Home Forums Discussions General Discussion Concierge practice-hybrid model

Most of you are familiar w/ the concierge model, right?
Have no staff, charge each patient $1,000 retainer, bill their insurance for services rendered, be on call 24/7, give them 30-60minut office visits and have a patient panel of 300-500 pts.
See 6-8 pts per day and have a nice lifestyle.

In Bangor, ME I think the possibility could actually work. I have many whom I KNOW would do it in my practice. Most wounldn't but I know a lot would, but not certain if 300 would.

So I propose a hybrid model. Keep my 2,300 patients, charge them all $100-250 retainer fee to stay in my practice. This buys them nothing than the right to see me. The less desirables would leave, those who truly want me would stay. It would make my days less hectic and more manageable.

I realize insurance exclusions and Medicare rules could be a problem. But Medicare is only 17% of my total practice. I could opt out of Medicare, charge the retainer. Cut some overhead.

Any thoughts on the matter? It's late, I'm brainstorming and interested in feedback.

I have looked into the MD-VIP program. They have already cleared the retainer fee with HCFA (Medicare), by calling it a "comprehensive evaluation for health status", which as preventive care, isn't covered by Medicare anyway (ironic, huh?). The patient signs a waiver that they will pay if Medicare doesn't. In MD-VIP, you actually have to do a face-to-face with the patient, but I can't see why you couldn't just provide the patient a report on health status, using the new AC version 5 features for instance.

By the way, each patient for MD-VIP pays $1,500/year, of which $500 goes to MD-VIP. I expect that, as primary care docs become scarce and the patient pool with insurance goes up from the health care legislation, patients may need to pay a retainer to get into a full-service practice, or to see an MD instead of the PA, for instance.

I currently have a concierge practice that I started de novo. My model is the strictly retainer model and I do not bill insurance. I have a staff of one and charge $1500 per year. I looked into adding insurance but it just didn't seem worth the hassle.

I absolutely love it as do my patients. I feel as if I am able to work smarter for each patient which in turn keeps them out of the hospital/ER, keeps them healthy, and also lowers their overall health costs.

I hate the idea of a concierge practice.

Therefore I need to investigate and understand it better.

What do you cover for $125.00/ month.

Do they have 4 hour acces to you. Do youseee them in the hospital.

Do they pay up front?

Any info would be appreciated.

Thanks.

In my practice, the $125/month covers everything that I do in the office including procedures, flu vaccines, injections, et al. The fee also includes in patient care should they need to be admitted to one of two hospitals where I am staffed. If a patient is very ill or incapacitated, the fee also covers the home visit.

The patients pay either up front, quarterly or monthly. I have lesser rates for students and young professionals.

They have 24/7 access to me.

My practice mainly consists of young working families with high deductible plans, but I have many uninsured, Medicaid, and Medicare patients.

Please feel free to ask questions because I truly do not think the outrage for direct care practices are warranted.

What happens when the pt needs imaging studies or a specialist or medications or a procdure (cardia cath or colonoscopy)? Do thy pay for it themselves out of pocket?

There is nothing wrong with a retainer model, and I personally think it is an improvement upon the concierge model.

The fee is designed to cover the enormous amount of staff an MD needs in order to service a practice of 2,500 + patient. It is simply getting harder and harder to keep up with billing, refills, pre-authorizations, referrals, phone calls, complaints, billing issues, etc. Obviously there is a lot more that goes into primary care than just a standard E/M, and physicians should be able to afford to pay a staff to handle all of that. The retention fee makes this feasible and greatly improves the patient experience by allowing the physician to provide higher quality staffing and more face time.

I think it is long overdue.

I negotiate reasonable out of pocket rates with hospitals and private entities for imaging to stress tests to colonoscopies to blood work for those patients who are paying out of pocket which is not the norm. But it is quite refreshing to know what one's costs will be prior to the procedure. Most of my patients have insurance to cover the pricey procedures/hospitalizations/emergencies.

WOW. What is life like with only 17% Medicare? I have over 50%. I just can't even imagine it. I am so used to dealine with 10 item chronic problem lists in 15 minutes or less that my brain feels like it is on chronic overdrive. I am jealous.

Don't they already?

