History of Concierge Medicine (1996-2022)
By Concierge Medicine Today | Last Updated: June 2022
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.
The past 5 to 10 were some the most eventful years in the space of Concierge Medicine, private-pay and DPC as news and headlines continued to circulate across the wire. From The New York Times to The Wall Street Journal and everywhere in between, Concierge Medicine was becoming a familiar term that people are beginning to understand as an affordable healthcare option. Concierge Medicine Today and our sister-publication, The DPC Journal covered this industry and reached millions of new readers, Patients and others with headlines now being read regularly in over 130 countries and inside thousands of medical offices and homes across the U.S.
“There Should Be Absolutely, Unequivocally, No Necessary Tension or Conflict Between DPC and Concierge Medicine, regardless of price, perception, optics or even insurance or Medicare participation. Each Physician is doing what they feel is right for the Patient and at the end of the day. ‘The Patient comes first!’ And, there’s nothing wrong with that in either niche, it’s simply opinion and the loudest opinion rarely represents a majority. So, while these two models are similar in subtle ways, (eg. their subscription programming), they each have uniquely different offerings that make them attractive to different audiences and Physicians. No one Doctor should be villainized for following their dream in Concierge Medicine, nor the opposite. These models are simply different vehicles taking Patients to similar destinations on the road to health and wellness. These are Physicians following their vision for how healthcare could be and should be delivered now and in the future. I’m proud to know Physicians in both models whom are uniting heart and hands together and helping Patients like we’ve never understood or seen before. Yes, they may have some things in common, but they are also BOTH beneficial and special to those Patients that seek them out around the country for different reasons. Each Physician should be respected [by their peers] for their differences and their shared values. Never should we denigrate the practice of medicine and those Doctors who choose a path different from your own. The world has high expectations and seemingly impossible goals and harsh realities placed upon Doctors. We don’t need more Physicians disparaging or discouraging one healthcare delivery model from another within any free market healthcare delivery space. As Truett Cathy, the CEO of Chick-fil-A once said, ‘If someone is breathing, they need encouragement.’ Let’s be a group of healthcare educators in subscription-based healthcare delivery, that is known more for who and what we are for versus who and/or what we are against. We have more in common than we realize. So, let’s be a group of people in medicine that is full of open-minded colleagues in the business of delivering great Patient care and which encourages Doctors to follow their passions, however unique or different it might from your own perspective and be the best Physician you can for your local community of Patients.”~Editor, Concierge Medicine Today and The DPC Journal
Last Updated: Summer/Fall 2022 Edition
By Editor-in-Chief, Concierge Medicine Today/The DPC Journal
As the Editor of both industry healthcare trade publications for the subscription-based healthcare delivery market since 2007, both Concierge Medicine Today and our sister publication, The DPC Journal believe that both healthcare delivery models (eg. Concierge Medicine and Direct Primary Care) can and are great career lifelines for both Doctors and Patients.
However, let me be perfectly clear here … those of you that know me understand this and have heard it echoed before. “There is a difference between Concierge Medicine and Direct Primary Care (DPC).”
It may be subtle for some of you and glaringly obvious for others.
Is one better than another.
It’s subjective, but our professional opinion as observers and advocates for both delivery models is that they both have inherent value.
We are of the persuasion that not one is better than another and anyone who may say different is of course, entitled to their opinion. But, that would be like saying one Doctor is better than another, and we all know what cyclical conversation that will lead to if we pull that thread in any conversation today.
So, it’s subjective, right? We can agree on that.
So, that being said, the conversations, interviews, events and even our observations from all sides of the free market healthcare delivery marketplace over the years provide us with a unique perspective that isn’t singular, nor is it biased or evangelistic. But based on interviews, exclusive conversations with both audiences and based on past, present and future observations in these niche markets, please feel confident that each model serves Patients and Physicians differently and in subtle, similar ways yet both are advantageous and provide wonderful services in unique ways to both Patients and Physicians.
This article today is not meant to persuade or convince you that one subscription healthcare delivery business model is better than another. Each have pros and cons. Each provide unique services to Patients and have different features and benefits that bend to the Patient and Physician being more closely connected. With all of this being our common ground or thesis, it should also be known that we are not affiliated with any Doctor’s office, consultant, medical group(s) or association(s), etc., which affords to us to critique and observe these subscription-based healthcare delivery models with an unbiased opinion and neutral context upon which to outline our opinions.
