Please note, this story has been updated and a new version is accessible here.
“If Concierge Medicine is about super servant-hood, then it has nothing to apologize for. People deserve to have access to a physician who spends the time necessary to gather appropriate insight about patients. People deserve transparency. They deserve answers to difficult questions. People deserve accurate information, especially when it concerns their health. Simply searching the web in today’s convoluted environment leads to inaccurate assumptions, misinterpretations, harms reputations and undermines the confidence that patients have in their physicians and local medical facilities they trusted. Concierge Medicine has been around for more than 20 years and it works to solve many of these problems. It has redefined healthcare delivery.” ~Michael Tetreault, Editor-in-Chief
“A lot of people like to compare Concierge Medicine to Direct Primary Care (DPC) and say … ‘DPC is the less expensive alternative.’ But the data, the patient interviews and the industry service offerings say something completely different. The distinguishing factor differentiating DPC and Concierge Care is not price … it’s insurance participation of the doctor, monthly billing (seen at most DPC clinics) and the amount of services offered. In both Concierge Care and DPC, people have inherent, not ascribed value. There’s no class order … no first class or second class, just people for whom doctors serve each day. They’ve built clinics for children, families and people who are sick … and it is these visioneering physicians who are drawing attention to the cost of healthcare across the country and designing ways for it to be available and affordable for anyone.” ~Michael Tetreault, Editor, The DPC Journal, Concierge Medicine Today
By Michael Tetreault, Editor-in-Chief
GLOSSARY of TERMS
See definition for Membership Medicine.
See definition for Direct Primary Care (DPC).
What Is Concierge Medicine?
Concierge Medicine is a unique relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer.
This may or may not be in addition to other charges. In exchange for the retainer, doctors provide enhanced care. Concierge physicians care for fewer patients than in a conventional practice, ranging from 100 patients per doctor to 1,000, instead of the 3,000 to 4,000 that the average physician now sees every year.
All generally claim to be accessible via telephone or email at any time of day or night or offer some other service above and beyond the customary care. The annual fees vary widely, from US$100 per month to $2,500 per year for an individual, with the lower annual fees being in addition to the usual fees for each service and the higher annual fees including most services.
Other terms in use include: boutique medicine, retainer-based medicine, and innovative medical practice design. The practice is also referred to as membership medicine, concierge health care, cash-only practice, direct care, direct primary care, and direct practice medicine.
While all concierge medicine practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the fee charged. At this writing, it has been estimated that concierge medicine and direct care physicians number approximately 5,000-5,5000 physicians and/or physician clinics across the U.S.
Direct Care Medicine.
See definition for Direct [Primary] Care.
Direct Care or Direct [Primary] Care (DPC).
Direct Primary Care (DPC) practices are distinguished from other retainer-based care models, such as concierge care, by lower retainer fees (82% cost less than $99/mo), which cover at least a portion of primary care services provided in the DPC practice; No insurance plan is involved, although patients may have separate insurance coverage for more costly medical services; Patients typically prefer to pay monthly vs. quarterly or annually; DPC patients typically come from the Generation X and Millennial population and earn a combined annual HH income of less than $100k.
DPC is primary and preventative care, urgent care, chronic disease management and wellness support through a monthly care fee patients (or an employer) pay to cover the specific primary care preventative care services. A DPC health care provider charges a patient a set monthly fee for all primary care services provided in the office, regardless of the number of visits. Because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.
DPC medical practices bypass insurance and go for a more ‘direct’ financial relationship with patients and also provide comprehensive care and preventive services for an affordable fee. DPC is a ‘mass-market variant of concierge medicine, distinguished by its low prices.’ Simply stated, the biggest difference between ‘direct primary care’ and retainer based practices is that DPC takes a low, flat rate fee whereas concierge medicine models, (although plans may vary by practice) – usually charge an annual retainer fee and promise more ‘access’ to the doctor.
Direct primary care (DPC) is a term often linked to its companion in health care, ‘concierge medicine.’ Although the two terms are similar and belong to the same family, concierge medicine is a term that fully embraces or ‘includes’ many different health care delivery models, direct primary care being one of them.
Source: The DPC Journal, 2015.
Direct primary care practices offer a membership-based approach to routine and preventive care that can dramatically reduce health care costs for individuals, families and businesses.
At the core of a direct primary care facility is a medical practice dedicated to providing routine, everyday care, essential for the well-being and ongoing maintenance of a patient’s health. This is where patients go for check-ups, vaccinations, sprained ankles, or frequent headaches.
