Dr. Bob Centor blogs that primary care physicians are staging a “quiet rebellion” by forming concierge practices and opting out of Medicare:
“The system has constrained primary care fees while systematically increasing overhead. The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement. The system has undervalued the value of a good primary care physician. The system has, without consciously meaning to, held primary care in contempt.
So what do primary care physicians do? They do what any sensible economic citizen would do, they alter the rules to their benefit.
So decreasing numbers of primary care physicians are taking Medicare or Medicaid. So primary care physicians are leaving their jobs to do hospital medicine. So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.
The rebellion is a quiet one. No one has declared this rebellion. This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera. This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.”
I have the greatest respect and affection for Dr. Centor. He writes the always interesting (and entertaining!) DB's Medical Rants blog and has been a mentor to me on the fine art of blogging, As a member of the ACP Health and Public Policy Committee (which I help staff), Bob is unafraid to challenge conventional thinking, often expressing healthy skepticism about the latest policy fad of the day.
But now, I am the one who is skeptical. Bob’s premise that “decreasing numbers of primary care physicians are taking Medicare . . . “and that “so many primary care physicians . . . are retreating to retainer practices” just didn’t read true to me.
So I went looking for the evidence, and found that retainer [otherwise known as concierge] practices are growing—but they constitute a very, very small niche of perhaps several hundred physician practices, concentrated mostly on the East and West coasts. I also found, counter-intuitively, given the ongoing specter of Medicare payment cuts--that the percentage of general internal medicine physicians who participate in Medicare reached an all-time high in 2010.
• Six years ago, the GAO did a study that found that "Concierge care is practiced by a small number of physicians located mainly on the East and West Coasts. Nearly all of the 112 concierge physicians responding to GAO's survey reported practicing primary care.
• An updated 2010 report on retainer-based practices, conducted by the University of Chicago for the Medicare Payment Advisory Commission "found listings for 756 retainer-based physicians, which could be seen as a lower limit for the number of physicians practicing this model of care. This is an increase from the 146 retainer physicians identified by the U.S. Government Accountability Office (GAO) for a 2005 report...the vast majority of retainer physicians are primary care physicians. Of the 333 physicians for whom we were able to collect specialty information, more than three quarters were internists, and a fifth specialized in family medicine." The study also found that the presence and distribution of concierge practices is very uneven by geographic area, with most concierge practice being on the East and West coasts and many states have few if any retainer practices.
• According to official CMS data files, in 2010, over 97% of internal medicine physicians signed an agreement to participate in Medicare (and accept the Medicare rates), a record number, and the percentage of internists participating in Medicare has increased each and every year since 2000 (when it was a little over 90%).
• ACP’s 2009 membership survey found that that only 0.5% of respondents said that they would switch to concierge/boutique medicine when asked to describe their expected professional situation in the next one to three years.
I don’t question Bob’s overall hypothesis, which is that more and more primary care physicians are dissatisfied with current practice models and looking for alternatives. But at least so far, it doesn’t appear that internists are dropping out of Medicare, or that very large numbers see retainer practices as the solution.
I believe it will take a revolution in the way that primary care is educated, financed, organized, reimbursed, and delivered to elevate it to status and influence it should have in our health care system, and to make the beleaguered internist feel better about their futures. But when it comes to retainer practices being the solution, I have to answer like John Lennon did when he wrote the lyrics to the Beatle’s cynical “Revolution” in response to the revolutionary fervor of the 1960s:
“You say you got a real solution,
Well you know,
We’d all love to see the plan.”
Can retainer practices, which depend on primary care physicians seeing fewer patients and charging them out-of-pocket for improved access and time with the doctor, be the real solution to the crisis in primary care? Well, you know, I love to see the plan. Retainer practices may work for some physicians, and some patients, in some markets, but I don’t see the plan for them to be a real solution, and so far, it seems like most primary care physicians don’t either.
Today’s questions: What do you think of Dr. Centor’s premise that primary care physicians are staging a quiet rebellion manifested by more joining retainer practices or dropping Medicare? And do you see retainer practices as a real solution?