House calls are back — for a price
House calls are back — for a price
Plush practices on the rise
Boston internists Steven R. Flier, MD and Jordan S. Busch, MD, currently practicing at Beth Israel Deaconess Medical Center, raised eyebrows and headlines last month when they announced they were leaving their current positions to set up a much smaller, but more expensive practice — Personal Physicians Healthcare Inc.
In contrast to their practice at Beth Israel, where they are currently responsible for thousands of patients, often seeing 30 patients a day, their new practice will restrict them to only 300 patients each, with each patient receiving perks such as 24-hour telephone access, house calls, and physician-accompanied visits to specialists.
The catch? Each patient of the practice must pay a premium of $4,000 per year in addition to maintaining existing health insurance coverage.
"They felt that this is what they needed to do to maintain a financially sound practice and provide the kind of quality care for patients that they want to," says Michael Blau, JD, partner in charge of the health law department at McDermott Will in Boston, the firm setting up the practice for Flier and Busch. "Physicians in a typical managed care practice see approximately 30 patients a day, with 10-15 minutes for each patient."
Flier and Busch want to see fewer patients, spend more time with each one, and be available in person or on the telephone should the patient need to speak with them unexpectedly, Blau explains.
Premiums up all over the country
Although the doctors’ decision spawned articles in the Boston Globe and other newspapers nationwide, including an op-ed piece in the New York Times, theirs is not the first practice of its kind.
So-called "boutique" or "concierge" practices, those charging patients a retainer fee for services outside of those that can be billed to third-party payers, have been a trend in medicine for a number of years, according to a recent article in AMA News Briefs.
Physicians who are members of MDVIP, based in Boca Raton, FL, limit their practices to only those patients who can pay a $1,500 annual fee. In return, the patients can expect to receive same-day or next-day preferred appointments, dedicated support personnel to make follow-up and specialist appointments, mail and home delivery for prescriptions, and a dedicated waiting room.
MD2 (pronounced MD-squared) in Seattle, charges $20,000 per couple, $13,200 for individuals, and an extra $2,000 for a child age 14 to college age. The fee includes all care that is rendered in the physician’s office, including some diagnostic tests and medications. Patients can expect to reach their personal physician by phone 24 hours a day and have him or her make house calls and accompany them on visits to specialists. In addition to faster, more personal service, MD2 patients also are treated to amenities such as monogrammed robes and slippers instead of paper or cloth gowns, an office with marble hallways, and the luxury of being the only patient in the office when seen by their physician.
New tier of care created
Critics have accused "boutique" practices of establishing a "third tier" of better health care for the wealthy. Patients with no insurance are the first tier — they often have no health care. Patients with only managed care insurance must still endure long waits to be seen by their primary care physician, who can only give them 10-15 minutes of time.
Though this may strike some as unfair or unethical, it is simply reflective of the current state of our health care system, says Blau. "People tend to react as if physicians are obligated to act on behalf of the entire public good — taking all comers without regard to payment. But that is not the system that we have."
The health care system in the United States is a private enterprise, and physicians are entitled to operate in that system in a way that enables them to establish the practice they want, he says. "They want to be able to cover the overhead of their practice, take home a decent salary, and take care of the patients in the manner that they believe is providing quality care."
Flier and Busch are giving their current patients plenty of notice about the practice change, helping those who wish to not remain in the practice find another provider, and, says Blau, they are waiving their new fees for a limited number of their longtime patients.
"If it comes down to someone who really does not want to change providers, who is really in need of health care, then they have decided to reduce or waive the fee, if they believe that leaving the practice would seriously jeopardize the patient’s care," he says.
Practices not unethical
Essentially, the spread of "premium" practices does not represent unethical actions by the physicians themselves, but, arguably, highlights an ethical problem for the system as a whole, says Richard Roberts, MD, JD, professor of family medicine at the University of Wisconsin-Madison, and past chairman of the American Association of Family Physicians.
"I don’t really see a problem as far as individual ethics, although it does make me rather sad," he says. "A lot of physicians, particularly in primary care, are just very frustrated with the current situation."
Faced with drastic cuts in reimbursement, higher overhead costs, and pressure to see more and more patients, many primary care physicians are frustrated, angry, and overwhelmed, he states. "A number of primary care providers are really struggling."
The main problem with these practices, as he sees it, is that they represent a failure of our health care system.
"We spend $1.4 trillion per year on health care, by far the most of any nation," he says. "Yet our outcomes are way below what they should be."
