Editor’s note: Recently Georgia Health News revived its Doctor’s Column section, giving physicians the opportunity to write about important medical issues.
The following column focuses on a growing trend in medical care. Dr. Juliet Mavromatis, an Atlanta physician, writes about her transition to “concierge medicine,” a style of practice in which doctors offer more personalized care.
In 2010 I opened a “concierge” internal medicine practice. To those living in urban areas, this may be a familiar concept, but to many of my own friends and family members it was a concept that needed explaining.
A concierge practice refers to a practice in which the physician charges each patient an annual retainer fee.
There are several types of concierge primary care practices. So called “direct care” describes a practice in which the annual fee covers all primary care services. Within that types of practice, the physician does not bill health insurance for services.
In another type of concierge primary care practice, the physician does contract with a health insurer and submits claims to the insurer for covered services. However, the annual fee goes toward providing extra amenities, such as longer clinic visits, direct access 24/7 to one’s personal physician by cellphone, email or text, and the guarantee of prompt access for appointments — meaning either same-day or next-day appointments.
As primary care physicians have become increasingly busy, adding more patients to their daily schedules and working with “physician extenders” (nurse practitioners and physician assistants), the appeal of direct and easy access to one’s personal physician is easy to understand. There are also “hybrid” concierge practices that allow a patient to choose between traditional primary care and concierge care.
The fees for concierge practices range from $1,000 to $5,000 annually. In the Atlanta area, most fees range from $1,500 to $2,000 per year. In an era of increasing out-of-pocket cost for consumers, this additional amount may seem beyond the reach of many people. However, those who can afford it are able to obtain a care arrangement that many find extremely valuable.
In my case, I chose to leave a career in traditional primary care to become a concierge physician. I made the switch in 2009, after 12 years of practice at the Emory Clinic, where I was involved with both clinical care and teaching medical trainees at Emory University School of Medicine.
My tenure at Emory was a very satisfying first job after my training in internal medicine. At Emory, I developed an interest in quality improvement and began to lead a multi-year initiative aimed at improving the care of patients with chronic illness. With my involvement in this initiative, I was introduced to the concept of a “Medical Home,” which has gained popularity with third-party payers (health insurers) over the past decade.
A Medical Home (https://www.pcpcc.org/about/medical-home) refers to a practice that is, as described by the Patient Centered Primary Care Collaborative, “patient centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.” I wanted to create my practice in this model. At the same time, I recognized that creating a primary care practice in this model would require significant financial resources.
Third-party payers were just beginning to provide extra reimbursement to practices that fulfilled Medical Home criteria as defined by the Agency for Healthcare Research and Quality. However, each third-party payer had a different set of criteria and administrative requirements to fulfill in order to quality for any extra reimbursement. With the disparate array of requirements, I would have had to hire a savvy and expensive full-time practice manager just to accomplish the administrative work.
Instead, I decided that rather than try to fulfill the requirements of multiple insurance companies and go through the tedious process of being certified as a Medical Home practice, I would open a concierge practice aimed at providing this type of care. I called it a Patient Sponsored Medical Home model practice.
My practice, Personalized Primary Care Atlanta (www.ppcatl.com), is currently a two-physician practice with two additional employees — a licensed practical nurse and a medical assistant. It is set up as an “extra-care” practice. We bill insurance for covered services, and the annual fee goes towards extras and amenities not covered by health insurance.
We limit our practice size to 500 patients per doctor. We do not employ physician extenders because part of our practice philosophy is that unless we are out of town we always see our own patients when they need appointments, as well as providing them with direct access to us by phone, email, electronic messaging, and texting 24/7. We find that medical care is most effective with direct and unencumbered communication between patient and physician.
When I first opened my concierge practice, I felt somewhat guilty about charging patients an additional annual fee. As I explained the practice model to patients during the first year, I often found myself sounding apologetic about the extra cost.
After several years in the practice, however, I gradually realized that I had nothing to feel sorry about, that I was providing a very valuable service to my patients, a service that traditional primary care was failing to provide. Patients with complex needs were able to reach me directly and frequently through electronic communications or through office visits that were easy to schedule, on time, and unhurried.
In many cases, a physician’s switch to a concierge practice has meant a difficult choice for that doctor’s “panel” of existing patients: They have had to adjust to the concierge model or stop seeing that doctor. Fortunately, this has not been a big issue in my case. The majority of my patients prefer this type of practice and have specifically sought it out.
I have found a niche with several kinds of patients — some who might be labeled difficult or “demanding,” some with psychiatric conditions on top of their other health problems, and others who just have unusually high expectations. Another group are patients with chronic illnesses, who are drawn to me because I can spend more time on care coordination with specialists. Still others, including healthy but busy professionals, have enrolled in my practice because of the convenience it offers, including the ability to email or text me regularly, and the ease of scheduling.
Concierge medicine has been criticized by some people for contributing to a shortage of primary care physicians. Concierge physicians provide care to a small patient panel, typically 300 to 1,000 patients, in contrast to traditional primary care physicians who might care for 2,000 to 4,000 patients.
In my view, however, this model of care is extremely valuable to some patients and provides care that patients are not guaranteed to receive in our traditional health care system. Just as parents are able to choose a private school for their children, patients should be able to purchase concierge medicine if they feel that it offers value above and beyond what traditional practices have become able to provide.
Juliet Kottak Mavromatis, MD, FACP, is a general internist in Atlanta. She founded Personalized Primary Care Atlanta in 2010. Prior to this, for 12 years, Dr. Mavromatis was employed by Emory Healthcare in General Medicine. She is also author of the medical blog DrDialogue http://www.drdialogue.com/