Wednesday, October 11, 2006

Concierge Practices

Is it right and good for primary care doctors to change their regular practices into "concierge" or "boutique" practices? Most of the doctors associated with BIDMC have the traditional kind of arrangements with their patients, but a few have adopted this other model. Here is a portion of an essay written by my friend and colleague Dr. Harold Solomon on this topic. Please let us know how you feel about his approach and his point of view:

"Four years ago, in frustration, and after a 38-year career in internal medicine and nephrology, I closed my Beth Israel Deaconess Hospital-affiliated practice, reopened as a "concierge" physician. As an alternative to quitting medicine altogether, I joined MDVIP, a national association of physicians. I wanted to make a loud statement about the error of undervaluing primary care.

"MDVIP charges a $1500 annual fee, covering a prevention-oriented physical and wellness plan, other services- newsletter, personal health information CD, website, and internet services. I limit my practice to 600 patients. I participate in all insurance, HMO, and Medicare. Fewer patients means quick access, same day visits for acute problems, a personal touch. I rarely sign out to coverage. Unless I am in a plane, or abroad, I am the first contact for my patients’ after hours needs.

"I was moved to preserve the quality of my work, and was willing, for the first time in my career, to be a bit controversial. . . . 475 patients signed up, and to my surprise, I had overestimated signups by the rich by a third, underestimated the middle class patients by a third. The demographics of my practice did not change. This was not an "elite" patient group. Why did more rich patients leave that I expected? I did not understand then, but I do now. The upper class patients already know how to get special care. They become hospital donors, are connected socially. Many hospitals have development offices which promise better access in exchange for donations. At Boston's most famous hospital, there is a "concierge" floor. Donors of $1000 get a unique color hospital ID card which alerts employees of your importance. You get a free flu shot, ahead of the line!

"Most doctors defer to patients with stature -- politicians, celebrities, physicians, the wealthy. A former cabinet secretary left me angrily, and was seen within three days by a colleague whose practice is "closed", and who is a public figure in the movement for universal access in Massachusetts! I wondered who pried his closed door open!

"The argument against "boutique" medicine is that it creates a two-tiered system. I would argue that the US has had a multi-tiered system for many years, as does Great Britain, Germany, New Zealand, Denmark -- countries I have visited recently. Whenever the government, or insurors, limit care, a segment of society looks finds more. Instead of forcing mediocre primary care from the bottom up, why not force quality care from the top down?"


Anonymous said...

I don't care how the rich get their care. I care how the poor don't. Mass Health covers less expensive medicines, less mental health, less everything.

In an admittedly two-tier system, there are still poor patients seeing great doctors in great hospitals. In the boutique system, they can't even get in.

Anonymous said...

To make one thing absolutely clear: When it comes to hospital care at BIDMC, we provide exactly the same care regardless of a person's income. And, we have no concierge floor.

This posting is about how primary care doctors choose to run their practices, not how the hospital is run.

Anonymous said...

Maxine says,
I can understand the doctor's point of view, I think a good many of them don't have the time a patient needs anymore. Consequently they are not practicing medicine like they might want, and we patients feel rushed during a visit.

On the other hand, I had a doctor go concierge on me and I was devastated. While I would have loved to have followed him, I simply could not afford it.

It was interesting to see that he was surprised at the socio-economic status of the patients who followed him, but it still leaves a have/have not gap in medicine.

As a patient at BIDMC, I have never felt I was getting less than someone of more means.

Grindstone Healthcare Consulting said...

i think the physician is following good tenets of american capitalism. he has a product/service, developed a price and is being compensated for that service.

Anonymous said...

This morning on NPR my news was brought to me by BI Deac's gastroenterologists, offering "expedited colonoscopies" . . . . Is this concierge medicine without the concierge? Giving all patients the illusion of special treatment? Or a service with low volume hoping to gin up the numbers?

Anonymous said...

It is actually about providing a high level of service to everyone, not the illusion of that. That is one of things we are trying to do here to distinguish ourselves from others in town.

Doc A said...

To the average doc, what we see is decreasing revenue to the point of seeing more and more patients to stay financially stable. If anyone thinks care is not comprimised, you are fooling yourself. That leaves doctors with a very real ethical challenge: See less patients and don't pay your bills or continue to cram as many as possible into the day.

Primary care is not a financially rewarding career. This is not the sole reason for choosing this field, I realize. However, actually becoming a physician is incredibly expensive - both financially and timewise. Until we are compensated fairly you will see an increase in this type of practice.

I say good for him!

Unknown said...

The health system in USA, if at all there is one, was designed on a free-market, capitalistic system - like everything else - why should concierge medicine be blamed for 'tiering' the society ?

Either have a national health insurance plan that covers all, or let market forces play


Unknown said...

Interesting read and this will give us some "history" as time goes on. I can totally relate to the idea this system being for the rich and the middle class. My wife and I have chosen a $2000 deductible in relation to our insurance. If, and when, our health needs are not met by our current system, I will gladly pay extra to know that quality care is just a phone call away.