Thursday, November 12, 2015

How does concierge and direct primary care affect access and cost?

We don’t really know, according to an ACP policy paper, written by me on behalf of our Medical Practice and Quality Committee and Board of Regents published in the Annals earlier this week.  What we do know that the numbers of such practices are relatively low but there is growing interest in them, and judging from a live twitter session I just concluded, considerable passion from those who have embraced direct primary care.

Why did ACP decide to take on this issue? A few years ago, the ACP Board of Governors adopted a resolution from our Florida chapter asking us to look into developing policy on concierge practices. This resulted in a general statement of College policy encouraging physician choice of practice arrangements that best meet their patients’ needs in an ethical and accessible way.   As time went on, though, it became apparent to us that a more detailed policy analysis and recommendations were needed, for several reasons.

It is now evident that increasing numbers of internists and other physicians are considering becoming part of a concierge, direct primary care, or some other practice arrangement that includes one or more of the following elements:  (1) downsizing of patient panels (2) charging a retainer or concierge fee and/or (3) not participating in patients’ insurance.  (Collectively, we define such practices in the new paper as direct patient contracting practices, or DPCPs.)  The Affordable Care Act allows the insurance exchanges to offer direct primary care with a wrap-around high-deductible insurance policy.   We also have had ACP members ask us whether the College has any policy or guidance on concierge or direct primary care practices.  The growth of such practices can have a significant impact on quality, access and cost of care, as well as patient and physician satisfaction, yet little has been published in the available research literature on their impact.

For these reasons, our Medical Practice and Quality Committee accordingly decided that the College could make a positive contribution by doing an evidence-based analysis of the reasons why a growing number of physicians are interested in such models, what we know and don’t know about their impact on quality and access, what issues require further study, and ethical considerations that apply to physicians regardless of their practice mode.  The members of our Medical Practice and Quality Committee who developed this paper included an internist in a direct primary care practice as well internists in more traditional independent practices.  The Committee was unanimous in supporting the paper and its recommendations.

If you have not done so already, I encourage you to read the entire paper included as an appendix to the summary version published in the Annals of Internal Medicine.  I think you will find that the paper is a balanced, objective, and evidence-based analysis of the implications of DPCPs as we intended.  Several highlights:

The paper clearly recognizes why many physicians are moving to DPCPs because of their frustrations with paperwork and insurance interactions, EHRs, and not being able to spend enough time with patients, and other external constraints on their ability to provide their patient with the best possible care.  We call on policymakers to address such frustrations.
We call on physicians in all types of practice to strive to provide care to all types of patients, including the poor and those on Medicaid, reflecting guidance from our Center on Ethics and Professionalism, Committee on Ethics and Professionalism, and ACP’s Ethics Manual on the obligation of all physicians to provide non-discriminatory care, regardless of their practice arrangement.
We observe that there are examples in the literature of DPCPs that have structured their practices to ensure access to low-income patients, including Medicaid enrollees.  Yet we also observe that there are concerns in the literature, supported by studies in our review of the evidence and input from our Committee on Ethics and Professionalism, which suggest that some practices that charge retainer fees and/or do not accept insurance could potentially create barriers to poorer patients who cannot afford to pay a retainer fee or pay out-of-pocket at the time the service is rendered.
We address concerns about the potential for patient abandonment associated with downsizing of patient panels, which can create legal and ethical issues that physicians should be aware of.
We provide practical suggestions for physicians who are in, or considering, a DPCP, to consider taking on their own to mitigate any adverse impact on poorer patients, such as waiving or lowering retainer fees, waiving requirements that payments be made at the time of service, and helping patients file claims.
We call on all practice arrangements to be transparent with patients.
We call for continued consideration of Patient-Centered Medical Homes
We call for more research on the impact of DPCPs.

The paper neither endorses nor opposes direct primary care, concierge practices, or other DPCPs; rather, it just tries to provide a balanced assessment of their potential advantages and disadvantages and issues that merit further consideration by physicians, policymakers and researchers.  Without more research, it would be premature for ACP to take a position on encouraging or discouraging them.

In summary, ACP affirmed our support for physician and patient choice of practices that are ethical and accessible and that best meet the needs of patients in a non-discriminatory way, whether in a more traditional independent practice, a large group practice, an academic practice, or a concierge practice, direct primary care, or other DPCP.  And we call for more research on the impact of DPCPs on quality, cost and access to care.

Today’s question: What do you think of concierge and direct primary care practices, and ACP’s recommendations?

10 comments :

Jay Larson MD said...

I am very much in favor of this new trend. I suspect if these physicians were assessed for burnout (once they have been in the new practice model for a while) it would be lower than the 50% nationwide. This model by design is more patient centric than the typical practice model. We recently had a family practice physician leave her community practice to work at our local VA, She felt it was only a matter of time before a lethal error was made as she was forced to only spend 8 minutes with a patient at a time. I just ran into her the other day and she was pleased that now she can spend the time necessary to deal with all of her patients' problems.

