Which option is best for you and your patients?
By Wayne Lipton Managing Partner
Concierge Choice Physicians
Independent and small group physicians in Texas and throughout the nation are literally at their wit’s end. They are seeing the practices they spent years to build erode as reimbursement is slashed and overhead spirals. They are becoming less the caregiver and more the administrators of care. Workdays are getting longer, worry about how to maintain the practice is increasing, and personal satisfaction is waning as physicians have less time to spend getting to know patients as people and spend more time inputting codes and impersonalized data into increasingly complex computer systems. It’s all a bit heartbreaking to many physicians.
In frustration, many sell their practices, retire early, or add other income-producing services, from aesthetics to weight loss products. What’s more, those who have joined groups wonder if there is a way to recapture the reasons they entered medicine in the first place: a chance to have one-to-one connections with patients and to be the “quarterback” who directs and manages all care.
As if these questions weren’t enough, physicians are also faced with a rash of new models and options all promising a better life, more income, less reliance on insurance, or any one of a number of other claims.
So, what to do? The reality of the physician marketplace in Texas is that it is changing and there is no going back. Now is not time to take a wait-and-see position. It’s the time to study options, to ask yourself what you want, and to make the decision to embrace change.
Such change doesn’t need to be foisted upon you. Texas physicians are still predominantly independent. Most are looking for ways to stay that way. The good news is there are options to maintain autonomy and remain a viable practice.
Is concierge medicine the answer?
One option Texas family physicians are considering is full-model concierge programs. While it’s hard to pinpoint a specific number as there are many permutations, it’s estimated there are more than 100 concierge programs in Texas today. In full concierge care, the goal is to limit the number of patients – typically to around 600 – to allow for more time and personal care. Fees are usually over $1,500 per year, which helps ensure profitability and limit the patient panel.
Full model concierge programs include:
- The potential for a significant increase in revenue;
- The opportunity to return to the style of practice most family physicians were taught in medical school; and
- The chance to build an ideal practice for physicians nearing retirement or dealing with physical limitations, as well as those wanting more time with family and those wishing to pursue other interests.
Concierge programs today can be flexible. Some physicians opt to continue taking insurance, including Medicare, and some decide to forgo that feature. While there are some constraints, including the fact that not every market can sustain such programs, for those physicians who enter the market judiciously and for the right reasons, it can be a life-changing move.
In the early 2000s, a new practice model called hybrid concierge was introduced to physicians. In this model, physicians continue to see all their patients, even those on Medicare, giving those patients the option to participate in a concierge program. Hybrid programs specifically offer non-covered and enhanced services, typically an in-depth physical, complete with relevant tests and lab work. Patients retain and use their existing insurance and as most physicians remain on insurance panels, there is practice stability and a guaranteed source of income.
The hybrid concierge program is built around a package of services tailored for the physician’s patient population. Most physicians emphasize prevention and wellness and a comprehensive approach to health. It also offers extended patient appointments and same- or next-day scheduling. Patients have direct access to their physician via a private phone line, e-mail, and text. Physicians also have the ability to provide more advocacy and care coordination services.
In a hybrid practice, a few hours each day are dedicated to delivering the concierge main services and follow up care. Members can schedule appointments during non-concierge time as well if needed. Since the concierge service represents from 10 percent to 25 percent of the practice time, the impact on the overall volume of the practice is minimal. If needed, overflow can be moved to other providers, like nurse practitioners. During concierge hours, physicians see one to two patients an hour with time built in to allow for patient outreach, personal follow-up, and coordination of care.
The typical patient who opts to join a hybrid program is often over 45. However, many are far from the stereotypical concierge image. They run the gamut from schoolteachers to truck drivers to retirees to busy executives who want the convenience concierge care offers. They share one common trait—an interest in prevention, wellness, and a closer relationship with their chosen physician.
It’s a very family-centric model as many patients join with their older parents and use the model as a way to provide the care coordination and personal advocacy that can be lacking in some practices today. Plus, in some programs, children up to age 25 are covered under their parents’ plan. Physicians note they often have up to three generations of patients, enabling them to provide true “family” medicine. Because the physicians’ primary source of future patients is existing ones, great care is taken to ensure that all patients in the practice are satisfied.
