When Tamara Houston’s daughter developed a painful eye condition – on a Sunday, during a high school rodeo competition – the Yuba City mom didn’t rush to the emergency room or head to the nearest urgent care clinic. Instead, Houston picked up her cellphone and called her family’s primary care doctor, who met them two hours later at his Rocklin office. He diagnosed a scratched upper eyelid and recommended over-the-counter eyedrops to let it heal.
The cost of the weekend emergency visit? Zero, because it was already included in her family’s monthly $200 fee.
Houston’s family of four – including two teenage daughters – is taking advantage of concierge medicine, a small but growing trend in health care, particularly among primary care doctors.
Under a concierge-style practice, patients pay a monthly or annual fee, typically $1,200 to $2,000 a year, in exchange for longer appointment times, same-day visits and round-the-clock access to their doctor by cellphone, text or email. Some concierge doctors even make house calls. Practice styles vary. Some take insurance, such as Medicare. Many don’t handle any insurance billing, but let patients cover lab costs and specialist visits through their regular health care policies or health savings accounts.
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“I would never go back to a regular practice,” said Houston, a self-employed court reporter. “This takes all of the bureaucracy out of the equation. I don’t have to deal with co-pays or insurance. And we get to see a doctor who knows us.”
Concierge medicine has been around for about 20 years, but it has gained more traction in recent years among both physicians and patients. Known variously as “boutique,” “direct pay,” “membership medicine” or “retainer medicine,” it was long considered an option primarily for the wealthy, but is becoming more mainstream.
“It’s an accelerating business model and among patients, there’s rapidly growing demand,” said Tom Blue, board member of the American Academy of Private Physicians, based in Clearwater, Fla. “For seniors, it’s because it’s harder to find doctors who can spend the time. For younger patients, there’s a growing appetite for high-tech access to medical care that’s preventive care.”
“Mainstream medicine doesn’t allow you to practice good medicine,” said Dr. Chris Campbell, who left a longstanding practice with Sutter Health in Yuba City to open his own concierge family care office in Rocklin in December 2013. In his old practice, the constant churn of patients – 28 a day in some cases – “felt like assembly-line medicine,” said the former U.S. Air Force doctor, who has been the Houston family’s primary care doctor since the girls were toddlers.
That “hamster wheel” of modern medicine is part of what drives many doctors into concierge-style practices, said Michael Tetreault, editor of Concierge Medicine Today, an online news publication that tracks the industry. Falling reimbursement rates from insurers, increasing overhead costs and the hassle of dealing with insurance billing are leading many to consider alternatives, he noted.
Since 1996, when one of the first U.S. concierge practices was started by a couple of Seattle doctors, concierge medicine has been steadily growing. Today, there are roughly 6,000 concierge practitioners, up from 4,400 in 2012, according to the American Academy of Private Physicians, a trade association for concierge and direct-pay practices.
But the actual number of concierge practitioners is likely far higher, as many as 12,000, according to Concierge Medicine Today, based on its interviews with doctors, consultants and investors.
That’s still only a sliver of the roughly 904,500 actively practicing physicians in the United States today.
While growing, it’s not for everyone. And it’s not without critics.
“Obviously we are concerned about any trend that further makes our health care system a multi-tiered system. It already has its inequities and disparities, so to add an additional element is concerning,” said Anthony Wright, executive director of Health Access, a nonprofit consumer health care advocacy group.
Wright said he’s also concerned that individuals might be missing out on coordinated medical care with a team of providers. “And, if they’re doing this on top of regular coverage, they’re paying a pretty penny on top of premiums,” he said.
Not without risk for doctors
The California Medical Association, which represents the state’s licensed doctors, said it understands the economic pressures on doctors wanting to make a switch. There’s no official federal or state registry, so it’s hard to pin down exactly how many physicians have switched to concierge or direct-pay practices.
“We have long recognized administrative burdens and payment issues that physicians in contracted relationships face,” spokeswoman Molly Weedn said in an emailed statement. The association will support doctors “who have turned to alternative practice models … to provide more access to care for their patients,” she said.
For physicians contemplating the change, consulting firms advise them on everything from how many patients are needed to make a practice financially viable to how to properly inform patients of what can be a startling change.
“It’s a critical moment in a physician’s career,” said Rob Lewis, vice president of marketing at Specialdocs Consultants Inc., a Highland, Ill.-based company that advises physicians on how to make the transition. “If they change their business model, you’re going from thousands of patients to hundreds of patients. If you don’t do it right, you can lose patients and not get them back. Then you’re left with a broken practice.”
