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October 26, 2007

My concierge health care experience

mdvip_logo.gifBill Lent is one of Houston's finest internists. How do I know this? Well, because I know who trained him (my late father) and he has been my personal physician for the past 15 years or so. Having been blessed with good health, the only medical service that I buy from Dr. Lent in most years is my annual physical, which I generally schedule for about this time each year. I always enjoy catching up with Dr. Lent, who provides me with "on the front line" information regarding the horrific cost of health care regulations, which are literally strangling the market for primary care physicians in the U.S.

It's been particularly interesting watching the evolution over the years of Dr. Lent's internal medicine practice, from one in which Dr. Lent provided an unusually high level of personal care to his patients (something my father emphasized in his teaching) to a high volume, impersonal practice that virtually all primary care practices have been required to adopt to remain even marginally profitable under the present U.S. health care finance system. Over the past ten years or so, Dr. Lent has continually confided to me during our annual visits that he was uncomfortable with the direction of his practice.

So, I was pleased to learn when I scheduled my physical a couple of weeks ago that Dr. Lent is doing something about it. Starting next month, Dr. Lent is commencing a concierge health care practice, administered by MDVIP out of Boca Raton, in which he is limiting his practice to about 600 patients who will pay Dr. Lent $1,500 annually for the benefit of receiving his personalized style of service. Coincidentally, this Wall Street Journal ($) article earlier this week described the proliferation of pre-paid health care plans, which is sort of a lower-priced form of what Dr. Lent is doing. The WSJ article essentially describes how many primary care physicians are simply dropping out of insurance plans -- both public and private -- in favor of prepaid plans that offer unlimited access to basic health care for set monthly fees.

Inasmuch as the employer-based health insurance system typically offers low-copays and deductibles for the vast majority of health care services, a substantial amount of the American health care finance system is basically prepaid health care already. In order to maintain profitability in a highly-regulated market, insurance companies compensate for these low usage fees by charging higher monthly premiums, lowballing doctors' fees, and challenging claims continually. The result has been the evolution of a primary care system that is incredibly bureaucratic (have you ever tried to figure out how your insurance pays claims?) and literally breaking down.

The MDVIP model treats primary care service similar to a health club membership. The model focuses on the delivery of relatively inexpensive, protocol-driven care than can be offered at a relatively low cost while still providing patients more overall access. MDVIP's model is relatively expensive, so low-income patients will have a difficult time affording the fee. However, providing a tax deduction for individual health insurance would make such pre-paid plans more affordable for low-income patients, while providing Medicaid patients with vouchers for prepaid health care would have a similar impact.

Who will be threatened from the proliferation of these plans under the current health care finance system? Well, it's a bit early to speculate, but my sense is that insurance companies with big stakes in employer-based health insurance will not enjoy the competition from MDVIP-type practices. Similarly, speciality providers who depend on state regulatory mandates in comprehensive insurance plans to subsidize their practices will also feel the competitive pressure if these types of plans catch on in a big way.

So, I'm going to enjoy learning about how Dr. Lent's practice changes over the next year under the MDVIP structure. If it is successful, as I suspect it will be, it makes you wonder -- if such entrepreneurial spirit can be generated even in the current highly-regulated health care finance system, then imagine what could happen if we unleashed the power of the marketplace to reform the delivery of health care and the health care finance system?

Posted by Tom at October 26, 2007 12:10 AM |


Thanks for the information -- I look forward to any future observations on the MDVIP program. After checking around a while, I am about to move to an MDVIP physician myself. I have decided that the price premium is worth the peace of mind of having a physician who is actually able to take the time to pay attention to me.

I have also been receiving information from a few practices focused on "anti-aging", such as Cenegenics (http://www.cenegenics.com/). I would be interested in your perspective on this trend. Thanks.

Posted by: Evan Author Profile Page at October 26, 2007 11:01 AM

The other problem is the supply of physicians, especially in Primary Care. Of course, better pay and working conditions will help bring more people into the field. But consider places like The Woodlands and Pearland that have experienced exponential population growth. With 30,000 new Pearlanders in the last 10 years, that would mean 500 new PCP's would be needed. We have had 12 of us start or move our practices there in that time. I don't think another 200 are available for just Pearland.

In Canada, they use a lot of nurses in primary care offices as extenders to do patient education and routine (cough/cold/vaccination) type visits. It'll happen here for the same economic reasons.

