Last summer my family doctor sent all his patients a letter saying that he was sponsoring a telephone-administered questionnaire, and asked if we would answer the survey questions should we receive the call. His letter said that the answers we gave to the questions would be used to help him improve his practice. What we did not understand at the time was that the practice would improve—but only for the doctor and about 25% of his patients. The other 75% of us would be “fired” because we couldn’t, or wouldn’t, pay a high yearly fee to “join” what would become his new practice.
Welcome to “concierge medicine.”
We didn’t realize it at the time, but the survey was a tool that would be used to create a problem that could then justify a radical repair. The next letter we received from our doctor stated that the results from the telephone survey of his patients confirmed exactly what he suspected: that patients felt rushed, they wanted more advice about preventive health care, and they really didn’t like to wait in the waiting room. I don’t recall the letter stating how many patients were actually questioned and what percentage of them said there were problems. No need for specifics, we were just to take it on faith: There was a problem.
Reality Check
In fact, we had never waited long in our doctor’s waiting room or for an appointment or felt rushed. I rather liked the fact that the waiting room hadn’t been redone in at least 10 years—it showed that the doctor had the right priorities. We had what seemed like relaxed, unhurried annual physicals and visits. The doctor talked to us at length, and discussed individualized preventive health care and lifestyle changes. We always felt that our doctor was accessible. He called us personally to discuss test results or answer questions. The only complaints I ever had involved members of his front office staff, but they were minor.
Maybe we had low expectations for our health care. So I asked a friend who had been seeing this same doctor for many years, and he too felt that none of the problems applied to his family’s care. So it was news to us when the doctor announced that he needed to make changes in his practice in order to be able to provide…exactly what he was already providing.
Members Only
The letter informed us that as of January 2011, our doctor would be changing his practice so that these “problems” were no longer an impediment to the health care we deserved–and that he wanted to practice. He was going to be joining a larger practice called MDVIP, and would be “limiting” his practice to the first 500 of his current 2000+ patients to sign up and “join” the practice. Patients who joined were promised greater accessibility to the doctor, more individualized preventive care, same-day appointments, no time spent in the waiting room, and appointments that lasted a minimum of 30 minutes.
I read the letter over a few times. There had to be a catch—money, fees, something. The letter referred me to the MDVIP website. The website was filled with smiling, happy people who were bursting to tell you why they switched to MDVIP, and how pleased they were to have done so. I was invited to click on the kind of patient I am: a frequent user of health care? A once-a-year type? Someone who needs to go more often? Hear their stories and you’ll recognize yourself, and better yet, imagine yourself with MDVIP! Still, all I was hunting for was the answer to one question: how much money was this going to cost?
The answer shocked me: $1500 per year, per person. So that would be $3000 per year for my husband and me. And that fee doesn’t mean I get to stop paying for health insurance, because although $1500 covers all the preventive care I’d need in a year, if we get sick, that’s not typically covered, nor are hospital costs or medications. Not to mention our children, who are not covered by MDVIP at all.
Five hundred patients multiplied by $1500 per year adds up to a nice bottom line start to the year for the doctor: $750,000 … minus whatever percentage MDVIP takes off the top.
What is MDVIP?
MDVIP is a Florida-based, for-profit provider of “concierge” (also called “boutique,” or “retainer”) medicine that was founded in 2000 and acquired by Procter & Gamble in 2009.1 MDVIP is the largest of the concierge medicine providers. As of October 2010, there were over 430 MDVIP-affiliated physicians in the United States. MDVIP has grown by more than 40% since 2008.2
The cornerstone of the MDVIP program is the annual comprehensive “executive-style” physical and a detailed, customized wellness plan.2 MDVIP also restricts which doctors are allowed to join their provider group. According to MDVIP, affiliated physicians are “carefully chosen through a rigorous screening process.”2 They must score highly on the company’s patient questionnaire to be considered in the first place. So that phone questionnaire gets you coming–and going—or should I say “leaving.” You, the patient, say how much you like your doc, and then he or she can qualify for MDVIP, and dump you when you can’t afford their membership fee. It reminds me of the Seinfeld episode when Elaine’s boyfriend, a medical student, breaks up with her:
Elaine: What? You’re breaking up with me? But I sacrificed and supported you while you struggled. What about my dream of dating a doctor?
