By Michelle Crumbley, MSN, FNP
Numerous changes in America’s healthcare system are affecting the future of NP practice. One is the trend toward hospital buyouts of physician-owned private practices. A 2010 survey found that 74% of hospital leaders planned on hiring primary care physicians.1
The percentage of physician practices owned by hospitals increased from 20% in 2002 to more than 50% in 2008.2 A year ago, experts estimated that by the end of 2014, approximately half of physicians would be working for a hospital or hospital-owned facility.3
Hospital efforts to encompass primary care are associated with advantages and disadvantages. For patients, it may improve access to and continuity in care.1,2 For physicians, incentives include an improvement in payment for services, more routine work hours and fewer administrative responsibilities.4
On the down side, private practice buyouts may lead to higher prices for hospital-provided primary care services.4 In most cases buyouts also mean that physicians and their staffs will become hospital employees. Some may embrace this evolution, while others may see it as a loss of autonomy.1 One alternative for providers who do not wish to become employees of a larger system is concierge medicine.
What Is Concierge Medicine?
Concierge medicine is a personalized form of healthcare delivery in which patients choose a provider and pay an annual fee to receive a menu of services. Benefits include convenient, often 24-hour access to care, personal coordination of care with specialists, home visits and other services.4,5 Concierge services are not billed to insurers.
Many private practices are transitioning into concierge care. Some of the driving factors behind this shift include lighter patient-to-provider load, more clinician autonomy and a reduction in administrative duties – all of which should translate to increased direct care and quality time for the patient.6 A 3-year analysis (2009 to 2012) surveyed concierge physicians and found that the majority reported being satisfied or very satisfied with the model after 5 years.4,5 Almost 90% of concierge physicians who responded reported doing better financially than the prior year.4
Critics of concierge medicine say it cuts out the underserved and poor citizens. The same 3-year analysis showed that 40% of the patients participating in concierge medicine had an average combined annual income between $100,000 and $200,000.4,5 Nearly 35% of patients on a concierge plan paid around $225 a month.4 However, a Government Accounting Office (GAO) survey calculated an average annual fee of $1,500 per patient for a concierge plan.6
In addition to the issue of fees, many patients who enroll in a concierge plan want to keep and utilize their traditional insurance as well, in order to cover nonconcierge service costs such as medications and surgical procedures.6
The number of physicians in concierge medicine increased more than tenfold between 1999 and 2004.6 This may have a direct effect on NPs in primary care.
Today’s Practice Landscape
Given the sizable shifts in the primary care landscape, what options are left for NPs who want to be in private practice? Nineteen states and the District of Columbia have passed legislation or already have laws providing full practice authority for NPs. The remaining 30 states have requirements for varying amounts of physician oversight or collaboration. Inconsistencies among state scope-of-practice laws place limitations on career options for NPs. Even in states where NPs practice independently, reimbursement for services is usually at a lower rate than for physicians who provide the same services.7
Due in part to the effects of the Affordable Care Act, which aims to provide healthcare access to all Americans in more efficient and effective ways, team-based care is a point of focus.11 Advocates of this approach argue that options such as concierge medicine will leave many people without primary care.8
While organizations representing physicians and nurse practitioners both support a collaborative approach to patient care, there is no consensus on exactly how this collaboration will be achieved. Until then, NPs will have to practice within the scope allowed in each state and try to meet the patient load that will present to primary care in the face of the physician shortage.
Options for the Nurse Practitioner
For the NP who seeks to stay in primary care and does not want to work for a large healthcare system, is concierge medicine an option? Richard Doughty, CEO of Cypress Healthcare in Baton Rouge, La., says “yes.” Cypress Healthcare (http://www.yourcypress.com) helps private practices convert to concierge medical homes.
The services of companies like Cypress Healthcare are not required to transition to concierge medicine, but they are helpful for providers who seek guidance in how to set up this system successfully. In a conversation I had with him recently, Doughty said his company would welcome opportunities to establish relationships with nurse practitioners.
“In states that allow NPs to practice independently, the process of setting up a concierge medical practice would be the same as it is for a physician,” he said. In states where NPs must practice with collaboration or supervision by a physician, the option of a blended practice exists.
In a blended practice, the physician converts from a traditional practice to a concierge model and allows patients to select between the new model and the traditional one. Patients who do not become members of the concierge plan can continue to see the providers who are left in the practice, such as the NPs. This is a variation that provides another option for physicians who do not wish to sell their practices. In this model, “even the NP or PA working on the side separate from the MD can convert into a concierge practice themselves – however, still under the supervision of the MD,” Doughty said.
The decision to enter concierge medicine has advantages and disadvantages. With the numerous changes in our healthcare system and so many unknowns, NPs can take some solace in the availability of one more option, concierge medicine. Whether practicing in collaboration with a physician or independently, the concept of concierge services could provide NPs with an appealing practice option.
Do you have a concierge practice?
If you have embraced the concierge practice concept, we’d like to hear from you. Tell us about your practice, how you developed it, and how successful or challenging it has been so far. Email: email@example.com.
1. Sun L. Hospitals courting primary care doctors. The Washington Post. June 19, 2011. http://www.washingtonpost.com/national/health-science/hospitals-courting-primary-care-doctors/2011/05/31/AGYutAcH_story.html
2. Robert Wood Johnson Foundation. The synthesis project: new insights from research results. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf73261
3. Gottlieb S. The doctor won’t see you now. He’s clocked out. The Wall Street Journal. March 14, 2013. http://online.wsj.com/news/articles/SB10001424127887323628804578346614033833092
4. Mathews A. Same doctor visit, double the cost. The Wall Street Journal. Aug. 27, 2012. http://online.wsj.com/article/SB10000872396390443713704577601113671007448.html
5. Tetreault M. Three year analysis of concierge medicine shows encouraging signs for boosting primary care medicine in U.S. Concierge Medicine Today. Nov. 14, 2013. http://conciergemedicinetoday.org/2013/01/08/three-year-analysis-of-concierge-medicine-shows-encouraging-signs-for-boosting-primary-care-medicine-in-u-s/
6. DuBois A, et al. Will concierge medicine’s image improve as it evolves? American Medical News. Sept. 3, 2012. http://www.amednews.com/article/20120903/profession/309039953
7. Cassidy A. Nurse Practitioners and primary care: Federal and state laws and other policies limit how these professionals can help meet the growing need for primary care. Health Policy Brief. Oct. 25, 2012. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_79.pdf
8. Altschuler J, et al. Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Ann Fam Med. 2012;10(5):396-400.
Michelle Crumbley is a family nurse practitioner at McDonough Pediatrics in McDonough, Ga.