Posted by: Kenneth Author Profile Page at October 26, 2007 7:53 PM

As a fellow internist, I applaud Dr. Lent's decision to attempt to regain control of his medical practice. Knowing him as I do (he was three years ahead of me as we both were trained by Tom's father), I have no doubt that he will succeed in this enterprise.

The concept of concierge medicine is an interesting development that I have been watching for several years. In reality, it's just a method by which the doc can get paid (thru the yearly fee) for the work that many of us internists were doing for free. By limiting the size of the practice to 600 patients, an internist now has the time to spend with each individual in a comprehensive and contemplative manner. And the internist also will be able to quickly respond to phone calls and e-mails from his patients, something that has been placed on the back burner presently as the pressure to see more and more patients evolved as reimbursement for each encounter has fallen. This recalls the apocryphal story of a doctor who was receiving less and less in payment for office visits from an insurance company, to the point that the amount he was now getting was less than his cost to deliver that care. When asked if he was going to opt out of being a "provider" in that insurance plan, the doctor replied, "No, I'm just going to try to keep making up the difference by increasing my patient volume...." No one has ever claimed that being a good physician makes you a good businessman.

Concierge practices should thrive in big cosmopolitan centers such as Houston, but will not translate well to smaller venues. Typically, there is not the population of well-heeled health-conscious persons to fill the needed patient roster. Additionally, there wouldn't be easy access to the coordinated centers of medical specialty and subspecialty described by the MDVIP website. Nonetheless, I am in favor of the idea, and will be anxious to hear Tom's follow up blog posts of his experiences with this.

To address fellow physician Kenneth's comment about "physician extenders", I concur that more and more primary care is and will be delivered by nurse practitioners and physician assistants, but I am not a big fan of this development. As an analogy, how many of us would feel comfortable when flying if the solution to a shortage in airline pilots was to put "pilot extenders" into the cockpits as replacements?

I have always thought that, as a well trained General Internist, a good NP or PA could do 80% of what I could do in diagnosis and management of patients in an office-based practice. A good Family Medicine doc can provide 90-95% of what I would have to offer those patients. The problem is, though, that patients do not wear a sign around their neck declaring which fraction of the population to which they belong. The best scenario is when the NP or PA knows their limitations, and refers a patient who is not responding to standard therapy up the specialty chain as quickly as possible, just as I try to accept my limitations, and refer the patient I can't figure out or treat on to the appropriate subspecialist.


Posted by: jim bob Author Profile Page at October 27, 2007 8:21 AM

I have decided that the price premium is worth the peace of mind of having a physician who is actually able to take the time to pay attention to me.

Exactly. I don't belong to such a program, because I am thus far young and healthy. But when one or both situations change, I'll gladly pay for access.

On a related note, many doctors complain about sites like WebMD.com, claiming such sites give inaccurate information or that those sites do not provide enough context. Yet such sites proliferate because doctors are not providing patients with enough information.

Finally some doctors are realizing that they can make a profit by providing detailed information to fewer patients. Medicine need not be a volume-based practice.

The best lawyers provide the most attention to their clients - and charge accordingly. Edward Bennett Williams was expensive, but when your life in on the line, can you afford a cheap lawyer? Perhaps some doctors might move to the billable hour method. "For x-dollars, you can talk to me for y-minutes about your medical condition." I'd have no problem meeting those terms.

Of course, many insurance companies might not pay for such consultations. Too many patients feel entitled to have every medical service covered by their insurer, and cringe when something is not covered. I've long thought that was misguided.

Typical insurance is for something catastrophic, e.g., the loss of a car or home. Yet routine medical visits costing $500 or less are covered under most insurance programs. What is up with that?

The market needs less entitled consumers and less risk-averse doctors. Routine medical car, like routine car and routine home repairs, are something you pay out of pocket. Only when a disaster strikes (leukemia, a car accident, the Santa Ana winds and fires) should insurance kick in.

Posted by: Mike Author Profile Page at October 27, 2007 5:11 PM

"A good Family Medicine doc can provide 90-95% of what I would have to offer those patients."

jrb- Actually, a good Family Medicine doc can provide 200% of what an Internist can offer. I treat kids, too;) I have to admit, most PCP's(Internists, pediatricians, and FP's) fall under Mike's "risk-averse" category.

As far as using RN's, NP's, and PA's, the key is how you use them. Train them to be patient educators and have them teach group classes. They can facilitate in discussion groups. They can help design protocols for patient care in a given office setting. One unaddressed problem is how to providers serve communities that do not have enough providers.

Posted by: Kenneth Author Profile Page at October 30, 2007 9:27 PM

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