Concierge Practice Fundamentals©

By

Joseph P Dougan

March 7, 2024

IS A CONCIERGE PRACTICE RIGHT FOR YOU: 

Physician concierge practices (CP) are trending across the country.  They promise better care and treatment, albeit at a significant increase in medical expenses that are NOT covered by insurance.  If you have insurance and are considering being a patient in a physician’s concierge practice, there are a few topics you need to consider before investing a considerable amount of money.

1.     If you are on a fixed income or have limited resources, a concierge practice is probably not for you. 

2.     Your doctor will explain it will mean increased accessibility to the physician – (phone calls, emails, same day/next day appointments) longer appointment times, meaning more benefits and accessibility for you.  That can be true, but is it worth the expense?  Seriously consider just how much access you truly need from your doctor.  How often do you see your doctor now?  How many times per week, month, or year do you have questions that need to be answered 24/7?  Do not be misled into thinking this new fee-based concept is for your benefit; it was designed to increase the physician’s profit for less work.

3.     Many doctors claim the improved doctor/patient relationship is the main reason for choosing the concierge model.  The closer doctor-patient relationships represented to you is transaction-based and will only last if you pay your way.  The CP fees can increase annually.  Eventually, only the wealthy (elites) will be accommodated.

4.     As you age and your medical needs increase, your doctor is more likely to refer you to a fee-for-service specialist (cardiologist, oncologist, etc.).  Your primary care physician (PCP) will still be collecting their annual retainer.  Because you are under the Specialist’s plan of care, the treatment decisions, etc., for your chronic medical conditions are managed by others; your PCP is not involved.

When considering a physician’s concierge practice for you or your family, be sure to look at the ramifications in your decision-making.  I wrote this document to help you see both sides of the equation.  The basis for this analysis is derived from my career-long background in insurance, management, and consulting.  Additionally, my wife and I have been paying customers for over seven years in a concierge medicine clinic. 

I have a degree in Personnel and Industrial Relations and a master's studies in group and retirement benefits.  Prior to graduating from university, I served two tours in Vietnam as a commissioned officer and helicopter pilot.  I have been managing people and operations my entire adult life.

 In 1984, I entered the insurance industry, which, over time, led to Fortune 200 corporate-level management and consulting.  I specialized in personal insurance, group benefits, and retirement planning and have lectured at multiple major universities.   By design, I focused on collaborating with physician practices.  The most widespread problem I found is doctors may know how to treat symptoms and prescribe medicine but are extremely challenged managing their business or time.  Most doctors have never taken a business management course in medical school.  Many fail to understand the complex issues in hiring, managing a staff of people, and the ensuing paperwork.  They also do not understand billing/coding, insurance filing, malpractice liability, etc.  Hence, many doctors choose to join a corporate owned management system and avoid running their business altogether.  Essentially, they become employees of a corporation with a financial interest in the entity.

I have a bias against concierge practices developed from direct personal experience.  When I first became aware of the concierge concept, I cynically remarked the concept would now be bribing our physicians to do no harm.  The CP implies either other standard practice physicians do not have the time to properly treat you or the time to develop a close doctor/patient relationship necessary for proper medical care.  Some patients have been allowed to believe that a concierge medicine doctor is more qualified than one from the traditional standard practice.  This misrepresents the medical profession and is not true.  A case can be made that a physician seeing fewer patients per day in a concierge practice infers there is less practical medical experience.  At best, your subscription to concierge medicine will only be paying for the increased access and your personal peace of mind.  That does have an intrinsic value.

WHAT IS A CONCIERGE PRACTICE:

A concierge practice is a marketing tool designed to free up the physician’s time by separating you from more of your disposable but non-reimbursable income; your insurance does not cover the CP’s upfront fee (paid monthly, quarterly, annually.)   There are a few concierge medicine programs that do not take insurance; however, most require you to be on an accepted insurance program.  Based on your insurance plan, the CP will still file for insurance and collect your co-pay for appointments.