Ben: I’m sorry, Elaine. I always knew that after I became a doctor, I would dump whoever I was with and find someone better. That’s the dream of becoming a doctor.
I went to the section of the MDVIP website dedicated to my doctor’s nascent MDVIP practice. There was a place to respond whether or not you were interested in signing up to the new practice. I wrote that I certainly was not signing up because of the high fee and added that I was really disappointed to see my doctor, who I had liked very much, going this route, effectively jettisoning all his middle-class patients.
Less than 10 minutes after hitting the send button, I got a phone call from an MDVIP operator, who essentially said, “Don’t let the door hit your ass on your way out.” He checked us off his list.
Next, I wrote a letter to my doctor explaining why we were not staying in his practice and expressing disappointment in his decision to join MDVIP. A few days later, he called. Our conversation was not rancorous, but neither of us ceded ground to the other. He stuck to his talking points. (I now know they are talking points because the more I read about MDVIP, the more I see the same statements, over and over. “It’s about making your health a priority.” “It’s just $4 per day. That’s the same as what you probably spend at Starbucks.” My doctor improvised, changing Starbucks to Dunkin’ Donuts in our conversation. My town is more of a Dunkin’ kind of place. Still, his comments about Dunkin’ Donuts irritated me because they so trivialized our (and so many others’) situation.
I told my doctor that we had already made health care a priority, and spent a great deal of money to pay for health insurance, deductibles, and our many uncovered or out-of-network costs and medications. He countered that his $3000 fee could be covered by a flexible spending account. I told him that we already deplete our account every year paying for our many uncovered expenses. (We no longer have this benefit anyway.) “Should I stop paying our tuition bills in order to join your practice?” I asked. He didn’t answer.
“I’m not doing this for money,” he said. “This change won’t mean more money for me.” I hadn’t suggested it. Okay, I thought it. I still think it.
Coming Soon, to a Doctor Near You?
Concierge medicine currently affects only a small percentage of Americans. We are just lucky, I guess. Nationwide there are estimated to be 3,500 concierge doctors treating 1 million patients.3 In my state, New Jersey, it is estimated that there are 100 physicians practicing concierge medicine.3 In some areas of the country, primarily urban areas, concierge medicine is more prevalent.
But it is a movement that is growing. In my area, seven doctors recently switched to concierge medical practices, forcing thousands of patients like my husband and me to find another family practitioner.3 It’s not as simple as it sounds because some practices are closed to new patients and there are always questions about which doctors take your insurance. And now there are at least 1,500 more patients from my doctor’s former practice who are, like us, searching for a new primary care doctor.
Implications
Doctors who join concierge practices undoubtedly like their new practices. What’s not to like–500 patients underwrite a several-hundred-thousand dollar base each year, and they tend to be more health-conscious patients who are also healthier to begin with. The only national survey of concierge practices, done in 2005, found that these patients have lower rates of diabetes, heart disease, and high blood pressure than the general population of patients.4
For the patients who can afford to belong to a concierge practice, it’s a nice arrangement: instant medical gratification–and no waiting rooms. While there is very little evidence as to whether concierge patients have better long-term health outcomes than those in traditional medical practices, concierge practices advertise this to be the case. MDVIP’s 10th anniversary press release states, “We are satisfying the demands of our patients who want to prevent disease and live healthier, happier lives.”2 And now for the naked ambition part: “As a result, we expect our double-digit growth to continue for the next decade.”