So, let’s get started and unpack the suitcase here.
Understanding the Basic Terminology
First, if you haven’t heard of these terms in healthcare, you’re not alone.
Monthly and annual subscription fees for a primary care doctors service and expertise is becoming a popular and emerging business model in our free market economy that has gained tremendous popularity since 2008. As of 2022, more Physician Assistants, RNs, MDs, DOs and even telehealth programs have emerged using such a subscription business model.
They’re all relatively new if you consider the event between 2009-2013 new. It’s semantics. It is often confusing when you see the brand or terminology of one Physician using these terms interchangeably. It’s confusing for the Patient, believe me! I know, because I am one.
Direct Pay vs Concierge Practices | Physicians Practice
I typically start by explaining it to novices new to the space in relative terms they are familiar with. Maybe it’s because of my marketing and public relations upbringing and education. So by explaining the difference between Netflix billing and Amazon Prime billing, it starts to make sense. But, I also am careful to explain and educate that you need Internet too in order to make the services all work for your family. The Internet here is the metaphor for health insurance if you didn’t catch that. 🙂
Years ago now, most of which many of you may not have even heard or had discovered these terms, I was interviewed by several healthcare publications and popular news outlets alongside some of the great Physicians in each of these healthcare deliver niches. The writer wrote something I really thought was great after our interviews were concluded. He wrote, 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.
Defining Direct Primary Care (DPC)
- According to the AAFP, they define Direct Primary Care (DPC) The Direct Primary Care (DPC) model is a practice and payment model where patients/consumers pay their physician or practice directly in the form of periodic payments for a defined set of primary care services. (Source: https://www.aafp.org/family-physician/practice-and-career/delivery-payment-models/direct-primary-care.html)
According to The DPC Coalition, Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. Patients have extraordinary access to a physician of their choice, often for as little as $70 per month, and physicians are accountable first and foremost their patients. DPC is embraced by health policymakers on the left and right and creates happy patients and happy doctors all over the country! 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. (Source: https://www.dpcare.org)
- According to GoodRx Health, Since arriving on the healthcare scene in the mid 2000s, direct primary care has grown in popularity. As health insurance gets increasingly confusing, expensive, and frustrating, new models of care are rising. Patients without health insurance, or those fed up with paying skyrocketing monthly premiums, are turning to direct primary care as an option to afford basic medical care.(Source:https://www.goodrx.com/insurance/health-insurance/direct-primary-care)
- According to STAT, In a nutshell, direct primary care is a model for delivering primary care, and only primary care. The doctor charges each patient a monthly fee, generally ranging from $50 to $200, in return for timely, convenient access to him or her and a buffet-like menu of mostly basic primary care services. The amount of the monthly fee is presumably set in relation to the scope of services covered, though every practice may do it differently. For services that aren’t covered under the fee, like more extensive management of a chronic disease, the patient’s insurance — if he or she has it — must be billed to pay for the service or, in some cases, the physician or practice will charge the patient extra fees to cover those services. (Source: https://www.statnews.com/2018/09/06/direct-primary-care-doctors-patients/)
- Many direct primary care practices do not build in concierge medicine customer service and advanced testing and analytics components received by such tests. Additionally, there are some DPC practice programs that do not offer 24/7 care, cell phone text messaging, and instant or same-day appointments. And yet, some do.
- 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.
- 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.
- Fast-forward now years later (eg. 2013 to 2022) and DPC has taken on various pieces of legislation in a majority of states which help protect the Patient-Physician financial relationship, typically educating lawmakers that DPC or retainer-based medicine (in any form) is not considered an insurance product.
- 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.
- In its simplest form, Direct Primary Care, often termed DPC, direct care or private, direct medicine has been around some would say since the late 2000’s. It truly hit its stride on or about 2012-2013. I can personally even remember the days when the terminology was in flux and a variety of terms were being used.
- 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.
- 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.
