Concierge Medicine Expected to Grow Under Health Reform

Internist Marcy Zwelling, left, listens as her patients Karen Gibbs, center, and Renee Howell share stories during a recent potluck supper at Zwelling’s office in Los Alamitos. Zwelling practices concierge medicine, which is expected to grow in popularity, in part due to the Affordable Care Act. Photo: Chris Richard.

Paying extra for better access to a doctor, often called concierge medicine, is drawing new attention, at least in part in response to the Affordable Care Act.

Although adherents are still few in number, concierge medicine is growing in popularity, particularly in California, according to surveys.

Proponents of concierge medicine attribute recent growth both to longstanding dissatisfaction with traditional managed care and to fears of doctor shortages and crowded waiting rooms under health reform.

Karen Gibbs, who is a member of Los Alamitos internist’s Marcy Zwelling’s concierge practice, said she sees the value in paying more for increased time with the doctor. Several years ago, Zwelling diagnosed Gibbs with an unusual form of cancer and shepherded her through surgery, Gibbs said.

“If I choose in my life to belong to a concierge practice that’s going to have less than 500 patients to it, I’m guaranteeing myself improved quality of care,” she said.

Patients who sign up for concierge medicine typically pay the doctor a membership fee in exchange for longer, more personalized visits. The fee often ranges from $600 to $1,800 per year, but can be even higher, according to the professional journal Concierge Medicine Today. It usually covers an extensive annual physical and as many other appointments as the patient wishes. The appointments often focus on preventive medicine and tend to include long, detailed discussions of the patient’s health. While membership typically includes the cost of tests and visits, patients must still pay for prescription drugs, visits with specialists or hospital bills, so concierge doctors encourage patients to carry health insurance.

Some concierge practices have a fee schedule based on age, and most provide free or reduced-cost service to some patients, based on their financial need. Unlike traditional, insurance-based practices where each doctor can have 2,500 or more patients, concierge doctors treat just a few hundred people. Instead of billing insurance companies, they make money by offering a service almost equivalent to a gym membership: charging an annual membership fee that doesn’t increase, no matter how much the member uses it.

The American Academy of Private Physicians website lists just 100 direct-pay doctors statewide. But the number is expected to grow.

Nationwide, the number of physicians operating under this model is estimated to increase by 15 percent annually, according to Concierge Medicine Today. California is a leader in this movement away from reliance on health insurance to direct payment.

In 2012, the physician-recruiting firm Merritt Hawkins conducted a national survey for The Physicians Foundation that found that 6.7 percent of California doctors planned to change to a concierge practice within three years. California ranked third in the nation, behind Texas and Florida, where 10.6 and 9.1 percent of doctors, respectively, planned to switch.

Wayne Lipton, founder and CEO of Concierge Choice Physicians, a firm that helps doctors make the transition into the concierge model, said he saw a marked increase in inquiries by California doctors at the end of last year.

“There’s been an acceleration of a trend,” Lipton said.

Doctors have become more interested in concierge medicine over the last 15 to 20 years, as insurance reimbursement rates fluctuate, he said. “But the Affordable Care Act brought to a head some other activity, which had to do with more virtual integration, and frankly that added to the insecurity,” Lipton said. “That insecurity led to doctors considering changes.”

Bill Ross, executive director of the American College of Private Physicians, which just set up its Signal Hill headquarters, expects more primary-care physicians will opt out of insurance companies’ bureaucracies and simply charge patients directly.

“The physicians are reporting problems trying to work within the new ACA structure and guidelines,” he said. “The effects of the law (are) causing many doctors to take another look at getting out of the system.”

Concierge medicine isn’t designed to replace health insurance, but some patients opt to forgo it, said Michael Tetreault, editor-in-chief at “Concierge Medicine Today.” He said surveys by the publication have found that up to 20 percent of patients who pay for concierge medicine don’t have health insurance.

“All doctors I’ve spoken to, and I’ve spoken with dozens and dozens, feel that patients need to have insurance,” he said, adding that practitioners typically recommend a high-deductible policy.

While some concierge doctors accept health insurance, many don’t, and they argue that that saves them money and time trying to navigate the insurance carriers’ payment systems.

Dylan Roby, an assistant professor of health policy and management at the UCLA Fielding School of Public Health and director of health economics and evaluation research at the UCLA Center for Health Policy Research, said concierge medicine can pose risks to patients. Concierge practices aren’t subject to the same regulatory authority that insurance companies face, he said. So if a concierge practice goes out of business, patients could lose their membership fee and have no recourse, Roby said.

Zwelling said she went into concierge medicine long before this year’s change in national health law because she thinks it’s the best way to serve her patients. She converted her practice in 2004, in part because she found herself working longer and longer days in order to give her thousands of patients the attention they needed. The breaking point came one day in 2003 when she was so booked that she couldn’t make time until midnight to meet with a patient whose nephew had just committed suicide, Zwelling said.

“I had to see her, because otherwise she wasn’t going to sleep that night, but afterward I said, ‘This can’t continue,’ because I showed her no respect by that,” Zwelling said. “I did what I could under the circumstances, but I’ve always felt my patients deserved respect and I had to have my own self-respect.”

Today, she restricts her practice to about 500 patients, most of whom pay $2,000 a year for unlimited visits. Zwelling gives about 10 percent of her patients steeply discounted or free care based on their financial need, she said.

Reducing her practice has made it possible for Zwelling to provide the kind of holistic care she believes in, she said. She’s started holding potluck suppers in her office after hours, where patients meet to discuss questions that rarely come up in a typical doctor’s office. A recent dinner featured a conversation about the afterlife.

Zwelling’s $2,000 fee is about what most such practices charge, research by the University of Chicago and Georgetown University shows. The charge often covers a comprehensive annual physical lasting more than an hour, as well extra services ranging from the ability to reach the doctor by cell phone around the clock to house calls.

Such fees usually don’t cover hospital or specialists’ bills, and Zwelling said she encourages her patients to carry some medical insurance to meet such expenses.

Still, Renee Howell, a KMart cashier who pays Zwelling’s discounted rate, said she rarely needs her insurance. With Zwelling, she gets the attention she needs, Howell said.

“Before, I’d have doctors who didn’t even want to listen,” she said. “They’d say, ‘Your insurance will cover this and that, so that’s what we’ll do.’ But here, if you have concerns, or you’re allergic to a medication, or you don’t feel comfortable doing something, Marcy will listen to you.”

Still, concierge medical care is controversial.  Critics accuse practitioners of skimming off the “wealthy, worried well” in small, elitist practices, leaving a diminished number of doctors to care for the poorer, sicker patients.

Tom LaGrelius, a family physician and geriatrician who has a concierge practice in Torrance, said he believes paying more attention to smaller numbers of patients can help improve care and lower costs.

He cited the example of a patient who slipped while walking her dog late at night, dislocating her shoulder and banging her head. LeGrelius said he was able to diagnose and treat her in his office immediately for about $350, a fraction of what the local emergency room would have charged.

But Roby, the UCLA scholar, said that had the situation been more serious, the patient might have needed the care of specialists.

“It probably is true that the services delivered in that physician’s office are cheaper, technically, and will be billed at a lower rate than those developed in an ER, if all things are equal,” he said. “But what is kind of being ignored is that that doctor didn’t have certain resources available.”

“Sometimes, that $1,000 ER visit saves someone’s life.”

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