Membership Medicine 101: Understanding the Basic Terminology
“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: Spring 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.
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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.
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.’
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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.
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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.
You and I don’t need to justify why concierge medicine or direct primary care and/or other subscription-based healthcare delivery models are relevant, anymore than we need to explain to each other why it is relevant to our lives today.
Both have relevance, just in and of itself.
Both find unique and personal ways for Patients and Physicians to understand each other and allow the Patient to more confidently participate in each others decision-making process. You and I both know that these models find ways to bring the Physician and Patient closer together. And, that the care and treatment discussions now held knee cap to knee cap, for longer periods of time, keep you and the Patient connected in a very personal and unique way.
The Patient, finally gets the time to examine all of their options that the Physician has now unpacked for them. The Patient has a voice and seat at the table again on treatment decisions versus blindly following the treatment plan. They can now ask their Doctor without guilt ‘Show me the evidence behind that therapy/drug or treatment.’
So you see, both healthcare delivery models are just plain relevant.
But I also don’t get mad around certain language used either, nor should you. Be proud of the brand and model you chose, but not evangelistic or degrading to colleagues who opt for a slightly different path. Physicians already feel bullied and six inches tall after leaving medical school. We don’t need that trait to continue into our 40’s, 50’s, 60’s, 70’s and 80’s.
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I’m also not mute to the fact that when people hear the term ‘concierge medicine,’ what it triggers is ideas of wealth or opulence. Yet when we all pause, listen for a moment and learn from all of these Doctors, we see that their heart beat is about bringing the Physician and Patient closer together. I also don’t believe in the altruistic idea that Physician’s in Direct Primary Care should make no money or break even in DPC because that’s just what everybody else, or the loudest voices in the crowd are doing. You see when 8/10 people surveyed inside your community and mine, don’t care if their Doctor’s Office closed at the end of the day today. Like, forever! We have a problem. We hear all of the time about Physician shortages and that narrative is a continuous drum beat that’s not going away.
So please, don’t under value yourself.
You are too important to our communities to do all of this wrong.
A lot of people like to compare Concierge Medicine to Direct Primary Care (DPC) and say … ‘DPC is the less expensive alternative.’
The data, the patient interviews, the web site and service contracts we’ve all seen as well as the industry service offerings we continue to see plus, the trend lines 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. Add to that, concierge medicine has put a significant focus on staff training, interior design and customer service and hospitality.
Still confused by this semantic hair-splitting? Join the club. Even concierge medicine and direct primary care physicians are still confused about which type of doctor they are. We see and hear quite frequently these terms used by the same Physicians interchangeably.
“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.” ~Neil Chesanow, Medscape/WebMD, May 2014
Please understand that whichever subscription-based healthcare delivery model you choose, please price your services and offerings in such a way (preferably with the help of a good consultant, attorney, financial planner and supportive spouse) that you have confidence in yourself and the team around you. Make sure you have a team that can show you your blind spots and tell you that ‘You are worth more than you think you are.’
I adore what attorney Jim Eischen, Esq. said at an American Academy of Private Physicians conference (April 2015) in Phoenix, Arizona when he said from the stage …‘Let’s focus on substance, not labels.’
We couldn’t agree more.
“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.”
Subtle Differences Between Concierge Medicine and DPC.
- Some would tell you (or rather, argue) it is insurance participation and/or Medicare participation with the added subscription. Others would tell you it’s all about pricing of the subscription that determines the brand you identify with the most.
- For me (and I’m providing both a marketplace observation professionally and that of a Patient perspective), it is about price, insurance compatibility or utility, services offered beyond the membership and most importantly, the customer service and the friendly demeanor of the Physician and staff.
Overall, Concierge Medicine and DPC style clinics are thriving in major metropolitan markets.
- 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.
- It is commonly understood and accepted that both subscription-based healthcare delivery models have a place in healthcare for different patient demographics. And Patient demographics is where we can kickoff these differences first. According to our study over the decades (and it is a lot), exclusive interviews with countless Physicians over the years, hosting industry conferences, speaking at conferences about these models and advocating for each, demographic patient populations in each of these respective models is where these two subscription-based healthcare delivery models part ways in our research.
- Is there some overlap? Of course, there always is.
- For example, Direct Primary Care, otherwise know as DPC or direct care is much younger than it’s familial subscription-based healthcare delivery business model in healthcare, despite reports in the media citing the same dates as Concierge Medicine. Physicians entering DPC are also usually quite young (eg 30-50s). Is that always the case? No. But the more and more DPC practices we see hanging their shingle, the younger the Patients are. Inherently, patient demography usually follows. Meaning, you can usually expect 80% of your customer or patient population to be on or about 10+/- years of the age of the Physician.
