Concierge medicine (also known as retainer medicine) is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges. In exchange for the retainer, doctors provide enhanced care, including principally a commitment to limit patient loads to ensure adequate time and availability for each patient.
The practice has been referred to as concierge medicine, retainer medicine, membership medicine, cash-only practice, and direct care. While all “concierge” medicine practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the fee charged. Estimates of U.S. doctors practicing concierge medicine range from fewer than 800 to 5,000.
There are typically three primary types of concierge medicine business models practiced today. Variations of these models exist, although most models usually fall into one of the following categories.
The Fee for Care (‘FFC’) is an annual retainer model, where the patient pays a monthly, quarterly, or annual retainer fee to the physician. The retainer fee covers most services provided by the physician in his/her office. Often, vaccinations, lab work, x-rays and other services are excluded and charged for separately on a cash basis.
The Fee for Extra Care (‘FFEC’) is similar to the FFC model, however, the additional services are charged to Medicare or the patient’s insurance plan. Some of the benefits and services typically included in these two retainer models are: same day access to your doctor; immediate cell phone and text messaging to your doctor; unlimited office visits with no co-pay; little or no waiting time in the office; focus on preventive care; unhurried atmosphere; cell phone, text message, and online consultations; prescription refills; and convenient appointment scheduling.
FFC or retainer plans may typically not be purchased with pre-tax dollars utilizing HSA and/or FSA accounts because it is not a fee incurred for a service. Instead, it functions more as an insurance policy where fees are paid in anticipation of an expense.
There is also a hybrid concierge model where physicians charge a monthly, quarterly, or annual retainer or membership fee for services that Medicare and insurers do not cover. These services may include: email access; phone consultations; newsletters; annual physicals; prolonged visits; and comprehensive wellness and evaluations plans. For all covered services, these providers will bill Medicare and insurance companies for patient visits and services covered by the plans. This model allows the physician to continue to see their non-retainer patients while providing their “concierge” patients a fee for the increased or “special” services. Some concierge practices are cash-only or ‘direct’ primary care practices and do not accept insurance of any kind. In doing so, these practices can keep overhead and administrative costs low, thereby providing affordable healthcare to patients.
Concierge physicians care for fewer patients than those in a conventional practice, ranging from 50 patients per doctor to 1,000 water bottle for sports, compared to 3,000 to 4,000 patients that the average traditional physician now sees every year. All generally claim to be accessible via telephone or email at any time of day or night or offer some other service above and beyond the customary care. The annual fees vary widely, ranging, on average, from US$195 to US$5,000 per year for an individual with incremental savings when additional family members are added. The higher priced plans generally include most “covered” services where the client is not charged additional fees for most services (labs, xrays, etc.). Some of the other benefits of concierge healthcare are: in-home visits, worldwide access to doctors and expedited emergency room care.
An informal one-year summary of findings related to the concierge medicine marketplace in the US was released in February 2010. The summary of the study concluded that at the end of 2009, over 66% of current U.S. concierge physicians operating practices were internal medicine specialists; and the second most popular medical specialty in concierge medicine was family practice. The study also noted that the number of concierge dental and pediatric practices increased markedly since February 2009.
In 2004, the Government Accountability Office counted 146 such practices, mostly concentrated on the US east and west coasts with practices such as MDVIP, 1 on 1 MD, and Signature MD being among the oldest. The American Medical Association does not track the number of concierge practices because the concept is so new. Lower-cost concierge medical business models have also been attempted, such as GreenField Health in Portland, Oregon, which charged an annual fee between $195–$695 depending on age. Another is One Medical Group, the first major low-cost concierge medical group to attempt this model in a large scale, which requests a $199 annual membership fee.
Both are variants of the traditional practice of medicine or primary care most common in the United States during the twentieth century. They represent a financial relationship that changes the sole dependency on a traditional insurance model.
Direct primary care (DPC) is a term often linked to its companion in health care, ‘concierge medicine’. Although the two terms are similar and belong to the same family, ‘concierge medicine’ encompasses many different health care delivery models, ‘direct primary care’ being one of them.
Direct Primary Care practices, similar in philosophy to their concierge medicine lineage, bypass insurance and go for a more ‘direct’ financial relationship with patients and also provide comprehensive care and preventive services.
DPC practices remove one of the financial barriers to accessing care whenever it is needed: the DPC annual fee often includes most or all physician services. This model does not rely on insurance co-pays, deductibles, or co-insurance fees, in contrast to models such as MDVIP and 1 on 1 MD, where the annual fee is structured to cover a wellness plan so that doctors may charge insurance or Medicare for most other services.
DPC is a mass-market variant of concierge medicine, distinguished by its low prices. Simply stated, the biggest difference between direct primary care and retainer based practices is that DPC takes a flat rate fee whereas models usually charge an annual retainer fee and promise more access to the doctor.
The origins of concierge medicine are often traced to MD2 International (“MD Squared”), which was launched in 1996 in Seattle by Dr. Howard Maron. However, Dr Maron did not invent the term “concierge medicine”.
According to the Association of American Medical Colleges (AAMC) estimates, the United States faces a shortage of more than 91,500 physicians by 2020. The Patient Protection and Affordable Care Act (PPACA) or “Obamacare” will expand coverage to more than 30 million Americans in the next decade. After incorporating insurance expansion, the United States will require nearly 52,000 additional physicians and 8,000 primary care physicians (PCPs) by 2025. The total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. The federal government requires over 68,000 charging codes with the upcoming ICD-10 diagnosis coding system a fivefold increase from the current ICD-9 diagnosis coding system. In addition to these government requirements, physicians have the usual insurance filing.
The Physicians Foundation found that 9.6 percent of “practice owners” and 6.8 percent of all practices were planning to convert to cash/concierge practices in the next three years. In 2012, there were 4,400 private physicians – a 25% increase from 2011.
The concept of concierge medicine has been accused of promoting a two-tiered health system that favors the wealthy, limits the number of physicians to care for those who cannot afford it, and burdens the middle and lower class with a higher cost of insurance. Detractors contend that while this approach is more lucrative for some physicians and makes care more convenient for their patients, it makes care less accessible for other patients who cannot afford (or choose not) to pay the required membership fees.
In early 2008, it was reported that one health insurer was dropping from their provider networks some physicians who charge an annual fee. Another insurer also expressed opposition to annual fees. Other insurers do not oppose concierge medicine as long as patients are clearly informed that the fees will not be reimbursed by their health plan.
In 2003 and 2005, several members of Congress introduced or cosponsored bills that would have prohibited physicians from charging retainer fees. No action was taken, and it appears that no similar bills have been introduced in more recent Congresses. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the Congress directed the GAO to study concierge care and its impact on Medicare patients. The GAO report, published in 2005, concluded that the “small number of concierge physicians makes it unlikely that the approach has contributed to widespread access problems.”43 In its comments on that report, DHHS noted its agreement with GAO’s findings and stated that it would continue to monitor the trend. No specific information is available on monitoring activities.
The USA Network television series Royal Pains focuses on such a doctor’s introduction to the practice of concierge medicine. A young doctor becomes a for hire physician for the wealthy residents of the Hamptons.
Also on USA Network television series Rush focuses on a doctor who serves a very specific clientele, the kind with a lot of cash and a lot of secrets.
The Robin Cook novel Crisis focuses on a medical malpractice trial involving a doctor practicing concierge medicine should i tenderize my steak.