What is concierge medicine anyway? The term concierge came to the fore some years back when upscale hotels started hiring “concierges.” These are basically people with the resourcefulness of a Navy SEAL, the patience of a saint, and a burning desire to be abused by spoiled rich people. Their job is to make sure the hotels’ very high maintenance guests are happy at all times. This could involve anything from fetching a toothbrush for a chap whose valet was dentally negligent right on up to providing guests with theater tickets to a sold out show, and doing it on short notice. This strikes me as a very stressful profession, incessantly bathing the concierge’s innards in cortisol and adrenalin. Not a good thing. To each his (or her) own, as they say.
Applying the term “concierge” to medical care, then, tends to imply exclusivity, coddling, and indulgence. These descriptors can have negative connotations, which may suggest that membership medical care is very expensive and only for the wealthy. Country club medicine, if you will. That is not the case. Personally, I don’t even care for the word “concierge.” It sounds French. (Maybe because it is French?) If you take stock in stereotypes, then you know “French” means snooty, and I don’t like snooty. Truth be known, most people don’t like snooty. I try to avoid snooty, and its close relative, haughty. I try to avoid stereotypes, too, because they are so often wrong. Case in point: all the French people I have known (both of them) have been very nice. Well, that pretty much invalidates the stereotype of French haughtiness. This is my opening to explain the genesis of membership medical care and to invalidate the idea that concierge medicine is only for the rich.
Let’s embark on a little trip through the retrospectoscope (don’t worry, it’s been sanitized, decontaminated, and anticepticized, if that’s even a real word). Legend has it that in the late 1900’s there was a great shortage of beans in the United States and other industrialized nations. As a result, the highly educated people who had been trained to count beans (we’ll call them “bean counters”) had to find other ways to make a living. Some moved into big business. Some moved into government. Still others moved into healthcare, which, if you’ll pardon me, they didn’t know beans about. But they did know how to make a living, and as they prospered, so too did they multiply. By the early 2000’s healthcare bean counters had become almost as numerous as lawyers, and only slightly better regarded. This was not a good thing for healthcare in general, or for physicians in particular, and was least good for primary care physicians. Primary care physicians are pediatricians, family medicine doctors, internal medicine doctors (a.k.a. internists), and gynecologist/obstetricians. To put it in simpler terms, these are physicians you can get away with addressing as, “Doc,” in contradistinction to medical specialists like cardiologists and virtually all surgeons. The latter view themselves as far more important and will give you the evil eye for shortening “Doctor” to “Doc.” Whew! Glad to have that out of the way.
Well, the bean-counters- turned-medical-experts devised a diabolical system for reimbursing physicians, called CPT (Common Procedural Terminology) coding. As if that were not bad enough, these misguided bean counters decided that “procedures,” such as sticking needles in people and operating on them, was a lot more important than sitting down and talking with patients to find out how to help them. The bean counters “allowed” more money for procedures, which often don’t take very long to complete, and allowed less money for the time consuming work of history-taking, medical record review, diagnosing, devising a medical plan, and explaining the plan to patients. So specialists and surgeons prospered, for a while anyway. These specialists and surgeons constituted, medically speaking, your BMW/Mercedes/Lexus types, as opposed to primary care physicians, who were financially limited to Fords, Chevys, and the like. Naturally, a few wild eyed primary care doctors did, in fact, purchase “pre-owned” Mercedes Benzes, only to find that they could not afford the repairs. Meanwhile, the bean counters started piloting upscale automobiles like BMW’s and Mercedes Benzes themselves. Even though the bean counters mostly graduated in the middle of their college classes, their new found power to push around the doctors (who graduated at the top of their classes), started going to their heads, like cheap wine on an empty stomach. This state of affairs I will refer to as a Situation Not Appropriate For the U.S. (SNAFU for short).
Okay, now where was I? Oh, that’s right, concierge medicine. Primary care physicians (as opposed to primary care providers, which is HealthSpeak for any warm body that can write a prescription) found that they were working harder, for more hours, for less money. Enter the hospital systems, which started vacuuming up primary care doctors like fuzz on a carpet in order to fill their hospital beds before a competing hospital system could vacuum up the same doctors. This created a feeding frenzy of sorts. Physicians thought this transition made sense, because they were paid, often handsomely, to sign over their practices and patients. However, this made them, essentially, indentured servants. There was no turning back. The practices they had spent decades building no longer existed. It didn’t take long for Godzilla Healthcare, et al, to sic their operations personnel on the unsuspecting doctors and require that enormous numbers of patients be seen every day if the doctor wanted to stay employed. You see, the bean counters had infected the hospital systems as well. Hospital system executives, it was determined, needed to wear Armani suits and drive their Porsches to exclusive country clubs. This, the thinking went, was only fair recompense for rescuing doctors from their cramped but efficient little offices and parking them in oversized, overdecorated, glitzy offices oozing with style but lacking in warmth. Overhead per physician rose so high that doctors who wanted to retain their sanity by working part time were “financially disincentivized.” “Don’t work harder,” the bean counters’ surrogates would say, “work smarter.” Translation: cut more corners, keep your CPT coding (insurance billing) up. As the demands for expensive diagnostic studies like MRI’s and CT scans increased, the costs of pharmaceuticals rose, and hospital beds became more costly, bean counters for the “third party payors” (Medicare, Medicaid, TriCare, commercial insurers) found that chipping away at the compensation of primary care doctors was the path of least resistance to balancing their books.
What effect did this SNAFU have on patients? If you like shorter visits and longer wait times, you’re in fat city. If you like visits with stressed out doctors assisted by stressed out staffers, you’re in the pink. If you like paying to see a doctor and being assigned to a nurse practitioner or physician assistant (though many of these “midlevel providers” are very good), the health care delivery system the bean counters have wrought is right up your alley. Many of us, though, yearn for more.
This brings us to the good part. Some of these stressed out physicians decided that enough was enough. They would reduce the size of their patient panels (“covered lives” in HealthSpeak). To make up for the loss in income, they charged a monthly membership fee (Costco, anyone?). This model has been referred to by myriad names, including membership practice, subscription practice, retainer practice, and direct pay primary care. However, the name that has stuck best with the public is, dare I say it, “concierge medicine.” Oh, no, you’re thinking, we’re back to that French thing again. Oui, oui! But please don’t blame yours truly. I would be happy to call it compassionate care, convenient care, congenial care, or even warm-and-fuzzy medical care. It’s a model that gives you the peace of mind of knowing that your doctor will see you when you need to be seen, and will be able to devote the time to you that you need. That, I maintain, is a very good feeling.
There are many variations on this membership practice theme. Some concierge practices bill insurance and charge a membership fee in addition. Others eschew insurance altogether. Some concierge doctors care for their patients in the hospital, many don’t. Some concierge physicians are members of group practices, and many are solo practitioners. What these concierge physicians all have in common, though, is a compulsion to provide the best care they know how to provide, and a realization that this can’t be done on an assembly line with ten minute visits. If you desire prompt, thorough, unhurried doctor visits in a relaxed congenial atmosphere, you may just find yourself… calling Dr. Concierge.