I guess it’s understandable why patients who can afford to do so sign up for concierge medicine. But is it ethical for doctors to be (as a headline in my local paper put it) “putting some patients at the head of the treatment line” because they paid for the privilege?1
Writing in the Annals of Internal Medicine last year, Michael Stillman, MD, a self-described “regular” physician, notes that while he understands why patients are attracted to concierge medicine, he’s less charitable about the physicians who offer it.5 “Each of us has vowed to ‘treat without exception all who seek [our] ministrations,’ and limiting one’s practice to several hundred wealthy patents undermines this tenet of our profession.Even though economic realities and scheduling limitations dictate that some physicians maintain a certain payer mix…I am certain that the legendary physicians of our profession would be embarrassed by the criteria some of our colleagues have used in selecting which patients they will and will not see [emphasis mine].”6
Critics of concierge medicine say it is less ethnically and economically diverse than the general population, with fewer African American, Hispanic, and Medicaid patients,4 and that such practices cherry-pick the wealthiest and healthiest patients, “leaving behind a comparatively sick population to be absorbed by others in the community.”6 Concierge medicine not only creates (or, some would argue, worsens) a two-tiered medical care system, it makes it more likely that the rest of us have less access to care. Because each time a medical practice “goes concierge,” there are more than a thousand patients who flood other primary care practices, already overloaded as they are.
No one is saying that traditional medical practices are perfect. We’ve all likely had less than wonderful experiences and we do have to be vigilant about our loved ones’ (and our own) care. But nothing is going to improve if a segment of patients can pay their way out of the system, either.
I’ll end with a quote from Dr Stillman’s excellent article:
“Physicians who opt out of the current system by expending their energies catering to “patron patients” rather than helping reform a flawed health care system or energizing a beleaguered professional community should re-enter the fray. There are patients to be cared for, both wealthy and underprivileged; ideas to be proposed and exchanged; and policymakers to be educated and persuaded. These difficult times call for engagement, not isolation and retreat.”
REFERENCES
Pilcrow 
Concierge doctors are just “cherry pickers” who are picking only a small number of patients who can afford this service.
As a physician, I can see how the stresses of a medical practice, particularly in primary medicine, can lead a physician to want to limit his/her practice to a smaller number of patients, with less stress, and a much higher income for the hours they spend.
However, these physicians must realize that they are simply exploiting the system they rely on but which they have chosen to opt out of for monetary reasons. Concierge doctors cannot exist without hospitals and specialists who take care of their patients when they truly become sick, and thus cannot exist without those who pay for this care.
J. Mark Engel, MD
Princeton, New Jersey
You hit the nail on the head. Without the non-concierge physicians staying in the trenches and taking care of the cast-out majority of patients, concierge doctors could not set up their boutique shops for the chosen few patients who can afford them.
nicely done: not just a rambling rant but a well-spoken (if the digital format has in fact the power of speech) and informed commentary on an important topic, that of the extent that the market influences health care ‘reform’. perhaps if you would publicize the name of the doctor involved more candidate patients could discover and reflect upon an alternative point of view concerning his motivation for changing his practice of medicine in this manner.
Thank you for your comment! I gave a great deal of thought about whether to use my doctor’s name. In the end, I decided that the people who have signed on with concierge practices really don’t care about the doctor’s motivation. I think patients are driven to sign up with boutique practices largely out of self-interest and, in some cases, fear. For example, a friend told me that her parents (in their 70s) recently signed up with a concierge doctor because they were scared NOT to (a number of their doctors don’t take Medicare). People who have the means to sign up may feel that like everything else in our capitalist system, if you can afford it, why shouldn’t you do it? What’s the down side? No more waiting rooms and your doc is at your beck and call. Go to the front of the line. I do think that our society is increasingly operating on an “every man for himself” mentality, and this is just another sign of it.
Thank you for your post and for referencing my article on concierge medicine. Most of the emails I received in response to that piece were supportive, from other doctors who were equally frustrated with our peers’ selfish migration toward concierge practice. Who wouldn’t like a lighter schedule and higher profits?
