Retainer-Based Medicine: Making Patients VIPs

How would you like to obtain patient satisfaction upward of 100%, a patient load between 100 and 1,000 that allows for much more time spent with each and more time to research illnesses and medications, and financial benefits unreachable through a standard practice? What’s the catch? All your patients can access you 24/7 via e-mail, office phone, and cell phone. Still interested? You could be a candidate for practicing retainer-based medicine.

What Is It?

Taking several names—including concierge practice, boutique practice, innovative medical practice design, and VIP medicine—retainer-based medicine is a new form of (mostly) primary care, originated with the 1996 launch of the West-Coast-based concierge medicine company MD2 by two Seattle-based physicians who’d had enough of their hectic practice, seeing as many as 40 patients per day. MD2 was soon joined by another nationwide group provider, MDVIP—which doesn’t consider itself a concierge practice but “a new model of primary care based on prevention and personalized care,” according to CEO Edward Goldman, MD—several local companies, like Kentucky-based OneMD, and numerous individual concierge physician practices.

There are several models of concierge/retainer medicine. According to the Maryland Bar Association, the “most prevalent model” charges an annual fee and requires patients “to make immediate payment for services based on a fee schedule developed and maintained by the practice. The physician agrees not to bill the patient’s insurance, although the patient may be expected to maintain any coverage that they do have in order to cover hospitalization and specialty and catastrophic care.” In other practices, patients may pay a lower fee and the physician bills the patient’s insurance at contracted or out-of-plan rates, charging a fee only for value-added services not otherwise covered by the third-party payor. A third model is “similar to traditional fee-for-service practice, where the physician bills the patient for all services rendered and the patient submits claims to their health plan with the knowledge that some services rendered may not be covered by their plan.”

All told, “anywhere from 350 to 500” practices—almost entirely primary care and pediatric, because they’re the specialties most affected by the time crunch that has spurred the creation of retainer-based medicine—are operating under some form of the concierge/retainer model, estimates Dr. Goldman, who told MDNG that MDVIP has “in excess of 160 practices opened, including those in transition, which care for about 55,000 patients.”

The Pros

The success of this practice model depends on the concept that there exists a sufficient number of patients who are dissatisfied with the harried nature of the care they currently receive and who would be willing to pay a fee to ensure greater access to their physicians and receive certain desired services. Depending on the provider and the services offered, patients pay anywhere from $1,500 to $20,000 per year. In turn, “It’s very easy to reach and see the doctor,” says Andy Gole, who recently began seeing a concierge physician in New Jersey. “I can usually get in to see him the same day I call—no later than the next day. I have his e-mail address and cell phone number. He has the time to explain in detail the answers to my questions. The access is important when I am going through a change process, such as trying different statins with side effects. I want to be able to talk to the doctor in this circumstance. I have the sense he is doing more research, staying on top of developments.” Plus, appointments typically run 30-40 minutes for concierge practices, with most able to accommodate patients who request additional time. With this extra time, physicians are able to take longer to evaluate and treat patients and consider in-depth preventive strategies and diagnostic and therapeutic techniques.

In exchange for around-the-clock services, physicians who have created long-term relationships with their patients and now practice retainer-based medicine can cash in—quite literally in the cases of those who run cash-only practices—on a large portion of patient fees. Physicians charging the $1,650 MDVIP yearly retainer fee will keep at least $1,150 MDVIP keeps $500 for its services as a “turnkey solution that assists physicians in transitioning their practices to, developing, and maintaining a concierge medicine model.” “We look at ourselves as an R&D company,” said Dr. Goldman. “MDVIP looks at the basic science in prevention and then interprets it into systems, mostly personal and electronic, which the physicians can use to enhance the health and well-being of their patients. Plus, in our model, our doctors either double or triple their income.” Indeed, family physicians who make the switch can expect increased earnings of about 40%, says Debra C. Cascardo, President, Cascardo Consulting Group, a New York-based medical practice management firm. “However, the real benefit for the physicians lies in being able to practice medicine the way they were taught without feeling rushed and always trying to play catch-up,” she writes.

Further, a lighter patient load translates into reduced need for staffing, paperwork, and overall expenses. This means physicians practicing retainer-based medicine who want to ensure maximum efficiency will certainly want to take advantage of the benefits of health information technology (see The Role of HIT below).

