Physicians Seek a More Personalized Approach in Retainer-Based Practice

Benefits include stronger physician-patient relationship and greater emphasis on prevention.

The opportunity to provide more personalized care and help patients with prevention is drawing a small but growing number of physicians to retainer-based or “concierge” practice.

In this approach, patients pay a flat fee for unlimited office visits and 24/7 access to the physician by phone and/or email. Same-day appointments are available. Tests, specialist care, and hospitalization are additional.

David Katzman, MD, was the first in St. Louis to convert to retainer practice in 2003. In practice with Jennifer DeLaney, MD, they each see about 600 patients a year compared to what would be 5,000 in a conventional practice.

“I converted to personalized medicine because I could not treat my patients in the manner I desired,” Dr. Katzman said. “In the traditional setting I found the visits were hurried due to the volume of patients I was seeing. It was difficult to establish a strong relationship with my patients, which to me is the real reward of being a doctor.”

Like many but not all retainer practices, Dr. Katzman opted out of Medicare and insurance contracts, but patients can use insurance on an out-of-network basis.

A search of local and national websites and media reports shows more than 25 St. Louis-area physicians practicing under some form of retainer-based approach. Nationally, it is estimated that fewer than 1,000 physicians have a full concierge practices that do not take insurance, according to the American Medical News, while estimates range up to 3,500 or more when including those that also take insurance and/or Medicare.

Internist Richard Bligh, MD, also started his retainer practice in 2003. “I was in a large group practice seeing 40–50 patients a day. I couldn’t put any emphasis on prevention and counseling,” he said. “Now I enjoy medicine much more. We do a much more aggressive prevention profile, including advanced cardiac testing. We educate patients about diet and exercise.”

Dr. Bligh also attends to his patients who are hospitalized, adding that he brings a greater knowledge of the patient’s history than the hospitalist.

For family practitioner Glennon Fox, MD, it is about the physician-patient relationship. “This practice format encourages and deepens the physician-patient relationship. Hour-long appointments offer the time to determine more information about the patient and his or her needs. The small patient panel allows for same-day and next-day availability for acute needs.”

Dr. Fox adds that he begins to consider patients as family. He has been practicing under the retainer model since 2004.

One of the newest converts to retainer medicine is Robert Saltman, MD. After practicing internal medicine and endocrinology for 25 years, he and partner Daniel Gaitan, MD, changed the internal medicine portion to retainer in 2011. Endocrinology patients continue to receive specialty treatment but not primary care.

They accept Medicare and private insurance in-network. The retainer covers services including longer appointments, comprehensive preventive examinations, and 24-hour access to the doctor. He now has 440 retainer patients.

“The advantage for physicians is a completely different level of care for patients, the kind of care we were trained for and what attracted us to medicine,” Dr. Saltman said. “There truly is time to direct the care for very complicated patients, to personally follow up on interventions, and to personally talk to patients when they call in for problems. It gives you a tremendous sense of satisfaction and returns the joy of practicing medicine.”

What Types of Patients Are Attracted?

Physicians say retainer practices attract patients from all socio-economic backgrounds who want more time with their doctors and strive to live more healthy lives.

“My practice generally attracts those who care about their health and want a meaningful relationship with a doctor who cares about them,” Dr. Katzman said. “They want easy access to me and the office. I think patients like this sort of practice because they know their doctor and staff, and know that they will receive timely attention when a need arises.”

Dr. Fox added, “Our practice format works well for families with young children who need quick response to problems, for patients with medical issues requiring close observation and management, and for anyone who would like to have time to talk with a physician about multiple questions without needing to make multiple appointments.”

Fears that some patients would abuse the unlimited access have proven unfounded. Dr. Saltman said, “Many assume that patients will constantly call for unnecessary issues. Nothing could be further from the truth. Patients are reassured they can reach us easily during office hours. I get very few calls after hours.”

Dr. Bligh said, “People have been very respectful and do not use the access inappropriately. I actually have fewer calls than I did before.”

