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Weekly Updates"Concierge" medical practices could help change the face of primary care as physicians establish closer relationships with their patients--and distance themselves from insurance
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Nearly everyone in the debate over health-care reform agrees on a few simple principles: that in a country as wealthy as the United States it is a travesty that 45 million people lack health insurance; that health-care costs are out of sight and rising; and that something needs to be done.
At the forefront in the battle for reform is primary care. Primary care physicians--family practice doctors, pediatricians, internists, OBGYNs--are essentially the gatekeepers in the system that has evolved over the years, called managed care.
People with private and company-sponsored health insurance, and those in the Medicare system, are required to visit their primary care physician for nearly every medical need, and that doctor is then charged with offering treatment or referring the patient to a specialist. Under managed care, observers say, primary care physicians handle as many as 2,500 patients, upwards of 25 a day, and the model is set up as "sick" care, rather than focusing on "wellness."
While it isn't a groundswell yet, thousands of primary care physicians nationwide and some in Colorado (no one has authoritative statistics) are simply opting out of the "sick" model of practice in overcrowded conditions, and moving to a "wellness"-based practice with fewer patients that allows doctors to spend more time with each one and a concentrate on managing health.
This type of primary care practice is generally referred to as "concierge" medicine, "boutique" medicine or, as the largest group to launch such practices calls it, "Personalized Prevention Care." It takes many forms, is manifest in franchise models and in go-it-alone efforts and eschews any direct involvement with health insurance or allows insurance on a limited basis. At its core, concierge medicine is the ultimate rejection of managed care.
OPTING OUT
After 11 years of coping with what he calls a dysfunctional health-care system, Denver primary care physician Dr. Fred Grover Jr. has decided to opt out of managed care, taking the go-it-alone route to a wellness-based "hybrid concierge model." He practices in the Cherry Creek area under the practice title "Revolutionary M.D., Advanced Prevention and Wellness."
Like most physicians making the switch, Grover sent his existing patients a letter describing his reasons for making the transition and invited them to join him. The new practice launched in late spring. He does not accept insurance and charges $1,500 a year per patient for his concierge plan (with discounts for additional family members). For those who can't afford the annual plan he offers a pay-as-you go a la carte service for each visit. His concierge plan includes quarterly wellness coaching, goal setting and additional services not found in other concierge plans.
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"I apologize, but I am no longer accepting insurance in my practice," Grover says on his website (www.revolutionarymd.com). "This was a difficult decision to make, but wellness based primary care is inadequately supported by managed care. If you have an insurance plan, health savings account or Flex account that accepts out-of-network providers you should be able to submit the superbill I give you for partial reimbursement."
In an interview with ColoradoBiz, he says, "Family physicians have not seen a significant pay raise in 10 years to adjust for rising overhead. Most are being driven to see 25 to 30 patients a day to compensate for the flat to decreasing reimbursement from plans. This limits visit times to less than five minutes, which is inadequate to provide preventative counseling and drives physicians to write prescriptions to get patients out the door.
"Phone calls for prior authorizations, and paperwork associated with managed care took away time from direct patient care, making medicine much less enjoyable," he says. "Poor to no reimbursement for preventative and wellness counseling in areas such as weight loss counseling and smoking cessation limited my ability to provide optimal care for patients, which I was trained for. How can our system not support counseling for weight loss and smoking cessation when these are two of the biggest killers in our country? Outcomes can be catastrophic for the system and patient when opportunities for preventative care are missed."
The system he left also discourages doctors by making their practices difficult to sustain, he says.
"Many family docs are reaching a tipping point and are choosing to retire early, or change occupations due to the environment created by the current managed care environment," Grover says. "Many are going bankrupt, or burning out trying to keep their practice afloat by seeing more patients each day."
The goal, Grover says, is to practice medicine the way he had always envisioned it--in a patient-centered, wellness and preventative-focused manner--the way he was trained. The soft-spoken advocate for healthy living sees his new practice as a way to provide much more thorough, personalized care. He says office visits now run anywhere from 30 to 90 minutes.
