The Trend towards Concierge Medicine

April 5, 2011- On April 2, an Associated Press article appeared “Doctor Trend Raises Medicare Fears.” The article concerned AARP and Medicare fears that doctors entering concierge practices would create an access crisis for Medicare beneficiaries.

The crux of the crisis is that primary care doctors who enter concierge practices often downsize their patient panels from to 2500 to less than 500, thereby leaving 2000 patients to seek care elsewhere. Abandoned Medicare patients may be left out in the cold, with no doctor to whom to go.

After the article appeared, I began to receive numerous emails from an organization with an e-mail address of AMA-TBPAG, which I learned stood for “Take Back The Profession Advisory Group.”

The Take Back the Profession Advisory Group (TBPAG) is a coalition of Delegates and Alternate Delegates to the AMA House of Delegates from various state and specialty medical societies. The Group is working, it says, to ensure that physicians retain control of their profession to protect and serve the best interests of their patients. The group is not an official arm of the AMA. TBPAG is led by David McKalip, MD, a neurosurgeon who is an alternative AMA delegate from Florida. The emails I have been receiving defend and explain the practice of concierge medicine.

In the Associated Press article, John Rother, policy director at AARP and members of MedPac, a commission created by Congress to instruct them on Medicare matters, express alarm over the rise of concierge medicine, wherein patients pay a primary care doctors an annual fee of about $1500 a year, or $125 month, or $4.25 a day, for the privilege of being seen on the day they call, for the doctor’s undivided attention, for a 15 minute to a one hour session, for preventive counseling, and for referrals to the best specialists and hospitals.

• Rother remarked, “If concierge medicine goes beyond a thriving niche, it could lead to a kind of insurance caste system. What we are looking at is the prospect of a more explicitly–tiered system where people with money have a different kind of insurance relationship than most of the middle class, and where medicine is no longer as universal as it used to be."

• “MedPAC chairman Glenn Hackbarth, is quoted as saying. “ My worst fear- and I don’t know how realistic this is – is that this is a harbinger of our approaching a tipping point. The nightmare I have - and, again, I don't know how realistic it is - is that a couple of these things come together, and you could have a quite dramatic erosion in access in a very short time."

Commissioner Robert Berenson, a physician and policy expert, adds, "The fact that excellent doctors are doing this (concierge medicine) suggests we've got a problem. When a primary care doctor switches to concierge practice, it means several hundred Medicare beneficiaries must find another provider.”

MedPac, fearful of dangers of limited access of Medicare recipients to doctors, investigated the growth of concierge practices and issued a report last September. The report found national listing of 756 concierge practices, a 5 fold increase since 2005.

The truth is that nobody knows how many concierge practices exist. Estimates vary from 2000 to 5000 concierge practices. Word on the street is that the number of these practices is growing rapidly, as doctors bail out of Medicare and other third party arrangements, and as they ponder the consequences of health reform, which proposes to cut their reimbursement below those of Medicaid by 2019 and to pay them 2% less by 2015 if they do not install electronic health record systems .

Thomas W. Legelius, MD, chairman of the concierges’ physician professional society, claims the number of patients joining concierge practices is “not just in the thousands but the millions, and the current number of physicians is not just in the hundreds but the thousands, perhaps in the tens of thousands. Most are under the radar. They just quietly do it and are never counted by the bureaucrats.”

Legelius maintains concierge practices cut costs of Medicare, citing studies that indicate concierge physicians cut ER visits by 25%, specialty visits by 50%, and prescription drug use by 50 to 95%.

I cannot confirm any of these numbers, but suspect they are over-hyped.

Nevertheless, I know at least a dozen patients and doctors in my circle of contracts have chosen to enter concierge relationships. And I know these practices serve as a haven for primary care physicians, particularly older primary care physicians, some suffering from burnout, others seeking a way out of third party relationships, still others trying to find a way to spend more time with patients, free themselves of regulations and overhead these regulations entail, and, to find a way of earning a decent income.

There is an ideological element to those who join or create these practices. These physicians argue: we live in a free country, we can still practice where and how we please, and we are not yet indentured servants of government. Concierge medicine, they are wont to say, is about bringing back the physician-relationship to the center of the health system, away from government rules, regulations, and restraints, and towards more patient and physician choice.

If concierge physicians were to answer their critics, it might go like this.

