Tuesday, August 31, 2010

The Truth and Facts about Concierge or Boutique Medicine

A recent piece in the New York Times wondered if the few patients who can afford to pay for additional attention and access to their primary care doctors in a concierge medicine or boutique medicine practice might be ethical since the extra dollars are used to support the traditional primary care practice that the vast majority of patients currently receive. 

Questions you might ask are:

What is a concierge medicine or boutique medicine practice?
Is it worth the money?
Is the care better quality?
Is it possible to get similar access and care by doctors not in a concierge or boutique medicine practice?

When you think of a concierge, you think about a fancy hotel staff person who answers questions, speaks various languages; and books reservations to restaurants, events, and tours, even sold-out attractions — right? The hotel concierge is your insider, someone who possesses intimate knowledge of the city and recommends must-see sites like a true local. You are personally cared for and pampered.

Imagine, then, your physician providing the same attentive service. Indeed, a small and growing number of physicians are offering this concierge care, also known as boutique or retainer medicine. Physicians provide services typically not covered by their traditional health insurance, like annual comprehensive physicals and direct access to their doctors twenty-four hours a day via home phones, cell phones, and pagers. Other benefits include same day appointments with longer physician face time, little to no waiting time in the lobby, and a focus on preventive care. In some practices, the physician will even accompany a patient to specialty doctor appointments and perform house calls. Sound pretty nice? But beware: this kind of service comes
at a price. Patients in boutique or concierge care pay a retainer ranging anywhere from a few hundred to a few thousand dollars per year.

The concept of boutique care may have started in 1996, when the Seattle Supersonics former team physician wanted to make available to the general public the same level of medical care and attention provided to professional athletes. MD2, the company he founded, provided a spa-like experience to a select few patients who could afford the $10,000 to $20,000 annual retainer fee (in addition to insurance premiums and

Many physicians are attracted to this new physician-patient relationship as they become more disenchanted with large patient panel sizes, lower reimbursement rates, shorter office visits, increasing overhead, malpractice costs, and paperwork. They want to slow down and spend more time with patients, which is difficult in the current climate of falling insurance reimbursement.

In the July 2002 issue of The Journal of Family Practice, one study noted that 27 percent of physicians anticipated a moderate to definite likelihood of leaving their practices within two years. Leland Kaiser, Ph.D., a healthcare futurist, also notes that lack of physician accessibility and availability is also causing consumer discontent and is a driving force toward concierge medicine.

The high retainer fees these physicians charge frees them financially from health insurance contracts and allow them to care for a much smaller patient panel (typically a third or less than an average physician’s panel of two to three thousand patients). Perhaps not surprisingly, these practices attract patients who are upper middle class, middle-aged entrepreneurs, and wealthy seniors.

Supporters of concierge care claim it’s a lot like private school education. Parents who wish to supplement their children’s education can send them to private school, paying extra for a potentially more personalized education that offers more choices (at a cost). “Like education, luxury primary care is simply a response to a market need [that] serves the interests of both the consumers (patients) and suppliers (physicians).” As long as there are people willing to pay extra for additional personalized care, the more likely the boutique medicine trend will continue.

Understandably, not everyone is happy about this new trend. While the American Medical Association (AMA) has not found concierge practices to be inconsistent with the goal of healthcare delivery, it bears repeating that a physician’s duty is first and foremost to his patients. So, as in the case with physicians who retire or leave a practice, doctors planning on changing to or adopting a new concierge practice need to help their former patients transition to other healthcare providers. If no other physicians in the community are able to care for these patients, the AMA notes that the original physician may be ethically obligated to
continue care.

State and federal healthcare agencies, as well as insurance companies, are watching the new developments carefully to ensure that physicians practicing boutique medicine do not require retainers to provide services already covered by a patient’s health insurance. In July 2003, the government took action and fined a physician over $50,000 after he charged his patients $600 for services partially covered by Medicare.  In 2004, the Health and Human Services Federal Agency reiterated the long-standing policy that physicians are not allowed to charge Medicare patients additional fees for services already covered in the Medicare program. The private health plan Harvard Pilgrim Health Care refused to allow three concierge physicians into its network because it expected that doctors who participated in the network should provide twenty-four-hour access and same-day appointments when appropriate and not charge extra for those services. Many concierge physicians opt to drop all health insurance participation to avoid running
afoul of regulators and insurers.

Although concierge patients may feel they are receiving higher quality health care because they have more physician time and attention, there is no scientific evidence at this time to support that assumption.