The hybrid model also works well in group and even large health care system environments. Because it incorporates insurance plans and doesn’t disenfranchise patients, it can be integrated into existing programs. It also ensures that practice referrals and hospital admitting privileges can continue.
Revenue generated varies significantly and depends on the number of patients who join. While one can attempt to introduce a hybrid model without assistance, using a company that can help practices avoid the marketing, regulatory, and strategic land mines is extremely valuable. In addition, external companies often cover all of the costs associated with the implementation and can ensure the overall risk to the practice is minimized.
There remains much uncertainty for physicians today. But there are also many choices.
Now is the time to fully explore available options—look at what is best for you and your patients and commit to embarking on a change that will enable you to continue to practice medicine the way you think is best for you and your patients.
One Texas FP’s experience with the hybrid concierge model
Gregory Fuller, M.D.
Gregory Fuller, M.D., is a family physician in Keller, Texas. He has been part of a successful independent family medicine group for 24 years. In addition to Dr. Fuller, there are two other physicians and a physician assistant in the practice.
Dr. Fuller has always enjoyed taking care of his patients, but over the past several years, he found it more frustrating. One of his biggest concerns was the evolution of insurance companies and Medicare becoming more involved in clinical decision making and increasing administrative burdens, thus decreasing his face-to-face time with patients.
Plus, as with many physicians, his reimbursement was continuously uncertain. Yes, there were payer bonuses and incentives (that typically added little real revenue when all was said and done) and there were small increases that would appear to bump up compensation. But there were also many payment reductions and often to earn incentives, considerable investment had to be made in infrastructure or administrative services, thus negating the benefit (EHR anyone?). Payers have always targeted primary care physicians first when trying to cut costs. As a result, practice revenue had gone down or stayed flat, while expenses continued to increase. He knew something had to change.
“I’m first and foremost a physician,” Fuller says. “But I also have an obligation to my practice, my employees, and my community to stay viable. The only way to break even was to increase the volume of patients in my practice.” As a result, he noted that both he and his patients often felt rushed. Unless there was a problem, patient visits were scheduled in 10 to 15 minute increments. If patients did have other questions, they were told to schedule another appointment. “All these changes were necessary, but they had me missing the days when I could have a real relationship with my patients,” he says. “I like being a doctor and I want to have the time needed to communicate fully with my patients about what we can do together to improve their health. I can’t provide patients with the information they need, or answer their questions, if they don’t get that dedicated time from me.”
To accommodate the demands of his practice, Dr. Fuller’s days became longer and increasingly more exasperating. He decided it was time for a change. In 2011, he heard about the hybrid concierge model and decided to find out more. He was aware of full model programs, but with a patient panel of 4,500, he didn’t want to embrace a practice model that might disenfranchise many patients. After careful consideration, he decided the hybrid model was the right choice.
With the program, patients have his direct phone line or can e-mail or text. While some of his contemporaries shared concern that such access might be abused, leading to calls late at night or weekends, Dr. Fuller notes that because he is more accessible during the day, patients don’t call off-hours unless it is a true emergency. “Patients are extremely respectful of my time,” he states. “I often have to remind them they can call any time.”
Dr. Fuller reports the model has worked well for him and his patients. The launch of the program was seamless, taking minimal time from him and his staff. It has enabled him to continue to see all patients, even those on Medicare, and most importantly to practice medicine the way he and his patients prefer. His income has increased about 7 percent monthly, without adding more patients or extra services, and with no additional cost to his practice. However, he has the capacity to increase the program to generate greater income. He could also opt when needed to move to a transitional program and over time, segue to a full concierge model.
Dr. Fuller notes that he has contemporaries who have opted to sell their practices to rid themselves of financial and administrative pressures, but that often they are simply changing one set of headaches for another. “I am hearing about a lot of physicians who joined large health care systems but who now want to return to private practice,” he says. He advises other physicians struggling to maintain their practice to consider all options available today and to move forward with making the decision they want quickly to avoid having that option taken away by outside forces.