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Concierge Medicine


The concierge model has very high risk and rewards. On the one hand your new practice can be a cash cow, and on the other you might alienate all of your patients and lose money.

There is a lot of pressure on doctors. They have to deal with increasing paperwork, flat or declining reimbursements, and rising operating costs, in addition to trying to keep up with the perpetual tsunami of new science and technology, patient demands, rising political pressure and uncertainty and the vagaries of life in general. So sometimes it's nice to daydream in the odd spare moment. What if I could make more, do less, have more time off, spend more time with my patients and, in so doing, do a better job of it?

Such desperation has spawned a small but noticeable movement to restructure private practice. And at least a dozen startup companies have appeared to cash in on the yearnings and earnings of overworked doctors.

For non-do-it-yourselfers, these as-yet small services will come in and set up the transition to a so-called "concierge" practice. And they will continue to oversee and monitor your operations going forward.

The basic assumption is that a percentage of your patients are also fed up with the current situation of long waits to see you and short shrift when they finally do get access. And their frustration has reached the point where they would be willing to pay an upfront annual fee of $1,000 to $25,000 to be among a much smaller patient population with guaranteed quick access.

To do the math, let's say the average primary care doctor has 2,000 patients and you want to cut that down to a more manageable 1,000. If each would be willing to pony up just $1,000 every year, that means you start each year with $1 million in the bank, not in receivables.

Changing the variables may yield even more (100 patients at $25,000 equals $2.5 million, etc). And you still will bill their insurances for any specific services performed. Pretty nice deal you say? Less work, more money, procedure-based medicine type money at that, more time with each patient, less paperwork and more time for your family and personal life. What a deal! Who wouldn't like that?

Not so fast, don't hyperventilate. Don't you expect strings? There are always strings. These companies will take a third or more of your income up front for their services. There’s also the very real question of whether a significant enough portion of your practice will actually go for this scheme. This also assumes you have an overstuffed practice. Young doctors without a full practice or without a very large marketing purse need not apply. The whole idea hinges upon a critical mass of affluent and loyal patients willing to go along and willing to stay once you have made the plunge.

People may be willing to put up with historically, and notoriously, poor service from even the best doctor, but the up-front fees guarantee that patients will expect a change in service that you must live up to. Or you will end up on the long line of doctors seeking salaried work with some group — sadder, wiser and poorer.

Experience has shown that even for the most well situated practice, the transition to concierge status must be handled with kid gloves. Your marketing and legal arrangements must be just so in order for this whole thing to work. You don't want to drive patients away, you want to soften the blow for those unwilling or unable to join your new venture and you want to avoid any hint of greed, abandonment or other irregularity. The process is so delicate that these companies tell you not to expect to break even for up to two years. Easy money, hah!

Some additional information may be helpful. There is an American Academy of Private Physicians to contact. The AMA does not yet track this new form of practice, but I did see one estimate that 2,000 practices nationally have made the conversion, primarily in upscale urban areas on the coasts. A non-scientific survey reported 60% of doctors are doing better, 30% the same and 10% worse. But it's hard to know what that means.

There are a few other caveats as well. First of all, several insurance companies have stated that charging up-front fees is a violation of the contract that doctors may have signed with them. Violating Medicare regulations is another concern. If that is not enough, some states have raised the question of whether or not a concierge practice is actually a small insurance program, which would bring state regulation into the mix. What will come of all this is as yet unclear.

Lastly, there are ethical questions raised by this acknowledged move to official two-tier medicine. And this would be made even worse by those doctors who might try to have it all by setting up a hybrid system in one practice. Imagine the glowering in the waiting room when certain folks are breezed in and others left to stew. Not a practice builder.

As I keep telling you, loyal readers, "that business stuff" is inherent to the practice of the best medicine. And it's well past high time that medical schools get the memo.

Out of desperation comes creativity. On one side of the idea of concierge medicine is better service for patients with improved revenues and quality of life for the physician. On the other side of the risk-reward fulcrum is disenchantment for patients, with uncertainty, legal challenges and potential ruin for the doctor. And you thought you were going into medicine just to help people and not having to worry about "that business stuff."

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Victor J. Dzau, MD, gives expert advice
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