Concierge Medicine Gains Ground
Published: Sep 28, 2013
Multiple sessions at the American Academy of Family Physicians (AAFP) scientific assembly informed attendees about the growing world of direct primary care, sometimes called concierge, boutique, or retainer-based medicine. These practices charge patients a monthly or annual membership fee for unlimited office access, and bill patients for the tests and supplies they use.
When Doug Nunamaker, MD, and Josh Umbehr, MD, ended their 45-minute AAFP talk about their direct primary practice in Wichita, Kan., the two had barely walked off stage when they were besieged by a couple dozen doctors wanting more information.
Nunamaker and Umbehr opened Atlas MD, a direct primary care practice, in 2009 shortly after Umbehr left residency. They charge $50 a month in membership fees for adults ages 20 to 44, with fees ranging from $10 to $100 a month for pediatric and older patients.
They describe their payment structure on the Atlas MD website as a "direct fee-for-services arrangement [that] frees us from the typical contractual agreements that prevent physicians from offering wholesale prices on laboratory tests, imaging, and medications."
The practice quickly grew to about 600 patients in the first couple of years, with a monthly revenue of $30,000 in membership fees. The only marketing has been word of mouth.
They said patients loved the open access to their physicians. Patients are encouraged to email, call, or text their doctors with questions. The office has no office staff, and the physicians answer the phones, which they said "freaks out" patients at times.
Nunamaker and Umbehr said they loved not having to deal with insurance payers for such issues as prior authorizations or rejected claims.
The practice has added three physicians along with one full-time nurse and one part-time nurse. They said they now count 1,300 patients in their practice for $65,000 in monthly revenue from membership fees.
The practice of direct primary care is growing, but the web of providers is so fragmented that even those in the field don't know how many physicians or practices work in this way, said Sharon George, MD, who owns a one-physician direct primary care practice in Irvine, Calif.
"It's definitely growing," she added. "You don't have to leave medicine if you're frustrated. You have your medical degree."
The Direct Primary Care Coalition formed as Congress was debating the Affordable Care Act (ACA). At that time, the coalition estimated there were between 30 and 50 practices in the U.S., with around 100,000 patients.
But Erika Bliss, MD, told MedPage Today that it's likely there are more concierge doctors -- and patients who use their services -- practicing today.
Bliss, a leader of the coalition and chief executive of the five-location concierge practice Qliance, based in Seattle, said she receives Google alerts monthly about a new concierge practice or converting practice, and now estimates one direct primary care practice in nearly every state.
"This model allows you to be the kind of doctor you always wanted to be, and allows you to develop lasting, trusting relationships with patients. [You] actually get to help them ... by being able to spend more time with them [with] minimal interference from an outdated and dysfunctional payment system," she told MedPage Today in a phone interview.
The first Direct Primary Care National Summit will take place in October in St. Louis.
"If people are interested, maybe now is the time for an association that would serve to pull together knowledge and experience ... on how to do direct primary care," Bliss said.
In March, the AAFP board of directors issued a position statement in favor of the direct primary care model (DPC), saying it empowers the physician-patient relationship.
"The DPC contract fee structure can enable physicians to spend more time with their patients, both in face-to-face visits, and through telephonic or electronic communications mediums should they choose, since they are not bound by insurance reimbursement restrictions," the statement read. "For these reasons, the DPC model is consistent with the AAFP's advocacy of the [patient-centered medical home] and a blended payment method of paying family medicine practices."
However, one of the common criticisms of direct primary care is that it's an unsustainable model. Given the current shortage of primary care doctors, will there be enough concierge providers to see patients under ACA coverage expansion?
Direct primary care can help keep family doctors from retiring or moving to hospitalists jobs, Umbehr said, adding that it also offers a more rewarding lifestyle to encourage students to go into family medicine.
Umbehr pointed out that "the current model is the cause of the physician shortage. To blame direct primary care is [to blame] the victim of a crime. The only way we're going to prevent the physician shortage is by making it fun to be a doctor, reward physicians, and make their work rewarding."
As for how patients access specialty services in the concierge system, Umbehr added that concierge doctors can work directly with specialists in their area, helping patients obtain services.
For example, his practice is able to negotiate $900 colonoscopies and $225 head CT scans for their patients when appropriate.
George said that many of her patients have insurance coverage, either through Medicare or privately, that gives them access to a specialist when needed.
Umbehr said he has seen patient habits change when they are billed directly for services; they may not always opt for the most expensive medicine or test.
"When you put the choices in front of the patient, you'll see the decisions change because it's their money," he said.