What the Hell Is Concierge Medicine?

Recently, I was dumped.


It seemed to come out of nowhere. As far as I knew, everything was fine, and I honestly had no reason to think otherwise. She dropped the axe by way of a letter, with plenty of flowery language to dress up the usual clichés: "I feel like I'm giving and giving, but getting little in return." "I'm just not happy with the way things are working out." "We both deserve better."

Then came the real shocker: "We can still see each other, but you'll have to start paying for my services out-of-pocket."

***

The letter was written by my primary care doctor, announcing an upcoming switch from a traditional medical practice to a new model: Concierge Medicine. This was a term I had never heard before, and I'm guessing most of her other patients hadn't either. (According to the US News & World Report, only 6% of practicing physicians in the USA ran concierge or cash-only practices in 2013.) It's a trend that's been taking hold in pockets and patches across the United States over the past few years, but it's still relatively unknown.

Although I was a bit skeptical, I tried to keep an open mind while reading the letter. The beginning seemed pretty reasonable, with statements that could get anybody nodding along:

Maintaining a private practice in the current managed care climate has become increasingly difficult... Regrettably, the current system is disease-focused as opposed to wellness-focused. Doctors are reimbursed for seeing ill patients frequently... There are no incentives for maintaining a patient's health and preventing the development of chronic disease

Any informed person would be hard-pressed to disagree with these statements. We've all heard about medical insurance companies working to maximize profits in backhanded, unethical ways. A significant portion of America's healthcare spending goes toward treatment of preventable diseases, instead of ways to help stop people from getting those diseases in the first place. Most doctors in the U.S. are reimbursed for tests and procedures rather than for helping people take steps toward healthier living. Of course this is a terrible way to go. Who could argue otherwise?

I fear that the system is going to worsen as the primary care physician shortage grows (approximately 50,000 short by 2025) and 30 million newly insured Obamacare patients seek treatment.

I understood her point - the thought of a doctor shortage in America is pretty terrifying - but couldn't help but notice an unsettling implication lurking below the surface. I'm fortunate enough to have had medical insurance before the Affordable Care Act was put into place, but I tried to imagine my reaction to this part of the letter if I had just gained insurance because of the ACA. I would probably feel portrayed as a parasite, a stupid newbie who's ruining everything for the people who were in The Health Insurance Club first. Besides, what's the alternative? Would it be better for less people to have access to affordable healthcare?

The gap will likely be filled by doctors with poor English language skills, nurse practitioners, physician assistants, and urgent care centers.

Ah yes, what good is fearmongering without a dash of dogwhistle racism? Beware, patients - if you thought non-Americans were scary before, just wait until you have to press 1 for English in a doctor's exam room.

As troubling as this sounds, there is another way – something I call personalized medicine.

The letter then goes on to sum up the basics of her new practice model, which admittedly turns out to be quite an appealing system. In concierge medicine, doctors create a more personalized, intimate relationship with their patients. Office visits involve the physician's total attention for a significant block of time – in my doctor's particular practice, up to a full half hour. Concierge doctors make house calls, give out their cell number, and offer round-the-clock answers to any medical inquiry their patients may have. No need to bother your roommate with a question like, "This is probably just a cold sore, right?" when you can snap a picture of it with your phone, text it to an actual M.D., and receive a credible answer within a few hours at most. Sounds pretty great, doesn't it?

As you might expect, the benefits of this type of personalized practice are only possible with a much smaller patient population.

Huh. A few paragraphs ago, we were all wringing our hands in panic over the impending doctor shortage. Now most of us are being cut loose to fend for ourselves? "Good luck out there, and beware of poor English language skills!"

The personalized practice... is sustained through a retainer model

Ah, the moment we've all been waiting for: The Catch.

Concierge doctors don't accept medical insurance. The only way to get in on a practice like this is to pay an annual out-of-pocket retainer fee. Under my doctor's model, the cost for my coverage would break down to $125 per month. ConciergeMedicineMD.com states that retainer fees in the U.S. range anywhere between $1500 up to $15,000 annually. Some concierge doctors charge their patients as much as $25,000 per year. On top of that, the retainer charge only covers your basic membership. If you come in for an office visit, you have to pay an extra fee. Need a house call? That's another extra fee. And if you're thinking of dropping your insurance altogether in favor of going 100% concierge, think again:

Patients with insurance are encouraged to keep their insurance for hospitalizations, medications, imaging studies and specialists.

Since primary care physicians aren't usually the ones who take the reins in the event of a medical emergency, all members of a concierge practice are advised to maintain their usual health insurance in case they need coverage for a serious medical problem involving a hospital stay, treatments from a specialist, or anything else warranting a four-figures-and-up pricetag. You'll be paying the retainer fee and appointment costs on top of what you're already paying for health insurance. This could add up rather quickly.

Please bear in mind that I'm not trying to pick on my former doctor as an individual. I am a firm believer in the eloquent, enduring life philosophy of "Don't hate the player, hate the game," and it certainly does apply here. I am also well aware of the frustration and the overworked/underappreciated feeling that many general practice doctors experience. The average reimbursement for primary care doctors is now a measly $72 per patient annually, and that's before taxes. Filing a health insurance claim costs money. A nursing staff costs money. Medical supplies, office space, and malpractice insurance all cost money, to say nothing of student loan debts from medical school. Primary care doctors hold a societal value that cannot be overstated, and if we want to attract the right people to this occupation, the right incentive has to be there.

That being said, why should it be the patients' responsibility to bear the burden of that incentive? It seems so incredibly wrong to drop the onus of monetary compensation directly on the most vulnerable factor in the health care equation. For many households, it's just not an option to spend an extra $125 per person per month, plus appointment fees, on top of the costs of medical insurance. And what about all the people left in the lurch after a doctor's reduced patient body reaches full capacity? If the earlier-mentioned prediction about an impending dearth of primary care physicians is true, this trend of doctors taking on a smaller number of patients is going to make the shortage even worse. Should medical care be framed as "I've got mine, screw everyone else," especially when the people doing that framing have taken the Hippocratic Oath?

The letter did not make one mention of a single-payer healthcare model, which ultimately would solve the problems created by private health insurance companies. Not to mention, hearing the virtues and praises of universal health care coming straight from a doctor's mouth would probably grab peoples' attention and help the issue gain more traction in the long run. Even now, the Affordable Care Act has a provision that encourages formation of Accountable Care Organizations, where doctors are rewarded for helping keep their patients healthy instead of treating them after they are already sick. But there's not one word about any of that - just the implication that "Obamacare" is going to make everybody less healthy because... it insures more people.

The old saying, "If you don't have your health, you have nothing" exists for a reason. A doctor's office is not a restaurant, or a salon, or a clothing boutique. It's a place people go when they are at their most vulnerable - they need to know why their throat won't stop hurting, or they want friendly reassurance that their mole is benign, or they have to get an assessment of that frightening pain in their side that just won't go away. A medical practice should be a place completely free of judgment and solely devoted to healing and nurturing. How is that supposed to happen if it becomes a market-driven service, and people with more money get more attention? Do doctors really want America's two-tiered healthcare system to have another tier?

As for me, I've done some reflection since receiving the letter, and I'm doing my best not to take it personally. I'm trying to get back out there and start seeing someone else – after looking around online, I think I've found a decent match in my area. Of course it's nerve-wracking to start a new relationship, especially one this intimate, but I'm trying to stay optimistic.

It's for my own good.

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