I knew that wading into the issue of retainer practices—and getting into a friendly debate with my friend Bob Centor (although I don’t think we really disagree on that much, as discussed later in this blog), would get a spirited reaction from some readers.
Yesterday’s posting, though, really didn’t say much of anything about the merits of retainer practices. My point was that whatever any of us may personally believe about retainer practices, the evidence so far is that they are a small—but slowly growing—niche found mostly on the East and West coasts and certain metropolitan areas. And whatever we believe about primary care physicians turning away from Medicare, the evidence (so far, at least) is that Medicare participating rates are at an all time high, and only a very small percentage of Medicare patients report “big problems” in finding a physician or getting a timely appointment. Our individual beliefs and personal experience matter, but good policy requires that our belief be tested and validated by evidence and data to the extent possible.
As I wrote yesterday, “I don’t question [Bob Centor’s] overall hypothesis, which is that more and more primary care physicians are dissatisfied with current practice models and looking for alternatives.” No one wants a good internist to go out of business, and if “their choices are retainer practice, cash only practice, hospital medicine or retirement” they shouldn’t be criticized for choosing the retainer option.
It is one thing, though, to say that retainer practices are a reasonable and sometimes necessary reaction by individual practices and patients in response to economic pressures, and another to offer them up as solution to problems facing primary care.
According to a studies done by the University of Chicago and the Government Accountability Office (GAO), “retainer physicians tend to have smaller patient loads and fewer appointments daily, compared to their non‐retainer counterparts. The retainer physicians who responded to the GAO survey reported having, on average, 491 patients. The average number of patients physicians had the year before they started their retainer‐based practice was 2,716.”
Let’s do the math. If more primary care practice go the retainer route, they will have to offload as many as 2000 patients, made up mostly of patients who can’t afford to pay an average of $1500 in annual retainer fees. They will have to find care somewhere else, but busy non-retainer practices won’t have the capacity to pick up them, leading to even longer waits for appointments and more trips to the emergency room. And for each primary care physician seeing fewer patients, the country would have to train even more primary care physicians to keep up with demand, or train non-physicians to take care of them.
We could end up with a two-tiered primary care system, one for those who can pay more to participate in a retainer practice, and one for people who can’t afford the retainer fee and will have to queue up for care from underfunded clinics led by non-physicians.
A more promising solution is to reimburse practices for providing team-based, patient-centered care led by a personal internist or other primary care physician.
This is the idea behind the Patient-Centered Medical Home. Under the PCMH model, patients would have access to same-day appointments when needed, just like in retainer practices. Internists would be able to spend more time with the patients who can benefit from internal medicine specialist care, because health professionals in the practice who have less training could see the less complex patients, and some of the follow up would be handled by electronic communications rather than a face-to-face visit. Instead of the practice asking patients to pony up a retainer fee, Medicare and private insurers would pay the practice a monthly, risk-adjusted payment per patient for the time spent managing and coordinating care and to help cover the investments in information systems and team-based support staff. Physicians in the practice also could share in savings from preventing unnecessary hospital admissions and achieving quality benchmarks.
Six years ago, I wrote in ACP’s monthly magazine (then called the ACP Observer, now called the ACP Internist) that:
“The medical home would, in other words, offer the best elements of what is known as ‘retainer’ or ‘boutique’ practices—without the accompanying inequities. Like the medical home concept, retainer practices appeal to growing numbers of patients and physicians because they offer patients the promise of timely access to a personal physician. But boutique practices typically require patients to pay a larger retainer fee not covered by insurance, making such practices more suitable to wealthier patients. The medical home model would be financed by insurance coverage so it would not be limited to patients with higher incomes. And unlike boutique practices, medical homes would be publicly accountable for the quality and efficiency of care they provide.”
The medical home has come a long way since then, and unlike retainer practices, we now have a lot of evidence to support the effectiveness of the PCMH model. But the concept remains the same. Patient Centered Medical Homes can offer the best elements of what is known as ‘retainer’ or ‘boutique’ practices—without the accompanying inequities.
Today’s questions: What do you think of the premise that Patient-Centered Medical Homes offer the best elements of retainer practices, without the accompanying inequities?