Dear Mr. Rother, MedPac members, and Medicare officials:
Concierge medicine isn’t about satisfying government beneficials.

It’s about kicking patients upstairs.
and knocking third parties downstairs.

It’s about spending more time with loyal patients,
not frittering way time on government relations.

It’s about cutting overhead expenses,
and returning to our collective senses,

It’s about attention to patient-physician priorities,
rather than priorities dictated by outside authorities.

It’s about direct one-on-one care,
rather than remote managed care.


Tweet: Patients and doctors are flocking to concierge medicine, which may threaten access for Medicare patients not in concierge practices.


Richard L. Reece, MD, has posted 1721 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation but his opinions are his alone. He has written ten books. His latest book, The Health Reform Maze, is now at the publishers and will be released in June. Doctor Reece’s website, www.doctorreece.com, will be up and running in several days. He invites comments on his blog and will respond to each comment on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.

A Forced Marriage: Hospitals and Doctors in Accountable Care Organizations

Forced marriage is a term used to describe a marriage in which one or both of the parties is married without his or her consent or against his or her will. A forced marriage differs from an arranged marriage, in which both parties consent to the assistance of their parents or a third party (such as a matchmaker) in identifying a spouse, although the difference between the two may be indistinct.

Wikepedia

April 4, 2011 - I see the Obama administration has just released a 429 page document, up from 7 pages in the Patient Protection and Affordable Care Act, describing Accountable Care Organizations (ACOs) and specifying rules and regulations for their formation.

Some government reform enthusiasts are calling ACOs as a “marriage made in heaven,” because of their potential for cutting costs, raising quality, and coordinating care. The basic idea is that you slash costs for those 10% of Medicare patients that produce 70% of costs by herding patients, physicians, and hospitals into the same feedlot and putting them on a diet consisting of fixed budgets and bundled bills. Some go so far as to call ACOs the “Last Great Hope” for saving Medicare.

Critics of the Accountable Care Act, however, which include hospitals and physicians, are not so kind. They are characterizing ACOs as a “shotgun wedding” or a “forced marriage,” Whatever you call the wedding, responses to invitations to the wedding and the wedding reception are mixed.

Healthleadersmedi.com Poll

A poll at Healthleadersmedia.com, website directed mostly at hospital executives, yields these results, when executive were asked:

What impact will Accountable Care Organizations have on hospital-physician relations?

• Deteriorate. 39%

• Improve, 36%

• Stay about the same, 23%

Physician Foundation Survey

A survey conducted by the Physicians Foundation of more than 40,000 practicing physicians produced these answers, when the physicians were asked this question,

Health reform provides pilot projects to test “bundled (capitated) payments” for episodic care, What is your view of bundled payments?

• A generally good idea, 11%

• A generally bad idea, 68%

• Unsure, 21%

These responses are not directly comparable, but they do reveal nervousness among hospitals and doctors, both of whom stand to lose income, and both of whom worry about who will be in charge of ACOs.

Here is how Donald Berwick ,MD., administrator, views the future of ACOs:

“Whatever form ACOs eventually take, one thing is certain: the era of fragmented care delivery should draw to a close. Too many Medicare beneficiaries — like many other patients — have suffered at the hands of wasteful, ineffective, and poorly coordinated systems of care, with consequent costs that are proving unsustainable. CMS believes that with enhanced cooperation among beneficiaries, hospitals, physicians, and other health care providers, ACOs will be an important new tool for giving Medicare beneficiaries the affordable, high-quality care they want, need, and deserve.” ( Health Policy and Reform, “Launching Accountable Care Organizations – The Proposal for the Medicare Shared Savings Program, “ March 31, 2011, New England Journal of Medicine, March 31, 2011).

Conclusion

I will conclude by citing statistics from the Washington Report, an informative non-partisan newsletter report of the Physicians Foundation. These statistics summarize federal activities and rationales behind ACOs.

• April, 2011, new ACOs rules released, Federal Trade Commission and Justice Department put out guidelines informing hospitals and doctors of “safety zones” to prevent anti-trust abuse. The public given 90 days, until May 30, to respond.

• HHS says more than half of Medicare recipients have 5 or more chronic diseases, such as diabetes, hypertension, and kidney disease, one in 7 admitted to hospital has been subjected to harmful medical care, and 1 in 5 readmitted in 30 days. Proposed rule, HHS claims, would save $960 million over 3 years for Medicare, which now has a budget of $550 billion.