They also dispute the notion that concierge practice is mainly for the wealthy. “We have patients from all socio-economic circumstances,” Dr. Fox said. “Our patients who do not have health insurance find that they can get their primary-care services less expensively through this practice than through urgent-care centers or emergency rooms.”

Regarding the cost of the retainer, many equate the patient’s cost of enrolling with a retainer practice to the cost of a latte per day.

Evolution of Retainer Practices

As the number of retainer practices grows, variations have evolved. One is the “hybrid” practice which sees both retainer and traditional patients, and accepts Medicare and insurance.

Some physicians are working with several national companies to help convert their practices. Dr. Saltman utilized Signature MD of Santa Monica, Calif. In return for a percentage of each patient’s retainer, Signature offers an array of services starting with comprehensive demographic analysis and patient survey and helping to manage the conversion process. Signature MD provides a conversion resource at the physician’s office for 90 days to meet with patients and explain the benefits of the program, said Matt Jacobson of Signature MD. The company also conducts an outbound mail and telephone campaign. On an ongoing basis, Signature MD manages retainer billing operations, provides regulatory and legal guidance, maintains the physician’s website, and promotes the practice through online advertising and corporate outreach.

Another vendor, MDVIP of Boca Raton, Fla., announced in November 2011 that it had 500 affiliated physicians. As of this writing, MDVIP’s website shows eight St. Louis-area internal medicine physicians affiliated: William Guyol, MD; Edward Heidbrier, MD; Patrick Majors, MD; C. Scott Molden, MD; Anna Niesen, MD; Timothy Pratt, MD; Paul Stein, MD; and Kevin Weikart, MD. MDVIP is owned by Procter & Gamble, according to American Medical News.

Concierge Choice Physicians of Rockville Centre, N.Y., has 200 affiliated physicians. Other companies include Personal Medicine International, Inc. of San Francisco, Concierge Medicine Direct of Durham, N.C., and PartnerMD of Richmond, Va.

First Stop Health of Chicago (www.fshealth.com) offers a new variation combining concierge with telemedicine. For membership fees ranging from $240 per year for an individual with infrequent medical needs to $600 annually, First Stop offers 24-hour telephone consultation from a team of on-call 250 physicians, plus support from personal health-care advocates and access to a website featuring directories and ratings of local health-care providers and health information.

Ethical Concerns Raised

Concerns have been raised that, should retainer medicine become more prominent, it could limit access to already strained primary care. In a Sept. 3 American Medical News ethics forum, members of the Saint Louis University Bander Center for Medical Business Ethics wrote, “In addition to paying a retainer, most patients will want to maintain insurance to cover medications, specialist care, surgical procedures and expensive tests. This can put retainer-based medicine beyond the reach of many or at least require a significant change in spending priorities.”

A November 2011 article in the Annals of Internal Medicine argues, “But even if it were granted that social justice required society to provide health care to all and social justice were recognized as a core professional virtue, it would not follow that primary caregivers should interpret the demands of social justice as requiring them individually to care for some minimum number of patients.”

If the social justice argument were carried through, the article continues, primary care physicians could be condemned for working less than full-time, going into hospital medicine or changing careers entirely. The forces behind the decline of primary care are much larger than retainer medicine, the article says.

The AMA has adopted a code of ethics for concierge physician practices. Key points include:

• Be clear about financial terms and do not pressure patients.

• Do not promote the retainer practice as providing better diagnostic care and therapeutic services and provide the same standard of care for concierge and non-concierge patients.

• During the transition to concierge, make it easy for patients who do not opt for the retainer to transfer to other physicians.

• If you are still billing to insurers, clearly define what is and is not covered under the concierge fee, and comply with all relevant laws, rules and contractual requirements.

• All physicians have a professional obligation to care for those in need regardless of ability to pay.

The AMA also offers a resource guide for physicians considering concierge practice.

Retainer physicians believe they offer a viable alternative for patients.

Biography

Jim Braibish, APR, Braibish Communications, is the Managing Editor for St. Louis Metropolitan Medicine magazine.

Contact: jbraibish@sbcglobal.net

Reprinted with permission from St. Louis Metropolitan Medicine.