- Conversely, we encounter in Concierge Medicine, that a lot of Physicians are in their 50’s, 60’s and even 70’s. Inherently, patient demography follows a similar pattern whereabouts 80%+/- patients are within 10+/- years of their Doctor’s age.
- One would want to believe that the services would be the same but they would be incorrect. You need only do a little Google search and visit a handful of each of these practices and you will quickly learn that the services offered are different.
- Once again, to each their own. Just because you offer less or more, isn’t necessarily a negative or a positive. Each Physician and Patient should make their own choice about what works for them.
- However, we have discovered over the years, a greater breadth of primary care services are provided (which are not covered or considered covered by Medicare of health insurance) by the annual retainer contract fee structure and contract between the Physician’s practice and that Patient Member.
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. In recent years however, DPC Physicians have pivoted their practice to overcome this financial problem, educational and marketing gap and are now working with employers, where healthcare expenditures for a majority of employer dollars spent each year. Meaning, the employer now pays the member (eg Patient subscription) fee vs. the actual Patient/Member.
Insurance and/or Medicare Participation
- Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “fee” is only for “non-covered” services. This results in two fees paid by patients — the concierge medicine fee, and their 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.
- Conversely, most DPC practices have chosen to opt out of all insurance/payor contracts and Medicare and rely just on the subscription fee as their primary/bulk form of revenue for the practice.
Patient Panel Size
- Annual fees at DPC practices may vary from $8-$170 per member, per year (PMPM). The average according to The DPC Journal from 2013 to 2022 is about $85/pmpm. Additionally, DPC Patients prefer to pay monthly vs. annually.
- “Direct primary care practices, because they charge a lower fee, need more patients on their rosters. They typically have under 1000 patients but numbers on DPC patient panels vary widely from 150 to 1,200 patients under subscription.
- 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 and according to Concierge Medicine Today, the average PMPM is approximately $225/pmpm.
It’s not easy doing either one.
Don’t let anyone tell you different.
Furthermore, don’t let anyone tell you what you’re worth or that ‘You should just pick the [salary] figure what you want to make each year and go from there …’
Don’t let people tell you that some prefer to think of DPC as the less expensive or generic alternative to Concierge Medicine or that any reference to Concierge Medicine in healthcare is only targeted for the ultra-wealthy Patient.
Most of the Doctors that I’ve known in my career and I have known a great many will tell you they went into one model or another based on a great deal of research, wise counsel and great ideas that they wanted to see become a reality. Fewer, went into one model or another because of frustration with bureaucracy.
Regardless of the reason, there’s inherent value and truth in either path.
What you’re about to read is what I hope is an open minded editorial which I welcome readers to share their insights and experiences as well. Furthermore, I always welcome an open open minded conversation to anyone willing to have a discussion about the pros and cons around each of these subscription-based healthcare delivery models. If at the end of our discussion, neither path is in your future, then we’ve done our job as well.
Do Membership Medicine Models Have Competition?
It’s not lost on me that Concierge Medicine is not for every Doctor, nor every Patient.
It’s also not lost on me that Direct Primary Care (DPC) is not for every Doctor, nor every Patient.
There’s similarities to be sure. There are also polarizing differences. The goal of each however is to provide a lifeline for Doctors and Patients that allows them to have a closer, more transparent and convenient connection with one another.
Most of your peers as you know move into medicine for the same reason most physicians do. Because their family was connected to medicine somehow. It tends to move along like that line. A sort of family business or as some might say, a patrilineal descent into the career known as medicine. It’s what your father or mother did. Or maybe there was a friend of the family who was in medicine that you encountered at a young age that forever changed what you wanted to do. It’s simply who you are, you’re a Physician, first and foremost.
It’s also important to note that most future and current Doctors were introduced to medicine as an act of love for human kind. I love that.
I know that might sound suspicious to some people given how they think of healthcare today as multi-tiered, impersonal and fraught with bureaucracy and high costs.
Though I have no illusions, there will always be a rift between people’s understanding of what concierge medicine is and does and the rest of what healthcare could be and should be. I believe personally that concierge medicine has become the conscience of our healthcare marketplace and the stories we share, show and tell her now for years at CMT prove that to be true. These Physician’s are truly doing great work and will continue to do so in the future.
I’m also open to discuss Concierge Medicine, subscription-based healthcare delivery, DPC and even the impact of retail healthcare and the concept of patient fatigue with anyone who will listen.
