Seeking more time with patients, DOs turn to concierge medicine
The son of an osteopathic family physician, Frank P. Pettinelli Jr., DO, of Mount Laurel, N.J., had a vision for what family medicine should be when he joined his father’s practice in 1984. Two decades later, after years of declining reimbursement and an ever-increasing patient load, he knew he had to make a change.
“I had approached the point where I was working 18-hour days,” Dr. Pettinelli says. “I would see up to 50 patients a day. Like many doctors today, I was unhappy practicing medicine.”
He first tried downsizing his practice and adopting electronic health records to become more efficient. But he still had 7,500 patients and two office locations. Nostalgic for a time when doctors knew their patients well, Dr. Pettinelli decided in 2007 to drastically reduce his patient base and embrace a primary care practice model commonly known as concierge medicine or retainer medicine, in which patients pay an annual membership fee for more personalized care. Like a number of such physicians, he had help from a firm that provides turnkey marketing, fee collection and technological support to a network of physicians adhering to a version of the concierge model.
“It’s like a joint venture,” says Dr. Pettinelli, a client of Pennsylvania-based Total Access Medical, which handles his patient enrollment, mailings, fee collection and practice promotion. “I am back to being a doctor, which I love.” Total Access receives a portion of the approximately $2,000-per-year membership fee it collects for each patient. Dr. Pettinelli no longer accepts Medicare or other health insurance, but this is not true of all concierge practices.
Because his practice is limited to 500 patients, Dr. Pettinelli can spend considerably more time with each of them and offer services he previously could not provide. For example, initial patient visits can last two hours, as he takes a thorough history, does a comprehensive physical examination and conducts various screening tests. He provides patients same-day appointments and access anytime via his personal cell phone number and email address. He also sees patients outside of the office and hospital, visiting them in nursing homes and rehabilitation facilities and making house calls if necessary. “This is the ideal way to practice,” he says.
Across the country in Monterey, Calif., family physician Scott H. Schneiderman, DO, shares a similar story. Burnt out from seeing more than 30 patients a day, spending no more than 15 minutes with any of them, and juggling multiple patients in examination rooms and the waiting area, he was on the verge of leaving primary care.
“My frustration level was very high,” Dr. Schneiderman says. “So my wife, who runs the business end of my practice, and I looked at several alternatives. I looked at becoming an employed physician. I looked at working for the prison system. I looked at working for the Veterans Affairs system. And I looked at moving out of California to a state with a lower cost of living.”
Patient likes personal attention of retainer practice
Although he lives 20 miles away in Salinas, Calif., Jack Borges has been a patient of Dr. Schneiderman’s for almost 10 years, originally referred to the Monterey family physician by a friend. A colon cancer survivor, Borges has many comorbidities, including back pain, Type 2 diabetes mellitus and chronic lung disease.
While he liked the care Dr. Schneiderman provided before transitioning to the MDVIP model a little more than two years ago, Borges appreciates that his primary care physician now has more time for care coordination. “I’ve had numerous operations,” he says. “Scott has made sure that proper referrals were made and has been in constant touch with my other doctors.”
He also likes the fact that he can call Dr. Schneiderman at any time. “When I call him, he either picks up or calls me back within a few minutes,” Borges says. “And I’ve talked to him when he has been on vacation a few times.”
Borges notes that Dr. Schneiderman diagnosed his lung condition during the annual comprehensive wellness examination, which includes a pulmonary function test. “I’m on a list for a lung transplant,” Borges says. “Scott has been helping me through this.”
Then roughly three years ago while at a conference, he happened to strike up a conversation with a physician who was transitioning from a traditional primary care practice to an annual-fee-based model focusing on wellness and prevention. Dr. Schneiderman became fascinated as he learned more about MDVIP, the nation’s largest network of retainer-based physicians.
Within months, Dr. Schneiderman counted himself among the network’s more than 550 primary care physicians in 40 states. Limiting themselves to 600 or fewer patients, MDVIP physicians do accept Medicare, Tricare and private health insurance. Patients pay an annual retainer fee of $1,500 to $1,800 for services not covered by insurance, such as 24-hour access to their physician and comprehensive wellness examinations. Physicians pay MDVIP for its services, ranging from setting up a practice with electronic health records to collecting the annual fee from patients.
“I’m so much happier now,” says Dr. Schneiderman, who restricts his practice to 300 to 400 patients—roughly one-tenth of his previous patient load. “I get so much joy from my daily practice. I love being able to discuss wellness and prevention. I love being able to not just treat patients when they are sick but work to keep them healthy.”
Dr. Schneiderman spends more than two hours with each patient to develop a wellness plan stemming from a battery of screening tests and discussions about lifestyle choices. “We talk about weight, we talk about smoking, we talk about alcohol, and we talk about exercise,” he says. “We do a comprehensive evaluation of their breathing, of their heart, of their hearing, of their vision, and then we sit down and come up with a plan.”
He now has plenty of time to talk with patients and their families and with physicians in other specialties. “In my old practice, there really wasn’t time in the course of the day to talk to families and get the information I needed to make an accurate diagnosis,” he says. “I now also have time to discuss my cases with specialists. I can coordinate care in a way that I never was able to in my traditional practice.”
Emerging but small trend
Nationwide, fewer than 2,000 physicians are believed to practice concierge medicine, which first emerged in the mid-1990s. Still, the number of concierge physicians increased more than tenfold from 1999 to 2004, according to the General Accounting Office.