Spending time with patients is a necessity that has been cut short by the current system demands. In regards to ethics of the new practice model, it is unethical now for primary care providers to be rushed through their patients like cattle. If the system will not support primary care, is it wrong for the primary care provider not to support the system. Where is the law that all patients get access to primary care? Where are the ethics of the GI doc pulling down $800 K per year just to do scopes and only scopes like we have in our community. Where are the ethics of dermatologists doing Moh's procedures on the back? Where are the ethics of a healthcare system demanding $100K up front to treat a cerebral aneurysm in a low income person without health insurance?

I see the new practice models as a way to get out of our sick healthcare system. I tip my hat to them.

Narayanachar S. Murali, MD, FACP, FACG said...

Does ACP not understand what doctors in direct patient care are doing or do they have some other agenda? I really want to banish the word concierge as it applies to medical practices. The connotation of "pandering to the rich " that is inherent to that term, the image of a " liveried, white-gloved, hatted, booted servant carrying your expensive junk for safe keeping"...is not easy to divest from the term "Concierge practice" . What idiot came up with this term for medical practice? why is ACP even mentioning it in the context of direct patient care??..Perhaps all of us involved in direct patient care should go further minimalist and just call it "patient care"

PCP said...

Why do ACP's views on concierge practices even matter?
Isn't it their advocacy or lack thereof that has led to the current toxic environment for small independnt practices?
I can't see anyway a concierge or direct care physician will have an allegiance to ACP.

Harrison Robinson said...

Direct patient contracting. Hmmm. I had not heard that term before and I will get around to reading the paper, but not being informed never stopped me (or anyone else) from commenting before.
:)

I know of doctors who have chosen direct contracting, or an enrollment fee for patients to be part of their practice.
I also know of a doctor who has a large panel of capitated patients, and he chooses not to accept any patients who are not in that panel. Therefore he gets a guaranteed sum based on per patient per month agreements, and that gives him a secure income with clearly defined practice expectations.
Not bad either.

I know of doctors who fire patients if they are contentious.
And by so doing they shape their patient populations.

Here in California many doctors cannot accept Medicaid as payment, because it doesn't pay enough to support overhead and because there is a fear that those patients will overwhelm a panel of patients and keep others out, and possibly besmirch a reputation.

But in my community, a direct patient contracting model would be difficult because patients have other choices and not many with straight Medicare have money to spend that would allow it.
On the coast, where people are generally more affluent, sure....
There they have lots of patients who can pay for it.

I think that direct patient contracting fits within the spectrum of care that should be available for primary care physicians, and I think it will be and maybe should be adopted by more of us, because it will influence the Medicare and Insurance company stipulations that are attached to newer physician incentive payments.
If Medicare starts feeling pressure from patients who do not have access because physicians are choosing not to play the game for a 2% increase, or whatever else is dangled in front of us, then maybe the models will change.

But I don't see me choosing that model any time soon.

Harrison

bruce said...

I was just notified by CMS that I do not "qualify" for my 2% PQRS reimbursement. I made a good faith effort, and after a period of anger, I realize I just can't be bothered by that kind of nonsense. I have 2300 patients in my panel, 1250 over 65 and 500 over 80. It is ridiculous, given the amount of attention I devote to the elderly, that CMS should diddle me like this. I keep an eye out for new practice arrangements - maybe the right one will come along one of these days and I can finally tell CMS to go stuff it.

Tough Customer said...

The free market is the driving force behind "concierge medicine" and other voluntary schemes whereby patients pay money directly to a doctor in exchange for a more intensive, personal and satisfying level of care. Patients have come to learn that, in any capitated system, the doctor is rewarded financially if the patient simply stays home and suffers quietly. Every medical intervention is either mandatory or prohibited by the "thought-leaders" of the medical profession, who have declared it a thought-crime to screen a 50 year old man's PSA or order an ultrasound to screen his carotid arteries for cholesterol deposits. As soon as any capitated patient seeks care, they become an economic liability, to be greeted with scowls, required to wait for long periods of time, treated in a perfunctory or even hostile manner by an under-qualified provider, and sent home empty-handed except for a multi-page printout describing the wrong diagnosis, with the warning to come back immediately for more futile harassment if any of a long list of symptoms occurs, many of which the patient actually has, and complained of to their provider, who dismissed those complaints.

The free market, as exemplified by the fee-for-service model of payment, is the natural order for all efficient human economies. If you want my service, you pay my fee. Just like with the plumber, the butcher and the prostitute on the corner. Nobody has proposed socialized plumbing - can you imagine what a mess it would create? Poor people would be herded into "accountable plumbing organizations" - (APO's)- which, as they would soon figure out, provide plumbers with incentives not to provide certain services which are frowned upon by the "flush-leaders" of the plumbing profession. Perhaps the reaming out of slow drains would be disincentivized, because it leads to overtreatment, defined as the curing of plumbing problems in houses that will probably collapse soon for other reasons. We would all soon be wading ankle-deep in wastewater, as the APO's proudly announced how much money was saved last quarter, with bonuses going to the plumbers who cleared out the fewest slow drains. The natural reaction, by those who could afford it, would be to establish Concierge Plumbers, which would be plumbers who would actually fix your clogged pipes, in exchange for actual cash money they would receive directly from, for example, a furious doctor who tried to flush the latest Blue Sword PPO contract down the toilet in a fit of rage.

