Concierge medicine (retainer medicine)

Concierge medicine is health care that bypasses health insurance in favor of a direct-transaction system. Patients establish a health care relationship with a doctor or group of their choice without being limited to in-network providers. Doctors engaged in concierge medicine—which is also known as retainer medicine, direct primary care (DPC), retainer-based medicine, boutique medicine, and personalized medical service—may offer services such as virtual telemedicine or video conference appointments and home visits. Patients pay membership fees to be under the doctor’s care and know the cost of services up-front.

While many people choose concierge medical care because they want fast access and personal relationships with their doctors, this service has its drawbacks. The monthly membership fee does not cover specialty care, medical testing, or catastrophic care, for which patients may need to rely on traditional health insurance. Doctors who offer concierge care may accept Medicare, but those who do not are permitted to charge patients up to 15 percent more than the amount approved by Medicare.

Background

Prior to the twentieth century, medical care in the United States was largely provided by doctors in private practice. In rural areas, one doctor may have served a large geographic region. Areas with high population density might support multiple doctors or practices. Payment for care was made to the doctor, who often would make house calls. Early hospitals were generally places for indigent people who did not receive much in the way of health care.

In the first decade of the twentieth century, health care in the United States was relatively inexpensive. The average person spent $5 annually, which translates to $154 in 2021 dollars. Treatments were still primitive, but as antibiotics and other new discoveries were made, hospitals began working to get patients. In the early twentieth century, they focused primarily on persuading women to have their babies in the hospital rather than at home.

As medical science and health care advanced, it became more expensive. Most people only sought care when extremely ill. In the late 1920s, Baylor University Hospital in Dallas, Texas, offered a plan to public school teachers. They could pay fifty cents a month and Baylor would cover their costs for hospital care. When the Great Depression began in 1929, hospitals across the country had empty beds. Many began to copy Baylor’s plan, which eventually became known as Blue Cross. While few people enrolled at that time, World War II (1939–1945) transformed the US economy. Factories had to increase production and used benefits such as health plans to entice workers. Legislation in the 1940s and 1950s that made employer-based health care costs tax-free further encouraged people to participate. By the 1960s, 70 percent of the US population was enrolled in private health insurance plans.

The US government has passed legislation over the years that has drastically affected health insurance. One of the most significant was the creation of Medicare in 1965. Title XVIII of the Social Security Act established the program to provide public health coverage to those older than sixty-five. Part A covers hospitalization, while Part B covers outpatient services and services provided by physicians, such as office visits and laboratory tests, after the beneficiary met an annual deductible. Another major change was the promotion of health maintenance organizations (HMOs) in 1973. The law promoted health maintenance organizations (HMOs) by, among other things, requiring employers who offered health insurance to also offer the option of enrolling in an HMO if possible.

Health insurance plans were unpopular with some people for various reasons. Among the most-cited complaints was that people’s preferred doctors were sometimes not in the insurance plan’s network. Patients then had to choose between paying more for a doctor they were comfortable with or see an in-network doctor. Sometimes people struggled to find an in-network doctor who was taking new patients. Doctors had to decide which insurance companies they would work with and submit claims for payment.

Such dissatisfaction with health insurance led some doctors to start concierge practices. The earliest was MD² with offices in Washington state and Oregon. MD² began in 1996 charging annual retainer fees of $13,200 for individuals and $20,000 for a family. As the idea gained traction, two doctors in Florida created the brand MDVIP in 2000 and set up hundreds of concierge practices around the country. The following year, the American Medical Association wrote guidelines for doctors in such practices.

Overview

In 2019, the national trade publication Concierge Medicine Today estimated that twelve thousand out of about one million licensed physicians in the United States were practicing concierge medicine. At that time, national average monthly membership fees were between $135 and $150. Doctors in these practices said the fees brought in predictable revenue and guaranteed them a minimum annual income, although the annual average salary of a concierge physician was $300,000 compared to $294,000 for primary care physicians in standard practices. At the same time, the patient caseload of a concierge physician was about 80 to 90 percent smaller, which gave doctors more time to devote to each patient. Consumer Reports reported in 2018 that primary care physicians on average saw a patient 1.6 times a year and spent fifteen minutes in each patient visit. The average visit with a direct primary care physician was thirty-five minutes, and patients averaged four visits a year.

While patients can expect more attention from doctors if they enroll in a concierge practice, many services will not be covered. Typical services include wellness visits, prevention screenings, minor urgent care services, and some diagnostic tests.

Advocates say that concierge practices best serve patients with chronic conditions that require frequent primary care visits. However, such patients would also need a health plan to cover other costs such as treatment and testing. Others who might benefit from concierge medicine are patients enrolled in health plans with high deductibles who might pay thousands of dollars annually in out-of-pocket costs. About 81 percent of Americans with employer insurance have deductibles that average $1,500. The deductible is the amount the person must pay out of pocket before insurance will cover costs. Even then, many plans require individuals to pay a copayment or coinsurance, meaning a percentage of the cost of the service. If an individual’s annual out-of-pocket costs for routine care are greater than the annual membership fee of concierge care, paying for both might be financially beneficial.

Not all concierge practices focus on affordability. Early adopters promised their patients a degree of exclusivity. In modern times, some continue to offer access to highly respected physicians to a small clientele for costly membership fees.

Bibliography

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Carnahan, Sandra J. “Currents in Contemporary Ethics: Concierge Medicine: Legal and Ethical Issues.” The Journal of Law, Medicine & Ethics, vol. 35, no. 1, 1 Mar. 2007, pp. 211 – 215, doi.org/10.1111/j.1748-720X.2007.00125.x. Accessed 4 June 2021.

Castaneda, Ruben. “Does Health Insurance Cover Concierge Medicine?” US News and World Report, 23 Nov. 2020, health.usnews.com/health-care/health-insurance/articles/does-health-insurance-cover-concierge-medicine. Accessed 4 June 2021.

“Concierge Care.” US Centers for Medicare and Medicaid Services, www.medicare.gov/coverage/concierge-care. Accessed 4 June 2021.

Daly, Laura. “Before You Pay Extra to Join a Concierge Medical Practice, Consider These Questions.” Washington Post, 22 Oct. 2019, www.washingtonpost.com/lifestyle/home/before-you-pay-extra-to-join-a-concierge-medical-practice-consider-these-questions/2019/10/21/90d8206a-ef8b-11e9-b648-76bcf86eb67e‗story.html. Accessed 4 June 2021.

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“The History of Concierge Medicine in America (1996 – Present Day).” Concierge Medicine Today, 2019, conciergemedicinetoday.org/the-history-of-concierge-medicine-in-america-1996-present-day/. Accessed 4 June 2021.

Levine, Hallie. “What to Know About Concierge Medicine.” AARP, 25 Apr. 2019, www.aarp.org/health/conditions-treatments/info-2019/what-to-know-about-concierge-medicine.html. Accessed 4 June 2021.

“What Is a Concierge Doctor?” WebMD, 2020, www.webmd.com/a-to-z-guides/what-is-a-concierge-doctor. Accessed 4 June 2021.