Direct primary care providers know their patients. They have talked with their patients in detail, gotten to know them, treated past conditions and know what recurring problems are experienced. If a patient has a chronic illness, like arthritis or diabetes, their primary care provider is already a partner in management every step of the way. And, in the unlikely event of a life-threatening accident or disease, the provider serves as the patient’s advocate, coordinating care across multiple providers, facilities, and prescriptions.
Membership Medicine is a broader term used to describe the subscription-based, healthcare delivery model of both Direct Primary Care (DPC), boutique, retainer-based and Concierge Medicine Models operating throughout the U.S. In membership medicine, the membership is accessible and affordable to many people, not just the wealthy. It’s a misconception that physicians participating in this style of practice are solely doing so to experience more financial success.
DPC and Membership Medicine: As of late 2014, The DPC Journal finds that key leadership in the Direct Primary Care (DPC) industry, interviews and reports received from the business, employer and investment community operating in the DPC marketplace nationally, center around the number that there are more than 600+ DPC physicians … and growing and growing at a rate of about 5-10% nationwide.
- DPC is primary and preventative care, urgent care, chronic disease management and wellness support through a monthly care fee patients (or an employer) pay to cover the specific primary care preventative care services.
- DPC practices are distinguished from other retainer-based care models, such as concierge care, by lower retainer fees, which cover at least a portion of primary care services provided in the DPC practice.
- Monthly fees at direct practices vary from $25-$85 per month or less. Patients prefer to pay monthly vs. quarterly or annually.
- DPC patients typically come from the Generation X and Millennial population and earn a combined annual HH income of less than $100k.
- A DPC health care provider charges a patient a set monthly fee for all primary care services provided in the office, regardless of the number of visits.
- No insurance plan is involved, although patients may have separate insurance coverage for more costly medical services.
- Because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.
Concierge Medicine/Boutique and Retainer-Based Care: Throughout the past several years of surveying the market (2007-2015), discussing the question with numerous doctors, interviewing industry business leaders, private equity investors, business consultants, key industry physicians and membership medicine leadership nationally — Concierge Medicine Today finds that there are slightly less than 6000 actively practicing Concierge Medicine physicians across the United States, with another 6k-8000 practicing in some form or model of “Membership Medicine” under the radar.
- Annual fees at direct practices vary from $101-$225 per year. Patients prefer to pay annually vs. monthly.
- Concierge Medicine patients skew upper middle class, with typical household earnings between $125,000 and $250,000 a year. They also tend to be Baby Boomers, generally in their 50s to 80s, according to doctors interviewed.
- A greater breadth of primary care services covered by an annual retainer contract fee structure.
- Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients — the concierge medicine fee, and the insurance premium. Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.
There are approximately 12k Doctors/Clinics Operating In “Membership Medicine” In The U.S. in 2015. This represents approx. 1% of All Licensed Physicians In The U.S. in 2014 or 5+% of all Licensed Primary Care Physicians In The U.S. in 2014.
See definition for Membership Medicine.
See definition for Membership Medicine.
That fees are payable by the month rather than by the quarter or year is important to many direct primary care patients, who may have cash flow problems in a tight job market. “That’s a big difference,” Tetreault says, “no long-term contract.”
Direct primary care practices may or may not offer same-day appointments. Most probably don’t, Tetreault says. The doctors probably won’t give out their cell phone numbers, meet patients in the ER if they have a late-night crisis, or make house calls — although some direct primary care doctors do make house calls, he adds.
If house calls are offered, they are typically billed separately, not included as part of the monthly fee. Flu shots and vaccinations are usually billed separately too.
Direct primary care (DPC) is an emerging model that has gained some attention nationally in recent years. Sometimes referred to as ”retainer practices,” DPC practices generally do not accept health insurance, instead serving patients in exchange for a recurring monthly fee — usually $50 to $80 — for a defined set of clinical services.
“Many direct primary care practices do not build in concierge medicine service components, such as 24/7 care, cell phone text messaging, and instant or same-day appointments,” Tetreault says. “And yet, some do.”
Concierge practices composed exclusively of concierge patients (most practices include a mix of concierge and traditional patients) generally limit their panels to 600 or fewer patients per physician. “Direct primary care practices, because they charge a lower fee, need more patients on their rosters,” Tetreault explains. “They typically have under 1000 patients.”
The distinctions between concierge medicine, private medicine, and direct primary care may be ultimately meaningless, since some doctors call themselves whatever they feel sounds better, and there are so many practice variations, many overlapping, that it often isn’t clear which is which.*
Still confused by this semantic hair-splitting? Join the club. Even concierge and direct primary care physicians may be confused about which type of doctor they are.*
“In polls, we’re asking the actual physicians, ‘Do you consider yourself a concierge doctor or a direct primary care doctor, or do you consider yourself both?’” Michael Tetreault, the journal editor, says. “Most say that they consider themselves a concierge doctor. But they still don’t understand the differences. A lot of doctors consider themselves to be both.”