The promotional pitch is that your doctor will limit their practice to a set number of patients, typically a much smaller total patient panel than a traditional practice.  They will then be able to spend more quality time with each patient.  This allows you greater access personally via in-office, direct phone, Facetime, texting, or email communications. 

At face value, this may make sense to a younger patient who is used to immediate and streamlined communications.  However,  I am old enough (77) to remember when doctors came to the patient’s house; mothers had to boil water to sterilize the syringes and hypodermic needles.  Family doctors were dedicated to their profession and built longstanding patient-family relationships.  Now, however, the physicians focus on their bottom line.  Medicine is no longer a vocation but a job with a large financial risk.   Patients are lucky to be secondary inclusions in their evaluations.  You must pay the physicians extra to ensure you get the medical care you deserve.

HOW DOES IT WORK:

The concierge business model allows the physician to grow their business three ways.  If the doctor wants a more flexible work-life balance, they can restrict their patient base.  The insurance carriers adjust their payment based on cost of living (COL); however, to keep up with the income the doctors have become accustomed to requires the physician to continually raise their annual retainer fee.  Fewer patients will require increased retainer fees.

As the business grows, they can employ Physician’s Assistants or Nurse Practitioners.  Under this option, when you require medical attention, there is no guarantee that you will see the physician whose practice you helped build.  Rapidly developing artificial intelligence (AI) medical models cannot be far behind.  Medical treatment algorithms have been in use for years.

Finally, if the doctor or corporation wants to expand their practice, they can continually take on new patients and increase their originally promised smaller patient panel size.  This will increase the revenue base but must compromise the doctor’s ability to provide the same level of personalized care.  An uncapped service contract does not preclude the CP from raising their annual fee year after year.  Being on a fixed or limited income, you may be priced out of the program as annual fees can go up dramatically.  Now that you are older with increased medical needs, you will have spent years and thousands of dollars investing in a doctor/patient relationship that will not be there for you as promised at a time when you need them.  Loyalty is a one-way street in a concierge practice, and it must be purchased.  This is the ultimate betrayal between a doctor and a patient.

PERSONAL EXPERIENCE:

The fee to access this special physician/patient relationship in the Dallas, TX area is approaching $5000/yr for an individual.  This annual fee is seldom capped and is subject to increases based on the corporation or practice needs.  Exactly how does that benefit you?  There are no regulations regarding fees; it is all contractual.  A patient will have limited options.   Without a cap on the annual fee, you have entered into an open-ended agreement with no long-term benefit to you.

I do not begrudge anyone from being financially successful; I was there once.  What I object to is the misrepresentation that the CP model supports and develops a meaningful and mutually beneficial doctor-patient relationship when, in fact, the CP’s model goal is purely financial.  

A few years ago, my wife’s young primary care internist joined a concierge practice.  I was skeptical, but objecting was out of the question.  She loved her doctor and with good reason.  Her physician was highly competent and engaging.  “Happy Wife, Happy Life,” so we spent the $2000 per year for her physician’s new practice.

Eventually, I lost my internist of twenty-five years.  I have multiple serious medical issues, including inoperable metastatic cancer, heart disease, pain management, etc.  Four highly specialized physicians treat me.  There is not a month out of the year that I am not in a doctor’s office or receiving treatments.

In looking for a new PCP, I wanted a Gatekeeper to oversee my treatment programs and be available to answer medical questions and, eventually, end-of-life issues.  This is complicated by the fact that I am difficult to work with; I question and  challenge everything medical regarding the overused phrase “evidence-based medicine.”  Most doctors do not like to be questioned by their patients.  So, before investing in a new doctor-patient relationship, I interview all my doctors.  I need to be sure there is communication compatibility between us.  If you cannot talk openly with your provider, what is the point? 

I  began interviewing new internists.  I also interviewed my wife’s CP doctor and presented her with an extensive, detailed document outlining who I am and what I am looking for in a primary care physician. 

