Concierge disease management

The concept of concierge medicine may not be new, but what about concierge disease management? The problem with traditional disease management or DM is that patients often get lost and they don't end up receiving the personalized level of care that they need. Why? Because it would be much more expensive to deliver that level of care.

I'm currently reading an article in BusinessWeek magazine titled, "Take Your Meds, Exercise—and Spend Billions" (click here to read that story)

There are many people who don't believe that traditional disease management programs are cost-effective. Given recent advances in technology, I'm sure that disease management programs can become much more effective and robust. There are mixed opinions when it comes to the topic of traditional disease management with health coaches and financial incentives, but what about exploring the idea related to concierge disease management? We probably don't have much data on that type of concept, but I'm sure it would make a tremendous impact on patient outcomes if people could afford such services. Unfortunately, the reality is that few people would be able to afford such boutique services, so you'd be left with clients who are from the "rich and famous" or elite upper class of society.

Physicians are burning out

Busy physicians are burning out because they are working very hard to see many patients and many are getting discouraged. Those who are working in a cash-only practice are probably experiencing less burnout. Those in concierge/boutique practices are also enjoying a healthier work/life balance. However, for the majority of physicians who are dealing with insurance companies and high volumes of patients, they are experiencing burnout and they're looking for a change.

Over the past six months, many physicians have approached me to learn more about non-clinical career opportunities because they want to leave clinical medicine. It's quite unfortunate to see so many physicians disheartened by the practice of medicine. We need good physicians to serve the public. We need capable and willing physicians who will accept Medicare and Medicaid.

What's going to happen in the setting of health care reform? We're going to have more patients out there who will demand medical care, but we'll have fewer physicians in the workforce.

Is there a growing interest in non-clinical careers among physicians

In my other blog (http://www.nonclinicaljobs.com), I write exclusively about non-clinical career opportunities for physicians and other healthcare professionals. Recently, I have noticed a significant increase in traffic to http://www.nonclinicaljobs.com directed from Internet search engines such as Google, Yahoo, and Bing. People are typing "non clinical physician jobs" into search engines and they are ending up on my site. This trend makes me wonder: are more physicians searching for non-clinical jobs these days? Are all these debates and discussions regarding health care reform causing physicians to re-consider their "calling" into medicine? Perhaps they wish to stay connected with the science of medicine but maybe they wish to get out of direct patient care. Maybe physicians are exploring their options and developing contingency plans. After all, they may not wish to practice medicine in the setting of reformed health care (although some are reforming their own practice by converting to concierge medicine - which is also often called boutique medicine).

Our nation already faces a shortage of physicians (some may argue this point), but there's no doubt that certain areas of this country have a significant lack of healthcare providers. What will happen if more physicians decide to leave clinical medicine to pursue non-clinical careers?

What's cooking at Sermo these days?

In case you haven't noticed, Sermo has a blog. There, you'll find somewhat de-identified physician comments regarding certain medical topics. I say "somewhat" because sometimes within the comments, you'll see certain physicians named by their username. Some have arbitrary usernames like "radiologist" or "mcdreamy," while others have usernames that reflect their identity (like "billyjones" or "samsmith" - well, I made up these usernames, but they could be real)

One of the interesting discussions that's rated a "top post" on Sermo is a discussion regarding concierge medicine (also called boutique medicine and several other terms). Does concierge medicine have a role in the U.S. society? President Obama receives concierge medical care. Celebrities do too. Look at Michael Jackson. He had his own anesthesiologist who administered propofol (Diprivan) for him. Does concierge medicine meet an unmet need? It's so fascinating to read all the comments about this topic. What's an ethical amount to charge your patients when there's no clearly defined "market standard value"?

People want healthcare coverage but many can't afford it

President Obama spoke about the fact that most Americans want healthcare coverage, but many simply can't afford it. I think my favorite moment was when he spoke about Medicare Part D. When seniors hit the Medicare Part D doughnut hole, they "drop off a cliff."

Here are some of my questions regarding healthcare insurance reform:

• How will hardship exemptions get allocated? Will they be fully transparent about the money that funds these exemption programs?
  
• How should the government "regulate" medical practice? Will the government really be transparent about all the regulations and changes?
  
