“We have just seen a really big upsurge in new practice start-ups” in the past half-year, said Mary Pat Whaley, a consultant at North Carolina-based Manage My Practice. “It kind of surprised us.”
That shift, however, fits with the findings of the Physicians Foundation’s 2012 biennial survey of 13,575 physicians. Results released in September showed that more than half of doctors plan to reduce their number of patients, work part-time, retire, move to concierge medicine, or otherwise cut patient access within three years.
Many physicians who became employees of big practices, health systems, or hospitals for income security are chafing at their lack of control, Mrs. Whaley said. After being trained to solve problems and be independent thinkers, “when they get into corporate health care, so to speak, a lot of them can’t stand it.”
But those doctors know the old “Marcus Welby” practice doesn’t work anymore, so they are trying different models. These range from the bare-bones micropractice, in which a physician rents an exam room in another medical practice and sees a limited number of patients with no staff; to the house-call practice, revived by the aging-in-place movement and increased Medicare payments for the service; to an orthopedist whom Mrs. Whaley said has no office but has contracts with primary care practices to provide their orthopedic care.
The most popular option appears to be concierge medicine, also called boutique care, direct primary care, fee for care, and retainer-based care.
The idea is that a doctor charges a monthly or annual fee in exchange for standard services, such as annual physicals and routine sick calls, and applies insurance for special needs, from MRIs and lab work, to surgery and treatment of serious disease. That approach is similar to car care, for which most people pay out of pocket for routine and preventive maintenance and turn to insurance for big, unexpected repairs. Like auto insurance, concierge care is not just for the wealthy.
Mrs. Whaley said there always will be a demand and supply for luxury health care, and traditional health insurance isn’t going away. But direct primary care provides a middle path.
In exchange for $1,500 to $2,500 a year for a full concierge approach, or perhaps $39 a month for direct primary care that might include a $10 charge for office visits, patients get to spend at least half an hour with their doctors instead of the 10 minutes typical in traditional practices. Doctors who carry fewer patients often offer them additional access by phone, email, and other electronic means.
Including health insurance for catastrophic care, the total price can be an affordable alternative to traditional, cover-everything health insurance, especially for young families, Mrs. Whaley said. The Physicians Foundation survey found that 6.8 percent of physicians plan to try a concierge approach within three years, little changed from 7 percent in 2008. That interest is much lower in Pennsylvania at 4.5 percent, according to a Becker’s Hospital Review report on the survey.
The decade-old American Academy of Private Physicians said the United States ended 2012 with 4,400 concierge doctors, a number projected to double within three years, Bankrate.com reported.
The Find a Physician search on the academy’s site produced six listings in Pennsylvania, the closest to Philadelphia being in Newtown and Washington Crossing. MDVIP, whose doctors charge $1,500 to $1,800 a year, arrived in the area in February 2005 when Wayne internist Jon Yardney joined. About two dozen of MDVIP’s 600 affiliate physicians are within 40 miles of Philadelphia, including four with full practices.
Sometimes health systems accommodate a concierge practice, an approach that works for MDVIP because it provides support services without owning or managing practices.
Wynnewood primary care physicians Daniel Lazowick and William Schetman, for example, became MDVIP affiliates Feb. 26 while remaining with Main Line Health.
University of Pennsylvania Health System also is trying the concierge approach. Gary Dorshimer and Gary Crooks offer Penn Personalized Care for an annual fee to supplement Medicare or insurance coverage.
Another direct care model coming soon to Lionville is MedLion, which started in California. Marcus Williams, a doctor at Chester County Hospital, hopes to have his practice running by May; it will be the first MedLion practice on the East Coast.
About 40 percent of MedLion patients have no insurance, and the company helps them negotiate cash prices for X-rays, labs, and specialty care. The rest of the patients have insurance. The direct care practice provides 60 percent to 70 percent of patients’ care.
“We learn their insurance and work with it,” Dr. Williams said. “We become a patient care advocate and help them utilize their insurance to their best advantage for their health.”
Doctors traditionally have avoided considering patients’ insurance when caring for them, choosing not to “look at the 800-pound gorilla in face,” Dr. Williams said. But, for example, sending a patient to an ear, nose and throat specialist for a sinus infection is dumb. Direct care doctors are slower to make referrals.
In a traditional practice, doctors need as many patients as possible to come into their offices. Otherwise, they can’t bill the insurance and don’t make a profit. But when doctors are working under a monthly retainer and aren’t billing insurance anyway, they can take care of things like prescription renewals and blood pressure checks through telemedicine, phone calls, and email.
“We can take care of a lot of things through the Internet in a secure fashion. That keeps the office visits down so we can spend time with those who are sick,” Dr. Williams said.
The twist with his practice is that he won’t have his own patients. Instead, he’ll partner with four or five nurse practitioners and physician assistants, each of whom will build a panel of 1,500 patients, half the typical amount for a traditional practice. Dr. Williams will be available to consult and advise as needed for any of those patients.
Taking advantage of the skills of nurse practitioners and physician assistants and treating them as equal partners will help address the long-term shortage of primary care doctors, a gap medical schools won’t be able to fill for decades, he said.
Direct primary care also will help with the shortage by paying primary care doctors more money, making it a more attractive specialty, he said.
“I was completely against Obamacare, like most physicians, but whoever created this direct primary care opportunity – they must have been a very astute person.”