“In our training, we’re taught to examine the patient and listen to the patient, and that’s what I’m back to.”
Originally regarded by many as elite care for the wealthy, annual retainer fees have become more affordable. A 2004 survey by the GAO indicated that fees ranged from $60 to $15,000 a year but averaged $1,500 per patient.
“A $1,500 annual fee is around $4 per day, the cost of a latte at Starbucks,” Dr. Schneiderman points out.
Still, concierge medicine remains somewhat controversial because not everyone can afford personalized care, and this is especially true in a sluggish economy.
“I, personally, have some ethical concerns about this care model creating a two-tiered health system,” says Paul A. Martin, DO, the president of the American College of Osteopathic Family Physicians (ACOFP), noting that neither the ACOFP nor the AOA have formal policies on retainer medicine. While not endorsing the model, the American Medical Association has developed guidelines for physicians interested in cash-only or mixed models of retainer-based care.
Dr. Martin notes that even annual fees of less than $2,000 a year per patient likely shut out a significant portion of the middle class, as well as nearly all low-income patients. “Even if you’re willing to give up small luxuries, such as expensive cups of coffee, you need to have considerable disposable income to receive this type of health care,” he says.
Dr. Pettinelli admits that he has struggled to retain some of his patients and has not reached his maximum patient quota. “I’ve had patients lose their jobs and lose their houses,” he says. His annual fee was one of the last discretionary expenses they gave up.
But even in the tough economy, MDVIP, which serves 185,000 patients, has a patient renewal rate of 92%, according to the organization’s medical director, Andrea B. Klemes, DO.
The fees are not the only ethical issue, Dr. Martin contends. “By dramatically decreasing their patient loads, family physicians and general internists who switch to a concierge practice model only exacerbate the primary care physician shortage,” he says, noting that the shortfall will worsen substantially when the Affordable Care Act’s health insurance mandate goes into effect in 2014.
But Dr. Schneiderman counters that the option of a manageable and fulfilling practice model could actually induce more medical graduates to pursue primary care. “And by practicing this model of care, primary care physicians like myself will stay in practice longer,” he says.
Dr. Klemes notes that the MDVIP model is not intended to be a panacea for U.S. health system woes, but its focus on wellness and prevention has already saved the federal government millions of dollars by reducing hospital admissions for Medicare beneficiaries. “In 2010 alone, MDVIP patients on Medicare had 79% fewer hospitalizations than a comparable sample of non-MDVIP patients,” she says. The company, a subsidiary of Procter & Gamble Co., analyzes outcomes data for all of its member patients.
Osteopathic physicians in concierge practices say they can now provide the whole-patient care they were trained to deliver.
“In our training, we’re taught to examine the patient and listen to the patient, and that’s what I’m back to,” says Dr. Pettinelli. “There are times when I listen to patients’ histories and I’m amazed that they are walking around with certain problems that have never been addressed before.”
In addition to having more time to interact with patients and their families, Dr. Schneiderman does more osteopathic manipulative treatment now. “I do craniosacral techniques and soft-tissue mobilization, which take a fair amount of time,” he says. “It was difficult for me to fit those techniques into my old practice.”
Although Dr. Martin likes the concept of patient-focused, preventive primary care, he prefers the patient-centered medical home model of care, endorsed by the AOA, the ACOFP, the American Academy of Family Physicians and many other major health care organizations. Touted in the Affordable Care Act, this model calls for all primary care physicians—as opposed to just those receiving retainer fees—to concentrate on preventive medicine, care coordination, chronic disease management and continuity of care and to offer patients better access to services. The ACOFP encourages its members to become recognized as patient-centered medical homes through the National Committee for Quality Assurance (NCQA).
Dr. Klemes points out that 30 MDVIP practices are NCQA-recognized patient-centered medical homes. The models are not mutually exclusive.
But the patient-centered medical home model alone does not address the impact of practice size on physicians’ ability to provide optimal care. Dr. Klemes notes that the physicians who founded MDVIP 12 years ago established a cap of 600 patients after analyzing the time it would take to provide the best possible preventive and follow-up care while still having enough patients to make a decent living.
The model wasn’t created as a way for physicians to make more money, Dr. Klemes adds. Most physicians have found the transition to MDVIP to be “revenue-neutral,” she maintains.
“It wasn’t about the money. It was about having a better lifestyle and being able to practice a better brand of medicine,” Dr. Schneiderman says.
Dr. Schneiderman insists that his outcomes prove he is a better doctor today. For example, one of his patients, a 54-year-old woman, came to him for her annual comprehensive physical examination. “She had no cardiac risk factors, she was in fairly good health, and she was on no significant medication,” he says. “She had no symptoms whatsoever. But during the course of her physical exam and in doing a detailed history, I found that she has some family risk factors for heart disease. And she hadn’t been taking care of herself in terms of diet and exercise.
“When I did her screening EKG, it showed some minimal changes—really minimal changes that I probably wouldn’t have paid that much attention to in the past. But because I had taken that comprehensive history, I suggested we do further testing. It turned out that she had a 99% occlusion of one of her coronary arteries. She needed an angioplasty and a stint.
“If I had been rushing from room to room and just had 15 minutes to spend with her, as in my old practice, I would not have been able to save that woman’s life.”