• How can we reduce the "waste" in healthcare? Perhaps we need to shift from a "defensive" medicine mindset to a cost-savings mindset.Perhaps we need to focus more on prevention.

I agree that repeat medical tests are wasteful. Whether you're repeating labs or imaging studies, this type of practice is really wasteful. Health information technology (Health IT) should help reduce this type of waste as long as all the systems talk to each other.

Role models healthcare organizations according to President Obama:

• Mayo Clinic
• Cleveland Clinic

Finally, I'd like to comment about his statement that he's followed by a doctor every minute. Sounds like some serious concierge medicine! And then he said, "it's not about me." Most people can't afford basic health insurance. The rich can afford concierge medicine. Where's the middle ground and how long will it take to get there?

Is Canada's health system better?

There's an interesting article on CNN titled, "Reality check: Canada's government health care system." According to CNN, the story highlights include the following points:

• Woman with tumor said wait would have been too long; she got costly U.S. treatment
  
• Canadian man with cancer says he was put on fast track for treatment
  
• Sen. Mitch McConnell says U.S.-run program would mimic Canada's problems
  
• Some doctors who spoke to CNN say McConnell doesn't have facts right on waits

Here's a snippet from the story: "The Senate's top Republican, Mitch McConnell, R-Kentucky, asserted several times on the Senate floor last month that a government-run health insurance option, which President Obama and Democrats want, could lead to a government-controlled health care system like Canada's."

I know many Canadians who have traveled to the U.S. to get an MRI or other type of imaging study. Some travel to the U.S. for surgery. If you can afford the luxuries associated with U.S. healthcare (and even concierge medicine), then why not? Right? What happens to all those patients who are unable to afford the luxuries of such healthcare? At least in Canada, you have some level of healthcare coverage. Here in the U.S., millions of people live without any level of healthcare coverage. Why? Because they're not old enough to qualify for Medicare and they have too much to qualify for Medicaid. These days, so many doctors don't accept Medicaid, so what benefit is that anyways?

What will healthcare look like after we go through major reform? Will we mimic the Canadian system on some level? Many are predicting a tiered healthcare system where a basic, universal plan will be available to everyone, and then those who can afford more will basically get more. Who determines what types of medical tests you deserve? The same person who complains of symptoms such as dyspnea, headache, and a cough may get one type of workup in Canada (few, if any tests) and another totally different battery of tests (necessary or unnecessary) here in the U.S. Why such disparities? Do we live in such a litigious society here in the U.S.? (Don't answer that last question) To read the entire CNN story, click here.

Ethics of concierge medicine

Concierge medicine is often referred to as boutique or retainer-based medical practices. We have seen a surge of physicians and medical groups converting to this type of model over the last several years. Why? Because you can get paid more for seeing fewer patients. Sounds almost ironic, doesn't it? In a typical concierge practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. What does this mean? It means that you may be able to call your doctor directly. Forget about answering services. Also, it may mean that you doctor will see you in the middle of the night if you develop chest pain. Forget waiting in the ER if you need to get admitted by your physician.

If political leaders like presidents can have concierge-type medical care, then is it unethical to offer it to other rich and powerful people? If a billionaire hires you to live and work as a personal doctor for his/her family, would it be unethical to do that? I think the bigger issue revolves around the accessibility to care. If you're the only doctor in a 50 mile radius and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. A related topic deals with the acceptance of Medicaid insurance. Many physicians are choosing not to accept Medicaid because the reimbursement is so low. Eventually, a cash-only model may become the prominent model (especially if the government steps in and offers some level of universal health coverage).

Let's evaluate the ethics behind concierge medicine:

• Autonomy: Probably not an issue.
  
• Beneficence: "the act of doing good things." Well, as long as you offer good care to those who are paying you, you're fine there.
• Non-Maleficence: "do no harm." Well, this is where concierge medicine may have a problem. If you move to a brand new area to set up your concierge medical care, then you may be fine. However, as I mentioned above, if you're the only doctor in a remote area and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. You may be "harming" those who are unable to afford your prices.
  
• Informed consent: Don't see any issues here as long as your contract is well-written.
• Confidentiality: Probably not an issue.