• Groups of ACO providers must see at least 5000 patients a year on fee-for-service basis and must sign 3 year agreements to be approved by CMS, CMS will approve 75 to 150 ACOs caring for 1.5 million to 5.0 millon Medicare patients. ACOs will require installation of electronic health records costing form $132 to $26 million.

There You Have It

So there you have it - the rules for engagement and marriage of hospital and physicians, as administered by HHS, CMS, the Federal Trade Commission, and the Justice Department.

The only thing missing is a Justice of the Peace.



Richard L. Reece, MD, has posted 1720 blogs at Medinnovation blog over the last four years. His themes include health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation. His opinions are his alone. He has written ten books on health reform. In 2007 Innovation-Driven Health Care was published, and in 2009 Obama, Doctors, and Health Reform. In June 2011, Greenbranch Publishers will print The Health Reform Maze, A Roadmap of Good Intentions and Unforeseen Consequences. He welcomes comments and will comment on each.

An Outrageous Thought: Republican Health Plan More “Progressive” Than Obamacare

Somebody who advocates social, political, or economic reform.

One Dictionary definition of Progressive

What I am about to say will enrage and inflame many “progressives” who equate more government control with “progressivism.” They may even call my words "outrageous," as a defamation and distortion of the progressive movement. If my message provokes and evokes contrary comments, so be it. I invite such comments.

In any event, I will say it anyway. I believe the Republican Choice Act is more “progressive” than the Patient Protection and Affordability Act (PPACA).

The PPACA neither protects nor makes things more affordable.

It does not protect patients against loss of their current health plans. Some 80 to 100 million Americans may have to switch to government-qualified plans before 2014.

It may not be affordable either. Premiums went up 10% in 2010 and are estimated to rise 12% in 2011. After that, who knows? If rising costs and lack of health plan choice constitute being "progressive," Americans seem to saying, "No Thank You!" if the polls are any indication.

The Republican plan – issuing refundable tax credits of $2300 for every individual and $5700 for every family, allowing everybody to shop across state lines for private plans, expanding pretax contributions to health savings accounts to allow patients to salt away more for retirement, offering free preventive services with high deductible plans for major chronic diseases – strikes me as much more “progressive” than the Obama plan.

How so? Well, to begin with, it is much more:

• Universal, i.e., it covers everyone in the private sector and may also be applied in Medicare and Medicaid populations.

• Progressive, in the sense that it gives every citizen roughly the same benefits at their Congressional Representative, Senator, or government employees in a Federal Health Benefit Plan (FEHBP). That's progress.

• Rational, in that it costs $61 billion versus $1 trillion from 2010 to 2020, and $2.3 trillion from 2024.

. Fundable, we can come up with the money to fund without driving the federal budget deeper and deeper into the deficit abyss.

• Equitable , because everyone, individuals and the self-employed, and corporate employees, gets tax deductions. It levels the playing field.

. Understandable, requiring only several hundred rather than 2801 pages to explain, and not needing passage to find out what's in it.

• Patient-centered, because informed patients are given more responsibility for making their own decisions and negotiating with doctors with the knowledge they will be spending more of their own money and in the process becoming more price and value sensitive.

• Predictable, so far experience with Health Savings Accounts indicate HSAs cut premiums and employer expenses by 10% to 20% and cause 30% more employees to buy coverage.

• Less intrusive, no individual or employer mandates, fewer regulations, no forcing of hospitals and doctors into awkward partnerships in into as yet undefined accountable care organizations, no uninvited increases in taxes to the tune of about $550 billion.

• Less of a “big Brother knows best” mentality, requiring the hiring of 16,500 IRS agents to enforce mandates; the formation of 159 new federal agencies, boards, and oversight commissions; and federal experts and analysts, sitting in judgment of the motivations and actions of their fellow citizens.

In my mind, it is “progressive “ to recognize that we are a center-right, individualistic, capitalistic nation that believes in smaller government that relies on the common sense of its citizens as expressed in national, state, and local elections.

I believe in social, political, and economic reform, but only if reform fits the culture and reflects the will of the people.

