A model for health-care reform: Opting out
Nearly everyone in the debate over health-care reform agrees on a few simple principles: that in a country as wealthy as the United States it is a travesty that 45 million people lack health insurance; that health-care costs are out of sight and rising; and that something needs to be done.
At the forefront in the battle for reform is primary care. Primary care physicians – family practice doctors, pediatricians, internists, OB-GYNs – are essentially the gatekeepers in the system that has evolved over the years, called managed care.
People with private and company-sponsored health insurance, and those in the Medicare system, are required to visit their primary care physician for nearly every medical need, and that doctor is then charged with offering treatment or referring the patient to a specialist. Under managed care, observers say, primary care physicians handle as many as 2,500 patients, upwards of 25 a day, and the model is set up as “sick” care, rather than focusing on “wellness.”
While it isn’t a groundswell yet, thousands of primary care physicians nationwide and some in Colorado (no one has authoritative statistics) are simply opting out of the “sick” model of practice in overcrowded conditions, and moving to a “wellness”-based practice with fewer patients that allows doctors to spend more time with each one and a concentrate on managing health.
This type of primary care practice is generally referred to as “concierge” medicine, “boutique” medicine or, as the largest group to launch such practices calls it, “Personalized Prevention Care.” It takes many forms, is manifest in franchise models and in go-it-alone efforts and eschews any direct involvement with health insurance or allows insurance on a limited basis. At its core, concierge medicine is the ultimate rejection of managed care.
After 11 years of coping with what he calls a dysfunctional health-care system, Denver primary care physician Dr. Fred Grover Jr. has decided to opt out of managed care, taking the go-it-alone route to a wellness-based “hybrid concierge model.” He practices in the Cherry Creek area under the practice title “Revolutionary M.D., Advanced Prevention and Wellness.”
Like most physicians making the switch, Grover sent his existing patients a letter describing his reasons for making the transition and invited them to join him. The new practice launched in late spring. He does not accept insurance and charges $1,500 a year per patient for his concierge plan (with discounts for additional family members). For those who can’t afford the annual plan he offers a pay-as-you go a la carte service for each visit. His concierge plan includes quarterly wellness coaching, goal setting and additional services not found in other concierge plans.
Dr. Fred Grover Jr.
“I apologize, but I am no longer accepting insurance in my practice,” Grover says on his website. “This was a difficult decision to make, but wellness based primary care is inadequately supported by managed care. If you have an insurance plan, health savings account or Flex account that accepts out-of-network providers you should be able to submit the superbill I give you for partial reimbursement.”
In an interview with ColoradoBiz, he says, “Family physicians have not seen a significant pay raise in 10 years to adjust for rising overhead.
Most are being driven to see 25 to 30 patients a day to compensate for the flat to decreasing reimbursement from plans. This limits visit times to less than five minutes, which is inadequate to provide preventative counseling and drives physicians to write prescriptions to get patients out the door.
“Phone calls for prior authorizations, and paperwork associated with managed care took away time from direct patient care, making medicine much less enjoyable,” he says. “Poor to no reimbursement for preventative and wellness counseling in areas such as weight loss counseling and smoking cessation limited my ability to provide optimal care for patients, which I was trained for. How can our system not support counseling for weight loss and smoking cessation when these are two of the biggest killers in our country? Outcomes can be catastrophic for the system and patient when opportunities for preventative care are missed.”
The system he left also discourages doctors by making their practices difficult to sustain, he says.
“Many family docs are reaching a tipping point and are choosing to retire early, or change occupations due to the environment created by the current managed care environment,” Grover says. “Many are going bankrupt, or burning out trying to keep their practice afloat by seeing more patients each day.”
The goal, Grover says, is to practice medicine the way he had always envisioned it – in a patient-centered, wellness and preventative-focused manner – the way he was trained. The soft-spoken advocate for healthy living sees his new practice as a way to provide much more thorough, personalized care. He says office visits now run anywhere from 30 to 90 minutes.
“This gives me time to promote wellness and prevention, manage chronic disease more effectively, and to apply my expertise in family medicine, anti-aging medicine, bio-identical hormone replacement, and other therapies when applicable, ” according to his website.
Although the end result is a smaller practice, that wasn’t necessarily the goal, he says.
“I can do well with 15 patients a day,” he says during the ColoradoBiz interview. “Practice size wasn’t a huge issue. The goal was to get away from managed care.”
On a personal note, this reporter, Jeff Rundles, and his wife have been patients of Grover’s for more than a year and have opted to remain in the a la carte program. We carry comprehensive health insurance, but we were frustrated with our previous primary care practice because we felt the doctors – whom we liked very much – never seemed to have enough time to spend with us. Grover’s appointments are unrushed, take as long as they need to take, and his concentration on wellness – the questions he asks us about diet, exercise, stress, and the coaching and counseling he offers – makes us feel as though we are receiving better medical care than we have in years.
