they kept only about 12 percent of their former patients.
On the other hand, about 84 percent of the concierge doctors surveyed provide charity care, and many continue to see some patients (about 17 percent) who do not pay retainer fees.
Alexander said the findings raise some ethical questions.
“Concerns have been raised about retainer-fee practices leading to patient abandonment as they convert, possible decrease in charity care and exacerbation of health care inequities,” Alexander said.
Engelhardt ,with MDVIP, said doctors in its network do not abandon their patients.
“We make sure that patients have ample information to decide what they want to do,” he said. “We make sure all patients who chose not to go with the continuity care plan, that while MDVIP provides a great choice, we make sure that patients who don’t want this type of care continue to be seen by a primary physician.”
If anything, he said, with the retainer-fee model, more doctors are able to do more charity work. He said there is a group of MDVIP doctors who are working on a project that serves 60 patients in Palm Beach County in California.
“Doctors see patients who are uninsured and within poverty level,” Engelhardt said.
“They do not pay the annual fee. The idea is for our physicians to give back to the community. It’s a worthwhile cause to open up the preventive care that is available to our patients for people who would not receive care like that.”
LaGrelius, with SIMPD, argues that if more doctors were to adopt the retainer-fee model, there would be less strain on hospitals.
“You will be getting away from hospitals and saving money,” he said. “You won’t have people stacked up in emergency rooms.”
But Alexander said that one of the key findings of his survey was the “significant overlap” between retainer and non-retainer services.
For example, a number of community doctors give their patients 24/7 access.
“It makes it more difficult to evaluate these practices” in terms of long-term effects on community health, Alexander said.
Earnest, with CU, said it would be very hard to show any hard outcomes ” such as people living longer ” as the result of receiving concierge care.
“I don’t think that translates to any real medical outcome,” he said.
“It’s a luxury item for people who want to pay for it. I think if you look at it from a community perspective, my hypothesis is that there is less care given to the community. When more practices are changing (into this model), the broad impact to the community will be negative, not positive.”
Still, Alexander said, in every country’s health care system, there have always been ways for people to buy additional care.
“Despite some ethical concerns that have been raised, I don’t think that most bioethicists would argue with this practice model,” he said.
So far, the number of concierge doctors in Colorado is so small that the Colorado Medical Society has not taken any kind of position on the practice.
“There is a concern that when you take care of the people who can pay for it, who is taking care of the people in the emergency rooms?” said Dean Holzkamp, director of communications for CMS.
“I don’t think it rises to a new trend in Colorado since there are so few who are doing it. It hasn’t risen to the level that the Medical Society has spent any time to research it.”