Concierge Medicine is an attempt by patients who want better service from their doctors to actually get it by paying out cold hard cash in advance. Concierge fees are purely a backhander, payola, schmiergeld, grease, baksheesh, tea money, you get my drift. These patients are not signing up for Concierge Medicine with any concern that the elevated level of care they seek will have a disparate impact on members of disenfranchised underprivileged communities. Concierge Medicine is a desperate measure, paid for by patients seeking to make their doctors accountable, once again, only to them.

David L. Keller, MD, FACP

Tough Customer said...

The free market is the driving force behind "concierge medicine" and other voluntary schemes whereby patients pay money directly to a doctor in exchange for a more intensive, personal and satisfying level of care. Patients have come to learn that, in any capitated system, the doctor is rewarded financially if the patient simply stays home and suffers quietly. Every medical intervention is either mandatory or prohibited by the "thought-leaders" of the medical profession, who have declared it a thought-crime to screen a 50 year old man's PSA or order an ultrasound to screen his carotid arteries for cholesterol deposits. As soon as any capitated patient seeks care, they become an economic liability, to be greeted with scowls, required to wait for long periods of time, treated in a perfunctory or even hostile manner by an under-qualified provider, and sent home empty-handed except for a multi-page printout describing the wrong diagnosis, with the warning to come back immediately for more futile harassment if any of a long list of symptoms occurs, many of which the patient actually has, and complained of to their provider, who dismissed those complaints.

The free market, as exemplified by the fee-for-service model of payment, is the natural order for all efficient human economies. If you want my service, you pay my fee. Just like with the plumber, the butcher and the prostitute on the corner. Nobody has proposed socialized plumbing - can you imagine what a mess it would create? Poor people would be herded into "accountable plumbing organizations" - (APO's)- which, as they would soon figure out, provide plumbers with incentives not to provide certain services which are frowned upon by the "flush-leaders" of the plumbing profession. Perhaps the reaming out of slow drains would be disincentivized, because it leads to overtreatment, defined as the curing of plumbing problems in houses that will probably collapse soon for other reasons. We would all soon be wading ankle-deep in wastewater, as the APO's proudly announced how much money was saved last quarter, with bonuses going to the plumbers who cleared out the fewest slow drains. The natural reaction, by those who could afford it, would be to establish Concierge Plumbers, which would be plumbers who would actually fix your clogged pipes, in exchange for actual cash money they would receive directly from, for example, a furious doctor who tried to flush the latest Blue Sword PPO contract down the toilet in a fit of rage.

Concierge Medicine is an attempt by patients who want better service from their doctors to actually get it by paying out cold hard cash in advance. Concierge fees are purely a backhander, payola, schmiergeld, grease, baksheesh, tea money, you get my drift. These patients are not signing up for Concierge Medicine with any concern that the elevated level of care they seek will have a disparate impact on members of disenfranchised underprivileged communities. Concierge Medicine is a desperate measure, paid for by patients seeking to make their doctors accountable, once again, only to them.

David L. Keller, MD, FACP

Rob Benton said...

It sounds like not a bad idea to pay a physician once a month. I think it would be easier. Not to mention, it could potentially cost less. I might consider it for myself. http://myfamilydoctorutah.com/family-medicine-practice-primary-care-clinic/

Armand Rodriguez said...

The free market finally comes to medical care! Previously there was only one tier in this market. Whether a patient received quality services or horrible care the physician reimbursement was the same....whatever the payer decided it would be. Everyone has always understood that in a free market higher quality commands a higher price, whether that be housing, cars or restaurants. And now patients and doctors alike finally realize that concept applies to medical services also!
The ACP committee wants to do an " evidence based analysis " of the impact on quality of these new arrangements. Huh? If the patient and physician both perceive quality and agree on a financial arrangement who is the ACP to conclude otherwise!? Should the ACP perform a similar "evidence based analysis" on exclusive hotels and their guests or luxury car owners and their car manufacturers to evaluate their "impact on quality and access."
Why does no one complain that having more expensive restaurants will cause problems with access to food for those that can't afford those high prices? Because the invisible hand of the free market will provide less expensive alternatives and the government (i.e. all of us) will create a safety net for the truly needy. Providing food, like medical care, is a moral challenge that the free market, with caveats, can address. Direct patient contracting models are a step in the right direction.

happy internist said...

I practice general internal medicine and I just did some end-of-year number crunching -- this year Medicare paid me on average $121 dollars per patient, not per visit but PER YEAR. I am not going to take it any further and figure out what hourly rate that amounts to because I would become too depressed! Now, I'm not overly driven by the bottom line (or I wouldn't be in primary care, right?) but that is a truly ridiculous sum for the extent of care I provide my patients. I don't blame primary care doctors one bit for seeking alternative payment models that allow them to actually do what they are trained to do, in a way that doesn't leave them burned out and looking for an escape route all together from medicine. More power to them!