A common misconception out there is that every Concierge Doctor who does it is in it for the money. That’s just simply not true. That argument has created a removed perspective.
What the doctor-patient relationship currently looks like today is a relatively new experiment in our human history. When we’re long gone and Millennials, Gen Y and Z’s are using Google glasses and asking their grandkids if they texted or video chatted with their Doctor we’ll soon see the Patient-Physician relationship hopefully in a far more connected place than Patients are experiencing today.
To say that Patient Fatigue and the stress of the unknown for a Patient is not an issue both mentally and physiologically for the Patient and Physician to deal with in the future is to also understand why these subscription models in healthcare today exist.
Horst Schulze, former executive at the Ritz Carlton and now respected author and speaker says it best in his book, Excellence Wins: A No-Nonsense Guide to Becoming the Best in a World of Compromise, “An organization can’t please every human being every time. But it never hurts to try.”
He also says later in the book, “No sound on earth is as sweet to a person’s ears as their own name.”
Those words reverberate in the hearts and minds of the Concierge Medicine Doctors that I know and have known.
I respect a Doctor who pursues his or her passion to help people.
But I’m naturally drawn as most people are to find, follow and befriend a Physician who has the kind of personable qualities that we all look for in a friend. I want to find a Physician for myself and my family who looks you straight in the eye and says “How can I help you today … “ or “It’s okay. We’re going to get through this together …” Furthermore, what we all want is a Physician who isn’t distracted and doesn’t let his or her circumstances or station in life dictate his or her bedside manner.
Author and speaker Jeff Henderson said “Every relationship has a climate—sunny, stormy, or even icy. And the current climate dictates the forecast. The problem is that many of us are unaware of the emotional climates we carry around with us.”
We shouldn’t have tribalism in healthcare. Sure it’s nice to celebrate and commiserate the hardships of our journey with friends and colleagues but the one thing I see both critics of Concierge Medicine and advocates of it have in common is that they all want to see the Patient and Physician brought back together in a way that’s satisfying to both the Doctor, the Patient and ultimately, the community.
In my personal opinion, there’s no room for tribalism in healthcare. There’s no room for the criticism of Doctors following their entrepreneurial inclinations that will help their community become healthier. Whatever form, brand or term that may be.
Today the tribalism in healthcare is evident. As an observer of this space and other healthcare delivery innovations, it’s easy to see.
Professional tribalism is an attachment of health professionals to their respective medical, nursing and allied health groupings instead of collaborating and identifying as cross professional team members (Weller, 2012).
For critics of Concierge Medicine, the tribalism can get pretty esotheric. Oxford Dictionary defines the adjective esoteric … as intended for or likely to be understood by only a small number of people with a specialized knowledge or interest.
I’d like to see that tension remember the common ground. It’s the patient. He/she, they’re right there. They’re sitting right there. And we all agree that the Physician and Patient need come closer and closer together.
The British Medical Journal (BMJ) researchers even went so far as to study tribalism in healthcare recently.
- The Results: At baseline, there were few significant differences between the professions in collective orientation, most of the personality factors, Machiavellianism and conservatism. Teams generally functioned well, with effective relationships, and exhibited little by way of discernible tribal or hierarchical behaviours, and no obvious differences between groups (F (3, 31)=0.94, p=0.43).
- Conclusions: Once clinicians are taken out of the workplace and put in controlled settings, tribalism, hierarchical and stereotype behaviours largely dissolve. It is unwise therefore to attribute these factors to fundamental sociological or psychological differences between individuals in the professions, or aggregated group differences. Workplace cultures are more likely to be influential in shaping such behaviours. The results underscore the importance of culture and context in improvement activities. Future initiatives should factor in culture and context as well as individuals’ or professions’ characteristics as the basis for inducing more lateral teamwork or better interprofessional collaboration.
Most of the Doctors that I’ve known in my life and I have known a great many, struggle in some way with how to design a practice, a career in medicine that focuses primarily on the Patient-Physician relationship without a lot of hassle.
It’s a process. There’s no perfect model, despite the rhetoric of some who are more tribal in their beliefs than others.
As a Physician you strive to make a difference each day. You struggle with the time you can’t spend with your Patient. You are fatigued by the bureaucracy, the control but yet an internal voice drives your vision to truly care for your patients inside an unfair ecosystem.
Concierge Medicine is only one way to help Physicians find a lifeline in their career and help with Physician Burnout. It’s not the only way.