Hi Kevin,

As I built my practice, I was selective about who we let in.
There is a big demand for PCP's in Maine. So I have no Medicaid and little Medicare. However the 17% Medicare generates about 30% of my office visits, because they are older and require the Q3 month followups and hospitalizations, etc.

I look at medicine, as should most of us in primary care these days, from a business model. Supply and demand. We are in short supply, therefore our demand is great. In coming years, the demand will only INCREASE. Therefore we will gain more control over certain things.

While we may not be able to dictate what insurance pays us, we will increasingly be able to dictate our fees and give up on accepting insurance.

As the nation nears the 100,000 doctor shortage that is expected soon, we will have greater power to take on the patients that we want and discard the ones we don't want.

In my region, I have built an excellent reputation and people are screaming to get in. We only take family members of existing patients, and only those who are insured or cash pay, and only those who have a GOOD referrence from the family already established. I tell patients that "if your mother is a pain in the a**, I'm not only firing her but I'm going to fire you too." I say this jokingly, but they get the point. I don't want bad patients.

Another thing Kevin, I'm solo FP and self-employed.
The product I offer isn't medicine. The product I offer is me.
If they don't like me, they can try to find another doctor.
If they don't like me and are too lazy to find another doctor, I nudge them out. If they don't pay, we get rid of them too.

I know I'm sounding harsh (although the actual number of patients fired in 2009 was only 5). the point is that I want patients that want me. And all of us know the studies which show patients who like (want) their PCP are 10x less likely to sue them for malpractice, or some such figure.

If they can't afford me, I cut them a huge discount. Cash pay sees me for $25 routine visit, and $50 if I do complex visit. $100 for annual physical or 40-60min time based visit.

My apts are sched 20 for routines, f/u, and acutes. 40min for physicals and complex mole removals. We build in 8 acute slots reserved each day. If we run out of acutes, the longer apt times allow me to double book in a reasonable manner in which time I can see both patients without running behind.

I love being my own boss and I love having patients that love to see me.

Can someone enlighten me as I'm extremely uninformed in this area? What is the disadvantage for not participating in Medicare? It's only 5% more on the fee to participate and you don't have to take them. Or is the better question to ask, why shouldn't we all limit the number of Medicare patients we accept?

I'm completely ignorant to Medicare. All I know is that it is by far the worst paying provider with the most unhealthy (i.e. stress-inducing) patients.

Travis,
Some very intelligent people have been asking themselves the same question:

www.bloomberg.com/apps/news?pid=newsarchive&sid=aHoYSI84VdL0

That's great! I love that the very organization that Obama is referencing to being "so great for so cheap" is losing tons on Medicare. Now there dropping it, at least at one clinic. Good for them. That's what we need. High profile places like Mayo and Cleveland Clinic telling Medicare to stick it.

I didn't like this moron: "Robert Berenson, a fellow at the Urban Institute’s Health Policy Center in Washington, D.C., said physicians’ claims of inadequate reimbursement are overstated. Rather, the program faces a lack of medical providers because not enough new doctors are becoming family doctors, internists and pediatricians who oversee patients’ primary care."

So let me get this straight. We're trying to figure out better, cheaper ways of keeping our doors open but the problem is not enough PCPs....it has nothing to do with inadequate reimbursement? These people are completely out of touch with day to day medical practice.

I'm in the process of applying Medicare fees to every single one of my charges in 2009 to see what my actual salary would have been if I saw nothing but Medicare patients.

This is exactly the point. Most of us are already providing most of the "concierge" level services to our patients: 24 hr call, same day appts, dealing with their long lists of often trivial concerns at the price of blowing up the schedule. I have to get up the nerve to start asking them to pay for it.

That moron needs to actually try to run a primary care practice. But of course he is above all that.

Wayne,
Mr. Berenson needs to explore the "WHY" behind his supposition that the problem is simply a lack of PCP's. "WHY" aren't there more PCP's?

All of us on this message board know the answer. I'm glad there are still some of us around to fight the daily battle.

But truthfully I'm scared to get old or to get sick. I witnessed horrible treatment of my late-wife when she was ill and the hospitalists did not treat her condition rather blamed her as being "psycho," while I watched her suffering.

