By Nancy Vickers | Tuesday, December 18, 2012 at 10:53 am
In the late 1990s, creative physicians dissatisfied with the status quo decided to opt out of the insurance-based medical system, to invent another way to care for their patients, in Seattle, Washington and Fort Myers, Florida. This movement came to be known as Direct, Concierge, Boutique or Private medicine.
In a direct health care practice, a health care provider charges a patient a set fee for all primary care services provided in their office, regardless of the number of visits. Patients pay a monthly fee. No insurance plan is involved, although patients may have insurance coverage for more costly medical services. Direct practices are sometimes called retainer or concierge practices.
As Knowledge@Wharton notes, “For anyone who has ever waited days or weeks to see the doctor, concierge medicine sounds appealing: For an additional fee, patients typically enjoy same-day appointments and 24-hour access, more face time with the doctor, and extra preventative care. Doctors who offer concierge medicine say the practice frees them from the constraints imposed by insurance providers and allows them time to give patients the individualized attention they need. Skeptics argue that concierge medicine promotes a two-tiered system, improving health care for a few but worsening it for everyone else.”
The American Academy of Private Physicians, (AAPP), is a national association of physicians who provide concierge medicine and fee-for-service health care. There are now several thousand concierge doctors in the U.S., serving almost a million patients. According to the AAPP’s executive director, 75 percent of concierge physicians hold on to their traditional practice, but take additional fees from a small number of patients who receive special perks, priority treatment and services not covered by traditional insurance. On the other end of the spectrum, doctors forgo relationships with Medicare, Medicaid and insurance carriers entirely, building their practice exclusively on patients willing to pay annual retainer fees for care. Depending upon the services, fees range from as little as $60 per year up to $30,000 per year. The majority of patients still carry health insurance to pay for specialized services that their concierge doctor is unable to provide.
However, as Constance Gustke notes in Bankrate.com, “concierge medicine” that offers a higher level of personal attention is morphing into a more affordable health care option for the masses, with lower yearly fees and more plan options. As a result, more patients are enjoying 24-hour access to doctors, longer office visits and even house calls. A “hybrid” model, such as Concierge Choice Physicians provides, helps physicians incorporate both concierge and traditional medicine under a single practice. Over 200 practices in 20 states are aligned with Concierge Choice Physicians. An amednews.com article discusses the various types of concierge-medicine practices, such as retainer medical practices, as well as their pros, cons and ethical considerations.
Washington State’s insurance commissioner discusses how other states regulate concierge medicine practices, in a 2009 annual report to the legislature:
“When state insurance commissioners have evaluated direct practices, most have concluded, as Washington did, that the practices are transacting insurance. However, at present, only one state imposes insurer level financial requirements and operational standards on direct practices. California requires direct practices to comply with the Knox-Keen Act, the California law regulating health maintenance organizations.
West Virginia specifically created a pilot program of prepaid medical services, partly due to the state insurance commissioner’s pronouncement that direct practice is insurance. The pilot expires in 2009. In other states, such as Massachusetts, bills introduced to study concierge medicine have not passed the legislature.
In 2009, Maryland’s insurance commissioner began investigating whether concierge medicine practiced in that state violated the state’s insurance law.
A bill is pending in New York to pave the way for conciergists, and legislation is expected to be reintroduced in Indiana to do the same.”
At its meeting in Austin, Texas December 1-2, 2012, CSG’s Committee on Suggested State Legislation decided to include SSL drafts about retainer medical practices and concierge medicine, based on Oregon and Washington law, in the upcoming 2014 Suggested State Legislation volume.
Retainer Medical Practices, based on Oregon SB 86 (Enrolled) of 2011, defines a medical retainer practice and sets criteria for becoming a certified medical retainer practice.
Concierge Medicine, based on Washington Chapter 267, Laws of 2007, finds the public policy of the state is to promote access to medical care for all citizens and encourage innovative arrangements between patients and providers that will help provide all citizens with a medical home.
It declares that the state needs a multipronged approach to provide adequate health care to many citizens who lack adequate access to it. It states that direct patient-provider practices, in which patients enter into a direct relationship with medical practitioners and pay a fixed amount directly to the health care provider for primary care services, represent an innovative, affordable option which could improve access to medical care, reduce the number of people who now lack such access, and cut down on emergency room use for primary care purposes, thereby freeing up emergency room facilities to treat true emergencies.
The Act provides that a “health care service contractor” does not include direct patient-provider primary care practices. It provides that direct practices must submit annual statements to the office of insurance commissioner specifying the number of providers in each practice, total number of patients being served, providers’ names, and the business address for each direct practice. The form for the annual statement will be developed in a manner prescribed by the commissioner.
It directs the state insurance commissioner to submit a study of direct care practices to the appropriate committees of the senate and house of representatives. The study shall include an analysis of the extent to which direct care practices:
- Improve or reduce access to primary health care services by recipients of Medicare and Medicaid, individuals with private health insurance, and the uninsured;
- Provide adequate protection for consumers from practice bankruptcy, practice decisions to drop participants, or health conditions not covered by direct care practices;
- Increase premium costs for individuals who have health coverage through traditional health insurance;
- Have an impact on a health carrier’s ability to meet network adequacy standards set by the commissioner or state health purchasing agencies; and
- Cover a population that is different from individuals covered through traditional health insurance.
The bill requires the study to also examine the extent to which individuals and families participating in a direct care practice maintain health coverage for health conditions not covered by the direct care practice. It directs the commissioner to recommend to the legislature whether the statutory authority for direct care practices to operate should be continued, modified, or repealed.