Direct Primary Care (DPC) is another great way, but it’s also not the only path. For the few …. the conversation around the differences between Concierge Medicine and DPC illustrates that central paradox between Do no harm … and Treat Others as You Want to be Treated.
When wrestling with this, I believe it’s important to remember that many of our most influential Doctors had a love of medicine at the beginning of their journey that inspired in them to save the world and help humanity.
My personal hope is that more Doctors will continue to wrest with their own frustrations about the delivery of medicine while at the same time not become tribalistic and develop an optimism that fuels their vision to ultimately marry The Hippocratic Oath with The Golden Rule.
So which ever path you choose, Concierge Medicine, DPC, hospitalists, executive in healthcare, advisor, etc., make the decision that’s right for you. Don’t be persuaded that one path is the only way. Someone recently said and we don’t know who so the credit here is not ours, The goal is not perfection, the goal is progress.
Communicator and author, Andy Stanley recently asked this question in one of his Podcasts to listeners which I think resonates with today’s article. He said, “Is it more important to be fair . . . or to do good? Do for one what you wish you could do for everyone. Because if we all did for one what we wish we could do for everyone, it might change the world. But certainly, it would change one person’s world. It may even change your world.”
We may have different perspectives on what you might be comfortable hearing about at niche industry conferences. Notably, we have observed DPC events since 2014 to present, are often marked by great collegial networking but or at times, unbridled enthusiasm and evangelistic excitement that desires to persuade young and middle-aged (and up) Physicians into starting a DPC practice and that it’s as easy as ‘Decide how much you want to make and back into your subscription price this way, and begin.’
Again, it’s not lost on me that Concierge Medicine is a polarizing term and unpopular among some Physicians. That’s okay. I welcome anyone who is willing to learn to have a conversation about it and DPC.
Conversely, we’re also aware of the rising young Doctors need for independence to start and strike out on their own in DIY-DPC. And at times, we see seasoned DPC Physicians whose rising enthusiasm to break away from bureaucracy and control to start a Direct Primary Care (DPC) practice is as much a statement against all things that hold the Physician and Patient away from each other as it is a personal mission to serve the Patient.
Each of these subscription-based healthcare delivery models are doing great things.
As we look to the future, particularly the future of DPC, we see closures going unreported and Physician’s moonlighting and DPC practices vanishing. While another may pop up quickly somewhere else, that’s great. However, these DPC practices we are observing over the past several years now are in need of business training and leadership development education that is simply not being taught in medical events, CME curriculum, medical meetings, industry events or webinars of any real value to the Doctor.
A recent story entitled Thousands of Doctors’ Offices Buckle Under Financial Stress of COVID, written by Laura Ungar in Kaiser Health News (KHN) should be sobering to all of us that proves this futuristic hypothesis.
At both CMT and The DPC Journal we have been talking about and addressing the lack of business education and support for Doctors and Physician-CEOs now shuttering their doors, forgoing the terms of their real estate leases and so on for years.
There’s truly little in the way of support to course correct the ship by medical groups, medical associations or even medical event CME organizers and medical office managers when these practices run into financial trouble. It’s clear that even in the niches of Membership Medicine, particularly the closures in DPC over the past few years that are not tracked, that still little support is being directed towards Physician’s when they face closure.
Laura Ungar at KHN further proves this out as well when she writes on November 30th, 2020 … Although no one tracks medical closures, recent research suggests they number in the thousands. A survey by the Physicians Foundation estimated that 8% of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn’t break them down by type, but another from the Virginia-based Larry A. Green Center and the Primary Care Collaborative found in late September that 7% of primary care practices were unsure they could stay open past December without financial assistance. And many more teeter on the economic brink, experts say.
We start with all of that to emphasize that there are not perfect business models in healthcare.
As enthusiastic and excited as DPC is, it’s not the pathway for every Physician. I get it.
Furthermore, Concierge Medicine isn’t the path either for some Physician’s either. We understand that too.
But as someone wiser and who has obviously sold more books than I have recently said, ‘The goal is not perfection, the goal is progress.’
DISCLAIMER AND USE: In no event is this information considered medical, legal, tax, financial, accounting or other professional advice (Please see full disclaimer below). This Publication, it’s article(s), opinions, Podcast, the content provided herein, etc., Is Subject to the Terms and Conditions of Use (https://conciergemedicinetoday.org/tcpp/) and is recorded/hosted/written by Concierge Medicine Today, LLC. Concierge Medicine Today, LLC., our representatives, agents or employees accept no responsibility or liability for direct, indirect, special, incidental or consequential damages or financial costs or claims made by the Physician(s) interviewed or our guests.