HAWAII and Concierge Care: The first of two parts examining the effects of a new health care model — concierge medical practices — in Hawaii.

The Health Beat: Emerging Health Care Model May Cost You More

By James Ireland 09/26/2013

Editor’s Note: This is the first of two parts examining the effects of a new health care model — concierge medical practices — in Hawaii.

KAILUA, HawaiiIt is estimated that the Patient Protection and Affordable Health Care Act, also known as Obamacare, will significantly increase access to doctors and health services for many people across the nation and Hawaii. This is good news — if you can find a doctor.

In states such as Hawaii, where there is already a well-known shortage of physicians, it is unclear how this increase in healthcare demand will be met. Researchers at the University of Hawaii John A. Burns School of Medicine estimate we are currently short nearly 750 physicians statewide.

Mid-level providers such as nurse practitioners and physicians’ assistants will help, but ultimately additional doctors are needed.

Medical schools, internship and residency programs that train new physicians have not yet collectively made significant enrollment adjustments to accommodate this increased need. After four years of medical school, all graduates must complete at least one year of post-graduate training, an internship, to see patients. A three-year internship and residency is required to become an internal medicine specialist, family practitioner or pediatrician.

Unfortunately, while medical school enrollment has increased nationwide, the required internship and residency positions that are federally funded have been capped for 16 years, creating a bottle-neck for new doctors. According to Dr. David G Kirch, the president of the Association of American Medical Colleges, in a release from the AAMC Reporter, “these (medical school) expansion efforts will not result in a single additional practicing physician until Congress lifts the 1997 cap on the number of residency training positions it supports through Medicare. Inaction will mean extensive shortages of both primary care physicians and a wide range of specialists.”

As this is happening, more physicians are feeling the frustrations of increasing costs, endless paperwork and declining insurance reimbursements. This reality coupled with a growing need for medical care has resulted in more and more patients being squeezed into a day’s clinic.

More patients are frustrated, too. Across the country, it takes longer to get a doctor’s appointment, waiting rooms are crowded and visits are shorter.

Some doctors are now saying enough is enough, and they are looking to a new practice model — one where they can spend sufficient time with their patients to deliver high quality health care. One Honolulu doctor I spoke with, who declined to be identified, felt he just could not deliver quality patient care in today’s environment.

In a sense, many physicians want to have the doctor-patient relationship that was common a generation ago. What has emerged is “concierge” or “boutique” medicine, which has now made its way to Hawaii.

Concierge medical practices offer a number of services to patients that are getting harder to find in many clinics today — personalized care, 24-hour access to your doctor and appointments “that will last as long as necessary to talk through all your concerns,” according to the MDVIP website, a company that offers this care in Hawaii and the mainland.

The cost for membership to MDVIP starts at $1,500 per year. Boutique clinics on the mainland have memberships that may reach $20,000 per year.

Concierge medical practices also limit their total number of patients, usually no more than 600 for the entire practice. This allows patients to easily get same-day appointments and spend an ample amount of time with their doctor.

When a traditional medical practice transitions to concierge, generally all patients get a letter explaining the new model, membership fees, and the opportunity to join. Once the practice is full at 600 patients, those who did not join must find another doctor. An average primary care practice has about 2,300 patients. This leaves the remaining 1,700 patients competing for the remaining primary care doctors and clinics in the area.

Four doctors on Oahu and two on Maui have now aligned with MDVIP, so there may be 10,000 or more patients looking for a new doctor from these practices alone.

Hilton Raethel, Chief Health Officer for HMSA, Hawaii’s largest private medical insurance provider, said, “We are confident that we can find participating providers for all our members. We do not support programs such as MDVIP because we do not believe that members should have to pay for services for which they are covered, nor should access to quality care be limited only to those who can afford it.”

Faumuina Lee Lauvao, a patient who elected to stay with her doctor in the transition to MDVIP was very happy with the program and felt the concept was a “great idea” especially the focus on prevention.

I also spoke with a group of patients displaced from one of the Oahu medical practices that aligned with MDVIP and they were upset, but understood the circumstances. Most would have stayed with their doctor, but the $1,500 a year was too much, especially when multiple family members required memberships. One patient commented, “I just couldn’t afford to join the country club.”

A message was left at MDVIP for comment, but was not returned.

Coming Friday: Doctors are dropping Medicaid and Medicare patients

Dr. James Ireland is an internist/nephrologist on Oahu and an Assistant Clinical Professor of Medicine at the John A. Burns School of Medicine. He is the former director of the Honolulu Emergency Services Department.


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