I also witnessed horrible treatment of my best friend as they tried to kill him with a morhphine pump that was set inappropriately WAY TOO HIGH. He actually had to call me at 2 AM to tell me his O2 sat was 71% (yes SEVENTY-ONE), and that I needed to call the nursing supervisor to intervene. They only checked his O2 sat after he begged them because he was feeling confused and couldn't breathe well.

The solution is simple, don't get old? Or sick?

Adam, its just that when I look at how hard my sister works, and how much she went through to get her MD and then I see some jerk said something like that I just see red. I know, you all did the same, but I don't has much of an emotional attachment to you as I do to her.

Adam et al,

I share your fear of getting sick/old and that extends to having considerable angst about sending patients off to the hospital.
The medical industrial complex is not a safe haven for the sick!

A recent experience with a family member reenforced my feelings; was in ICU for 3 weeks and never saw the same Dr. twice (nor had the same nurse ). Everyone on rotating schedules - no one took an interest in the patient and had I and other family not been there 24/7, the patient would not have made it out alive.

Not sure what the answer is. I can't imagine that PCP's will ever again be paid to round on their hospitalized patients unless acting as 'attending'. And there simply is no other person that even makes an attempt to 'pull it all together'

Defintitely

Medicare problems and benefits are a mixed bag and depend alot on your location. In Florida, insurance companies are often offering just 80% of Medicare fee schedule and they are getting a lot of takers (I call them insurance sluts). Medicare patients are sicker - and need more of our services. A Medicare base gives you leeway when negotiating with insurance companies. I can tell the insurance company to go elsewhere if they don't want to give me 120% of Medicare fee schedule.

Adam - If you charge only $75/hr, how do you pay your overhead? Do you have others who pay a higher fee?

This is an apparently successful pay as you go practice model.

Seems like a workable model and a good one. But I hate it when they, as many others do, "bad-mouth" other models as basically being unethical. Like the claim that this doesn't , oh price discriminate (I cant remember the quote now. sorry) like the retainer fee does. $33/5 minutes can add up really quickly. I'm not passing a judgement of if it is or is not a fair price. But It is not necessarily any more fair than $1000/year for "all you can eat." One bad thing is people may not ask necessary questions because of the fear of another 5 min. $33 charge. One good thing is people will not answer questions in a stupid manner for fear of dragging out the visit.(How long have you had this pain? Since forever, doctor! Oh, one more thing! Is a cold contagious?) It takes about 5 minutes to write you an excuse from work letter. Do they charge for that too? (Everyone probably should.) Every model can be open to criticism.

Hi Toby,
I have a very small cash pay percentage of my payor mix.
It amounts to perhaps one pt per day, or less who has no health insurance and pays so little for health care. We offer a discount for payment on same date of service. While $25 seems like so little, it probably translates into $50 of equivalent health insurance charges. When you account for my biller's time, claim submission fees to our clearing house, submission and resubmission to the insurance company to get my money, then not seeing that money for several weeks to months.... we spend a lot to collect what we charge. Cut out the middlemen and health care would cost a lot less.

I have chosen not to sign up/accept Medicare. Consequently, it's illegal for me to accept any payment for seeing Medicare patients for any covered service - even if for free.

I have a request pending at the Office of Inspector General in DC asking for permission (an opinion)in writing to allow me to see a few Medicare patients for free.... go figure

I was counseled not to charge anything less than medicare acepted fee schedule, or medicare and other carriers could come in and try to renegotiate my contract.

I pick a reasonable cpt and collect the fee.

Frank,
I agree that your advice is correct.
However you are allowed to offer a "same date of service, date of payment" fee reduction schedule. This is fine.

Since the other payers will not/do not ever pay on the same date of service, they do not benefit from the fee reduction. They are privvy to it however, and if they want to start paying me on the same date of service I will offer them the same discount.

I'm not worried though, the big insurers will never agree to it.

Plus, by purposefully downcoding the visit a doctor can be held to the same penalties as upcoding a visit. So I simply charge what the documentation supports, then I cut the fee for same date of service-payment discount. It amounts to about 1 patient per day or less. And like I said before, money today is worth more than money that I get in 3 months.