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Posted: August 17, 2009

A model for health-care reform: Opting out

“Concierge” medical practices could help change the face of primary care as physicians establish closer relationships with their patients — and distance themselves from insurance

Jeff Rundles

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.

Opting out

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.

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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.

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VIP medicine

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).

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Darin Engelhardt

“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.”

Change

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.

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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.” 

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Jeff Rundles is a former editor of ColoradoBiz and a regular columnist. Email him at jrundles@cobizmag.com.

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Readers Respond

I wonder if the concept will be adopted by addiction treatment as well. Since the relapse ratio is very high, many patients are in need of lifetime concierge service. New York Alcohol & Drug Addiction Treatment Rehab. 14 Wall Street Fl 20, New York NY 10005, (212) 380-3841 By Vlad Kogan on 2012 06 22
True private doctors providing unrestricted white-glove service cost up to $10,000 a year. I am a primary care doctor in NYC. The fixed price membership has been quite successful there, but patients realize that they only get a handful of benefits for an extra $1,800 a year. They still need to have a medical insurance card for procedures. On the other hand, this allows doctors to concentrate on preventative care which by itself reduces the number of follow-up visits. By Dr. Marina Gafanovich, MD on 2012 04 16
Both my husband and I have benefited greatly from Dr. Fred Grover, Jr.'s careful health analysis. His contribution of extra time, combined with his broad base of knowledge, have saved us from what could have easily become a long-term disability. Managed health care insurance, including Medicare, would not have paid for this high quality of care under the current pathetically inadequate systems available for supporting the time of primary care physicians (PCP). I believe the shared health of the United States depends on moving toward a nationally funded, privately administered, nonprofit health insurance system that allows and contributes to a patient's choice for PCP quality care. By Fran and Richard Rew on 2009 09 24
Great comments. In regards to best option in our current environment, I believe that having a health savings account coupled with a catastrophic plan provides much better value and flexibility for the individual to obtain more personalized care, and still have the protection in the event of getting broad-sided by a drunk driver. Additionally we are not robustly supporting the unethical greed of the insurance companies,and can focus on wellness and prevention services that are rarely covered by traditional plans. Keeping ourselves out of the hospital and out hiking! Fred By Fred Grover Jr. M.D. on 2009 09 18
Although "boutique" or "concierge" medicine usually has an elitist and exclusive connotation, I applaud the concerted effort to shift the care paradigm from sick care to health care. The fees mentioned do not seem exorbitant and it appears the increased level of access to caring physicians would make a large difference to patients' health. I do see a large downside in that any family would also need to carry additional expensive insurance for major medical, or catastrophic events. No mention is made of what happens in the event that a patient does need an expensive test or procedure. Even very healthy people get cancers, have accidents etc. Some kind of universal safety net insurance, coupled with creative and caring general practice docs seems like the best combination to protect the financial AND physical health of average Americans. By Maria on 2009 08 18
Thank you!!! I have heard about more and more doctors stepping outside of the insurance and Obama plan and creating something that individuals and families can continue to pay for that is a decently well groomed health plan. I have worked hard for what I have earned and I pay a lot of money to offer my family decent healthcare. My sister, hear husband and kids live off of the system. They choose not to elect to have healthcare and walk into the emergency room everytime they cough. So now I get to pay for that?!?! I am happy to hear that I can now elect to have a plan introduced by you and have the same quality of healthcare at an annual price that is the same if not better than what I pay for insurance right now. I do not like being a handicap to what Obama and his administration has up his sleeve. I refuse to pay for my family and all of those that refuse to provide for themselves. As a small business owner, I am extremely concerned with Obama's "socialism" package with a bow on top. Thank you for what you are doing and I hope to see more of this in the near future. I am sorry that this may hurt the insurance industry but you all can feel free to send Obama a THANK YOU card. By Kimberly Stewart on 2009 08 13
I've scratched my head over the years and no matter how much I try, I cannot understand why my Family Practicioner refused to refer me to a specialist when needed. He was willing to play dermatologist, OB-GYN, audiologist, orthopedic specialist, only to send me to the physician initially required. Not only was my insurance company paying twice, but so was I, plus the time we both wasted to address the problem. He was fired. My next physician I met during my the first check-up. I never saw her again, only her nurse practicioner (who misdiagnosed an ailment) but continued to invoice my health insurance company just as much as if a licenced physician was seeing me. MDVIP sounds interesting just to experience a scheduled appointment on time! I've given up doctor's offices for acupuncture, massage, reiki, etc. So far, it's worked incredibly well and my state of mind is healthier than becoming a fixture in a waiting room waiting to be dusted! It isn't rocket science. By gaylene garbizo on 2009 08 04

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