The time is now
to fix a broken model

By Chris Ewin, M.D., F.A.A.F.P.

It’s time to play a new game … change the deck … and get a new dealer. The cards have been stacked against us for too long. Let’s face it. The system is broken. We need a new primary care model that attracts our brightest medical students to become primary care physicians.

Just imagine your dream life … no involvement with insurers, no CPT nor ICD 9 codes, decreased liability, minimal staff and overhead, zero accounts receivable, time with your family, time for personal and professional growth, and as much time with your patients as you need … Interested? Read on.

We are seeing the tragic decline of primary care. Physicians and patients alike are unhappy with the way we conduct the business of medicine and for good reason. When patients call to schedule an office visit, they have no idea what the bill will be. They don’t know if they will be seen right away or if they will see their own doctor.

Physicians are frustrated by the slow or lowered reimbursement they get from payers while they are shouldering increasing malpractice premiums. They feel that managed care companies are exerting control over their patients’ treatment plans. Chasing and tracking payments is causing administrative duties and costs to soar, and doctors are forced to take on more patients to maintain their incomes. Liability, whether perceived or a reality, appears to continually increase. Touch a nerve? It should.

On a personal level, physicians are left wishing for a saner, less stressful lifestyle and feel distanced from the reasons they chose family practice in the first place. In a poll conducted by Medical Economics, September 2002, 73 percent of family practice physicians surveyed responded “yes” to the question: “Are you sorry you went into primary care?”

After 10 years of private practice in family medicine, I asked myself the same question. I was “managing” about 4 - 5,000 patients. I had to cram many patients into my daily schedule just to pay the bills and stay ahead. There just were not enough hours in the day to adequately practice the preventive care that I expected from myself. If someone was acutely ill, they often had to see physician extenders or go to the emergency room instead of seeing their doctor.

I decided it was time to make a change. In 2000, I left my chosen profession to pursue a different career. During that time, I heard about an innovative business model that allowed physicians to practice medicine with fewer headaches.

In 1996, the first “concierge” practice was founded by some very forward-thinking physicians. Other pioneers began experimenting with new models of so-called “retainer,” “boutique” or “concierge” medical practices. These unique practices, although somewhat different in their approach, share many attributes. By design, concierge physicians reduce the number of patients they see, enabling them to deliver timely, highly personal and comprehensive services. Concierge practices vary widely in their structure, fees and level of service provided.

After months of intensive research, I embarked on a new journey to design and implement my new retainer-based practice.

I realized that patients really want service and a medical home. They want access to our two greatest assets as physicians: our knowledge and our ability to establish personal, trusting relationships — the proverbial doctor-patient relationship.

My concierge practice is called a retainer model. Patients pay a reasonable monthly fee in return for priority access to their physician, unlimited office visits, annual physicals, preventive care and wellness screenings. Patients must have a PPO, Medicare or major medical plan to allow referral and access to specialists, hospitalization and emergency care. Because it is voluntary, patients can drop out of the program at anytime.

Some concierge practices have chosen to charge a retainer fee and handle their patients’ insurance claims. Some practices accept Medicare, others do not. Some have opted to integrate their practice with the services of a local hospital or clinic, sharing medical records systems, diagnostic services and other support functions to improve efficiency. Other practices charge an established, up-front fee at the time of service and let their patients handle any insurance claims, just like the good old days. Clearly, one size does not fit all.

Physicians who embrace retainer-based practices report feeling more satisfied and less frustrated in their personal and professional lives. Personally, I have rediscovered the joy of practicing medicine. I have time to really get to know my patients. I also have time to cultivate a healthy personal life and pursue other outside activities, including community service and charity care. Patients involved in concierge practices report that they appreciate the close relationship with their physician and the personal attention they receive, and feel more confident and comfortable with their health care.

Medical students should be encouraged as well. As awareness grows of the dissatisfaction expressed by family physicians, internists and their patients, medical schools are witnessing a drastic decline in the number of graduates who choose to enter the field of primary care. In 1997, 16.6 percent of U.S. medical school graduates chose to enter a family practice residency. By 2002, that number had dropped to 10.3 percent. It is clear that a crisis is looming in family medicine and primary care. Established concierge practices offer a compelling model to attract our youngest and brightest minds to the joys of clinical family medicine without the hassles.

Over the last year, much has been written about the Future of Family Medicine Project and the recommendations published in the March/April 2004 supplement of Annals of Family Medicine. The recommendations included the creation of a new model of clinical practice, re-thinking family physician training, and providing family medicine’s “basket of services” to patients through their family physician. They also identified a number of other significant issues that needed to be addressed to meet the needs of family physicians and their patients. The proposed New Model of family medicine would provide patient-centered care using a team approach. Project researchers saw a need for integrated, whole-person care that is culturally sensitive and community-oriented.

They felt it was essential to establish a personal medical home for each patient, with an emphasis on quality and safety. They also pointed out the importance of the elimination of barriers to access through open scheduling, expanded office hours, additional lines of communication and implementation of electronic health records. Additionally, the New Model would need to improve practice finance.

Since the publication, many physicians have expressed concerns that the New Model still lacks a solution to the crisis facing family medicine. Some of the most distressing problems faced by family physicians have not been addressed including frustrations with slow and lowered reimbursement, increasing workloads and dissatisfied patients. In short, we have let other market forces take over our practices.

Retainer medicine could provide direct solutions to the problems faced by family medicine and I believe it mirrors, item-for-item, the recommendations of the FFM Project. It improves access for patients, reduces workloads for physicians, and simplifies reimbursement. Retainer medicine is a model that is especially well suited to primary care, internal medicine or geriatric practices. Many who have explored retainer medicine are convinced that it offers a real solution to the complex factors that continue to threaten the specialty of family medicine for patients, physicians and medical students.

What about the working uninsured? I propose that this would be the ideal model for many patients — not all — in our local crowded charity and county hospitals. What would an individual pay to have same-day, timely access to their physician and their cell phone or pager number: $10 per month? $25 per month? $50 per month? $100 per month? With cigarettes at $4 a pack, or $120 each month, retainer medicine costs less than a pack of cigarettes a day. Individuals prioritize expenditures everyday. The retainer model is all about service, and people will pay for it.

A stitch in time saves nine. Translation: by providing preventive care and timely access to physicians for the acutely ill, the system could realize huge savings by decreasing emergency room visits and hospitalizations.

The bottom line: we need more board-certified family physicians, internists and geriatricians with smaller, patient-financed practices. We need to move away from government- and employer-financed practices as a primary care model. Let us not waste any more time waiting for employers, legislators and insurance companies to fix our problems. The time is now to seriously consider retainer medicine as the new model that will transform health care.

Dr. Ewin received his undergraduate and medical degrees from Tulane University in New Orleans, Louisiana. He completed a pediatric internship at Tulane and a family practice residency at John Peter Smith Hospital in Fort Worth. He began practicing in Fort Worth in 1990 with Southwest Medical Associates. He is a member of the American Medical Association, Texas Medical Association, Tarrant County Medical Society (board member), Tarrant County Academy of Medicine (president), American Academy of Family Physicians (fellow), Texas Academy of Family Physicians, Tarrant County Academy of Family Physicians (past president) and the Society for Innovative Practice Design. He is board certified by the American Board of Family Practice.