Richard L. Reece, MD, has posted 1720 blogs at medinnovation blog over the last four years. His main themes are health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation but his opinions are his alone. He has written ten books, the latest five are: Sailing the Seven “Cs" of Hospital-Physician Relationships, with James A. Hawkins, 2006; Innovation-Driven Health Care: 34 Concepts for Transformation, 2007; Navigating the Maze of Health Coverage And Access, 2008; Obama, Doctors, and Health Reform; 2009; The Pros and Cons of Accountable Care Organizations, 2011 (an e-book). His new book The Health Reform Maze, will be published by Greenbranch publishers in June 2011. On his blogs, he asks readers to comment . Otherwise, he says, how else can I tell if I making an imprint.

Health Reform: As Vermont Goes, So Goes the Nation?

If Vermont can navigate its political waters and successfully implement this plan, it will provide a model for other states and the country as a whole.

W.C. Hsiao, PhD, from the Department of Health Policy and Management, Harvard School of Public Health, “State-Based Single-Payer Health Care – A Solution for the United States?" New England Journal of Medicine, March 31, 2011

Vermont is a tiny Northeastern state. It houses 0.20% of U.S. population and contains 0.26% of the U.S land area. Its population is 1% black, 1.5% Hispanic, and 95.0% white, hardly representative of the U.S. as a whole. It is the home of Ben and Jerri’s ice cream. It has lots of cows, 215,000 in all which emit 34 tons of methane gas. It is a beautiful mountainous and heavily wooded state.

It is a heavily Democratic State. It is the home of Dr. Howard Dean, former head of the Democratic Party. Its governor, Democrat Peter Shumlin, ran on a platform of single-payer health reform. One of its Senators is a member of the Socialist Party, the other is a Democrat. Its Democratic legislature is committed to a single-payer.

The Vermont Legislature in May 2010 commissioned a study, carried out by the a group of experts at the Department of Health Policy at the Harvard School of Public Health. The purpose of the study was to determine the impact of a single-payer system in Vermont.

The study concluded single payer would be good for Vermont. It would quickly save 8% in health care costs through administrative consolidation and simplification, another 5% by reducing fraud and abuse, and 25% in costs over 10 years.

Furthermore it would achieve universal coverage, reduce the rate of health care increases, and create a primary-care focused, integrated delivery system.

I say fine – go for it. But Vermonters, do not delude yourself into thinking you are the weather vane for health reform in the United States. Your demographics are less ethnic, your politics are more Democratic, your Medicaid debts are lighter, and your present coverage of 7% uninsured is less that half that of the U.S.at 16%.

The Harvard folks assumed their single payer design would end the perverse incentives inherent in fee-for-service by risk-adjusted capitation coupled with pay for performance bonuses, care integration, and formation of accountable care organizations.

The rest of the country stoutly resists single-payer and Obamacare, a quasi-single payer which will still leave 23 million uninsured after 10 years, and which has been carried out for the last 5 years in your neighboring state of Massachusetts, with mixed results, including less than 3% uninsured, but with higher costs, longer waiting times, and growing primary care shortages.

Still, I repeat, go for it! The States ought to be experimental laboratories for social reform. Maybe the federal government will grant you waivers from the health reform law. Maybe Vermont will lead the single-payer band. Good luck. You may need it. The rest of the U.S. lives outside the Washington Beltway and the Boston Kneltway in fly-over country.

Health Care Reform Now! A Book Review

Lately I’ve been reviewing books of health reform, First, it was Why Obamacare Is Wrong for America. Then it was The Truth about Obamacare. Now it’s the turn of Health Reform Now! A Prescription for Change ( John Wiley & Sons, 2007,$27.95).

The author of Health Reform Now! is George Halvorson, Chairman and CEO since 2002 of Kaiser Foundation Health Plan and Hospitals in Oakland, California. Before that he was president and CEO of HealthPartners in Minneapolis, where, as editor-in-chief of Minnesota Medicine, I was privileged to know him and interview him.

Why review this 2007 book now?

After all, four years have passed, and it predates the debate and passage of the health reform law. It even precedes the campaign and election of President Barack Obama.

Why?

For the simple reason that its contents contain many of the “prescriptions,” i.e. ingredients for change, that the Obama administration recommends. These include reducing the fragmentation of American medicine, organizing doctors into larger more managed entities, using data to measure quality and outcomes, installing electronic medical records, building a marketing infrastructure to make the market work, and, of course, assuring universal coverage.