However, I also received several emails from community private-practice docs who really just couldn’t make ends meet: folks who were seeing 25 patients a day, which is a crushing schedule, and trying to support their office expenses and pay their kids’ tuition bills. It is a complicated matter. I recognize that I’m lucky in that I run a hospital-sponsored practice in which I can see fewer than the customary number of patients per session or day. If I had to see 100 patients a week–standard for private practice docs–I’d be in trouble. I spend a large chunk of time on the phone with patients, arguing with insurance companies to get approval for MRIs, writing letters, and filling out forms, all tasks that take me away from spending time with patients and billing for my time. And I take home work every night.
But I do not equivocate on my point that concierge medicine violates a sacred bond doctors have with patients. Corporate concierge medicine is wooing doctors away from their patients, corporate greed in the worst sense. Yes, it is a free market, and physicians are free to practice concierge medicine. But I continue to maintain that when you ditch 75% of your patients–many of whom have been loyal to you—you’re making a pact with the devil, and there is a different price to be paid.
Nice job, Jackie. I’m so glad to see you generating content for yourself for a change, and putting it out there.
I learned quite a bit from your blog essay. I have never liked the idea of a boutique practice, but I saw it within the perquisites of the practitioner. Your essay opened my eyes to its cherry picking character and the marauding tactics of the corporations who have taken it over.
Country club medicine is more like it. I hope for the $1500 you at least get your own chair in the waiting room and maybe a locker. It is a winning formula for the group and the doctors— as you say, they get the wealthiest and healthiest patients—they will have much better odds in getting paid promptly by the select few. Now if Wall Street could only bundle these “triple A” patients and sell them as a fund…
A nice massage might be complimentary, don’t you think?
My mother sent me the following link as the “anti-concierge” doctor story:
http://Www.aarp.org/health/doctors-hospitals/info-03-2011/rural-health-care.html.
It really is therapeutic to read it.
A concierge practice benefits the doctor and the franchise that converts the practice as there is big money to be made for both at the patient’s expense.
Physicians can make much more money, see far fewer patients and can let most of their administrative staff go because these companies pick up most of the papework and reduces overhead.
I’m a medical biller and what I would question the legalities and future challenges especially if these patients are treated for covered services and the provider bills the carrier.
This can be a very big problem if the physician doesn’t terminate their insurance contracts or opt out of Medicare which has strict guidelines regarding the balance billing of beneficiaries.
Charging patients a membership fee and accepting payment from a carrier can be considered an over charge or double dipping.
Another problem at the state level is that accepting a fixed annual fee can be considered a practice of insurance which requires a license.
Many of these franchise type concierge or retainer corporations that partner with the physician before, during and after the practice conversion claim to have legal teams who will oversee compliance with applicable laws.
I find this difficult to believe as the issues I mentioned above will most certainly come into play at some point.
Charging thousands for a physician’s attention and still having to pay for the visits and services is arrogance at its worst.
They want you to think it’s about your health but at the end of the day it’s about the money.
To add, I would strongly recommend to any physician or group practice considering this type of conversion to have a consultation with an attorney who’s admitted to the bar in their state and specializes in insurance law.
The main interest of the corporation is to get the practice to sign on as to make a hefty profit. I doubt whether any of these companies can guarantee to every client that they are compliant with all laws. They’d have to staff dozens of lawyers and they don’t come cheap.
It’s the provider’s responsibility to ensure that the practice is compliant.
Just today when my husband went to our doctor of many years, he was “interviewed” by a Jeanne Jankus of MDVIP. When myhusband got home and told me it would cost of 3200 a year for us both to keep our doctor I was very upset so I called in. What I am trying ot understand is he is in a private practice. If we don’t do this can we see one of the other doctors if he himself as the owner is part of the MDVIP? I’m trying to figure this out.
Hi Jane,
While I don’t know your specific doctor, I do know that once your doctor is part of MDVIP, it really will not be possible to be seen by him unless you “subscribe” –join–his practice by paying the yearly fee. If he is in an existing group and the others in the group are NOT in MDVIP, and your former doc somehow remains in the group, my guess is you would only see the non-MDVIP members of the group. You really do have to pay up or you don’t see your doctor once the arrangement is finalized.
I know just how you feel, it really is upsetting.
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Thank you very much for your kind words and appreciation!