With more than 30 million people in the U.S. population uninsured or underinsured and challenged to even receive basic primary care, it’s difficult to think about practices asking patients to pay additional money for luxuries, he says.
As a physician, Roberts questions the assertion that physicians must drastically reduce their patient load in order to be responsive and provide quality care.
"I have always taken all kinds of insurance, including Medicare and Medicaid; I see 25-30 patients a day, and patients have my home number," he says. "I am able to do that. But I can appreciate that for some other physicians, it is not possible."
Aaron Katz, CPH, director of the health policy analysis program at the School of Public Health and Community Medicine at the University of Washington in Seattle, agrees that the spread of "concierge" practices is more an overall indicator of the health system’s health than an ethical dilemma for providers.
"I don’t blame the physician. They are merely playing the game as we have set it up," he says. "But my concern is that we have the most expensive health care system in the world, and it is not clear that the benefits we receive are worth all the extra money that we spend. We spend so much money and, what these practices are saying by their existence, is that that is simply not enough to get what most people say they expect of the system: good access to their primary physician, timely care, answers to their questions."
Limited access not yet an issue
Although some critics have warned that the spread of boutique medicine will mean fewer physicians available to treat the masses of people left out of the loop, Katz doesn’t see this as a problem — yet.
"It is not a big-enough phenomenon, in my view, to realize any policy issues in the short term," he says. "Right now, it is mostly in urban areas that have a sufficient number of providers." If we were to see a mass exodus; if we were to see 25% of physicians move to this kind of practice, then, I think we have something very big and troubling to worry about."
If, for example, a number of physicians in a specific geographical area were to form these kinds of practices, limiting the access to care of people unable to afford premiums, then we would probably see some government action, he adds.
"If you had a town of 10,000 people, and three of the four physicians decide to go into one of these practices, OK, now we are talking about potentially causing problems outside of the folks in that practice," he explains. "Then, you would see problems of it driving up the cost of health care."
Lawmakers would react, he says, if large numbers of the middle-class suddenly had difficulty finding care, he says. "That’s what happened in the early 1990s when we had the health care reform debate. We were in a recession; middle-class people started feeling like their security was threatened. We may be entering a phase like that; I don’t know."
Legal issues examined
Ethicists are not the only ones concerned. Currently, insurance regulators in two states are examining concierge medical practices to determine if their way of doing business violates the terms of their contracts with third-party payers or with federal programs.
But, as long as the practices have established a clear line between what services are paid for by the retainer fees and the clinical services covered by medical insurance, the practices should be OK, says Blau.
Regulators have been most concerned about "balance billing," a practice prohibited by most payer contracts. "Balance billing" is the process of charging the patient the "difference" between what the physician charges for a service and the reimbursement provided by the payer. If physicians sign the contract, they agree to take only what the company reimburses for that service and not bill the "balance" to the covered person.
Some practices may walk a dangerous line by not making abundantly clear in establishing their business structure that the extra fees charged actually pay for extra services and are not just a way for physicians to get the level of charges they feel they deserve vs. what payers want to pay, he says.
Personal Physicians has established two separate business entities for the practice. The first is a business corporation that only handles the nonclinical services provided to patients. That works in conjunction with a separate professional medical practice that provides the actual medical care, he says.
"The corporation is in charge of a range of convenience services offered to our patients, that are not clinical and not covered by insurance," he says. "The practice provides all of the medical care, he says.
As an example, he notes that the pagers, computer systems and other support personnel necessary to maintain direct 24-hour access to the physicians are the purview of the corporate side. But the services the doctor renders when being called in on those pagers or via those computers is either billable to payers (often it is not) or written off by the physician, Blau says.
Establishing such physician practices does raise a lot of ethical issues about access to care and about the value of medical care that needs to be examined.
In establishing Personal Physicians Healthcare, Blau has met with representatives and ethics advisory panels from a number of health care organizations and payers that will interact with the practice to address concerns that they have.
"What we have been doing is sort of a didactic examination of different issues; there is not an investigation of a problem," he notes. "But we felt it was important for these issues to be raised and addressed."
Sources
- Michael Blau, JD, McDermott, Will & Emery, 28 State St., Boston, MA 02109.
- Aaron Katz, CPH, School of Public Health and Com-munity Medicine, University of Washington, 1107 N.E. 45th St., Suite 400, Campus Mailstop 354809, Seattle, WA 98105.
- Richard Roberts, MD, JD, Professor of Family Medicine, University of Wisconsin Medical School, 777 S. Mills St., Madison, WI 53715.
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