Many primary care physicians are now finding themselves in hot water. Declining reimbursement for evaluation and management has undercut the economics of providers who cannot also bill for a complement of procedures. Coordination of care remains difficult with high patient turnover and the absence of standardized personal health records. A lack of time for physicians to stay abreast of new clinical guidelines has contributed to a tendency toward lowering the threshold for specialist referrals.
One response for making ends meet has been to increase the volume of patients, squeezing appointment slots down to as little as 10 to 15 minutes each. Other actions have been retirement, an exodus to specialties, or even the addition of minor yet higher-margin interventions, from liquid nitrogen–based wart removal to heel densitometry to annual EKGs.
As is frequently the case in health care, good ideas to change the structure of primary care abound, but vested parties are fragmented, and physicians and nurses struggle to find the wherewithal to assume leadership roles.
Hats in the RingThoughtful reformers of primary care have promoted the model of a “medical home,” which is well described by groups such as the American College of Physicians and the Massachusetts Medical Society. This concept could greatly improve the health outcomes of patients with chronic, complex conditions.
Other major headliners in both the popular and professional literature are retail clinics that operate outside the established delivery system. Mayor Thomas Menino made a splash this January when publicly criticizing the approval of MinuteClinics in Boston CVS stores, but a segment of health care consumers seems to be voting with its feet for the moderately priced, rules-based services.
Not to be forgotten in the mix is one controversial innovation that emerged in Seattle in the mid-1990s and that seems to be making a quiet comeback. What has been variously labeled as “concierge medicine” or “boutique medicine,” and criticized on moral and legal grounds, has been redesigned by some clinicians in the form of “direct primary care.” What was once exclusively high end and raised concerns of elitism now holds promise for broader appeal.
A Decade of Concierge MedicineDrs. Howard Maron and I. Scott Hall claim to have founded the movement with the start-up MD2 in 1996, which offered personalized care for a fixed retainer. They now brand themselves as “the definitive provider of concierge medicine” and run offices in Seattle, Portland, San Francisco, and Chicago. However, their high price—upwards of $1,000 per month—and limited access—only 50 families per practice—have elicited negative press that has hounded the general model ever since.
The concierge company MDVIP has enjoyed what appears to be the greatest commercial success (it originated in Florida, another hotspot for boutique medicine). This venture-backed organization helps physicians set up concierge practices, often involving a transition from traditional arrangements with a larger panel of patients. The MDVIP network comprises nearly 200 physicians, with plans to expand to more than 1,000 in the next five years.
A few physicians in the Boston area have attempted the switch to a boutique model, with a pair of internists from Beth Israel Deaconess Medical Center reported to have made the move first, in 2002. There are a few hundred concierge practices in the United States, most of them located on the coasts.
Promise at the Low EndDr. Garrison Bliss began practicing medicine in 1980, but noted over the years how patients and doctors alike were dissatisfied with the status quo. He marveled at the incongruence between what he was taught in medical school about open-ended questions at the bedside and the reality of hurried office visits. As third-party payors began to play larger roles in medical access, decision-making, and management through the early 1990s, he began to wonder if physicians were “working for the wrong people” due to misaligned incentives.
Bliss cofounded Seattle Medical Associates (SMA) in 1997 as a way to work directly for patients. The three-doctor team promised that someone would be available for patients when they were sick, and the providers tried to do so in a way that the uninsured could afford. Patients alone funded the practice at roughly $65 per month. While not an insignificant amount for individuals earning less than the federal poverty limit, the community was receptive. And from the provider perspective, the financials compared favorably to the net receipt of $10 to $15 per month under capitation arrangements.
The SMA practice worked well for all parties, but Bliss realized that the business concept was not scalable, which led him to launch the next iteration last summer: Qliance. The goals of the current model include an even lower monthly fee, an average of $55 compared to the 2008 SMA price of $95; expanded primary care services in pediatrics, geriatrics, and gynecology; comprehensive in-office procedures such as X-rays and blood draws; a range of discounted prescription medications; and greater availability on weekends to address emergency room overutilization. With outside financing, this new version of direct primary care has the potential to grow significantly, to serve millions of people instead of thousands.
Experimentation is not without challenges, though. A major hurdle for direct primary care in many states is insurance regulation. In Washington, for example, Qliance would have been treated as an insurance company under the purview of the state commissioner: the reasoning was a blanket assumption that collecting fees in advance for medical services is insurance. Yet in an encouraging display of support, local legislators worked with Bliss to rewrite the regulations.
Governor Christine Gregoire praised the primary care innovators in November, commending their efforts to serve the uninsured and underinsured: “It is patient safety. It is driving down costs. So I come simply to say thank you to those who are investing.”
And in another signal that the future growth of direct primary care might not be just at the high end, the American College for Concierge Physicians recently changed its name to the Society for Innovative Medical Practice Design.
Jason Sanders is a fifth-year medical student at HMS.
