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Concierge medicine helps put the patient at the center of medical practice

More than 90 percent of patients are satisfied with their primary care doctor, according to a survey for the Physicians Foundation. They believe that their doctors are respectful, listen and explain well.

On the other hand, they are not happy with the hassles of the administrative aspects of medicine — making appointments, scheduling procedures, paying bills, dealing with insurance companies.

Office schedules tend to revolve around the physician, not the patients. Most clinics do not have extended or weekend operating hours. When patients arrive at the clinic, front-office employees often curtly ask them to repeat their insurance verification and then “take a seat.” Not always the best first impression.

Are the clinics, or for that matter the hospitals, designed for patients, or for physicians? One indication is the parking lot. The closest parking spots often say, “Physician Parking Only.”

Understandably, when patients have a medical issue, they crave and deserve an attentive and unrushed physician.

Reimbursement has steadily declined for most physicians and, to compensate, many have tried to squeeze more visits and more procedures into each day, which squeezes out time for relaxed, detailed discussions. Some physicians have given up trying. They are referred to as “doorway doctors,” who stand in exam room or hospital doorways, ask a few quick questions, and then leave before the patient has time to reply.

Set up properly, a concierge medicine practice can ensure that there is always time and room for the patient to call, pop in, or email a concern and, receive unhurried, focused attention to their needs. If you have an 8 a.m. appointment, you will be seen at 8 a.m. No more need to bring a book or a computer to occupy your time while you wait to be seen. The concept of a waiting room thus becomes obsolete. There may be a “greeting room” where patients are welcomed by name and offered a cool beverage or coffee. In addition to such staff-provided hospitality, my patients often enjoy running into other patients with whom they are familiar, and the greeting room provides a pleasant environment in which they can do so.

Running on time is a luxury for both the patient and the physician. Visits in a concierge medicine practice are unhurried and detailed discussions on a variety of issues are possible. There is always time to administer or schedule any immunizations or preventive studies that are due, and to review previous studies, consultations, emergency visits, and hospital stays.

Another benefit to the unhurried nature of the concierge medicine office visit is that notes are thorough and can be shared with the patient during the visit, and copies can later be mailed or accessed via computer. Such sharing helps to clarify patients’ understanding and reinforces instructions.

The patient also can offer edits or additions when appropriate, which not only improves communication but enhances trust in the relationship. While patient access to their own charts—and even the ability to add information to them—is becoming more common in traditional medical practices with the advent of electronic health records and patient portals, time restrictions on office visits in traditional settings seldom accommodate such collaborative reviews of the chart.

David Winter, MD, is author of Service Extraordinaire: Unlocking the Value of Concierge Medicine. He is also president and board chair of Dallas-based HealthTexas Provider Network, a 1300-physician subsidiary of Baylor Scott & White Health. His concierge practice has won the Press Ganey Beacon of Excellence Award for five consecutive years.

The migration to “concierge for all”

The concierge ideas are migrating to traditional medical practices.  Concierge practices are learning laboratories that refine patient flow and enhance communication.  Email access to a physician, a standard in concierge practices, is now more common in all practices.  Traditional office practices now seek to minimize wait times.  Attention to preventive services and immunizations, between office visits, is becoming more common.  The provider teamwork philosophy, refined in progressive concierge practices, has spread.

An important concierge tactic is efficient use of a patient’s time.  If I am running behind, the staff reviews medications, allergies, and new issues.  Coffee or water is offered, and needed immunizations are administered.  The concierge movement itself does not get full credit for all these enhancements, but it has been influential.  Change can be difficult.  As one of my previous partners said, “I don’t have time to learn how to be more efficient.”

The luxury of extra time with patients can have long-term benefits for patients and providers.  In traditional practices, it is easier to fulfill patient requests than to explain why the requests are not justified.  It takes less time to write a prescription for an unwarranted antibiotic or to order an unneeded MRI scan than to explain why these may not be in their best interests.

Patients may believe they know exactly what they need and become argumentative when their requests are not honored.  A useful approach is to give them what they want while explaining when an antibiotic, for example, might be helpful.  As I write the prescription, I say I would not take the antibiotic unless I developed one or more specific symptoms.  I write these down on a separate piece of paper.  I then hand them the prescription along with the note of instructions.  This approach reduces the likelihood that the patient will fill the unnecessary prescription while also satisfying the patient’s request.

Additional time spent with patients allows opportunities to gather important information.  As I was wrapping up an appointment with one of my patients, he announced, “Come to think of it, I have been wondering whether to mention some discomfort that I have noticed when walking up stairs.”  A partially blocked coronary artery was causing his chest pain.  His condition was caught early enough that we can treat him with medication.

As physicians and patients get to know each other, the relationship naturally builds.  Trust and confidence are key factors in a successful physician-patient relationship.  They can develop more rapidly with extended concierge visits.  Physicians in traditional practices who enhance relationships create better outcomes for patients.

Studies of patient outcomes in concierge practices have reported lower emergency department utilization and reduced hospital readmission rates for serious illnesses — which reduces the overall costs of care. If these reports are validated by studies in a broader population of patients, health care delivery organizations may seek to provide personalized, preventive medicine (what some call “concierge for all” or “concierge for the masses”) for much larger populations.

David Winter, MD, is author of Service Extraordinaire: Unlocking the Value of Concierge Medicine. He is also president and board chair of Dallas-based HealthTexas Provider Network, a 1300-physician subsidiary of Baylor Scott & White Health. His concierge practice has won the Press Ganey Beacon of Excellence Award for five consecutive years.

A concierge practice can benefit a large health system, and vice versa

A concierge practice can benefit a large health system, and vice versa

Baylor Health Care System senior executives initially viewed concierge medicine with consternation. No other North Texas concierge practice was affiliated with a health care system, leaving the question of how a concierge practice would fit into a not-for-profit, mission-driven health care organization.

