Concierge medicine, an alternative to traditional medical practices, is an umbrella term for medical practices with a direct financial relationship with patients. These practices are known by a variety of names including concierge healthcare, direct primary care (DPC), direct care, direct practice medicine, retainer-based, membership medicine, cash-only medicine, cash-only practice, boutique medicine, personalized healthcare, hybrid models, and contract carrying healthcare (Concierge Medicine Today [CMT], 2014a; McDonough, 2013; Tetreault, 2014).

Concierge medical practices typically charge a monthly or annual fee so that the patient receives additional access and personalized care. The range of access and amenities depends on the physician and the fee charged. For example, the patient may receive 24-hour physician availability by having the doctor’s phone number and email, as well as telephone consultations; executive-type physical examinations that last up to three hours long; expedited appointments, such as same-day or next-day appointments and no wait time at the office visit; longer appointments (as per CMT [2013], more than 70% of concierge and DPC physicians have 30-60 minute patient visits); personal visits in the hospital and sometimes in-home visits; follow-up calls after a specialist referral and/or hospital stay; and customized treatment plans including lifestyle and preventive plans (Carnahan, 2007; CMT, 2014a; McDonough, 2013). The VIP concierge physicians are not the only ones out there, like some believe. However, the ones who are VIP offer additional amenities such as luxury robes, shower facilities, personal toiletries, and even cable television and Internet access (Carnahan, 2007).

There are two main types of concierge medical practices – retainer-based (what is commonly known as “concierge”) and direct primary care (DPC). Both of these do not have co-pays, deductibles, or co-insurance fees. Retainer-based concierge practices charge an annual retainer fee for enhanced services. Many of them are hybrid models, meaning that they also accept insurance (CMT, 2014a). “Over 80% of concierge physicians accept insurance in their practice, while the remaining have cash-only, menu-style healthcare practices” (CMT, 2014b, para. 24). DPCs, on the other hand, do not accept insurance so as to reduce overhead costs, which can be as much as 40% of each medical dollar spent. They charge a monthly recurring fee for a defined set of clinical services and avoid unnecessary referrals by referring patients to specialists that are willing to offer significant discounts. However, because of the defined set of services, concierge practices generally provide more services and access than DPCs (CMT, 2014a). Even though pricing structure and operations are a little different, “price transparency, access, affordable rates and the personal level of service provided to each patient is what they have in common” (Tetreault, 2014, para. 24)

Popularity and Growth of Concierge Medicine

Between 2005 and 2010, the growth of concierge physicians rose five-fold to more than 750 doctors (McDonough, 2013). In early 2013, it was estimated that there were between 5,000 and 5,500 concierge and DPC physicians in the United States (CMT, 2014a). In 2014, it has been estimated that the number of these physicians have grown to as much as 12,000+ in the United States. “This data is based upon an in-depth review and recent examination of the national marketplace as well as interviews with corporate industry leaders and marketplace decision makers” (CMT, 2014b, para. 23).

The four states with a very large lead in the number of concierge physicians in practices, as well as consumers seeking their care, are Florida, California, Pennsylvania, and Virginia. In these areas, the franchise concierge fees are increasing and the independent concierge doctor fees are decreasing due to competition (Tetreault, 2014). However, the number of patients seeking concierge medicine far outweigh the number of available physicians, especially in rural areas. According to CMT (2014b), states with high demand but very few concierge physicians include Hawaii, Idaho, Iowa, Mississippi, Maine, New Hampshire, South Dakota, North Dakota, Louisiana, and Alaska.

The most common specialty for these types of practices is obviously primary care with family medicine a close second. The next top two specialties are cardiology and pediatrics (CMT, 2014a). In 2011, specialists were growing in numbers in concierge medicine, which include general surgery, psychiatry, spine surgery, gynecology, dentistry, addiction medicine, dermatology, oncology, and the cardiology and pediatric specialties already mentioned. Specialists offer the same increased access and patient attention as the primary care concierge doctors and tend to have patients with chronic conditions. The main difference is that the primary care concierge physicians tend to have a patient load of 300-750, whereas the specialists tend to have a patient load of 150-300 (CMT, 2014b).

Cost of Concierge and Cost to Patients

The cost of concierge physicians ranges widely depending on if the patient is paying a monthly recurring fee or annual retainer fee, what services are included (i.e. if it is a VIP facility), the demand in that area for concierge physicians, and whether or not the doctor also takes insurance since not taking insurance reduces overhead costs. For example, a VIP facility may charge as much as $4,000 per year and the physician will be limited to 300 patients in order to have more time per patient. Other physicians may only charge $660 per year and be limited to 800 patients. This is still substantially less than the 2,000-2,500 patients that a typical primary care physician sees (Carnahan, 2007). This limitation in patients allows a concierge physician to see an average of six to eight patients per day (CMT, 2014a; Press, 2011) compared to the typical primary care physician who sees 20-24 patients per day (Press, 2011).