I do not want a friend for a physician, but I want someone that I can access on an as-needed basis.  Friends can be too close to the relationship and miss trivial things that do not seem important when only treating symptoms.  I am one who believes when you hear hoofbeats, you also need to also think, Zebras. 

My wife’s doctor accepted my requirements, and by paraphrasing, she  stated, “I want to be your doctor ‘til you are 100.”  Trusting in her comment and my wife’s judgment, I signed my $2000 contract ($4000 annually for the two of us.)

I finally had what I needed, a doctor I could communicate with at will and who would be there until the end, though at a considerable family retirement expense.  I called my new PCP, my email buddy.  I routinely do medical research.  Being able to review what I have found regarding my treatments, drugs, etc., with my PCP gave me peace of mind.  More importantly, as the relationship developed, we bonded;  I trusted her.

A concierge practice is a good management tool for the physician.  If the practice is limited, each January the CP can multiply the patient base by the annual fee, less corporate partnership fees, to see what their patient nest egg represents.

Once the patient becomes acclimated to paying the annual or quarterly fees, eventually, the other shoe drops.  The fee will increase, sometimes incrementally, but other times exorbitantly.  Our latest increase was almost 34%.  What do I get for this $750 increase when this year (2024) Social Security only went up 3.2%?

Taken from the practice’s rate increase letter:

“·  USB flash drive or DVD disk upon request, with curated content of personal health records 

 ·  EKG tracing with physician interpretation upon request, provided in a laminated, miniaturized wallet-sized format.”

FYI: your personal health records must be provided to you by law, if requested.  If you are my age, the EKG tracing is going to be in your cardiologist’s office though not neatly encased in a fifty-cent piece of laminate i.e., who cares?

After two rate increases, our doctor is charging existing patients $3000 per year.  New patients will start at $5000, again with no cap on the fees.  When my wife and I leave the practice and its misrepresented promises, the physician must only find two new patients to get another $4000 raise.  Our doctor is not concerned about losing the individuals who helped build her thriving and lucrative business.  To us, our investment into this physician was a very personal decision with long term personal financial consequences.  For the doctor, it was clearly a business decision.  There is never a downside to a CP physician.  Find two more patients with deep pockets to be there  “ … ‘till you are 100.” 

As a consolation, to mitigate the fee increase, our doctor has given us the option to refer us to another physician in their clinic who does not charge as much.  Presumably, we can help build another new doctor’s practice and await their 34% ++  rate increase.

Peace of mind has a financially limiting value.  In the seven years I have been with this CP, I spent almost $15000 ($30000/family) on retainer fees.  Because four Specialists manage my serious chronic health conditions, I have only seen my PCP in person a handful of times; most issues were resolved with an email or phone call.  When I had serious medical issues, I was directed back to a fee-for-service Specialist not affiliated with the concierge practice.

IS IT WORTH THE EXPENSE:

Under the CP’s revised terms of service, the money I will save by not continuing with the CP could pay for multiple visits to a Doc-in-the-Box if I need care for an acute treatable sickness with plenty left over.  If the condition is more serious, I can pay the hospital emergency room co-pay and be dollars ahead.  If needed, the ER will refer me to a specialist as did my internist.  For less than this annual increase alone, I can subscribe to multiple medical AI sites as they become available.

At least with those options, I will avoid investing in the façade of a doctor-patient relationship.  Exercising any of these options, there is no betrayal of trust or an investment in false relationship building.

Remember, paying more for a CP service does not mean you are getting a more qualified, educated, or dedicated doctor.  In fact, the opposite can be true; think Zebra.

If money is no object, a concierge practice might work for you.  However, if managing your money is a necessity, I do not think a concierge practice is a prudent, shrewd, or affordable investment.  At best, it is a luxury expense built on false promises.

Didn’t understand some of the language or acronyms … there is a glossary that is updated weekly on my SubStack page, https://josephdougan.substack.com/publish/posts  “Dad to English .. English to Dad.”

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