Baylor Health Care System appointed a committee of senior executives to consider these issues:

  • Panel sizes of primary care physicians were growing, displeasing both patients and physicians.
  • Primary care physicians were under pressure to see more patients.
  • An important constituency of clients wanted extra attention and were willing to pay for it.
  • Physicians wanted to spend more time with their patients.
  • Demand for concierge practices was being met elsewhere.
  • There was an association between concierge patients with philanthropic grants.

After careful and diligent consideration, the committee concluded that concierge medicine indeed could play a role in our system.  With this blessing, I began the transition from my traditional fee-for-service practice within MedProvider to a newly established concierge practice – named “Signature Medicine.” The staff included me, a nurse, a front-office administrative assistant and a part-time business manager. That’s it.

The concierge model belongs in a health system if it supports a full range of health care delivery services, a variety of different medical practices, wellness programs and a large population of patients with diverse needs.

As the recently retired Baylor Scott & White Health CEO Joel Allison is fond of saying, “Concierge medicine fits within a menu of services that we offer to our patients.”

Like many independent urgent care centers and freestanding emergency departments, concierge medicine programs typically developed outside of health care systems.  The problem with this for hospitals is downstream referrals.  Without some type of affiliation or loyalty, patients who visit non-aligned clinics (or non-aligned concierge practices) can be directed away from their preferred hospitals.  Concierge practices sponsored by health care systems are expected to refer to hospitals, imaging centers, laboratory services, and other physicians associated with the network.

The advantages of concierge practices in health care systems also accrue to the systems in other ways.  Concierge patients rely upon their physicians for specialty referrals.  It behooves health care systems to inventory concierge practices and encourage their allegiance.  Tighter alignment results when the health care system sponsors or employs concierge physicians.

Integration has led to better care in the ambulatory, inpatient, and post-acute care environments, faster uptake of technology and specifically health information technology, and a stronger shared ability to improve population health.

Concierge medicine practices may also participate in health system ACOs.

Concierge practice also can be fertile grounds for philanthropic donations.  It is not unusual for grateful patients to make donations or bequests to hospital systems to honor their physicians.  They may even set up their own foundations.  Several years ago, one of my faithful patients asked me to meet him for lunch.  I was surprised when he announced that he was setting up a medical research foundation and wanted me to oversee it.  I was intrigued but initially resisted the added responsibility.  It has since become a labor of love and I quite enjoy directing grants to deserving research projects.

Identification with a trusted hospital brand adds to the concierge practice’s credibility.  The intricacies of setting up the concierge model can be handled by hospital administrative staff, allowing the physician to concentrate on patient care.  It also can foster referrals to the concierge practices themselves: Hospital administrators and executives frequently are asked for recommendations regarding health care issues, and they can identify and recommend patients who would favor and potentially benefit from a concierge practice.

David Winter, MD, is author of Service Extraordinaire: Unlocking the Value of Concierge Medicine. He is also president and board chair of Dallas-based HealthTexas Provider Network, a 1300-physician subsidiary of Baylor Scott & White Health. His concierge practice has won the Press Ganey Beacon of Excellence Award for five consecutive years.

Who enrolls in a concierge practice can be a surprise

Leaving my patients of many years was not something that I relished when I decided to start a concierge practice.  I mailed letters to about 3,000 of my private practice patients on the same day inviting them to join a panel of 300 patients in a concierge model.

I filled the 300 slots quickly, but that meant I had to end my relationship with more than 2,500 patients.  Partings often were emotional on both sides.  Most understood my need to cut back my clinical hours. The final weeks of my traditional practice brought a stream of grateful patients bearing gifts and congratulations.  Those joining my concierge practice were excited about the new idea.  Those who did not join were often tearful as they talked about our good times together.  There were, of course, those who were frustrated by my decision, including those who explicitly did not want to pay extra for services.

Many people join a concierge model because of longstanding relationships with a physician.  As one senior physician once explained, “After 40 years, I don’t have anyone that I simply consider a patient:  they are all personal friends.”  While such a close, satisfying relationship is influential when patients are considering following their physician into a retainer-fee concierge model, it is not always determinative.

Physicians who have made the transition to the concierge model report that the patients who signed up for the new model were invariably not always the ones that they expected.  Some patients simply cannot afford the added expense of the retainer fee.  Others can afford it do not see the value. A former patient said: “I have paid into Medicare throughout my working life; it should now cover my medical expenses.”

On the other hand, some greatly value the physician relationship and strain their budgets to afford the retainer fee.  One of the first patients to join my concierge practice was a retired lower-income worker whom I had not expected.  In fact, he drove an hour through a thunderstorm to sign up.  As he smacked his signed contract on my receptionist’s desk, he announced, “You can’t leave me, doc.  I depend on you.”

The first six months were busier than expected. Patients would challenge me by phoning about a lot of minor illnesses. That eventually faded away.

Payment is not always from the patient themselves. It also can be paid by the spouse, the patient’s adult children, parents of children who value extra attention for their offspring, and companies with benefits that cover the concierge fee. Practice retainers are $1800-$10,000 annually. Our practice is in the lower end of that range.

Patients most likely to value and benefit from the concierge model include those chronic or multiple medical conditions, or those with busy lifestyles who appreciate convenience and flexibility.

David Winter, MD, is author of Service Extraordinaire: Unlocking the Value of Concierge Medicine. He is also president and board chair of Dallas-based HealthTexas Provider Network, a 1300-physician subsidiary of Baylor Scott & White Health. His concierge practice has won the Press Ganey Beacon of Excellence Award for five consecutive years.