The AMA Principles of Medical Ethics ends with this statement: "A physician shall support access to medical care for all people." Hmm, not sure how this relates to concierge medicine.

However, the AMA Principles of Medical Ethics also has this statement: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."

9 comments so far on the Forbes story on Concierge Medicine

An interesting article popped up on Forbes last month titled, "Should You Dump Your Primary Care Physician?"

So far, there are 9 comments and several are from physicians who are actively practicing boutique or concierge medicine. This is a growing industry and may see a huge burst depending on what types of changes occur within the nation's healthcare system.

Boutique medicine or non-clinical medicine?

Some doctors may be contemplating some serious career changes because of worsening reimbursement problems. Many are converting their practice to a cash-only boutique or concierge style practice. Others are moonlighting or doing some cosmetic laser surgery.

What about a transition to a non-clinical career? Pharma and finance aren't the only options out there. Yet so many physicians find themselves limited because they don't recognize what types of opportunities exist.

There are some serious questions to first consider:

• Are you willing to take some risk?
• Do you have the financial luxury to be unemployed for a few months while you make the transition?
• What do you really enjoy doing in life?
• Do you like to learn new things?
• What do you think about the corporate world? Of business?

At the end of the day, you may realize that a non-clinical path is better than simply converting to boutique medicine. It's important to recognize your options and to do your due diligence. Research your options. Meet people working in non-clinical settings. Prioritize what's important in your life.

Finally, make sure that you're really willing to leave clinical medicine. It may get difficult to go back if you change your mind.

Executive Health Programs

I was on the plane the other day thumbing through the airplane magazine. An article on Executive Health caught my eye. More and more concierge-type Executive Health programs are emerging in this country. Cleveland Clinic, Duke, Mayo Clinic, Johns Hopkins, UCLA, Mass General - these are just a handful of some of the programs that are out there.

So, if you're rich and you can afford this type of care, what's wrong with that? These programs often include luxury spa treatments, relaxation sessions, lengthy counseling with clinicians, and a very personalized touch to medicine. Resort-style accommodations. No waiting rooms. Comprehensive exams. Add a game of golf (integrated golf package offered by Duke and others), swim in the outdoor pool, and get daily massages. Maybe you'll be eager for your next colonoscopy if it takes place in a resort and you get a relaxing massage before the procedure.

Busy corporate executives often don't have time to sit around waiting rooms, but should they get a $3000 visit to a luxury resort for their physical? The other aspect that I find interesting is that certain programs include full body CT scans as "add-on" options (offered by the Cleveland Clinic among others). Such scans may be more harmful than helpful - but why not offer them to rich executives since their companies are paying for the bill, right?

Boutique practices, retainer fees, concierge medicine

People often ask me about these so-called boutique practices (AKA: retainer fees, concierge medicine, patient financed medical care, etc.). I usually refer them to the SIMPD. The Society for Innovative Medical Practice Design (SIMPD) is an organization of physicians promoting a direct financial relationship with their patients. Translated = patients who are willing to pay for personalized health care can have more one-on-one time with their physicians by paying cash and bypassing insurance companies.

I think that's fine for patients who have that type of money. If doctors want to offer personalized services and cater to those who can afford it, so be it. However, in today's world, the leading cause of bankruptcy is healthcare bills. As the population ages, fewer can even keep up with the bills. Fewer patients can afford their medications. And, when people reach 65, they can hardly understand the instructions to sign up for all the appropriate Medicare plans. What does this say about our healthcare system?

Working adults (and non-working adults) face different types of struggles. Insurance premiums are escalating, and many have a difficult time keeping up with these rising costs. Consumer directed health plans (CDHP) are starting to get more popular for healthy patients who don't have any serious problems. Fewer physicians are accepting Medicaid, so those who accept Medicaid are getting all the patients in the area. Patients on Medicaid often can't afford medications, so now you have non-compliant patients all going to a single clinician. That clinician will never excel based on pay-for-performance standards since none of his/her patients are being compliant and reaching goal levels. So who gets punished for accepting Medicaid?

The entire system needs a serious overhaul. I wonder what American's health system will look like in a few years. Will these presidential candidates make a dent in the way healthcare is delivered? I guess we'll have to wait and see...