Concierge Medical Practice

Is Your Doctor Thinking About Switching to a Retainer Practice?

Concierge Medical Practice - Is your doctor switching to a practice with a retainer fee?. Tom Gill/Getty Images

Are you joining a concierge medical practice?

The Affordable Care Act, which President Obama signed into law in March 2010, includes mandatory health coverage for people without health insurance. Adding more than 30 million newly insured people into our health system will make the shortage of primary care physicians (PCPs) worse. There will be many more patients and a lot fewer primary care physicians!

Concierge Practices

Faced with the burdens of an aging population and low reimbursement for their services, many PCPs are leaving primary care or changing the way they practice. Some PCPs are switching to concierge practices, a growing trend, also known as retainer, boutique, or direct medical practices. They are controversial and many in the healthcare system think they will make the shortage of PCPs worse, especially in 2014 when many more Americans will have access to affordable health insurance.

The concierge practice model, allowing PCPs to offer more personalized care by decreasing the number of patients they care for from about 2000 to less than 1000, first appeared in the 1990’s. In return for these enhanced services, PCPs charge patients a retainer fee, which can range from about $1500 a year to as much as $15,000 per year depending on location and the type and extent of new services.

If you are in a retainer practice, your doctor may continue to bill your health plan for covered services, with the retainer (or supplement) you pay being used to pay for the extra services your doctor provides that are not covered by health insurance. Some doctors will not except any health insurance and will use the retained fee to pay for all services; this type of arrangement is known as a “cash-only“ or a “direct primary care” practice.

The ability to spend more time with patients, decrease the amount of paperwork and office administration, and make more money, improves physician satisfaction. And, patients who can afford the increased cost are likely to be more satisfied with the attention they get from their doctor.

Concierge Practice Services

If you are in a retainer practice you will continue to receive basic healthcare services that are traditionally provided by your doctor. Depending on how your doctor has set up the retainer practice (and perhaps how much extra you pay each month), you may receive some of the following additional services:

  • more time with physician during each visit
  • same day appointments or within 24 hours of calling
  • extended evening and weekend office hours
  • around-the-clock access to your physician, including 24-hour availability by pager, cell phone, or home phone
  • personalized coordination of hospital care
  • house calls
  • accompanied visits to specialists
  • procedures and services that may not be covered by traditional health insurance, such as annual physicals, preventive care, weight loss programs, and wellness advice
  • nicer and less crowded reception and waiting areas and spa-like amenities

The main selling points for most patients who decide to join a retainer practice are better and more immediate access to, and more undivided attention from, their physician.

Pros and Cons of Retainer Practices

Healthcare experts and others opposed to the concept of concierge practices are concerned that these practices promote a two-tiered health system that favors wealthier patients and reduce the number of physicians who are available to care for patients who cannot afford an additional fee.

While running a retainer practice may be more lucrative for some physicians and makes healthcare more convenient for their patients, it may make care less available for other patients who cannot afford (or choose not) to pay the required practice membership fees. Since Americans are already coping with a shortage of primary care physicians, the increasing numbers of concierge practices along with health reform changes (millions more with health insurance) may further place a burden on the people trying to find a PCP.

People who support retainer practices argue that the practices meet consumer demand, allow physicians to provide the treatment they deem necessary, improve both patient and doctor satisfaction, and improve quality of care by increasing the amount of time that can be spent on prevention and wellness services.

Physicians Debate Ethics of Retainer Practices

Among physicians there is an ongoing debate about the ethics of retainer practices that has become more heated since the passage of the Affordable Care Act and the concern about the worsening shortage of PCPs.

In an editorial – Concierge Medicine: A “Regular” Physician's Perspective – published in the Annals of Internal Medicine (a journal of the American College of Physicians) in March 2010, Dr. Michael Stillman, a primary care physician from the Boston University School of Medicine, raised concerns about the ethics and quality of care delivered in retainer practices, and urged the physician community to abandon “the neutrality with which the medical community has addressed” this issue thus far.

However, there is a growing interest among internal medicine physicians and family physicians to change their traditional practices to a retainer practice. Seminars are being offered around the country, including at annual meetings of various medical organizations.

For example, an affiliate of the American Academy of Family Physicians offers a seminar for physicians (for a fee of $800) “to learn the nuts and bolts of building a concierge practice.” An excerpt from the course description provides an interesting overview of the type of message physicians are getting about retainer practices:

Concierge medicine is emerging as the only solution for physicians to escape the failing health care system. Over 1,000,000 patients across the country are in a direct practice and 17,000 primary care doctors intend to transition to a direct practice in the next 5 years. Direct practice is a way to get back to practicing medicine without all of the interference of insurance companies. Physicians simply can no longer increase volume and push patients through an assembly line to survive, and yet practice quality care, while enjoying being a physician healer.

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