First Class Treatment
Concierge medicine offers an enhanced relationship with the doctor for those who can pay extra. But what about those who can’t?
Enter the office of Zeyad Baker, M.D., and you sense immediately that something is missing— something that’s been a fixture of medical offices for ages: a waiting room. It’s missing because, if you’re a patient of Dr. Baker’s, you don’t have to wait to see him. The Paramus-based pediatrician is one of a growing number of primary care and other physicians who’ve adopted a relatively new model of care known as concierge medicine. (It’s also sometimes referred to as retainer-based medicine, membership medicine, direct primary care, boutique medicine or platinum practice.) The model is becoming particularly popular in comparatively wealthy areas like Bergen County; it requires patients to pay a membership fee over and above the cost of doctor’s visits. In exchange for that fee, patients get what seems almost unthinkable in these days of insurance-driven healthcare: virtually unlimited access to their doctors without the wait for appointments. You can view it as either revolutionary or incredibly old-fashioned—medicine the way it used to be practiced, before PPOs, HMOs and the obligatory 15-minute doctor’s appointment.
WHAT’S UP, DOC?
While there are no reliable statistics for the number of doctors practicing concierge medicine in the U.S., the trade publication Concierge Medicine Today estimates that about 12,000 physicians—most of them primary care doctors, such as family medicine practitioners, internists and pediatricians—are currently offering some version of retainer-based care, and virtually all industry analysts expect that number to grow significantly in the coming decade, perhaps at a rate of 3 to 4 percent annually. (Among the wealthiest individuals—specifically, the top 1 percent—one in five are already paying their doctors an additional fee in exchange for direct access.) The retainers paid to doctors don’t necessarily increase their income; instead, they allow physicians to see fewer patients, both overall and on any given day. What the doctors do glean from the model, then, is time.
“Most doctors can’t spend the time they need to on their patients because they’re under restraints due to decreased reimbursements from insurance companies,” says Gary Schwartz, M.D., an internist in Hackensack. “To make up for that lost income, they’ve had to increase their volume of patients tremendously.” The average primary care doctor now carries a panel of 1,500 to 2,500 patients, compared with 600 for concierge doctors, and sees 25 to 30 of them in a day, as against six to 10 in concierge practices. For those traditional docs, it’s a burden that frequently leads to burnout, which, in turn, can result in diminished patient care. It’s also one of the reasons doctors cite for leaving primary care, a trend that’s resulted in a serious dearth of family doctors. Concierge medicine, on the other hand, allows doctors to give their patients whatever time they need (the average visit lasts 30 minutes) and offers physicians an improved work/life balance. A happy doctor, most M.D.s will tell you, is a better doctor.
WHAT’S IN IT FOR PATIENTS?
As it is with physicians, the greatest benefit of concierge medicine to patients is time: more time during doctor’s appointments and less time waiting for them. In traditional practices, says Dr. Schwartz, “more often than not, if you call up a doctor on Monday and say, ‘I don’t feel well,’ they’ll say, ‘Well, maybe we can see you on Thursday.’ And if you say, ‘Well, I don’t feel well today,’ they’ll say, ‘Well, then, go to urgent care.’ I don’t do that in my practice. We see patients in a timely fashion—same-day appointments.” “He’s always available,” says Fair Lawn resident Rita Sullivan, a longtime patient of Dr. Schwartz.
“I don’t have to wait to see him, and he’s even come to the house, twice for my husband and once for me.” Like most patients in concierge practices, she has access to her doctor 24/7 by phone. That’s also true for Amanda Salameh, a mother of three in Saddle River whose children are patients of Dr. Baker. “As a mom, I find it reassuring to be able to speak to someone at any time,” she says. Baker’s patients can also communicate through an app that allows them to send photos and videos to the office. When Kristin Giovannone’s son was bitten by a tick, Dr. Baker asked the Saddle Brook mother of three to send photos of the bite and the tick; after examining the photos, he prescribed an appropriate course of antibiotics.
In addition to convenience and attention, many concierge practices stress wellness and prevention. Bret Jorgensen, CEO of MDVIP, one of a number of networks of concierge physicians, notes that when doctors reduce the size of their practice, “they can, in fact, focus more proactively on prevention and wellness.” The network currently includes four physicians in Bergen County, all of whom make wellness a priority. Patients who see concierge practitioners in the Castle Connolly network, like Dr. Schwartz, have access to a program called SENS, for Sleep, Exercise, Nutrition and Stress Management, through which they can see a number of health coaches, including a nutritionist.