Approximately two-thirds of concierge and DPC practices are charging an average of less than $135 per month (CMT, 2013; CMT, 2014b). According to The Collective (2013), average concierge and DPC patient fees are broken down as follows:

• Less than $50/month: 11%
• $51-$100/month: Nearly 14%
• $101-$135/month: Nearly 31%
• $135-$180/month: Less than 9%
• $181-$225/month: Less than 1%
• $226 or more/month: Nearly 25%

The physicians charging in the higher range are the VIP practices with “a-list clientele”. For example, one doctor in Monterey, California charged as much as $30,000 per month and $550 per visit (Wieczner, 2013).

Concierge Physician Salaries

Just like patient fees range, so do the physicians’ salaries. However, their salaries are very close to a traditional-practice physician’s salary. Many of these physicians report that working in concierge medicine helps them reduce administrative costs, operational expenditures, and staffing. More than half of these practices (58%) employ only one to two employees (CMT, 2014b). “A 2012 Medscape study found that the average salary for a [traditional] primary care physician ranged from $156,000 to $315,000, while Bloomberg Businessweek reported that the average salary for a concierge physician ranged from $150,000 to $300,000” (CMT, 2014b, para. 7). Concierge physicians can make a substantial salary. For instance, if a doctor accepts a limit of 600 patients and charges $1,500 per year, that accounts for a gross income of $900,000. If the physician charges insurance for some of the services, that will add to the practice’s income. “One physician told Medical Economics recently that membership fees in his practice accounts for two-thirds of his gross revenue, while insurance brings in the remainder” (CMT, 2014b, para. 20).

According to Concierge Medicine Today (2014b), concierge physician salaries can be broken down as follows, which also shows the increase in their salaries from 2012 to 2014:

Concierge Medicine and the Affordable Care Act

Concierge medicine in and of itself does not comply with ACA minimum coverage requirements; however, the majority of patients who use concierge medicine pay for it in addition to health insurance. There is a clause in the healthcare law that “allows direct primary-care to count as ACA-compliant insurance, as long as it is bundled with a ‘wraparound’ catastrophic medical policy to cover emergencies” (Wieczner, 2013, para. 6). Therefore, the emergence of concierge medicine has encouraged some health insurance plans, such as Cigna, to create employee health plans that incorporate concierge services (Wieczner, 2013).

In addition, with more than 80% of concierge physicians accepting insurance (CMT, 2014b), many patients use concierge medicine in conjunction with a high-deductible health plan (HDHP). This gives the patient catastrophic coverage that meets ACA minimum coverage requirements with minimal premiums and they are still able to see a concierge physician. With an HDHP, most patients will never meet the high deductible anyway, so they spend their money at the concierge physician where around $135/month is cheaper than a better health plan. However, patients do need to be aware that the fees paid to concierge and/or direct primary-care physicians are not recognized by the IRS as HSA expenses. Therefore, they are not counted as a tax deduction like other healthcare expenses are (Wieczner, 2013).

Drawbacks to Concierge Medicine and Legal Issues

There are some potential legal and ethical issues that concierge physicians and their patients must face. Some states are fighting concierge physicians and saying that they are assuming risk and operating as insurers of medical care without being licensed as insurers. This is a complicated issue, however, since there is a conflict regarding whether it is defined as insurance under state versus federal regulations. Another state issue they may face is being viewed as discriminatory. For example, it could violate New Jersey’s insurance code since the “enhanced” services are only available to plan members who are able to pay the physician’s access fee, which can be viewed as discriminatory (Carnahan, 2007).

Concierge physicians who also accept insurance could face violating the hold-harmless clause that is in most HMO provider contracts. “This clause obligates the physician to look only to the organization, and not its plan enrollees, for payment for services covered by the plan, other than co-pays, coinsurance, or deductibles” (Carnahan, 2007, p. 212). These physicians may also have issues with Federal Medicare laws that prohibit charging Medicare recipients more than the “allowable amount” for participating physicians or the “limiting charge” for non-participating physicians (Carnahan, 2007).

Concierge physicians must also be careful with their marketing techniques and make sure that they do not violate the anti-inducement provision of the Health Insurance Portability and Accountability Act (HIPAA) (Carnahan, 2007), which states, “A person who offers or transfers any remuneration that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider, practitioner or supplier of Medicare or Medicaid payable items or services may be liable…” (Miscoe, 2006, para. 3). Therefore, when physicians decide to transition from a traditional practice to a concierge practice and send a notice to their patients, they need to be careful in how they are marketing their new practice (Carnahan, 2007).

Ethical Issues

In addition to a few legal concerns, there are some people who feel that there are ethical issues to consider. For example, with the decreasing number of primary care physicians, especially due to the ACA, when a concierge physician reduces his/her patient load from 2,500 to 500, that leaves 2,000 patients per new concierge doctor to find a new traditional primary care doctor. This is also at a time when fewer physicians are accepting Medicare patients (Carnahan, 2007).

