Lifestyle Medicine in a Concierge Practice: My Journey

Abstract

While lifestyle medicine (LM) has been increasingly recognized for its value in preventing and managing chronic disease, the conventional primary care practice has struggled to be a financially viable model for this time-intensive, highly personalized approach. However, the concierge medicine model provides many advantages to those seeking to incorporate the tenets of LM. Concierge medicine is characterized by smaller patient panels, extended visits, continuous follow-up, and a distinctive emphasis on prevention and wellness. These characteristics promote high-quality, individualized care. North Cypress Internal Medicine and Wellness was able to successfully transform from a more traditional medical model to one with essential LM-focused offerings with expert assistance, as well as ongoing support from a dedicated team of lifestyle-oriented health professionals who provide wellness coaching, proactive chronic care management, and prevention programs. This article describes the transition and includes specific details of services and care offered at a concierge practice. It illustrates how this alternative model can provide an effective solution for delivering the full potential of LM.

‘Both LM [lifestyle medicine] and concierge medicine strive to provide patients with improved quantifiable outcomes, enhanced well-being, and a deeply personalized patient experience.’

Lifestyle medicine (LM) is serving a critical need as the population ages and the impact of chronic disease takes its inevitable toll. Establishing a private practice in 1998, now known as North Cypress Internal Medicine and Wellness (NCIMW), was a direct response to that need. However, as the health care environment continued to change, brief office visits dealing almost solely with acute issues became the standard for traditional practices. This made it increasingly difficult to fully offer LM to patients. On a personal level, this resulted in burnout—having lost much of the joy of practicing medicine due to the new reality that it was difficult to have enough time with patients to make a real difference in their lives. Helping patients adopt healthier behaviors and not simply handing out more pills to address chronic diseases was undeniably the best path, but extremely time consuming. The challenge appeared insurmountable, particularly when considering a reimbursement system that rewards volume, steadily rising overhead expenses, and never-ending administrative burdens. This was not a sustainable way to practice.

A very viable solution was presented in the form of concierge, or membership medicine. Its hallmark difference, a dramatically reduced patient panel, allows physicians to offer individualized care and focus strongly on the prevention and wellness measures that define LM. Both LM and concierge medicine strive to provide patients with improved quantifiable outcomes, enhanced well-being, and a deeply personalized patient experience. Its corollary—a career- and life-saving change for physicians—is particularly noteworthy for LM practitioners who value time as the most precious commodity both personally and professionally.

This article describes how the practice transformation took place and seeks to raise awareness of how and why this alternative model provides an ideal environment for realizing the vast potential of LM.

The Road to Change

From its beginnings in 1998, the NCIMW practice leaned strongly toward the LM approach, reflected in a succinct but meaningful value statement “taking the time to listen and care.” For 15 years, the practice represented a more traditional type of medicine, continually working with patients to access additional support and resources within the existing system. This became more difficult over time as the healthcare environment rapidly deteriorated. Concomitantly, the attraction to the principles of LM—treating the underlying cause of disease with nondrug modalities and evidence-based lifestyle changes—began to shape a different vision of how care was provided.

By 2013, wellness coaching was introduced at NCIMW with the assistance of a wellness development and training specialist. I became coach-trained myself in order to maximize the benefits of this approach for patients. The changes achieved by individual patients were remarkable (see examples below in “improved patient outcomes”) and extremely gratifying. However, the time commitment needed to appropriately guide, advise, motivate and monitor patient progress rose substantially.

In 2015, the approval of Medicare reimbursement for chronic care management provided additional fuel for the proactive approach of LM. The unique approach at NCIMW involved strong attention to healthy lifestyle behaviors. It was becoming evident however, that while patient outcomes were unquestionably improved long term, the practice model itself was not financially viable. There were simply not enough hours in the day to schedule longer visits for patients while simultaneously needing to see greater numbers of patients in order to remain an independent physician. Compromising patient care was never an option, but this situation felt impossible to rectify.