Related Article … The Difference Between Concierge Medicine and Direct Primary Care >>
Collectively, direct primary care (sometimes linked to the term concierge medicine) has more than a half million people on their rolls, according to the California HealthCare Foundation. They highlighted five large direct pay practices that use the retainer model in an April 2013 report. These direct primary care patient rosters are estimations:
- Iora Health, with 2,400 patients
- MedLion, with 3,000 patients
- Paladina Health, with 8,000 patients
- Qliance, with 7,200 patients
- White Glove Health, with 40,000 patients via self-insured employers and 450,000 via health plans
Direct primary care providers help keep costs low by avoiding unnecessary referrals and by referring mainly to specialists willing to offer significant discounts. Despite this advantage, the DPC model may be hampered by low awareness among health plans and primary care physicians, resistance from some insurers, and resistance from competing hospitals and specialists.
NOTE: The DPC Journal and their research and data collection arm, The Concierge Medicine Research Collective (www.AsktheCollective.org), we have found that there are four (4) distinguishing factors that differentiate Concierge Care from its demographically diverse and often misunderstood companion, DPC … and it is NOT price …
- Insurance participation of the doctor/practice;
- DPC, most commonly, attracts a Gen. X and Millenial demographic under the age of 45.
- Monthly billing (seen at most DPC clinics), compared to annual and quarterly retainers offered at most concierge clinics, and;
- The amount of services offered.
The Direct Primary Care Coalition (DPCC) Defines DPC As:
Direct Primary Care (DPC) is an innovative alternative payment model for primary care being embraced by patients, physicians, employers,payers and policymakers across the United States.The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider.
Empowering this relationship is the key to achieving superior health outcomes, lower costs and an enhanced patient experience. DPC fosters this relationship by focusing on five key tenets:
- Service: The hallmark of DPC is adequate time spent between patient and physician, creating an enduring doctor-patient relationship. Supported by unfettered access to care, DPC enables unhurried interactions and frequent discussions to assess lifestyle choices and treatment decisions aimed at longterm health and wellbeing. DPC practices have extended hours, ready access to urgent care, and patient panel sizes small enough to support this commitment to service.
- Patient Choice: Patients in DPC choose their own personal physician and are reactive partners in their healthcare. Empowered by accurate information at the point of care, patients are fully involved in making their own medical and financial choices. DPC patients have the right to transparent pricing, access, and availability of all services provided.
- Elimination of Fee-For-Service: DPC eliminates undesired fee-for-service(FFS) incentives in primary care. These incentives distort healthcare decision-making by rewarding volume over value. This undermines the trust that supports the patient-provider relationship and rewards expensive and inappropriate testing, referral, and treatment. DPC replaces FFS with a simple flat monthly fee that covers comprehensive primary care services. Fees must be adequate to allow for appropriately sized patient panels to support this level of care so that DPC providers can resist the numerous other financial incentives that distort care decisions and endanger the doctor-patient relationship.
- Advocacy: DPC providers are committed advocates for patients within the healthcare system. They have time to make informed, appropriate referrals and support patient needs when they are outside of primary care. DPC providers accept the responsibility to be available to patients serving as patient guides. No matter where patients are in the system, physicians provide them with information about the quality, cost, and patient experience of care.
- Stewardship: DPC providers believe that healthcare must provide more value to the patient and the system. Healthcare can, and must, be higher-performing, more patient-responsive, less invasive, and less expensive than it is today. The ultimate goal is health and wellbeing, not simply the treatment of disease.
*Source: Neil Chesanow, MedScape, WebMD, May 19, 2014
NEED TO FIND A DIRECT PRIMARY CARE DOCTOR?
Until just a few years ago, people mostly based choosing a doctor on the personal recommendation of a trusted friend or relative. Now with the advent of social media, word of mouth marketing is changing from a spoken word referral to a social media link referral.
Nationally, direct primary care practice is considerably newer than concierge practice — and there are considerably fewer direct primary care than concierge physicians. Michael Tetreault is Editor in Chief of 2 online journals: Concierge Medicine Today and The Direct Primary Care Journal and estimates that direct primary care physicians make up about 20% of the retainer medicine movement right now; the other 80% are concierge physicians.*
“Generally, direct primary care is a cash-only practice,” he says. “However, although we have no hard data, we estimate that less than 20% of direct primary care practices accept insurance. So there are some that do.”
Direct primary care physicians charge less than private or concierge physicians: “from $25 to less than $100 a month,” Tetreault says. “We believe that these fees represent about 90% of the direct primary care physician community.”
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