NOTE: To assist you, we have provided a Glossary of Terms in last section of this book. Please reference this Glossary to help define/explain terms such as ‘concierge medicine,’ ‘boutique medicine,’ ‘direct care,’ and others.
What Is Concierge Medicine?
Concierge Medicine is a form of membership in which doctors provide medical care to Patients generally providing 24/7 access, a cell phone number to connect directly with their physician, same-day appointments, visits that last as long as it takes to address their needs and varying other amenities. In exchange for this enhanced access and personal attention, the Concierge Doctor receives a fee (most fees average between $135-$150/mo., Source: ConciergeMedicineToday.com, 2014) which enables them to increase the amount of time they spend with Patients.
“We are a family of mom, dad, and 10 year old daughter,” says a mother in Marietta, GA. “Dad’s retirement from his job means leaving his insurance plan. We are healthy and looking for affordable medical care.”
A Concierge Doctor becomes the source for all things medical. Essentially, you become a trusted friend, advocate and stand fully prepared to help your Patients navigate the complex healthcare system. In the event of emergencies, hospital care is closely monitored, and specialists are often personally briefed and debriefed by you on behalf of your Patients.
“Even if you (a Patient) have insurance, you still do not have access to care,” says Dr. Chris Ewin or 121MD in Dallas/Fort Worth, TX. “You can have all the insurance you want. You still cannot get in to see the doctor.”
This is why thousands of people are now actively searching for a Concierge Doctor or a DPC physician. They also discover that out-of-pocket costs to this type of doctor can actually save them thousands of dollars a year. At the same time, they can have their doctors cell phone on speed dial.
What Is Direct Primary Care (DPC)?
If you haven’t heard of this term, you’re not a lone … but think of DPC doctors as the less expensive or generic alternative to Concierge Medicine. This monthly fee for a primary care doctor is another popular and emerging business model in our free market economy that has gained tremendous popularity since 2008.
In most DPC doctors’ offices, Patients pay one low monthly fee, sometimes as low as $49-$99/mo. directly to their DPC physician for all of their everyday health needs. Like a health club membership, this fee (avg. $50-$99/indiv.) provides Patients with unrestricted access to visits and care. Patients can use the services as much or as little as they want. Many DPC practices are open seven days per week and offer same-day or next-day appointments. At many clinics, physicians are on call 24/7.
“This primary care business model [DPC] gives these types of providers the time to deliver more personalized care to their Patients and pursue a comprehensive medical home approach,” said a spokesperson at Qliance Medical Management based in Seattle, Washington. “… The provider’s incentives are fully aligned with the Patient’s incentives.”
With DPC, there are no insurance co-pays, deductibles or co-insurance fees. DPC doctors do not typically accept insurance payments, thus avoiding the overhead and complexity of maintaining relationships with insurers. This can save significant overhead expense as managing insurance relationships can consume as much as $0.40 of each medical dollar spent.
DPC practices typically have monthly membership fees under $100 and serve a population of households earning $70,000 or less, according to The Concierge Medicine Research Collective. Monthly Concierge Medicine membership fees usually are slightly higher, about $135 per month and can include more in-office services. Despite the cost 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. Although, significant efforts are underway to accelerate the DPC movement, so this disadvantage may disappear as awareness grows.
In a report published by the California HealthCare Foundation, five large DPC clinics in the U.S. using a DPC healthcare service model serve over 500,000 lives. These charge either direct fees paid to the doctor, the physicians practice, or via self-insured employers and health plans.
Overall, Concierge Medicine and DPC style clinics are thriving in major metropolitan markets. Of great benefit to the consumers, prices are dropping dramatically due to increasing competition among physicians entering the marketplace, retail medicine pricing, price transparency demand from Patients and continued uncertainty about the implications of the Affordable Care Act.
The Difference Between Concierge Medicine and DPC
DPC (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, DPC being one of them.
DPC practices, similar in philosophy to their Concierge Medicine lineage – typically bypass insurance and go for a more ‘direct’ financial relationship with Patients.. They also provide comprehensive care and preventive services for an affordable fee. However, DPC is only one branch in the family tree of Concierge Medicine.
Similar to concierge health care practices, DPC removes many of the financial barriers to accessing care whenever it is needed. There are generally no co-pays, deductibles or co-insurance fees. DPC practices also do not typically accept insurance payments, thus avoiding the overhead and complexity of maintaining relationships with insurers, which can consume as much as $0.40 of each medical dollar spent (Sources: Dave Chase and California Health Foundation).
Under most Patient-physician contracts in DPC and concierge medical clinics, Patients (and workers at employer groups, small and mid-size businesses) pay no co-pay for services. In addition to the services that the doctor provides on-site and inside the practice, individuals and companies maintain lower cost insurance plans to accommodate major medical expenditures and more intensive procedures. In that sense, the model for healthcare is similar to that being pursued by many internal medicine, specialty physicians and family practitioners, who are today, reducing their Patient load by two-thirds, dropping insurance wrangling and adopting a DPC model paid with an (almost) all-inclusive, monthly, quarterly or annual subscription fee.
According to a spokesperson at Qliance Medical Management based in Seattle, Washington, DPC is a ‘mass-market variant of Concierge Medicine, distinguished by its low prices.’ Simply stated, the biggest difference between ‘DPC’ and retainer based practices is that DPC generally takes a low, flat rate fee whereas concierge models plans usually charge a slightly higher annual retainer fee and promise more time spent with a doctor. Also, services in concierge models tend to more service-focused and added-value oriented versus just providing access and more convenience to the practice.
“This primary care business model [DPC] gives these type of providers the time to deliver more personalized care to their Patients and pursue a comprehensive medical home approach,” said Norm Wu, CEO of Qliance Medical Management based in Seattle, Washington. “One in which the provider’s incentives are fully aligned with the Patient’s incentives.”
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A History of Concierge Medicine. Bringing History Back To Life.
Doctors carrying a medical bag and coming into a Patient’s home was standard into the late 1960s. Look at The Andy Griffith Show. Remember Marcus Welby, MD? That is what our grandparents know. Medicine became more and more government and insurance regulated and that started to end. It came in for a reason — there did need to be some amount of administration. But now regulation and administrative tasks have frustrated doctors.
“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
“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.*
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.
“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.”
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