Seeking outside advice and consultation, the message received was clear: the quality of my care was excellent but an additional 1000 patient visits annually would be needed to sustain my practice in a traditional environment. My search for a realistic, workable solution led me to concierge, or membership medicine. This represents a growing but still relatively unknown alternative practice model based on significantly reducing a physician’s patient panel in order to ensure highly personalized care. The concierge model established at NCIMW in 2017 has meshed seamlessly with the components of LM and the ability to provide exceptional patient care.

Creating the Concierge Medicine Experience

While some physicians attempt to transform their practice by themselves, using the service of a trusted advisor made the transition much easier. For NCIMW, the flexibility and autonomy that Specialdocs Consultants was able to offer throughout the process matched the practice perfectly. The care provided at NCIMW is not a “one size fits all” plan for patients, and a templated concierge model would not have allowed the innovation I desired. I cannot emphasize enough the importance of identifying and working with a partner who respects the vision of medicine one has and helps create a practice around it.

The practice is structured as follows:

• The concierge model is based on an annual fee that varies by patient age. For physicians, switching to this model means a steady, predictable income from membership fees and no longer being dependent on shrinking fee-for-service reimbursements.

• Private insurance and Medicare are accepted at NCIMW. Patients appreciate being able to use their insurance for covered services, including labs, imaging, and studies that may be done outside the office.

• NCIMW is open 5 days a week with a typical 9 am to 5 pm schedule. A full work day may encompass an average of 1 to 2 comprehensive examinations and 6 regular visits, with ample additional time to advise and accommodate patients with acute needs, offer longer visits, arrange for specialists when needed, and conduct continual, proactive outreach to patients by phone.

• The team members are all trained extensively to serve as health and wellness coaches. The staff includes a physician assistant certified in both LM and health and wellness coaching, a nurse practitioner who is formally coach trained, a third highly experienced wellness coach who also provides LM outreach regularly, the director of our chronic care management program, and myself (a physician who is board certified in LM and a certified health and wellness coach through Wellcoaches). The physician provides primary care services directly to patients and ensures that care is coordinated among other providers and specialists when needed. The dedicated team provides ongoing support to help patients achieve their health and fitness goals and improve their well-being.

• For NCIMW patients, a 90-minute Comprehensive Annual Health Assessment lays the groundwork for developing an individualized Wellness Plan. This includes a thorough history and physical examination, an in-depth wellness questionnaire and an appropriate array of screening tests (such as metabolic panels, lipid profiles, inflammation markers, blood counts, diabetes and thyroid screens, and coordination of cancer screenings such as colonoscopy, mammogram, etc) based on age, health status, and risk factors.

• All appointments are 1:1, as is wellness coaching. This provides patients with an experience tailored to their individual needs. We also offer group LM visits in our clinic, with a strong coaching focus. In addition, a series of ongoing complimentary seminars on a variety of health and wellness topics (healthy eating, exercise, stress management, making connections) are provided. These events may be exclusively for patients in the practice, as well as their family members and friends. We also present this information at a series of ongoing community events.

• Same or next-day appointments are an important benefit of the concierge model. Extended appointments are the standard, not the exception. This allows sufficient time to fully connect with each patient and explore in depth lifestyle issues impacting an individual’s health.

• Visits are at least 30 minutes long and can be as much as 60 minutes if needed. Return visits are scheduled based not only on clinical status but also on lifestyle goals, to help support the patient’s progress and offer accountability and guidance.

• When actively working with a wellness coach or more aggressively working with the physician toward LM goals, patients typically schedule return visits within 2 to 4 weeks—and outreach by staff often occurs before that and then continues on a regular basis.

• Proactive telephone check-ins are a regular part of our care management plans. In addition, patients are encouraged to contact the practice at any time with questions, concerns, and progress updates. What happens between visits is essential to understand, but almost impossible to monitor in traditional models. Direct availability to myself 24/7 via a patient-dedicated cell phone, patient portal, and email makes this possible.

• Most concierge practices limit patient panels to between 300 and 600. Practices with an LM focus like NCIMW would expect to be on the lower end of this number because of the time commitment required to go well beyond typical primary care services.