The retainer, of course, is essential to concierge medicine, though the amount and what it covers can differ from practice to practice. When the concierge model was new, it wasn’t unusual for patients to pay five-figure annual retainers, but that’s less likely today, though $10,000 retainers aren’t unheard of. Jorgensen says MDVIP patients pay an average fee of $1,800 to $2,000 and, in fact, the average annual retainer countrywide is around $2,400. Depending on the doctor, it can be paid monthly, quarterly or annually.
About 75 percent of concierge practitioners accept health insurance; the remaining 25 percent only accept cash. Most insurance plans will cover fees for medical services, with deductions and copays applying as they would in any medical practice. Retainers, on the other hand, aren’t usually covered by insurance, though some Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) do cover at least a portion of these fees.
IS THERE A DOWNSIDE?
The obvious drawback is the cost of the retainer; some patients can’t afford it, and others simply don’t want to shell out more for medical care than the substantial amount they’re already paying. Robin Ellen Leder, M.D., a holistic family doctor in Hackensack, wanted very much to switch her practice to a concierge model, but “I offered it to my patients, and they didn’t want to pay anything upfront,” she says. To help doctors make the sometimes difficult transition to a retainer-based model, many turn to networks like MDVIP, Castle Connolly and Signature MD, which may also take over the management of billing and other time-consumers.
Some people will clearly benefit more from concierge medicine than others. They include patients who are likely to see their primary care doctors multiple times in a year, such as older people and those with chronic conditions. In fact, most concierge patients are over 50, though the model seems to appeal to people of all ages who are fed up with the long waits and short appointments typical of traditional medical practices.
But does the increased convenience and attention translate to better medical outcomes? A recent study published in the Journal of Health Economics found that, over a five-year period, there was no difference in mortality rates between those in concierge practices and those seeing traditional primary care doctors. Even if further research bears that out, though, concierge patients may still reap benefits. MDVIP’s Jorgensen cites a number of peer-reviewed studies the network has conducted that found its patients had significantly fewer ER visits and hospitalizations than patients in traditional practices, and that those who were hospitalized experienced fewer readmissions—results that most medical consumers would find enticing.
Of course, if you’re one of those patients who can’t—or won’t—pay a retainer, you face another problem: The U.S. is currently experiencing a serious shortage of primary care physicians. A 2021 report from the nonprofit Kaiser Family Foundation noted that 83.7 million Americans live in what’s known as a health professional shortage area (HPSA), where family doctors are in extremely short supply. To remedy that shortage, we would need to see an additional 14,800 primary care doctors enter the field. Unfortunately, fewer and fewer young doctors are going into primary care medicine, which pays significantly less than lucrative specialties like cardiology, neurology, dermatology, oncology and almost any kind of surgery. Nurse practitioners and physician assistants can provide many primary care services and are increasingly sharing the load of overworked family doctors. But the shortage still hurts.
The U.S. is already experiencing a medical inequity crisis in which the well-to-do have access to excellent medical care while those in rural and underserved urban areas are far less likely to get the care they need. And, says Stephen Crystal, Board of Governors professor in the Institute for Health, Health Care Policy and Aging Research at Rutgers School of Social Work, the move to concierge medical care is exacerbating that problem. “In many cases,” he says, “when doctors change their practices to concierge, there are individuals who lose access to their doctor.” In that sense, he notes, retainer-based medicine “is an obvious problem from a community perspective.”
Perhaps surprisingly, Crystal doesn’t entirely condemn the trend toward concierge medicine. For one thing, he notes that it could draw increasing numbers of medical students into primary care. For another, he explains, “it actually points toward what could be solutions for the larger population. The model is showing us a better way to do primary care—we just need to find a way to bring it to the broader community.” That could be done, he suggests, by moving away from the traditional fee-for-service model and toward a model that would give patients greater access to their primary care doctors in the mode of concierge medicine. But to make that happen, Crystal adds, we’d have to significantly increase payment to primary care doctors, a revolutionary concept that health insurance companies might not instantly embrace. On the other hand, he notes that “the insurance companies do what the purchasers of health insurance”—state agencies and corporate employers, for instance—“ask them to do.” So the task at hand could be to convince those health plans that a newer, more expensive model is worth asking for.
Currently, as noted, concierge medicine is largely benefiting physicians and their wealthier patients and fueling an increase in health disparities. If Crystal’s hunch is right, though, the model may contain the seeds to revolutionizing our system of healthcare in a way that serves virtually everyone. Ironically, that revolution could yield the sort of primary care delivered to our grandparents and great-grandparents, in which the family doctor felt, in many cases, very much like a part of the family. Just as long as it did not require also reverting to the state of clinical knowledge and medical technology those generations experienced, that could be a sweet deal.
