By Tammy Wort, Renal & Neurology News
March 20, 2014 — Urologist Marc Richman, MD, said he and his former colleagues used to joke with each other about the need to speed patients through visits. If a physician was in an exam room with a patient for longer than 5 minutes, they would ask, “What took you so long?”
They kept a sense of humor despite knowing that, to pay the bills, they had to see as many patients as possible. Eventually, he and fellow urologist Shane Geib, MD, decided they had had enough of the current model of care and decided to venture into a differ type of practice. The two physicians spent two years in research and preparation that resulted in the opening of Obsidian Men’s Health, a concierge medical practice in McLean, Va.
“We decided to say, ‘To heck with it all,’ and not take insurance,” Dr. Richman said. “Now we try to spend time with patients and get to know them and provide the education and care they deserve.”
Concierge medicine is a small movement. According to Medscape’s 2013 Compensation Reports, only about 2% of urologists and 1% of nephrologists practice this way. But for physicians working in that environment, the changes they make are far from insignificant.
Prepare to lose
Dr. Richman said there are two things physicians have to be prepared to go without when opening a concierge practice: referrals and surgeries. Most urologists are tied to a hospital and receive referrals from primary care providers in the region. This will change with a concierge model.
“You just show up and patients are there in a traditional practice, but not here,” Dr. Richman said. “You have to develop relationships and think about referral sources and market directly to patients as well.”
Physicians also have to know they may have to end or curtail their surgical practice. Dr. Richman said losing his surgical practice was difficult because he really enjoyed performing surgeries beyond the minor ones he does in their new office. He explained that it may be possible to enter into arrangements with hospitals to perform surgeries there if all the red tape that is involved can be deciphered. “We decided to avoid it and focus on the office setting,” Dr. Richman said.
Start with a plan
Part of any new plan is going to be setting fees and medical care packages. This is partially guesswork and partially analysis of the practice and market. Dr. Richman worked with a business consultant to determine their fee structure.
They wanted to work between 40 and 50 hours per week. They started there and determined how much would be needed to pay bills and make a reasonable salary. They also considered what they would be reimbursed for procedures and found out what they could about what other local concierge groups were charging.
Their practice is a two-tiered system. There is a set fee for a new-patient consultation that usually takes an hour. The second tier is for patients who will need more follow-up care. They also offer what Dr. Richman calls a “club fee” that allows greater access to physicians and appointments.
Patients can pay a fee that enables them to schedule an appointment within 48 hours and have e-mail and phone access to physicians during normal business hours. Another fee is offered for 24-hour access and is only purchased by a handful of clients, he said.
Nephrologist Axel Pfleuger, MD, PhD, said his concierge medicine practice, the Center for Comprehensive and Diagnostic Medicine on the Upper East Side of New York City, consists of a consultation fee or membership fee. His initial meeting with a patient is usually around 90 minutes and costs $500. Follow-up appointments are $250 for 30 minutes. His membership plan is $3,000 a year, which entitles patients to one visit a month and correspondence with him by phone and e-mail.
Give me time
Dr. Pfleuger, formerly director of the chronic kidney disease program at the Mayo Clinic in Rochester, Minn., where is an associate professor of medicine, said patient visits used to take 90 minutes, but this has since been whittled to 60 minutes and then 30 minutes. When he set up his concierge practice, he decided to continue the practice for which Mayo is famous—comprehensive diagnostic workups— on his own timeframe.
Each day he sees 5 or 6 patients for a full consultation and 10 or 20 patients for 30-minute visits. Instead of having patients follow the typical disease progression of moving from dialysis to transplantation, his goal is to improve kidney function or halt progression in patients. Dr. Pfleuger said he is able to do this for more than 90% of his patients.
Dr. Richman used to see 25 to 45 patients in a day and now sees about 8. He said he would rather spend time at a late appointment or weekend visit at a hospital, sometimes without reimbursement, than see more patients.
“It just seems like we have more time,” Dr. Richman said. “We are seeing far fewer patients, but are spending more time with them. There is so much less red tape, I can’t believe how much more time we have to spend with patients.”
Dr. Richman said his new practice is more comprehensive than his traditional one. Instead of just telling a patient he needs to quit smoking, now he spends time educating patients on why smoking is bad for an erection or their bladder. He also has more time to go into pros and cons of tests and various treatments; consult with other doctors involved in a patient’s care; and do more lab testing and overall health screening.
“I’m not a primary care provider, but I am looking for other conditions and overall health risk factors that could be causing sexual health problems,” Dr. Richman said. “I can educate him and tell him he needs to accomplish goals like losing weight, and I can send him to a nutritionist or personal trainer of if there are relationship issues.”
Dr. Pfleuger stressed that concierge medicine under current methods of capitation reimbursement emphasizes comprehensiveness of medical care and primary, secondary, and tertiary prevention, which in the long term reduces healthcare expenditures and improves morbidity and mortality. As a result, it represents a better mode of healthcare than procedure-oriented and complication-associated medicine, he said.
Moreover, Dr. Pfleuger pointed out that in concierge practices, patients typically get to see a highly qualified physician (he noted that he has published numerous research papers and is a nationally and internationally recognized speaker) and not a nurse or nurse practitioner, as this has become the “new” standard in the capitative system.
One option that allows physicians the best of both worlds is a hybrid practice. Wayne Lipton, managing partner of Concierge Choice Physicians based in Rockville Centre, N.Y., said this works best for specialists with low turnover and a stable patient base requiring ongoing care.
Lipton said anywhere from 3% to 10% of a practice takes part in the concierge model and the remainder are traditional patients. Concierge patients usually pay an annual fee that gives them an hour of defined time for a consultation, typically four to five times throughout the year. Physicians can block a day or time a day during the week to see these patients aside from their traditional practice.
Lipton said there is often a greater consultative and advocacy role created, built around non-covered services. The physician becomes a core provider who patients can go to for advice and education, often learning to manage secondary and tertiary effects of the core disease.
“The hybrid model will tap into a private source of revenue that can be married to the current approach to healthcare,” Lipton said. “It keeps doctors from throwing up their hands and saying they are not going to play anymore.”