On the contrary, it is possible that as the doctor spends more time caring for fewer patients, his clinical skills may worsen because of decreased volume and exposure to different patients. If your physician starts to practice concierge medicine, understand that any future contact with your physician may require payment or a
retainer prior to you receiving any additional care or service not covered by insurance. Since most concierge physicians are no longer paid by insurance companies, this cost comes directly to you. And if you choose not to continue care, it is your physician’s responsibility to help you find another doctor.

Should you take part in a concierge practice? It depends. If you can afford it and you enjoy the personal attention and pampering, concierge medical care might be right for you. Your physician is on a retainer and essentially is on your payroll as a paid consultant. Direct access to your doctor, long comprehensive office visits, and same-day appointments can’t be beat.

Or can it? With a bit more time and energy, you can get similar care for less money. Instead of an hour-long consultation with a concierge doctor, you could get the same amount of face time with your regular doctor over a period of three to four separate office visits. The latter would certainly be more inconvenient, however.  The bottom line is that only you can determine how much the extra convenience of concierge care is worth. The lowest retainer for concierge care runs about $600 per person per year. If your current office co-pay costs $20 to $30 per visit, you could see your regular doctor twenty to thirty times for the same amount of money. Also be aware that more and more physicians are working on open-access scheduling. This system focuses on providing patients with same-day appointments, which has improved satisfaction among patients and physicians.  With more physicians adopting this mindset, the same-day access benefit touted by concierge medicine may be less of a deciding factor.

Will concierge medicine be successful? Time will tell.

As much as I understand the attraction to many primary care doctors as well as medical students, I am quite pleased with my own practice and have no intention of joining a concierge boutique either as a doctor or as a patient.  Despite the benefit provided by concierge patients at the Tufts Medical Center to assist other patients, ultimately its existence simply widens the gap between the haves and the have-nots.  Whether the have-nots can continue to receive benefits from the philanthropy and willingness of others to pay even more above their health insurance premiums will depend on if healthcare continues to be increasingly unaffordable.  Unless the healthcare costs change, no one will be able to afford anything let alone concierge medicine.

Tuesday, August 24, 2010

Why the Solution to the Primary Care Crisis, the Patient Centered Medical Home, Will Fail

Everyone understands the need for a robust primary care workforce in making healthcare more affordable and accessible while keeping those in our care healthy.   With the aging of America and healthcare reform, even more Americans will need primary care doctors at precisely the same time doctors are leaving the specialty in droves and medical students shun the career choice.  So as a practicing primary care doctor, I've watched with great interest the solutions for the primary care crisis.

I've been utterly disappointed.

Patients so far don't like the patient-centered medical home (PCMH) as noted in Dr. Pauline Chen's New York Times column.  The changes recommended won't inspire the next generation of doctors to become internists and family doctors.  Experts understandably look at a dwindling workforce and unprecedented demand to come up with solutions like (from the May 2010 Health Affairs article - Transforming Primary Care: From Past Practice to The Practice of The Future):

  • "physicians can no longer enjoy trusting relationships with all of their patients.  Just as tasks must be shared among the primary care team, the joy of personal interactions with patients must also be shared."
  • "no contact at all with patients having uncomplicated needs.  The new primary care practitioner would function as a team leader and clinical teacher rather than as a healer to all who seek help."
  • "nurse practitioners and physician assistants could take responsibility for common acute and chronic care issues."
  • "small practices without a robust team would be limited in their capacity to institute such team-based care [for preventive and chronic conditions]".
  • "the primary care practice of the future must adapt to the reality of large panels - the number of patients under the care of a single doctor."
  • "models in the United Kingdom that have employed longer visit times with advanced-practice clinicians, patient satisfaction is high."

I wouldn't want to do primary care either as a practicing doctor or as a medical student contemplating a future career.  Having a larger panel size isn't attractive in a field lacking work-life balance. Putting aside the issues of reimbursement and medical school debt, which also need to be fixed, what experts have fundamentally failed to appreciate is that these solutions perpetuate the cottage industry that they so desperately need to transform.

First, Americans are not like people from Great Britain.  Americans are uniquely different. We have our own views.  Note how rapidly we've adopted the metric system.  Though the British may have high satisfaction with non-physician providers, given a choice and a level playing field of the same amount of time and access, I believe Americans will choose a doctor over a nurse practitioner (NP) or physician assistant (PA).  Telling future doctors that they can't see young and healthy individuals for acute problems not only makes them highly unlikely to choose primary care, it also will be quite upsetting for the general public.  As other articles have noted, NPs and PAs numbers are also insufficient to close the gap of an overwhelmed primary care workforce.

