By Benjamin Lanka CentralOhio.com
MAY 27, 2014 – Dr. Jeffrey Milks’ medical office in New Albany looks like that of most doctors. It has a lab, patient rooms and a reception area.
But something about the waiting room would be jarring for patients of many physicians: It’s empty.
“This is the least used room in the office,” Milks said. “Nobody ever waits.”
With declining reimbursements from Medicare, Medicaid and even insurance, many doctors are forced to take more patients to maintain revenue. That often leads to long waits for appointments and short visits when a doctor finally sees a patient.
A 2014 survey by Vitals found patients wait more than 20 minutes on average yet get only six minutes of face time with a doctor at the appointment.
The time crunch might get worse with federal health care reform and Medicaid expansion providing access to health insurance to more people. Such realities have some doctors considering retiring early or an alternative practice.
“Jeff was always behind. Patients were waiting an hour to see him,” said Deb Milks, Jeffrey Milks’ wife and a nurse at the practice.
That changed eight years ago when a patient suggested Jeffrey Milks investigate the concept of concierge medicine, a system in which patients pay an annual retainer to their doctor for more exclusive and available access to health care.
The Milks’ story resembles those of doctors across the country becoming stressed with patients and paperwork, said Tom Blue, chief strategy officer with the American Academy of Private Physicians.
“Ultimately, having more time with patients, either to deepen their relationship or enhance the quality of care, is the driving motivation behind most of these doctors,” Blue said of physicians who go into concierge medicine.
The practice started on the coasts but has now spread across the U.S., he said, with 5,500 such doctors — a number that is growing at about 25 percent annually. Instead of seeing 1,800 to 2,500 patients, doctors see between 300 and 600.
“These practices have gotten so bloated,” he said. “It’s a recipe for frustration for the doctors and patients as well.”
Jeffrey Milks, who was seeing dozens of patients a day — and more than 60 while working urgent care — now sees roughly eight per day and is able to spend 30 minutes or more with each one. After contemplating retiring with some of his fellow doctors because of the stress, he now sees no end to his practice.
“I love medicine again,” he said.
Cause of concern
The causes of stress for primary care doctors are pervasive and systemic, said Dr. Randy Wexler, a family physician with the Wexner Medical Center at Ohio State University.
For one, doctor reimbursements from insurers are largely based on face-to-face visits. Though doctors can get paid more if they provide more services during those visits, Wexler said, getting higher fees is difficult.
For example, he could be paid the same for helping a patient with 12 problems as he is paid for helping a patient with three. That essentially encourages doctors to see as many patients as possible in a day for a short amount of time each.
In addition, primary care physicians have become inundated with paperwork, as specialists and other physicians run all their documents through patients’ primary care doctors. And although he must handle all that paperwork, he doesn’t get paid for it. That adds a burden on top of the general increasing costs of running a practice.
“Primary care physicians have basically become the paperwork provider of the medical world,” he said.
Changing the game
Dr. Larry Doss said he spends the first half of his 10-hour day completing paperwork and returning patient calls. But instead of seeing patients for the other five hours in his office, he travels to their homes.
The self-styled “old-time country doctor” specializes in house calls, a practice that he said increases patients’ trust in him and allows him more time and access to treat them. One patient even donated her dog because he was viewed as nearly family. Tiny, a Welsh corgi, still lives with Doss in his home on the outskirts of Lancaster.
“There is a small subset of patients who really need to feel they are in control, and they can’t feel that if they’re going to a clinic,” he said.
In addition, traveling to the home gives Doss a firsthand look at a person’s lifestyle and allows him to better diagnosis any issues.
Doss does not practice concierge medicine, as he doesn’t charge a retainer. Instead, he’s decided to keep working in today’s environment by reducing the area in which he provides services, cutting staff and simply making less money.
At his peak, he was driving 4,000 miles a month to see patients; that’s down to 2,400 now. He said he isn’t a fan of concierge medicine, viewing it as too elitist.
Stories of doctors charging $25,000 a year for their services are fun to talk about, Blue said, but such high-end practitioners make up roughly 1 percent of the concierge medicine industry. He said the average price is $135 a month and falling.
When compared with what many people pay for mobile phones or other services, it becomes a question of whether people prioritize their health care, Blue said.
Jeffrey Milks admits his practice isn’t the right fit for all patients. Charging $1,900 per year — which he called average for the area — patients must see a value for that cost.
Roughly 40 percent of his patients are business executives who choose the practice for the ability to see the doctor whenever it fits their schedules. The rest of the patients are people who need more intensive care with regular treatment for diabetes or other chronic ailments.
Finding a solution
Wexler, however, said he opposes concierge medicine because it could create a situation in which fewer doctors are able to practice in rural communities, among other issues.
“It is a sign of the problem, not a solution to the problem,” he said.
Even Jeffrey Milks conceded concierge medicine is not the cure for the medical crises facing the country.
“If every doctor did this, the health care system of the United States would collapse,” he said.
But Blue said concierge medicine can be helpful, as it has reignited an interest in medical students looking at primary care as a career — something all the doctors interviewed said was a struggle in today’s environment.
Additionally, he said, the practice allows doctors to work later in life, providing care for a longer time, if for a smaller number of people. Jeffrey Milks said that was his rationale: It was better that he treat 300 patients instead of none by retiring.
Doss said he has concerns that the continued government intervention into medicine will drive more doctors out of practice. For example, he tells the story of when he prescribed medication for one of his patients but Medicare instead sent a cheaper alternative against his wishes.
The problem? The patient was allergic to the medication and blind so unable to read the label. The elderly woman took the medicine, became ill and could have died, he said.
“This is saving pennies and risking lives,” he said.
About 10 percent of Doss’ patients pay for their care out of pocket, which makes providing the care much easier, he said. Instead of worrying about what insurance says is allowed to be provided, he and the patient can decide what is best. Such arrangements, however, are not financially possible in every situation.
Fortunately, Wexler said, he sees hope for the future of medicine. Medicare is looking at providing a fee to primary care physicians for care coordination, but the question is how to compensate doctors when they prevent a service.
He said it is easy to bill for a patient receiving an MRI, but how do you compensate the primary care physician who tells his patient an injury doesn’t need such a service?
“We need to move away from a complete dependency on fee for service and move to pay for value,” he said. “We’ll get there, but I think it will take a number of years.”