Overcoming Objections

A number of misconceptions surround the concierge medicine model, chief among them that only the very affluent, very elderly, and very ill choose to become members. The patient panel at NCIMW is diverse economically, predominantly younger than 64 years, and runs the gamut from patients enjoying excellent health to those dealing with multiple chronic conditions. Concierge medicine holds multigenerational appeal—from Baby Boomers who want to safeguard their quality of life as they age, to Millennials interested in preserving their long-term wellness. Throughout the transition process, the driving factor in membership decisions was not a higher-than-average household income, but rather, it was viewing a concierge practice membership as an investment in health and disease prevention.

Physicians often express the fear that in a concierge model, patients will abuse cell phone privileges. At NCIMW, patients are not only extremely respectful but are also incredibly reluctant to call after hours, despite being routinely encouraged to contact the physician directly when needed. In the first 18 months of this practice, there have only been a handful of overnight calls, all of which were completely appropriate.

Vision Accomplished

At NCIMW, the concierge/LM-focused model has fulfilled its promise on every level.

• Enhanced patient satisfaction. According to the most recent 2018 patient satisfaction survey, quality of care at NCIMW was rated 5.0/5.0, and availability after hours, in emergencies and for routine issues was rated 4.9/5.0.

• Improved patient outcomes. The impact on patient outcomes has been remarkable. Many are doing and feeling better than they have in years, with significantly less medication needed. For example:

  • ▪ a 47-year-old man with lifelong weight management issues and poorly controlled diabetes despite numerous medications, including insulin, made tremendous health improvements. In his first year of active engagement in wellness coaching and LM visits at NCIMW, he lost 14 pounds, decreased hemoglobin A1c from 7.6% to 6.5%, cut insulin from 160 units to 100 units daily, and was able to completely stop taking one additional expensive oral medication for diabetes. I’ve been dealing with diabetes for more than 20 years but no one had ever explained why or how to change my lifestyle to improve the condition. Understanding my trigger points with food, exercising four times a week, and learning to de-stress has literally saved my life. (patient quote)
  • ▪ an 81-year-old man and his 79-year-old wife, both with diabetes and weight issues, benefited from the wellness coaching program at NCIMW. The wife lost 31 pounds, cut the amount of insulin taken in half, achieved an excellent A1c of 6.6% and experienced improved asthma control and breathing. Her husband lost 26 pounds during his first year in the program and decreased A1c from 8.0% to 6.9%; to date, he has lost 72 pounds from his highest weight. We tried every diet that has come along, from Nutrisystem to Weight Watchers, but nothing ever worked until this. (patient quote)
  • ▪ a 40-year-old woman presented with a swollen optic nerve, deteriorating vision, headaches, overweight, and with a family history of diabetes and hypertension. Working with the team at NCIMW, the patient lost over 50 pounds, resolved her headache issues, restored vision, and is officially considered to be in remission from pseudotumor cerebri with no complications. My quality of life is excellent, and I can focus on my job, not my health. Coming to NCIMW was life changing for me, and continues to be. I’m one of the few in my family able to avoid the need for blood pressure or diabetes medications. (patient quote)

• Personal and professional transformation. The change to a concierge practice and my passion for LM has inspired an additional personal embrace of its principles in order to keep serving as a conscientious role model to patients. There is nothing more powerful than sharing how this approach has transformed my own journey to personal wellness. Most important, being able to continue guiding patients along their individual roads to wellness—incorporating nutrition with a strong plant-based focus, encouraging regular exercise and activity, addressing the importance of sleep, and teaching mindfulness—has brought real joy back to my practice of medicine.

Conclusion

While many models that incorporate LM exist, the concierge model represents one of the most viable options for providers with a real interest in delivering this type of high-quality, high-touch care. With expert help, the NCIMW practice successfully transitioned from a more traditional medical model to a clinic that is highly focused on LM, offering an array of services, including 1:1 extended visits, wellness coaching, proactive chronic care management and prevention programs, complimentary seminars, and group visits. Having a truly dedicated team of lifestyle-oriented health professionals has enabled NCIMW to be successful.

It is important to recognize that concierge medicine does not necessarily equate to increased revenues or a better lifestyle, and change should not be considered for those reasons. However, what it does provide is the opportunity to fulfill one’s own deeply felt mission of caring for patients in a way that they need and deserve . . . and that is a tremendous privilege.