Second, stop rebuilding and perpetuating the cottage industry and reinforcing the fragmentation of primary care.  Except for very small medical practices like the ideal medical practice model where there is only one doctor with no staff, supported with technology, and extremely low overhead, having all primary care doctor offices create a team of staff to care for chronic conditions is absurd.    It isn't scalable.  Three quarters of primary care doctors are in either solo to five person practices.  Each doctor office shouldn't re-invent the wheel.  Instead, third party organizations should be accountable for managing chronic conditions and reporting to a patient's primary care doctor if the patient is not compliant with care or not following practice protocols.  Employer groups are leading this change as well.  This is a good thing. 

The article "Prospects For Rebuilding Primary Care Using The Patient-Centered Medical Home" notes that taking payments to invest in a "community-based organization provides infrastructure, such as care coordination services, that can be shared among several primary care offices" is already occurring in North Carolina and Vermont.  In addition, "local virtual organizations might consist of networks of small independent practices or of practicies affiliated with a hospital.  They could be linked through sharing of care management health IT or human resource for case management or care coordination."  These are ideas that must be pursued.  Few doctors want to be the doctor, the clinical chronic conditions leader, and the IT expert yet this is what most articles of the PCHM propose.

Having infrastructure that is scalable and seemless via health IT will off load both chronic conditions and preventive care to these other organizations which can assist doctors in providing the right care.  As a result, a doctor with an average panel size of 2000 is free of the 17.4 hours per day needed to do it alone.  This time is now available to do what primary care doctors were trained to do, to evaluate patients with problems that don't quite fit standardization or protocols.   Opportunities to see those who are young and healthy if they wish to be seen even if a protocol could treat a bladder infection over the phone or email are possible.  Patients and doctors would find this encounters far more satisfying.  One thing these third party groups must do is to agree to common reporting standards rather than proprietary ones to make the evaluation of clinical data quick and easy. 

An area which is already being carved out of a primary care office is the acute care provided by retail clinics like Minute Clinic as well as start-ups like Zipnosis.  Focused on a subset of problems where protocols are developed delivers care more rapidly and at less cost.  Primary care doctor offices can either try to replicate this as well or perhaps better would be having the healthcare system virtual integrate these providers offering precision medicine (protocols) with primary care doctor offices who do intuitive medicine (cognitive / clinical decision making).

So what does this all mean?  Avoiding the discussion of the federal government's role of community clinics, the future of primary care will thrive in three areas: large integrated healthcare systems like Kaiser Permanente, individual doctor offices virtually integrated by third party vendors as well as other non-physician providers like retail clinics, and the solo practitioner doing the ideal medical practice.

My fear, however, is that this won't happen.  Instead, medical students will be more appalled with the future vision of primary care, fewer doctors will be in the workforce, patients continue to bypass primary care doctors, and the unthinkable crisis that experts are trying to avoid in fact occur more rapidly.

I hope I'm wrong.

Thursday, August 19, 2010

Dr. Frank Ryan Car Accident - Learning From His Tragedy

I'll be honest.  I never heard of Dr. Frank Ryan, a Hollywood plastic surgeon, until his tragic motor vehicle accident recently.  Clients included actress Heidi Montag and boxer Oscar De La Hoya.

Although the California Highway Patrol investigation is not complete, rumors have suggested that Dr. Ryan might have been text messaging when driving.  If this is true and a well-trained intelligent doctor can fall prey to allure of technology, then what does it mean for the rest of us?

First, realize that we can't multitask.  You have one brain. You can focus at one task at a time.  Though laws allow hands-free cellphone calls, the issue isn't trying to dial the phone but rather that the mind is engaged in the conversation and not on the road.  Yes, we are all increasingly busy, but we can't multitask.  In fact, researchers have found that it takes more time and effort to re-focus when we are distracted from one task to the other.

So have a hard and fast rule.  The cell phone is off when driving.  You don't need to answer phone calls when doing something important; that is what voice mail is for.  The FAA requires airline pilots to follow the sterile cockpit concept for flight under 10,000 feet when communications is restricted to essential communications.  Failure to abide to this regulation was thought to play a role in the Continential Connection Airlines crash in Feburary 2009 near Buffalo, NY. 

It should be obvious that the same goes for text messaging.

Also, get a safe car.  The Insurance Institute for Highway Safety rates cars annually for crashworthiness.  Some reports indicated that Dr. Ryan was driving a 1995 Jeep Wrangler when it ran off the Pacific Coast Highway.  For Jeep Wrangler years 1997 to 2006, the crashworthiness for frontal offset impact was deemed acceptable.  There was no safety rating for roof integrity.  There is no data for 1995.