Halvorson is different than most writers on health reform, including me. He leads a large, integrated, sophisticated organization, with both hospital and outpatient components, Kaiser covers the health care spectrum. With its cadre of over 10,000 salaried physicians and associated health professionals, he and his organization can implement changes easier than government. They can show what works and doesn't work in the real world, rather than in a theoretical world, setting.

Above all else, George is a “systems thinker.” He believes the most fundamental “foundational” fault of America health care is the “almost total lack of systems thinking in health care.”

He says we focus too much on individual procedures and personal exchanges. He laments that we rarely track or measure relative outcomes. We think too much in terms of paying for individual performance rather than organizational or system performance for populations of patients. If you give the matter any thought at all, systems thinking is a part of the Obama health doctrine.

To get from here, from individualism, to system-wide thinking, Halvorson in his opening chapter says we must accept a “few hard but useful truths":

One, care costs are unevenly distributed, e.g. five chronic diseases – diabetes, congestive heart failure, coronary artery disease, asthma, and depression take 70% of all health care dollars.

Two, excessive fragmentation, fostered by paper records, overspecialized care silos, disincentives for change, abound.

Three, economic incentives significantly influence health care, but they are the wrong incentives. We have no incentives for improvement, for measuring outcome, for cure, for performance.

Four, systems thinking is almost never on the radar screen, no data to track overall performance.

To correct these deficiencies and to make the system work, Halvorson recommends these “next steps and expectations”:

• Specific quantifiable goals, using data to measure outcomes and improved health measures.

• Standards for population health, which will require a personal health record (PHR) and electronic health record (HER) database, towards which Kaiser has committed some $ 3 billion dollars.

• Data-supported, informed choices, supplying consumers with data about outcomes of various disease, , performance of various providers and systems , and satisfaction and experiences of patients.

• Competition on basis of quality and cost embedded in the brave new world of web data to reward best data and maximize care value.

• Benefit plan design to appropriately incentivize and support consumers and employers to make the right decisions about coverage, care systems, caregivers, and care.

• Link payments to performance, which is embodied in many of the pay-for-performance (P4P) models now being tested by the government and health plans.

As I re-read this book in light of what is contained in the Patient Protection and Affordability Act and the turmoil that has ensued and the opposition that has hardened since its passage, I realize the American public does not readily accept much of what Halvorson proposes, or what is in the health reform law itself.

An average of seven major poll results as of today indicates 38.9% favor Obama and the Democrat’s health plan, 53.0% oppose it, and 67% want it repealed.

Much of what George Halvorson advocates is in the Obama plan and features managed competition. There is a huge difference, however. Halvorson focuses more on market forces, rather than government oversight and centralized control, as an antidote to correct the flaws in today’s fragmented system.

Gastric Bypass as a “Cure” for Diabetes

I find fascinating reports that gastric bypass procedures “cure” roughly 80% of obese diabetics. Even before diabetics start losing weight or shortly thereafter, they go off insulin, have a drop in their blood sugars, and experience declines in their hemoglobin A2 levels.

What’s going on here? Is there some mysterious hormone in the gastric mucosa that triggers and sustains diabetes? Why do these procedures work in some patients and not in others? Would the procedures work in non-obese diabetics? How common are the complications, re-do’s, and deaths secondary to bariatric procedures? Does the cost of the procedures exceed the cost of treating diabetes in the long run?

With the number of diabetics in America approaching 20 million, even more pre-diabetics sitting in the wings, and more and more kids developing type 2 diabetes, we desperately need answers.

According to Population Health Metrics, total diabetic prevalence (diagnosed and undiagnosed cases) will increase from 14% of the population now, to 21% by 2050.

I can foresee costs of performing bariatric procedures on millions of diabetics exceeding the costs of cataracts, hip and knee replacements, back surgeries, and cardiac stents and pacemakers combined.

In any event, it seems to me, the causative factors behind these diabetic “cures” in significant numbers of diabetic undergoing bypass and gastric band procedures is worth more intensive research.

When is a cure a cure?
How can you be sure?
What if a procedure cures sometimes,
but for unknown reasons or rhymes,
What if diabetes comes back,
when weight returns back?
When does a temporary remission,
qualify as a path to total abolition?
Until those questions are answered,
The cure mystery remains unanswered.