I practiced internal medicine in a concierge medical practice for 12 years, and found it to be the best decision I have ever made in my career. Initially, there was a good deal of fear and insecurity about changing my practice. They turned out to be unfounded.
There were many people who advised me not to proceed for a variety of ethical, financial, or legal concerns. To be honest, initially many of my colleagues voiced their misgivings about giving up a busy practice to try an unproven practice model.
To be honest, I had the same misgivings initially, particularly ethical ones. This came down to the debate in my head of whether it was ethical to select a group of patients who were willing to pay an extra fee to remain patients. The model of practice I chose was a retainer-based model, MDVIP, perhaps the oldest and most established model in the country.
In this practice model physicians see a limited number of patients who pay an annual fee of around $1500.00 per year to cover non-covered services. I remained in all the medical plans I had been associated with, including Medicare. I wondered if I had the right to charge for the services I knew I was already providing without compensation. Another dilemma was wondering who would take care of the patients who couldn’t afford to join. What would they do without me?
MDVIP made great efforts to reach out to all the patients in my previous practice multiple times with different options to pay, or with a list of physicians I had recommended, who would be willing to accept them as patients. Additionally, they gave me the ability to accept a percentage of patients who could join without paying the annual fee.
I reached out to many of the patients I didn’t think could pay and offered to see them at a reduced fee. At the end of the day most of the 2,000 or so patients opted not to join the new practice. It turned out that the patients who didn’t join chose to leave me, I didn’t leave them. And despite my egotistical concerns about their welfare, they turned out to do just fine without me. As it turned out, 450 patients decided to sign up prior to opening the practice.
Several of my colleagues asked, “what if every doctor did this, who would take care of the large number of primary care patients?” As I started the new practice I quickly realized that about half or more of the daily patient visits I was doing were actually unnecessary. Many of these patients could be managed safely over the telephone or with remote monitoring devices, or didn’t need to come at all. I realized that we had been keeping our schedule full to keep it full.
Seeing only the patients who actually needed visits, allowed for walk-ins and add-ons, patients who might have been sent to the ED previously because the schedule was full. It turned out to be a great savings to the system. For example, patients with migraines could be managed in the office and not after a costly workup in the ED. MDVIP did a five-state survey which showed that MDVIP patients saved Medicare about $350,000,000 per year by avoiding unnecessary admissions, readmissions, and providing shorter hospital stays.
Some doctors and patients felt that I was looking to get wealthy by changing practice models. It is true that my income went up substantially after changing models, but it hardly made me wealthy. I had to get over the idea that physicians had a right like everyone else to be fairly compensated for hard work. Plus, because I was making more money I could afford to provide much more charity care, and only accepting co-payments for covered visits. It turned out there was no need to charge for every service or visit provided because the money generated from the annual fees was more than enough to keep the office running well.
I realized that after 20 years of hard work I was earning less than $150,000 a year. This was far less than most other professional people I knew, who had considerably less training than I, but it was a livable wage and that is that was what I was used to. After changing practice models I began to earn a salary more in line with what my skills were worth, but it took some time for me not to feel guilty. If you look at an MDVIP practice with 400 patients it would not be unusual to see earnings of $300,000 a year, which is more in line with what I think good internists are worth.
From my experience earnings are only estimates and will vary depending on things like how efficient the practice is at collecting copays, and how much money they choose to spend. I think that one of the things I needed to develop was better self-esteem, and accept that the things that internists do on a daily basis are grossly underrated by the medical community at large. We are held down by an unfair payment system that exploits us, knowing we will do the job even if we don’t get paid. That’s how I thought it would always be. I think many primary care doctors feel the same way at some level because we feel our obligation as physicians to patients transcend how much money we earn.
Having more time allowed me to continue to admit my own patients to the hospital instead of using hospitalists. This was not required by MDVIP, but it was something I felt was necessary. After all, the patients needed me the most when they were sick. Hospitals are dangerous place, lots can go wrong, and they need an advocate who knows them.
A higher salary allowed me to provide more charity care. I began to teach residents and students in my office because I had more time, and I began to read more and keep up on CME. It also allowed me to pay a fair salary with benefits to my staff, who were one of the keys to my success.
By directly contracting with patients we became equally committed to the relationship. They agreed to pay an annual fee, and I agreed to provide services. They had the power to terminate the relationship if I didn’t live up to my commitments. Unlike at my old practice, where, when a patient left, I barely noticed it financially, in the concierge model, a patient leaving was not only an emotional setback, it was a financial one as well.
It really was the way things should work in a free market system. When insurance pays medical bills to doctors instead of patients, it takes the power from patients who have little recourse for poor services. The doctor is payed regardless of how he or she performs. The government’s efforts to define and reward quality are so primitive they are laughable.
There are different care models where doctors drop all insurance plans and accept a reduced fee. I have a problem with those model because I think that many medical procedures, consultations and admissions require insurance coverage. In some states, patients have trouble getting coverage for those services if their doctor does not belong to the patient’s insurance plan. In the MDVIP model I could refer and admit as I always had because I remained in all the insurance plans.
I had been told when I started the concierge model that it would never work. No one would join. They were wrong. I quickly enrolled 450 patients. Later I was called the doctor for the rich and famous. They were wrong. The average family income of my patients was $71,000, and the typical occupation was retired teacher, professor, policeman or doctor.