All vehicles even built by the same manufacturer and same model can differ based on the year.  Not all Jeep models received good or acceptable ratings for frontal offset impact.  Both Cherokee and Grand Cherokee year 1997 to 2001 and 1996 to 2004 respectively received a marginal rating, just one step better than poor.  However, the 2011 Grand Cherokee was rated a best pick for safety and received a good rating for frontal offset and roof integrity.

Obviously a Grand Cherokee isn't quite as fun to drive in Malibu but may have been safer.

Clearly, Dr. Ryan died too early.  Even though famous for his Hollywood clientle, he also did a lot of important charitable work for those who didn't have as much.  The fact that they won't have his services in the future is the real tragedy.

Wednesday, August 11, 2010

Water Safety - Drowning Kids Don't Scream

This summer I learned a couple of very important lessons. Drowning kids don't scream. Mothers have a sixth sense even when it's not their own child.

On a beautiful warm sunny day in San Diego, my family and our good friends were enjoying a well-deserved vacation.  My five year old daughter was splashing around with her friends as their father and I observed them from the pool.  Though he had to watch three kids, one was already on a swim team and the two younger children had followed their big sister in swim class.  He also had some help.  His wife was watching the kids from her chair.  The scene was certainly picturesque, serene, and unassuming.  Children playing happily in the pool.  Adults relaxing and talking.  It was a great day to be away from home and work.

Who would realize that nearby, a little boy would be in serious trouble?

In a moment his wife bolted from her chair, arm reaching out to grab a little boy. Both my friend and I were confused what was exactly happening.  There was no splashing.  No screaming.  Simply silent bobbing.  

He was drowning.

He was just a little bit beyond her reach.

The boy's father suddenly aware of the situation jumped into the pool fully clothed.  He lifted his son out of the water, which was only four feet deep.  Understandably stressed, the father admonished the boy.

"What do you think you were doing?"

I'm sure the little boy was equally as scared, though he probably wasn't aware of what could have happened.  He might have been only three years old.

Though the father thanked my friend and defended himself in not being a "bad parent", we wondered the same thing and were equally as outraged.

"What do you think you were doing?"

How could you put your child in an situation where he can't possibly succeed?  He can't swim.  He isn't wearing a life jacket.  He isn't being supervised or watched.  He's too short to be in the pool.

Drowning is the second leading cause of death for children between the ages of 1 to 19.  In 2006, 1100 children died.  The American Academy of Pediatrics has recommended that children age 4 years and older learn how to swim and recently shifted their position of being against swim classes for children between 1 to 3 years old to having parents make an individual determination.  This change reflects some evidence that children in that age group were less likely to drown with some swim instruction.

Water safety is so important that even though we don't even own a pool, my nearly three year old son attended his first swim class a couple of weeks ago.  One on one in a positive safe environment and with me in the pool, his instructor had him place his head under water.  Sometimes prepped and sometimes not.

When his head popped up, he spit and sputtered particularly when he didn't know she was gently bringing him under water.  He coughed for a second or two.  A little annoyed with a brief cry, he happily played with the many pool toys scattered around the pool.  She showed him how to spit out the water.  He copied her.  Throughout the 15 minute class, his instructor showed how a perpetually smiling Buzz Lightyear enjoyed having his head fully immersed.    

But having him under water without warning?  Why did she do that?

She explained that for children to be safe because they might fall into water unexpectedly and to prevent drowning, it is important they are conditioned to react correctly and instinctively.  They won't have time to prepare themselves.  Think of it as a dress rehearsal for the real thing.

I hope his father understands the importance now and will enroll his child in a swim class.

Thank goodness for a vigilant mother and board-certified pediatrician.  Although all three of us are doctors and have plenty of training as either a pediatrician or family doctor, none of us want to be in a situation where we can't win.

Performing CPR on a little boy who deserved a lot better.

Thursday, August 5, 2010

How to Talk to Your Doctor - Simple Easy Steps

As a practicing primary care doctor, I continue to work incredibly hard on making my bedside manner even better so that patients feel heard.  The other reason is because as most doctors learned in medical school 90 percent of getting the right diagnosis comes from taking a good history from a patient.

Unfortunately with shorter doctor office visits and doctors interrupting patients within 23 seconds of starting, you need to know how to get your concerns across.  While I don't believe this is the responsibility of patients, the reality is not everyone has access to doctors with great bedside manner.

