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Patient-Driven Primary Care Shouldn’t Be Labeled “Concierge”

I bristle when my patient-driven, fee-for-service primary practice, DocTalker Family Medicine, gets lumped into the “concierge” movement, as it frequently does. First, veterinarians, accountants, mechanics lawyers and all other service providers in everyday life who work directly for their clients and not as “preferred providers” for the insurance companies are not labeled “concierge.”  Secondly, the label “concierge” implies exclusivity, membership, high yearly retainers, and capped patient enrollment. Each of these labels we too reject.

A practice like ours out-competes the traditional model and the “concierge idea” in almost every measurable way:  access, convenience, patient control, speed to treatment, quality and finally and maybe most importantly for the sake of the health care debate, price. Our boss is each patient one at a time, and our goal is to provide the most cost effective delivery model achievable. We strive for nothing less than making primary care immediate, high quality, patient controlled and affordable to every American.   We deliver a concierge-level service at a price that is much less than even the price-fixing controlled by the insurance-driven model to date.

Central to our philosophy is how we approach payment. What we sell is time; we charge purely on time-based services.  Prices for materials, like supplies, vaccines, and labs are posted on the website and have little mark-up so that we can pass on the savings to our patients. Everyone who interferes with patient control, causes a conflict of interest, or increases cost has been dismissed from the relationship. This includes insurance companies, Medicare, dataminers, coders and drug reps. Our patients pay when services are rendered, just like any other services purchased in our lives.

We applaud concierge practices for providing VIP-service that all patients deserve:  immediate access to a practitioner, convenience, and personalized and high quality care. We offer the same high level of service, but with key differences:

  • No rationing of care by price: Unlike the concierge philosophy, there is no access fee, which in many concierge practices can total $1500 per year.  We instead sell time. We charge in 5 minute increments of time since it’s the most transparent and policeable way of measuring our productivity. Our patients have a choice to pay-as-they-go, which means that they pay when service has been rendered, ($33.33 for five minutes) be it a  phone call, 10-minute office visit, 10-minute email or 10- minute videoconference, no matter what time of day or day of the year. We do offer a 25% discount to patients who put money in a pre-paid account, which means that patients can pay for service ahead of time, and will use the time when they need it. These pre-paid patients have a discounted rate of  $25 for every 5 minutes.  Patients can close their accounts with us at any time at no penalty.

The average person needs about an hour of care a year meaning they have 24-7 instant access to us for $300/year. Over 50% of interactions are solved through phones and emails.  About 75% of the patients in our system spend less than $300 in a year.  Fewer than 1% of our patients this year (out of an active patient group 3000)  spent over $ 1500 and most of these people are elderly, trapped at home with significant medical problems. We are the only medical practice left in Fairfax and Arlington County, Virginia (combined population of 1.3 million) that offers house calls.

This gives you an idea of the price difference that we have over the concierge and even the typical business model of care.

  • No exclusivity or capping of patient numbers: Our philosophy and business model is based on a volume business. We estimate that each medical provider in the practice must carry a work load of about 2,000 active patients to make a competitive living. We do not limit the number of patients we will take. When we need to add on a new PCP to accommodate new patients, we do.  Our satisfaction comes from the mission of providing excellent care at an excellent price and eliminating all conflicts of interest that arise between the doctor and patient that either undermine the relationship or increase the cost of the service.
  • Helping to solve the primary care crises: PCPs are in short supply. There are not enough of us to go around and more retiring faster than they are being made. Medical schools fail to attract primary care specialists in any large numbers since the field typically promises soul crushing work loads and frustrations in reimbursement, which rapidly leads to high burnout. One of the directions the burned-out physician heads is towards the concierge model. By most definitions the concierge solution is a solution for the doctor.

The concierge model places a premium price on access to primary care, taking advantage of the shortage of primary care physicians. I predict this is not sustainable. The typical concierge practitioner collects $1 million in access fees from clients and takes care of 600-800 patients, which totals 25-33% of capacity in a typical practice where physicians are expected to care for 2,000 to 2,500 patients. Under the concierge banner, primary care costs 3-5 times more than needed, it would also require a primary care work force 3 times larger than it is today.

I understand that our practice seems a little radical, but some call us “the practice of the future.” In truth, it’s how medicine used to be practiced only a few decades ago. Likewise, or practice embodies the medical home described by many  who believe in the key role primary care needs to play in our health care system. To make this happen, we’ve upgraded phones, emails, video, computers , EMR and direct communications between patient and doctor into the practice and  linked it  to time based billing like most other sectors of the economy.

My partners and I hope that others with the same hopes and goals for primary care will consider this model or something like it soon. The future of primary care depends on it, and doctors are the solution.

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2 Responses to “Patient-Driven Primary Care Shouldn’t Be Labeled “Concierge””

  1. Michael Taytro says:

    Concierge medicine has had somewhat of a “brand/identity” issue in the media and health care marketplace. It’s also referred to as: membership medicine; boutique medicine; retainer-based medicine; concierge health care; cash only practice; direct care; direct primary care and direct practice medicine.

    I agree, all concierge medicine practices share similarities, but they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the amount of the fee charged, such as the one you deliver at your DocTalker practice.

    In a recent (fall 2009) poll of consumers and physicians, Concierge Medicine Today asked “Which term would you prefer the media use to describe ‘concierge medicine’?”

    The majority of respondents (I.e. traditional PCPs; concierge PCPs; office managers; media executives; specialty physicians; health care consultants; traditional family practice doctors; concierge family physicians; national associations; etc.), agree that the term they prefer most to describe retainer-based/boutique/direct care practices is in fact, ‘Concierge Medicine.’


    Direct primary care (DPC) is a term often linked to its companion in health care, ‘concierge medicine.’ Although the two terms are similar and belong to the same family, concierge medicine is a term that fully embraces or ‘includes’ many different health care delivery models, direct primary care being one of them.


  2. Alan Dappen says:

    Thanks for you informative response. By the sounds of it, I stand corrected and remain off-base.

    The term “concierge” still rankles me and I think does a disservice to the many physicians out there who are working on new business models that deliver better service, quality, and focus heavily on a price that is more competitive.

    I stand-by my earlier statement that no other sector of the economy would label a professional “concierge” when they labored to do a better service at a lower price that can reach the masses. For example, the Minute Clinics provide a convenient service for much less money. To those who would dare compete on price the label wildly swings the opposite direction from elitists (concierge) to shotty (nurse in the box.)

    To physicians working in the front line of primary care these two opposing labels stereotype and misrepresent our mission and purpose. One wonders, to whose advantage.

    AD MD

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