Years ago I had the pleasure of speaking to a spokesperson at now closed, Qliance Medical Management based in Seattle, Washington. He described DPC is a ‘mass-market variant of Concierge Medicine, distinguished by its low prices.’
Defining Concierge Medicine
According to WebMD, They’re often physicians who choose to form a private practice to limit the number of patients they’re responsible for — usually a smaller number compared to the volume of a more traditional office practice — and to minimize the amount of paperwork associated with insurance payouts. Concierge doctors can do everything a primary care physician can, including administer lab tests and conduct annual physical exams. They also typically provide diagnostic screenings and minor urgent care services like stitches or treatment for minor skin conditions. However, they can’t provide many specialized treatments or major medical procedures, like surgery. (Source: https://www.webmd.com/a-to-z-guides/what-is-a-concierge-doctor)
- According to Medicare.gov, You pay 100% of the membership fee for concierge care. Concierge care is when: A doctor or group of doctors charges you a membership fee. They charge this fee before they’ll see you or accept you into their practice. Concierge care may also be called concierge medicine, retainer‐based medicine, boutique medicine, platinum practice, or direct care. When you pay this fee, you may get some services or amenities that Medicare doesn’t cover. Doctors who provide concierge care must still follow all Medicare rules: Doctors who accept assignment can’t charge you extra for Medicare-covered services. This means the membership fee can’t include additional charges for items or services that Medicare usually covers unless Medicare won’t pay for the item or service. In this situation, your doctor must give you a written notice called an “Advance Beneficiary Notice of Noncoverage” (ABN) listing the services and reasons why Medicare may not pay. Doctors who don’t accept assignment can charge you more than the Medicare-Approved Amount for Medicare-covered services, but there’s a 15% limit called the ” limiting charge.” All Medicare doctors (regardless of whether or not they accept assignment) can charge you for items and services that Medicare doesn’t cover. The membership fee is governed by the contract or agreement you sign with the doctor or doctor group. Additional state laws and consumer protections may apply. For more information, contact your state’s insurance departmentor consumer protection bureau. (Source: https://www.medicare.gov/coverage/concierge-care)
- According to Forbes, For a flat monthly fee, you get unlimited office and telehealth visits that last as long as you need, as well as direct care from a doctor without worrying about copays and other charges. You also gain access to your doctor’s direct phone line for medical questions and simple diagnostic and blood tests in their office. And if you have a major health problem, your doctor coordinates specialist referrals and/or hospital care as needed. With concierge medicine, there’s no insurance or corporate health system interference—just doctors and patients. (Source: https://www.forbes.com/health/healthy-aging/concierge-medicine/)
- According to Definitive Healthcare, When the concierge medicine model first appeared in the mid-1990s with Seattle-based MD2 International, it introduced the idea of “luxury medical care” and came with a price tag to match—with patients paying up to $25,000 per year for the boutique healthcare experience. What’s more, this cost was paid in addition to regular health insurance premiums and didn’t cover the costs of hospitalization or specialist consultations. Though some patients still pay a five-figure fee for their care, the average fee for membership in a concierge practice nowadays is between $1,500 and $2,400 a year—or between $125 to $200 a month. (Source: https://www.definitivehc.com/blog/what-is-concierge-medicine)
- In its simplest for, Concierge Medicine, sometimes called Concierge Care, boutique medicine or private medicine has been around since the mid-1990’s. It’s actually much older, decades in fact but that’s a story for another day.
Finding Common Ground
“It is no longer about being the best Doctor in the world anymore. It is about being the best Doctor FOR the world, FOR your Patients and FOR your local community.” ~Editor, Concierge Medicine Today/The DPC Journal
- DPC practices, similar in philosophy to their Concierge Medicine lineage – typically bypass insurance and go for a more ‘direct’ financial relationship with Patients. But, it’s not always the case. Both healthcare delivery models may also provide comprehensive care and preventive services for an affordable fee.
- 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.
In summary, both terms are often globally used in this article and within our publications, events, Physician interviews and books as Membership Medicine. Or, as some outside of healthcare but business title, part of the subscription-based service economy.