There is also a concern that minorities are not being represented in concierge medicine. “In one survey of concierge physicians, the majority reported patient panels with 0%-5% African-American and Hispanic patients” (Carnahan, 2007, p. 213). Furthermore, with the doctor’s ability to choose their patients, it is speculated that they are cherry-picking the healthiest patients, thus leaving the sicker population to be absorbed by the remaining, traditional physicians. Finally, it is felt by some that these physicians have an ethical obligation to see more patients since their schooling was subsidized in part by the United States taxpayer through the Medicare program. “Medicare dollars pay the salaries of residents and teaching staff, maintain classroom space, and pay for the additional diagnostic tests ordered by trainees treating the sicker population served by teaching hospitals” (Carnahan, 2007, p. 213).

Drawbacks for the Patient

As mentioned previously, fees paid to these physicians are not tax-deductible like other healthcare expenses (Wieczner, 2013). Patients need to consider this when determining if they want to use a concierge physician. In addition, some of the less expensive concierge practices do not have the advanced medical technology, so if a patient needs certain testing, they will have to get it done elsewhere. However, “concierge doctors often negotiate with specialists and labs to secure discounts for patients who would otherwise pay out-of-pocket” (Wieczner, 2013, para. 13).

 Additional Facts and Statistics

The following are the kinds of people are seeking concierge physicians (CMT, 2014a):

• Individuals: 49%
• Couples without children: 23%
• Families with children: 21%
• Business owners and top executives: 4%

The following are the top 10 fastest growing cities for concierge medicine in 2014 (Tetreault, 2014a):

1. Los Angeles, CA
2. San Francisco, CA
3. New York, NY
4. Palm Beach, FL
5. Baltimore, MD
6. Washington, DC
7. Philadelphia, PA
8. Seattle, WA
9. Chicago, IL
10. San Diego, CA

The following are the top 10 best states to start a concierge practice or DPC in 2013-2014 (CMT, 2014b):

1. Utah
2. California
3. Texas
4. Florida
5. Washington State
6. New York
7. Colorado
8. Georgia
9. Tennessee
10. North Carolina

The following states have the fewest number of concierge physicians as of 2014 (CMT, 2014b):

• Hawaii
• Idaho
• Iowa
• Mississippi
• Maine
• New Hampshire
• South Dakota 

Conclusion

Any type of healthcare and health insurance-related issue is going to have legal and ethical issues that everyone will not agree on. The bottom line with concierge medicine is that it is quickly growing, presumably due to physicians and patients fed up with the current state of America’s healthcare system and where it could be going due to The Affordable Care Act. In fact, even with the growing number of concierge physicians, “the number of patients who are seeking concierge medical care in the past 24 months is far greater than the actual number of primary care and family practice concierge physicians available to service them” (CMT, 2014b, para. 22). Only time will tell how this will pan out, but for now, it looks like this is where our country is heading.

References

Carnahan, S. J. (2007, Spring). Concierge medicine: Legal and ethical issues. The Journal of Law, Medicine, and Ethics, 35(1), 211-215.

The Concierge Medicine Research Collective [The Collective]. (2013). Concierge medicine cost. Concierge Medicine Today: Concierge Medicine News. Retrieved from http://conciergemedicinenews.wordpress.com/concierge-medicine-cost/

Concierge Medicine Today [CMT]. (2013, November). Concierge medicine doctor infographic. Retrieved from http://conciergemedicinenews.files.wordpress.com/2013/11/concierge-medicine-doctor-infographic-2014.jpg

Concierge Medicine Today [CMT]. (2014a, April). Concierge medicine: 101. C. Sykes & M. Tetreault (Eds.), 1-28. Retrieved from http://conciergemedicinenews.files.wordpress.com/2014/04/concierge-medicine-101.pdf

Concierge Medicine Today [CMT]. (2014b, May 19). 2014 Concierge physician salary report. Retrieved from http://conciergemedicinenews.wordpress.com/2014-concierge-physician-salary-report/

McDonough, S. (2013, February 5). Paying for an open medical door. Canadian Medical Association Journal, 185(2), E105-E106. doi: 10.1503/cmaj.109-4385

Miscoe, M. D. (2006). Is your marketing compliant? Federal regulations dictate what you can and cannot do to attract patients. Chiropractic Economics. Retrieved from http://www.chiroeco.com/article/2006/Issue1/Leg1.php

Press, M. J. (2011). Improvement happens: An interview with Deeb Salem, MD and Brian Cohen, MD. Journal of General Internal Medicine, 27(3), 381-385. doi: 10.1007/s11606-011-1947-7

Tetreault, M. (2014, February 20). Concierge medicine’s best kept secret, the price (revised). Concierge Medicine Today and Direct Primary Care Journal. Retrieved from http://conciergemedicinenews.wordpress.com/2014/02/20/concierge-medicines-best-kept-secret-the-price-revised/

Wieczner, J. (2013, November 10). Pros and cons of concierge medicine: More practices are catering to the middle class, with the goal of providing affordable care. Wall Street Journal. Retrieved from http://search.proquest.com/docview/1449678285?accountid=458

By – C.J. Miles, MBAHCM, MSA, Research Analyst, AMAC Foundation

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