It typically takes a doctor six months to make the transition. “You need to educate patients on what’s happening. You can’t just throw out a letter on pricing and say, ‘Here’s what you get,’” said Lewis. “You want (patients) to make an educated, not an emotional, decision.”
Generally, he said, physicians switching to a concierge practice are in their late 40s to early 60s. They’re often frustrated with high-volume patient loads, shrinking insurance reimbursements and the grind of dealing with insurance paperwork.
The advent of Obamacare has accelerated interest in concierge medicine, say some experts.
“There’s a lot of uncertainty and physicians are looking at options,” said Lewis, who said his company had a 30 to 40 percent increase in physician inquiries between 2012 and 2014, after the Affordable Care Act went into effect.
One of California’s pioneers in concierge medicine, Dr. Marcy Zwelling, an internal medicine doctor in Los Alamitos, switched her practice nearly 15 years ago. Her motivation: sheer frustration. “I could not see patients in seven minutes, listen to their stories, do the research on their (conditions),” Zwelling said. “As a professional, I couldn’t do my job.”
Today, she has about 350 patients, who typically pay $2,000 a year for unlimited visits. Additional family members are charged on a sliding scale. For those who are unable to pay that amount, she arranges a barter system where, in exchange for their volunteer time in the community, she provides their care for free.
Zwelling sees six to eight patients a day and answers “thousands” of phone calls at night. She does follow-up appointments by Skype or email, where a patient might send a photo, for example, of a leg injury or an infected bug bite to discuss with her how it’s healing. “My patients work for a living. Why waste their time on the freeway coming into the office? In time and money, it’s much less expensive.”
She views concierge medicine as a panacea to some of the common complaints ailing health care: high costs and low satisfaction. Like Dr. Campbell in Rocklin, she does not handle insurance billing but does negotiate with local laboratories so her patients can get discounted rates on lab tests. For example, she said, an MRI at a local imaging center might cost $5,000, with the patient on the hook for $2,500 after insurance. By contrast, she said, her patients who pay in cash are charged only $400.
“We’ve arranged for good, cash prices so patients can get their care and understand the value of what they’re buying,” she said.
Middle class, not millionaires
Concierge physicians and experts say it’s moved beyond being affordable only for the rich. “When you look at who’s using it, it’s not the millionaires. The monthly fees are very reasonable and affordable for many middle-class families,” said Concierge Medicine Today’s Tetreault. He said typical concierge patients, though, tend to be in their 50s to 80s with household incomes between $125,000 and $250,000.
Campbell, 54, who recently completed a fellowship in anti-aging medicine, typically charges patients $1,200 a year. After 18 months building his business, he handles both primary care patients as well as rejuvenerative medicine clients and does some cosmetic procedures.
Campbell calls concierge medicine a hybrid of old and new: An old-fashioned doctor-patient relationship – with cellphone and text access – that’s purchased like a monthly gym membership.
Longtime patients like Houston and her husband, a former Yuba City rodeo star turned horse farrier, carry a high-deductible catastrophic health insurance plan to cover major medical emergencies. They also contribute more than $6,000 annually to a federal Health Savings Account, which they draw from to pay for specialists, such as a cardiologist or gynecologist.
Three years ago, seeing a doctor proved cost-prohibitive under a high-deductible health insurance policy that cost $760 a month in premiums but didn’t cover everyday appointments, Houston said. “If my daughters had an earache, I’d get a bill and it would be up to $210 for an appointment.”
Now, the 51-year-old said, “I love this so much more. To have one cost per month that covers everything – with zero boundaries for visits and treatments. … It’s huge. And it’s absolutely cheaper.”
Concierge Medicine at a Glance
What it is: A membership style of medical practice where patients pay a monthly or annual fee, in exchange for same-day appointments, longer appointment times, 24/7 access to their doctor by email, phone or text. In some cases, doctors make house calls. Known as “boutique,” “direct pay” or “membership medicine,” it’s mainly used by family medicine or primary care doctors, but a few specialists, including pediatricians, have concierge-style practices.
What it costs: Annual fees typically run between $1,200 to $2,000 per patient, but can go as high as $2,700, depending on the doctor, location, age of clientele, etc. More than 62 percent of concierge patients spend less than $135 per month, according to a 2013 study.
What’s the appeal: Doctors like it because of the reduced patient load, more one-on-one time and less overhead spent on insurance billing. Most concierge-style doctors see six to eight patients a day, compared with 20 to 30 a day in a typical medical practice. Patients like the instant access and personal relationship with their doctor and fewer insurance billing hassles.