The Cons

Why haven’t more physicians transitioned to a retainer-based practice? “I think physicians by-and-large are risk averse,” stated Dr. Goldman, adding that the transformation affects physicians’ primary source of living. Converting to a retainer practice means “taking what’s feeding the kids and paying the mortgage, and changing the fundamentals of it, and that’s a scary thing. It’s not surprising that physicians are more reluctant to do this than perhaps the average business person who’s used to risk taking.”

Adding fuel to the fire, an anonymous Florida internist who looked into converting to a retainer-based practice says “It’s fine to offer longer visits and no waiting time, but a primary care doctor’s day can’t be neatly scheduled. Emergencies happen, and they often happen in a bunch. I think there are bound to be lots of disappointed patients who will have paid a lot of money for immediate access to their doctor, but that's not always possible.” Perhaps the number of crossover practices remains low due to many physicians’ desire to not be associated with accusations that concierge medicine promotes a two-tiered health system, favoring those patients who can afford it and limiting the number of physicians to care for the remaining population, in turn burdening middle- and lower-class patients with higher insurance costs. The AMA addressed this in 2003, arguing that if no other physicians are available in an area to care for patients, switching to a concierge practice is unethical.

Dr. Goldman disputes the idea that concierge medicine will create or exacerbate healthcare disparities, stating that “we have always existed in the US with a multi-tiered system, from Medicaid to Medicare to HMOs to PPOs. We think that as opposed to creating a two-tiered system, [concierge practice adds] yet another layer of choice. We hear that there’s an efficacy issue about people who can’t pay. We’ve tried to keep our price point at $125/month; it’s in the same line as the NFL TV package or the decision to smoke cigarettes. I will tell you that I question the efficacy of giving a patient an eight-minute office visit, when you know you can’t begin to address the patient as a whole. So, when it comes to ethics, we need to start looking at what we’re doing in the whole system right now and how we are not stopping illness, but letting illness progress.”

Making the Leap

It’s important to keep in mind that retainer-based medicine is best suited for primary care physicians and specialists with ongoing and regular relationships with their patients. Those who do opt to convert will want to make sure some of their current patients will come with them, as well as research the demand for such a practice in their geographic and specialty area. It should be noted that the most successful retainer-based practices seem to be those that opened first in a market.

Dr. Goldman understandably recommends that a physician interested in starting a concierge practice work with a group like MDVIP, adding that “the regulatory slope is very slippery. This is something you need adjunctive support for. I ask physicians all the time, ‘Why do you refer someone to a cardiologist? You studied cardiology in medical school.’ They refer because they want a certain expertise that they don’t have. Why would you take your primary source of income when you don’t have the business expertise in general or the expertise in this particular model of primary care, and do that on your own without a commensurate amount of expertise? If somebody did that with your patients, you would say they weren’t treating them very well.”

The Role of HIT

Through enhanced Web services, many concierge practices provide medical record access to patients online, as well as test results and appointment scheduling. These portals also provide physicians with a helpful tool to provide relevant, health-related news and reports to their patients. In the MDVIP system, health information technology plays a huge role, according to Dr. Goldman. “We put an EMR in every one of our offices at no cost to the physician,” he told MDNG. “We have point-of-service decision support that does everything from differential diagnosis to protocol recalls. Each one of our 55,000 patients has their own personal wellness portal, called MyMDVIP, with a PHR that updates instantaneously whenever the doctor updates the medical record. We have tracking applications for exercise, calcium, fiber, blood pressure, and sugar. We approached Duke University to develop 150 video tutorials for us—which they have done—all geared toward risk factors. So, if a patient is at risk for coronary artery disease, they’ll be enrolled in the Duke videos, and then our tracking system will track these so the doctor and patient can make certain they’re addressing these potential risk factors. We also have a doctor site so that the doctor and patient can talk to each other in a HIPAA-secure environment. And we have applications that will help the doctor take histories on literally 8,000 symptoms. If a patient e-mails the doctor about a problem, the doctor will be able to get a complete history, so he can advise the patient in a cogent matter.

We also have discussion rooms, chat rooms, and a medical-centers-of-excellence program, for which we have affiliations with Beth Israel Deaconess in Boston, Joslin Diabetic Institute at Harvard, Memorial Sloan-Kettering Cancer Center in NY, University of Miami, Cleveland Clinic, and UCLA. We are able to access expertise online as well as personally, if we send the patients there. They are able to interact, educating our patients and physicians through both patient and physician portals. So, in our world, the electronics are a terrific adjunct. Right now, we’re looking to do voice and video coaching for everything from weight loss to nutrition and exercise, and all of that is being developed as part of the infrastructure that we put into the physician’s office at no expense.”