By Heather Loveridge, Senior Editor, The Institute for HealthCare Consumerism
Long linked to the wealthy, concierge medicine is being reinvented. Gone are the days of only those with deep pockets being able to afford personalized heath care. Instead, concierge medicine is being described as “concierge for the blue-collar worker”, direct primary care, retainer-based medicine and more.
“Those who are helping redefine medicine describe it as ‘concierge-style service without the concierge cost’,” said Brian Hill, urologist with Urology Specialists of Atlanta LLC. “We think you should be able to receive personalized care across the board – no matter how many zeros are on your paycheck.”
As the health care landscape continues to change thanks to the Affordable Care Act – among other things – consumers are recognizing the benefits of alternative models of health care. In fact, according to Concierge Medicine Today and The Concierge Medicine Research Collective, executives and celebrities account for less than 4 percent of those seeking personalized care. The reality is, more than 50 percent of concierge medicine patients make a combined household income of less than $100,000 per year.
“Quite surprisingly, the ACA is in large part responsible for the rapid growth of concierge practice arrangements,” said Lee Gross, M.D. and co-founder and senior vice president of Epiphany Health. “Patients are waking up to the realization that they want to make individualized health choices and are seeking those opportunities. Physicians are waking up to the same. Also, while more and more care is being relegated to mid-level providers/physician assistants, many patients want the option to actually see a physician. In many systems, that is only guaranteed by a concierge relationship.
“Additionally, section 1301(a)(3) of the Affordable Care Act allows a direct primary care plan to be sold in conjunction with a wrap-around insurance product to avoid tax penalties. This is presently only being done by Qliance in Washington state with a wrap around Ambetter insurance product. In 2014, this combination was about 40 percent cheaper than the next most expensive option, without any out-of-pocket expenses for routine care under the DPC arrangement.”
Gross founded Epiphany Health as a direct result of clients seeking cost savings through personalized care.
“In 2008 a small business owner approached my partner and asked about saving money by contracting directly with us to care for his 10 employees, then changing his policy over to a catastrophic policy. With the money he would save, even if he paid for his employees’ deductibles, he would still see a savings,” Gross said.
“A light went off for us – ‘Why does this need to be so complicated? What we provide is cheap. Basic health care can also be cheap if we just focus on the doctor, the patient and the very basics that one needs, like labs and imaging services.’ We signed up our first patients a year and a half later.”
A concierge doctor, instead of seeing 2500-3000 patients a year, typically cares for 400-600 patients, charging a set fee per visit or a yearly retainer.
“The new style is more of a direct pay medicine – some practices are saying ‘You know what – I don’t need to be paid $3,500 for you to see me, you don’t even have to insurance to see me’,” Hill said. “They adjust the fees based on age or risk and may charge $45 a month, $50 a month and so on.”
As the concept has gained popularity, distinct offerings have emerged.
“We are definitely seeing the beginnings of what is sure to become a two-tiered health care system. One approach is going to be a government run, centrally controlled approach, with rationing and waits. The second is going to be private pay, focused on the basic relationship between the doctor and the patient. This will be a self-funded relationship where the patient pays the physician directly in exchange for needed care,” Gross said.
“However, in the past 5 years, direct primary care practices, such as our Epiphany Health program, are starting to pop up all around the country. These arrangements are much like that of a health club that charges a monthly fee, but doesn’t bill you to come in and use the exercise equipment or the sauna. Many of these arrangements include routine labs and several practices even distribute wholesale medications. Most services that need to be sent out of office are usually done in a pass-through no mark-up cost arrangement, such a pathology services for a biopsy interpretation or urine culture.”
For employers, the idea of concierge care is intriguing. They understand a healthy employee is a productive employee and finding a way to accomplish that at a reasonable cost is paramount to them.
“In some companies, 30 percent of the workforce doesn’t have a primary care doctor, which means they’re not getting needed health screenings and so on to ensure they stay healthy,” Hill said. “For us as doctors, we can really make an impact on a workforce when we can create relationships with each individual employee. That can’t be done when you are running around seeing 30-40 patients a day and spending 5-10 minutes with each one.”
According to Gross, employers often save money by bringing primary care in-house. For decades, large corporations, cities, school boards, etc., have opened on-site primary care clinics to care for their employees at no additional cost out of pocket. They realized the cost savings of making sure employees had access to basic timely care; saw improved productivity and health of their workers; and also saw health insurance premiums coming down as a result.
“With direct primary care, we can now offer a similar service to the small businesses in the community. It is just spread across many small businesses rather than one large employer,” Gross said. “These businesses now have the opportunity to self-insure and save even more money.
“The minimum number of employees to have a self-funded health plan varies by state, but usually ranges from 2-20 employees. Without a DPC arrangement, usually a company would need 500 employees before considering a self-funded plan. Self-funded plans are exempt from many of the costly provisions of the Affordable Care Act (aka Obamacare) and companies are able to customize plans to their individual needs. They can then work with third party administrators to rent provider networks, track claims. They can also have a stop-loss insurance plan in place to cap annual out-of-pocket costs. These employers typically will save 30-40 percent off of their routine insurance expenses, and their employees will pay nothing out of pocket for their routine care with the DPC arrangement.”
One of Gross’s clients is a dog groomer.
“The employees there are frequently scratched and bitten by the animals,” he said. “We don’t charge to care for their employees in this situation. Had they not had the DPC plan in place, every bite would be a workers’ comp claim, drastically driving up the cost of their worker’s comp policy. Since signing the DPC agreement, they haven’t had a single worker’s comp claim filed.”
While some argue that this model would exacerbate the primary care doctor shortage, both Gross and Hill disagree.
“I spend 22 percent of my time each day doing paperwork. If I could eliminate that unnecessary drain on my time I could take care of more people,” Hill said. “In turn, if we can help make people healthier, they shouldn’t need to see us as much. All things considered, it becomes a win/win.”
As Gross related, the physician shortage would also decrease.
“If a doctor can make a respectable living with a high career satisfaction in primary care, often earning as much as a specialist, you would have a massive expansion of interest in primary care residencies,” he said.
“We are approaching an era of medicine where we will be able to personalize a patient’s therapy down to the level of their DNA. This is not an era where we should be practicing a one-size-fits-all approach to a patient. With so much third party interference with the doctor/patient relationship, this is the only truly ethical practice model, in my opinion.”