How to talk to your doctor is quite easy if you follow these simple steps.

Set the agenda.  Before you go into the doctor’s office, decide what you want to discuss.  Are you there for a physical and to receive preventive care and tests? Do you have new problem that needs a medical evaluation or an ongoing problem that requires follow-up or further treatment?  If you want to talk about four concerns, tell your doctor at the beginning of the visit that you want to talk about four items and list them, without going into too much detail at first. Be sure to indicate which one is the most important to you.

Bring up the most important concern you have first and not at the end of the visit as you are about to leave.  We find this extremely frustrating and maddening. This will help the doctor enormously as he determines how much time to spend on each problem and how to pace the office visit.  If you leave a surprise at the end of the visit, the doctor may not spend adequate time to address your issue.

Write up a list of problems and questions you wish to discuss and make the number manageable.  If at all possible, I recommend tackling no more than four concerns in your office visit, especially if the four are new problems never before evaluated by your doctor. The goal is not to cram in as many problems as possible in a visit, but rather to get the most out of the visit by getting an accurate diagnosis and treatment plan. The aim is quality, not quantity.

After setting the agenda, next go into detail into each problem with the 4 W's the When, What, Where, and Why.

Ask your doctor which problem he wants to tackle first. Alternatively, you can just begin by talking about each problem in depth.  Always tell your problem the same way you might tell a story. Start in chronological order. Give it a beginning, a middle, and an end. Understanding your problem is far easier to follow if you do it this way.  While this may seem obvious, you’d be surprised how many patients don’t start at the beginning. They talk about their symptoms in no particular order and blurt out whatever thoughts enter their heads.

To help you organize your thoughts, use the Four Ws — the when, what, where, and why. The Four Ws help enhance your story to make sure that important details aren’t overlooked. Your doctor may ask you to clarify or expand on details if you forget them. Organizing your thoughts logically using the Four Ws brings a level of sophistication and detail to the office visit that increases your chances of getting the right diagnosis.

Start with the when, the what, and the where.  Finish with the Why.

  • When did you first notice the problem? Describe how the problem has changed over time.
  • When does it seem to occur?
  • When was the last time you had the problem?

  • What activities, treatments, or behaviors seem to make the problem better, worse, or no different (this can include home therapies like taking over-the-counter medications, applying heat or ice, eating or not eating, going to the bathroom, movement, activity or lack of, etc., depending on the problem).
  • What does the problem feel like? How would you describe the pain (i.e. sharp, dull, burning, gnawing, pressure-like, tight, achy, constant, increasing, comes and goes).
  • What other problems or symptoms have you noticed?

  • Where did the problem start? Did it move over time, and if so, where?
  • Does the pain or condition move anywhere else in the body?

Finally, end with the why. The why is the reason you are at the doctor’s office. While you don’t have to provide this information, as it may be completely obvious, doctors may ask when it isn’t clear why. They also may not.  Reasons are personal and quite varied.

  • I want to make sure it isn’t anything serious, like cancer or a heart attack.
  • I wanted to make sure I don’t need to take antibiotics, change my behavior, or forego my vacation.
  • The problem is interfering with my lifestyle.
  • My wife/husband/family member is worried about my problem.

Once you finish describing your first problem, move on to the others using a similar format. Although it does take some time to think about how to fill in the details about a particular issue, the payoff is that your doctor will have plenty of information to work with. This will increase the chance of him providing you with the right diagnosis and treatment.

Avoid the urge to diagnose yourself and say things like “I have the flu.” Although it seems like convenient shorthand, doctors are very specific with terminology and what you mean could be completely different than what a doctor understands the term to mean. Going to medical school is like immersing yourself in a foreign country. In four years medical students learn an entirely different culture, language, and perspective on the world. Their new vocabulary provides them the precision, understanding, and tools to communicate with their peers.

Perhaps it isn’t surprising that many doctors have forgotten how to speak normally!

Instead of self-diagnosing, talk about your symptoms. This doesn’t mean you can’t ask questions like, “Do you think I have a pinched disc in my back?” or “Do you think I have pneumonia?” or say things like, “These symptoms remind me of the time I had pneumonia.” If you have had the problem in the past, go ahead and tell your doctor. Many times these comments are very helpful.Wise patients know that getting an accurate diagnosis requires that their doctors have all the information they need.

Set the agenda.  Describing your problems in a concise format, using the four Ws, means your doctor has all the information he needs to make an accurate diagnosis.  Better diagnosis may mean fewer visits, getting healthier sooner, and possibly less unnecessary testing and interventions saving you both time and money.


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