Physician Thoughts and Perspectives From Both Angles
“Direct Primary Care (DPC) is not insurance, does not strive to replace health insurance, nor is it adversarial to it. On the contrary, many DPC practices are eager to work with insurance carriers to co-create blended plans which integrate DPC with high-deductible insurance and ultimately correct the perverse incentives which are rife in the traditional fee-for-service system.” ~Dr. T., DPC Physician, Colorado
“We recognized back in 2000 that health care was moving from personal to a more institutionalized form, and it wasn’t what we wanted to do,” said Dr. J.B., Michigan, who operates a concierge medicine practice and a DPC-employer based program with offices in Michigan. “We felt we needed to have time with our patients, to have the excellence to have the time with patients. Health care has been cutting reimbursement to doctors, which has forced doctors to see more patients, so the time doctors have with their patients have declined. The average time today with patients for most doctors is only 10 minutes.”
“Instead of viewing the status quo PCP model as the center of the universe. Maybe we should take some plays from the Retail Clinic playbook before we become obsolete.” ~DPC Physician and CMT/DPC Journal Contributor/Writer, Dr. R.N.
“I have decided to adopt a blended model of concierge medicine. My current patients may continue their medical care at our clinic, and a well-trained and capable nurse practitioner under my supervision will be seeing them. When necessary, I will be brought in with the nurse practitioner to discuss and formulate the medical management plan. Those patients who sign up for the concierge service be seen by me and get to enjoy extended appointment time during their visits, have access to me via telephone 24 hour/7 days a week, same day appointments, and get detailed in-depth yearly physical that focuses on disease prevention and wellness. My motto is “Preventive Healthcare, A Smart Approach to Healthy Life”. I believe that a healthy body and stable mind gives the opportunity to live an enjoyable and rewarding life.” ~Dr. M.T., Concierge Medicine Physician, Baton Rouge, LA
“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, Concierge Medicine Today & The DPC Journal
“The road was much more difficult than I expected, but also much more satisfying. I spent much of my time learning what doesn’t work, but in the end learned that most good ideas grow out of the remains of a hundred bad ones that didn’t survive.” ~Dr. L., MD, DPC Physician/CMT/DPC Journal Contributor/Writer
“We ask people to do really hard things: gluten and dairy free diets, mold remediation, massive amounts of targeted vitamin and mineral supplementation based on labs, calorie counting and exercise logs, meditation. When they are willing to do these things they usually get better. When they don’t, they are wasting our time and their money. We coach them with a lifestyle coach included in their membership, we follow up with them via snail mail cards, phone and email, and we do everything to give them tools for success but if they are not willing to make the changes, we tell them that the relationship is not working and they need to seek another doctor.” ~Dr. E.C., Concierge Medicine Physician, Cumming, GA
“What I found interesting was that when I left my old practice — I had a 10% Medicare population. That fraction has grown to almost half, suggesting to me that some of the folks most interested in this model are older patients.” ~Dr. F., Northeastern United States
“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 the former Qliance Medical Management based in Seattle, Washington. “One in which the provider’s incentives are fully aligned with the Patient’s incentives.”
What’s does Concierge Medicine and Direct Primary Care have in common?
In both Concierge Care and DPC, people have inherent 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.
For anyone looking at which model they want to choose, you must understand that the Doctor is the story here, not the delivery vehicle.
Physician’s have a customer service problem. Healthcare has a price problem as well.
But both Concierge Medicine and Direct Primary Care help provide a solution to the victim whom is the Patient and the healer, the Physician.
I’m of the persuasion that Physicians are too &$#! important to close up shop because of a lack of business acumen that wasn’t provided in medical school and poor performing financial margins.
You’ve heard us say it over and over but it is worth repeating.
“It is no longer about being the best Doctor in the world anymore. It is about being the best Doctor FOR the world, FOR your Patients and FOR your local community.”
As a Patient, I would prefer never to know if my Doctor was one or the other. Frankly, I don’t care. What I do care about is my health. Patients don’t care how hard your life was before this job. That might not be fair, but it is true.
All of that bureaucracy you’re complaining about, leave it in the break room. Or, the board room, which ever you prefer. It doesn’t belong on a Twitter feed that your patients are going to read or in a blog post on your web site.
Patients don’t care how much you know, they want to know how much you care.
Show, don’t tell.