"This gives me time to promote wellness and prevention, manage chronic disease more effectively, and to apply my expertise in family medicine, anti-aging medicine, bio-identical hormone replacement, and other therapies when applicable," according to his website.
Although the end result is a smaller practice, that wasn't necessarily the goal, he says.
"I can do well with 15 patients a day," he says during the ColoradoBiz interview. "Practice size wasn't a huge issue. The goal was to get away from managed care."
On a personal note, this reporter, Jeff Rundles, and his wife have been patients of Crover's for more than a year and have opted to remain in the a la carte program. We carry comprehensive health insurance, but we were frustrated with our previous primary care practice because we felt the doctors--whom we liked very much--never seemed to have enough time to spend with us. Graver's appointments are unrushed, take as long as they need to take, and his concentration on wellness--the questions he asks us about diet, exercise, stress, and the coaching and counseling he offers--makes us feel as though we are receiving better medical care than we have in years.
VIP MEDICINE
Grover is not alone. At least six other primary care physicians in Colorado have opted to go "concierge." Dr. Kevin Lutz of Denver has a go-it-alone model like Grover's. Two, Dr. Michelle Eads of Woodland Park, and Dr. Erik Mondrow of Louisville, use a franchise model through the Society for Innovative Medical Practice Design (www.simpd.org) in Richmond, Va. And three others, Dr. David M. Abbey and Dr. Robert C. Homburg, both of Fort Collins, and Dr. Jon J. Cram, of Littleton, operate through another national franchise organization called MDVIP (www.mdvip.com) of Boca Raton, Fla.
The most notable franchise concierge model is MDVIP, which has in nine years enrolled more than 300 physicians in 27 states and Washington, D.C., with Colorado the latest state to join in. All three Colorado members launched their new practices in June. The member doctors were unavailable for comment. However, MDVIP officials in Florida were more than willing to talk about their personalized prevention care model.
"Primary care has become frustrating, with the size of the practice upwards of 2,500 with only seven to 10 minutes for a patient to see a primary care doctor," says Darin Engelhardt, president of MDVIP and a lawyer by training. "And it's equally frustrating for the physicians. They are focused on treating the illness, and that certainly wasn't the intent of the physician (coming out of school).
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"So we thought, how could we re-orient primary care to put the focus on preventative medicine and wellness?" he says.
The MDVIP model, once a doctor signs up, limits the practice to a maximum of 600 patients who each pay $ 1,500 a year, or $ 125 a month. The doctor keeps $ 1,000 of that fee, and MDVIP's "margin" is in the other $500.
Like most of these types of practices, MDVIP begins with an annual detailed physical exam, with multiple screenings for things like sleep disorders, depression, exercise, nutrition, pulmonary function, EKG, lab panels and more, based on a protocol called the National Executive Physical Program, Engelhardt says.
"It serves as a starting point," he says. "Now we have wonderfully detailed information to use so the physician may serve as a coach. All of these preventative care services could not have been provided (in managed care) due to the limitation of time."
Beyond the physical, MDVIP patients enjoy unlimited doctor visits, which can be booked on short notice, and great access to their primary care physician via cell phone and Internet. There is also reciprocity in the system, so if patients are traveling and there is an MDVIP physician in the area, they can visit those doctors at no additional charge.
Critics of the concierge medical movement charge that the fee-based practice is elitist and caters to the wealthy, but Engelhardt dismisses that notion.
"In the context of MDVIP, that is not true," he says. "At $125 a month, that's the same people pay for cable or a cell phone. We have found that the demographics of the previous practice (of its members under managed care) are the same once the switch is made--except that it skews a little older. We have seen success in all types of economic settings, urban and suburban. One of the things that surprised us was the breadth of interest in this model, especially geographic. We did not expect the appeal of the practice being embraced by so many people--doctors and patients alike--in so many places."
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