Grover is not alone. At least six other primary care physicians in Colorado have opted to go “concierge.” Dr. Kevin Lutz of Denver has a go-it-alone model like Grover’s. Two, Dr. Michelle Eads of Woodland Park, and Dr. Erik Mondrow of Louisville, use a franchise model through the Society for Innovative Medical Practice Design (www.simpd.org) in Richmond, Va. And three others, Dr. David M. Abbey and Dr. Robert C. Homburg, both of Fort Collins, and Dr. Jon J. Cram, of Littleton, operate through another national franchise organization called MDVIP
of Boca Raton, Fla.
The most notable franchise concierge model is MDVIP, which has in nine years enrolled more than 300 physicians in 27 states and Washington, D.C., with Colorado the latest state to join in. All three Colorado members launched their new practices in June. The member doctors were unavailable for comment. However, MDVIP officials in Florida were more than willing to talk about their personalized prevention care model.
“Primary care has become frustrating, with the size of the practice upwards of 2,500 with only seven to 10 minutes for a patient to see a primary care doctor,” says Darin Engelhardt, president of MDVIP and a lawyer by training. “And it’s equally frustrating for the physicians. They are focused on treating the illness, and that certainly wasn’t the intent of the physician (coming out of school).
“So we thought, how could we re-orient primary care to put the focus on preventative medicine and wellness?” he says.
The MDVIP model, once a doctor signs up, limits the practice to a maximum of 600 patients who each pay $1,500 a year, or $125 a month. The doctor keeps $1,000 of that fee, and MDVIP’s “margin” is in the other $500.
Like most of these types of practices, MDVIP begins with an annual detailed physical exam, with multiple screenings for things like sleep disorders, depression, exercise, nutrition, pulmonary function, EKG, lab panels and more, based on a protocol called the National Executive Physical Program, Engelhardt says.
“It serves as a starting point,” he says. “Now we have wonderfully detailed information to use so the physician may serve as a coach. All of these preventative care services could not have been provided (in managed care) due to the limitation of time.”
Beyond the physical, MDVIP patients enjoy unlimited doctor visits, which can be booked on short notice, and great access to their primary care physician via cell phone and Internet. There is also reciprocity in the system, so if patients are traveling and there is an MDVIP physician in the area, they can visit those doctors at no additional charge.
Critics of the concierge medical movement charge that the fee-based practice is elitist and caters to the wealthy, but Engelhardt dismisses that notion.
“In the context of MDVIP, that is not true,” he says. “At $125 a month, that’s the same people pay for cable or a cell phone. We have found that the demographics of the previous practice (of its members under managed care) are the same once the switch is made – except that it skews a little older. We have seen success in all types of economic settings, urban and suburban. One of the things that surprised us was the breadth of interest in this model, especially geographic. We did not expect the appeal of the practice being embraced by so many people – doctors and patients alike – in so many places.”
MDVIP differs from some of the other concierge models in that physicians signing up still accept insurance and stay “in network.” Engelhardt says MDVIP doctors will bill insurance for “sick” visits, and make the usual referrals to specialists when called for. The only difference there is they won’t accept new patients over the 600-patient limit in the practice, and any new patients would be required to pay the annual fee.
The insurance issue, however, could be a sticking point, particularly as it relates to concierge practices limiting their patient loads to a maximum of 600. ColoradoBiz reached out to one of the largest health insurance providers in Colorado and in the nation, Cigna HealthCare, and in response to a question on the company’s take to concierge medicine we received the following statement via e-mail from spokesman Mark Slitt:
“Cigna’s contracts with physicians call for network physicians to provide equal access to all people covered by a Cigna plan,” Slitt says. “Cigna has not objected to network physicians offering their Cigna patients the option of joining their concierge program, provided that Cigna patients who are unable or unwilling to join the concierge program continue to have access to these physicians’ services.
“However, Cigna will terminate the contracts of participating physicians who have indicated to us that they are willing to accept as patients only those Cigna participants who agree to pay the concierge program membership fee,” he continues. “This is an issue that arises infrequently; and over the past several years, we have terminated only a handful of physicians from our network due to this issue.”
Still, most health-care reform initiatives being discussed focus on big changes in managed care, especially on the primary care level, and there are many calling for a change toward wellness care versus sick care. And most of these discussions begin with pronouncements that changes of these types will result in significant cost savings.
“We spend about 30 cents of every dollar (in health care) on administrative costs, and we spend more on health care than any other country,” says Dr. William Jessee, who is president and CEO of the Medical Group Management Association, a national organization based in Englewood that represents the interests of 22,500 professional managers of medical practices in which some 275,000 physicians practice.
Dr. William Jessee
“There’s pretty universal agreement that the more things you (doctors) do, the more you get paid,” he says. “We’re not getting value for what we are spending. We have islands of excellence (in health care), but we have a lot of mediocrity.”
Change, Jessee says, “demands doing away with the current system of getting paid for the piecework like we have now.
“Let’s be candid: People are motivated to do the things in their own economic best interest,” he says. “There is no incentive in the system (today) to keep people less fat. The doctors make money, the pharmaceutical industry makes money, the food industry makes money.”