Archive for November 8th, 2012

Concierge Medicine

Thursday, November 8, 2012 // Uncategorized

    • Updated October 29, 2012, 6:21 p.m. ET

    ‘Concierge’ Medicine, ObamaCare and the End of Empathy

    Traditional primary-care doctors are finding themselves, and their patients, squeezed by the government and the marketplace.



    I call my cousin Irene regularly. She is 90, frail, living alone in New York in an apartment in Queens, and I worry about her. This time there is distress in her voice:

    “I just don’t know what I’m going to do. I got a letter from my doctor, the one I’ve been seeing for a long time. It said she was making some changes to her practice. I had to go to a reception at a hotel in Manhattan where the details would be explained. I have such a hard time getting into the city, so I called her office to see if someone couldn’t just tell me over the phone.”

    Irene was crying now. “No, they said, I needed to come to the reception. So I paid a car service to take me there and back.”

    What Irene learned was that her internist was converting her fee-for-service office into a “concierge practice.” For a yearly retainer of $2,200 (in addition to the usual charges that would still be billed through Medicare and supplemental insurance), Irene would receive “value-added” services. These include same-day appointments, electronic access to her medical records and lab reports, shortened waiting times, and other “frills” that Irene said her doctor always provided anyway.

    “Do you think I should do it?” Irene asked me, her younger cousin, the doctor in the family, the internist and geriatrician. “I don’t even own a computer.”

    My cousin, of course, is not alone. This same question is being asked by patients, many of them elderly, all over the country as more primary-care doctors opt for the concierge model.

    Meanwhile, companies are springing up to help doctors make the change. For a piece of the action, they help transform a struggling primary-care practice into a well-oiled profit center.

    As one such company, SignatureMD, advertises on its website: “It can be challenging for any physician to remain independent and profitable in the face of severe reimbursement cuts, increased regulation, and increased overhead. Our seasoned team of professionals have devoted years to developing a high reward, low risk concierge practice model. SignatureMD enables you to deliver the care that your patients desire while securing your financial independence.”

    Don’t get me wrong, for nearly 40 years I practiced as a primary-care internist and geriatrician, so I understand both sides of this issue. Primary-care doctors have been undervalued and under-reimbursed by Medicare since the inception of the program. There has not been a real increase in fees in the past decade, during which time costs have soared.

    “If you like this doctor, and you want to keep seeing her,” I said to Irene, “you won’t have a choice—you’ll have to join her concierge practice.”

    The Affordable Care Act, in theory, places more value on primary-care services. But so far this remains just theory. At the medical school where I teach, only a small minority of students are considering primary care as a career choice. That’s not unusual. Worse, in an era of burgeoning need, just 2% of young doctors in residency express any interest in geriatric medicine.

    Those of us who have spent our careers in the cottage industry of medical practice and working in America’s single-payer health-care system known as Medicare hear only this nowadays: “Get ready, changes are coming.” The talk is all wonky babble about “primary care medical homes,” “accountable care organizations,” “service bundling” and “resource-based relative value units.” Through the din, one thing is clear: The single practitioner will be unable to survive without joining some much larger entity, or by transforming into a concierge model.

    Medicare now looks the other way as the concierge-medicine movement grows. In times past, had physicians attempted to charge Medicare patients additional fees while still billing this agency for services rendered, all manner of fines and sanctions would have been imposed. No more. With the nation short 40,000 primary-care doctors—and that’s before 30 million more patients come on board in 2014 due to the Affordable Care Act—the policy gurus have looked around and concluded that they can’t afford to alienate the worker bees that still remain.

    Yet as financially tempting as a concierge practice might be, I could never have turned away a patient unable to come up with an annual retainer fee. I had a history with each and every one of them. They were my “family.” I tried to treat each of my patients equally and with the full measure of my time and concern. To do otherwise violates the basic justice principle of medical ethics that we teach medical students today.

    The last time I spoke to Irene, I asked her if she had been back to her internist since she had decided to pay the annual retainer. “I was in to see her last week,” she said. “Everything works the same way it did before—even though I’m paying all this extra money. . . . I just don’t feel the same about my doctor anymore.”

    I must ask: Are we witnessing the end of empathy in the practice of medicine?

    Dr. Winkaur practiced internal and geriatric medicine for 36 years. He is a clinical professor of medicine at the University of Texas Health Science Center at San Antonio, and the author of “Memory Lessons: A Doctor’s Story” (Hyperion, 2009).

    A version of this article appeared October 30, 2012, on page A23 in the U.S. edition of The Wall Street Journal, with the headline: ‘Concierge’ Medicine, ObamaCare and the End of Empathy.


  • 8 days ago

‘A good article almost until the end- when the author interjects his self-congratulatory “I could never have turned away a patient unable to come up with an annual retainer fee.” The author- like I- practiced during a different era. If he had to make ends meet, feed his family, pay for educating his kids and save for something that resembles a retirment in today’s healthcare economic reality he might well be singing a different tune. One will never know but without a doubt- he sure does not know what he’d have done if his practice realities were those of today’s doctors.

Not only does this ‘there but for the grace of God go I’ insertion smack of stories from non-combat troops opining about what they would have done had they been at the front line; but it serves to call into question the commitment of docs today who try to get the job done while paying off their student loans while at the same time listening to their future dictated by Obamanomics and Obamacare. Today’s doctors deserve better on a host of fronts- but particularly by the ‘old guard’ (including me) opining on their fate.

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