“Their relationships with specialists give you immediate access,” Mody says. “You get exclusive privileges, almost like having an American Express black card.”
After the surgery, the doctors checked in with Mody frequently through e-mails and phone calls to make sure he was following his home routine for recovery. “They stayed after me,” Mody says.
Kelleher patient Bobbie Kilberg, CEO of the Northern Virginia Technology Council, says the doctor took two hours out of his day to go with her for an imaging scan she was worried about: “He has your back every step of the way, no matter how many specialists you go to.”
Critics of concierge care say it smacks of elitism. They worry that its growth will lead to a two-tiered health-care system where patients in the second tier get inferior doctors and poor care.
“Concierge care is great, but who can afford it?” says Dr. Barbara Starfield, codirector of the Johns Hopkins University Primary Care Policy Center. “It’s not a solution for the country; it’s a solution for rich people.”
Concierge advocates claim that their model of medicine is unfairly cast as something only for the rich. They say teachers, plumbers, and other middle-income workers sign up because they’ve made health a top priority.
“I hate the term ‘concierge,’ ” says Darin Engelhardt, president of MDVIP. “It connotes someone who can get tickets to a good show or a Redskins game. We like to refer to it as ‘personalized preventive care.’ At $4 a day, it’s a very viable option for many, many Americans.”
More than a few entrepreneurs are banking on the idea that concierge medicine can be done more cheaply. Privia Health, a start-up company in Alexandria, is building a network of doctors in Washington who charge monthly fees of between $25 and $75 for concierge-like guarantees of 24/7 access and care focused on prevention and wellness with the help of fitness and nutrition counselors. Unlike MDVIP or other concierge doctors, Privia physicians maintain a traditional practice and ask patients to see nurse practitioners for routine ailments.
“I don’t need a trained, experienced doctor to look in my ear and tell me I have an ear infection,” says CEO Jeff Butler.
New Atlantic Ventures, a Reston venture-capital firm, invested $1.5 million last spring in Qliance, a Seattle company that’s pioneering what it calls “direct primary care” because it eliminates insurance companies as the middleman. For a fixed price as low as $600 a year, Qliance patients get concierge-like guarantees of 24/7 access to the company’s doctors and 30-minute appointments along with free X-rays and basic lab tests. Patients need catastrophic insurance coverage, but they pay nothing beyond the retainer for their office visits and primary care.
Qliance has opened only three clinics in Washington state, but its backers believe its business model could revolutionize health care in the same way that Amazon transformed the book business. By doing away with insurance, they say, Qliance is eliminating the back-office support that’s driving up the costs of all care.
“It’s concierge medicine for the masses,” says New Atlantic founder John Backus. “We really think it is the solution to the health-care problem in America.”
If nothing else, concierge medicine offers a case study of what primary care should look like—and how it might cut costs. More-personalized care might lead to early detection and proper treatment for diabetes, heart disease, hypertension, and other chronic illnesses that untreated can explode to require expensive surgical procedures and hospital stays. MDVIP touts a study showing that its patients are admitted to the hospital much less frequently than others. Research by the David Drew Clinic shows that its preventive screening catches diseases early and lowers the death rate for patients.
It’s easy to dismiss the findings of a for-profit company that makes its services look good, but no one disputes that the concierge model of care is attractive.
“We all agree that you need to be able to really coordinate the care of your patient,” says Lori Heim, president of the American Academy of Family Physicians. “If you do that, you will have a tremendous cost saving in the future. It’s a whole lot cheaper for me to manage my diabetics than to pay for an amputation or dialysis.”
But Heim is skeptical that the concierge model could be made affordable on a widespread scale. She’s talked to many doctors—particularly in rural areas—who’ve researched the idea and find they could never make it work financially.
Heim and others see potential in other solutions. They say policy reformers have awakened to the primary-care crisis and its role in the growing costs of health care. The reform moving through Congress likely will include Medicare-reimbursement increases for primary providers as well as loan forgiveness and other measures to make general medicine more attractive to young doctors.
More promising are schemes to reinvent how health care is delivered. Today that delivery is fragmented: A middle-aged professional might see an internist, an endocrinologist, an orthopedist, and a rheumatologist or pulmonologist. Yet rarely does any single doctor adequately monitor the progress of a patient.
The health-care-reform legislation includes pilot projects to end that fragmentation by paying the general practitioner to coordinate a patient’s care. In a pilot program that loosely resembles the concierge or retainer practice, fee for service would remain the norm, but Medicare and other insurers would pay a monthly per-patient fee to physicians who treat chronically ill patients through a “medical home” model. The home would include a medical team—perhaps a nurse practitioner, a nutritionist, and others—who would emphasize preventive medicine through routine visits, screenings, and monitoring of diet, exercise, and medication. The doctor would also oversee patient visits to specialists and hospitalizations.
The medical-home concept is backed by Heim’s American Academy of Family Physicians and other doctor groups. “We understand the pressures that drive physicians and patients to the concierge model,” Heim says. The medical-home concept and payment system, she argues, could offer comparable care for more people.
Another Medicare pilot program would pay primary-care providers not through a monthly fee but through a share of savings generated by the reduced costs of care. In one such program, called Independence at Home, geriatric physicians would head teams of nurse practitioners and social workers to coordinate care for severely ill Medicare patients in their homes. Such care could head off serious complications and hospitalizations, leading to cost savings that the teams would share.
Dr. Eric De Jonge, who runs an at-home geriatrics program at Washington Hospital Center based on this model, argues that using patient outcomes to determine pay will improve care as well as reduce costs. “How do you justify paying extra money to providers when not holding them accountable for results?” De Jonge says. “We have to start paying for quality and economic results.”
In the meantime, Sandy Ibrahim continues her own version of health-care reform. Ibrahim says she practices medicine more cost-effectively now than she ever has. In her old practice, with only ten minutes to see each patient, she often ordered tests because she didn’t have time for a thorough evaluation. Now she can take her time and focus on prevention and wellness.
PartnerMD recently added a second doctor to its McLean practice—Donald Rhodes, who’s a solo practitioner in Centreville. That means Ibrahim’s patient load shouldn’t top 400 anytime soon.
Ibrahim resists the notion that her care is elitist. Many of her patients aren’t wealthy, she says. Some pony up for PartnerMD to get a doctor who has time to monitor a chronic illness closely—people with diabetes or heart disease or patients recovering from cancer treatment or surgeries. “They want to make sure things aren’t missed,” she says.
Ibrahim likens her move into concierge practice to the teacher who decides to work in a private school: “It’s a personal choice.”
She’s heard the argument that if more doctors go to concierge medicine, the shortage of physicians will only get worse for the average Joe. “Well, you almost lost me as a family doctor to a non-clinical job,” she says. “At the end of the day, I’m a happy practicing doctor, which I think is much more important than being a disgruntled doctor who’s not practicing medicine.”
Al Newland, meanwhile, couldn’t be happier. His wife has a chronic illness that he believes Ibrahim is watching closely. His son, Martin, now a sophomore playing football and soccer at Madison High in Vienna, has broken a finger and injured his knee since the appendix episode. Each time, Newland says, Ibrahim has arranged for him to see specialists and watched over his care.
Newland is not wealthy; he and his wife are both retired 20-year Navy veterans, though he continues to work as an IT specialist for the Department of the Treasury. The PartnerMD retainer isn’t cheap, but his military insurance isn’t expensive at $450 a year. He’s willing to pay more to get better care.
Says Newland: “The peace of mind for me is worth every penny.”