About two decades ago, a Seattle doctor looked at the quickening pace of primary care medicine and devised a practice model that would limit a physician to 50 patients, each of whom would have immediate and unlimited access to their practitioner. He came up with an annual membership fee that currently ranges from $15,000 to $25,000 for such exclusive clubs, so the market remained just that—
exclusive.
His idea prompted others to think about alternatives to the traditional fee-based practices in which doctors and health care providers bill insurance companies for the costs of examinations and procedures. “It started as the ideal medical care movement and branched into direct primary care and concierge medicine models,” says Dr. Andrea Otto, a family medicine physician who recently opened a direct care practice SproutMD in Kirkwood.
Both concierge and direct care models offer patients enhanced physician access for monthly or annual fees. Concierge plans bill the patient’s health insurance carrier for services, but direct care practices do not. However, doctors at both encourage patients to maintain medical insurance coverage for costly care such as emergency room visits and major surgery.
These alternative models can be attractive to physicians as well as patients, says Dr. John Patrick Stein, who operates a concierge practice in Chesterfield. A traditional practice can require a doctor to see a lot of patients or work long hours. “The concierge model lets you get deeper into what is going on with the patient rather than cramming it into a 12-minute appointment,” Stein says.
The traditional model also has changed with the times, though, and still suits many with health insurance, says Dr. Richard Ihnat, an internist with SSM Health Medical Group at St. Mary’s Hospital. Electronic medical records, online patient portals and web-based prescription transactions have streamlined the practice of traditional medicine, he notes. “The benefits of the traditional model are that it is what people know and they don’t have to pay an additional fee,” he says.
direct primary care
>> Monthly fee for unlimited access to basic primary care
>> No insurance billing
>> Medical insurance encouraged to cover major events
“We are going back to the small-town family doctor,” says Otto, who opened SproutMD in May. “We have open lines of communication and know a lot about our patients. They get unlimited office visits, texts, video chats and emails. My patients have my cell phone number and can call whenever they need me. Plus, we use modern technology and evidence-based medicine. Every office visit is an hour long. If someone only needs 15 minutes, they can come and go.”
By eliminating the administrative costs of insurance billing, Otto believes she can provide primary office care at lower costs. “It became apparent that a lot of patients were skipping out on things they needed because they were afraid of the costs,” she explains. “I researched why practitioners were charging $176 to remove a skin tag when the supplies and equipment cost $2. Calculations showed that a traditional office had to charge co-pays and charge insurance to cover the doctor’s and nurse’s salaries, along with those of about 19 other people. Do patients really need to pay for insurance coders, billers, a collection department, IT, human resources and middle management? Not unless you’re dealing with insurance companies.”
SproutMD charges $15 a month for patients up to the age of 18. Age-based fees for adults range from $55 to $75. The practice can provide many basic services, such as lung function testing, skin mole removal and EKGs at no additional cost, Otto says. “I have a medical assistant, and we clean our office, sterilize our equipment, order supplies and do our own billing.”
Knight & Gayles Health Care in St. Charles has been providing skilled home health care since 2008 and has offered direct primary care for two years, says owner Darrion Phelps, who holds a master’s degree in health care administration. He works with three physicians. “People are calling us because they are looking for more personalized care, and physicians are looking to get away from the red tape of health insurance,” he says. “Here, they can offer longer visits and have better relationships with patients.”
His practice bills adults $67 monthly and children $49. A typical office visit lasts 35 to 45 minutes, Phelps says. “The membership fees cover primary care, which is 80 to 85 percent of why we go to the doctor,” he notes. “We encourage everyone to maintain some type of insurance for things that aren’t covered, like emergency room visits or an MRI.” Because basic care is covered, patients can opt for insurance plans with higher deductibles and lower costs, Otto says.
The direct care model does require physicians to limit memberships. “I am going to cap somewhere between 300 to 500 patients, so we have plenty of same-day and next-day visits available,” Phelps says. “Traditional medical practices run 2,000 to 3,000 patients.”
concierge medicine
>> Monthly or annual fee for enhanced access
>> Insurance billed for primary care
>> Some specialized procedures provided
Stein says in his concierge practice, patients receive expanded access to the physician as well as services that may not be available in most primary care offices. Included could be procedures that generally are referred to specialists. “We are doing more total patient care,” he says. “Most folks don’t want to go all over St. Louis to see a lot of physicians. If we can do a knee injection and psychiatric counseling, it is easier to have it all done at one spot. If someone needs a stent or a complex orthopedic procedure, we will consult that out.” Medical insurance is needed to cover those specialist referrals. Membership in Stein’s practice is $1,700 to $2,100 annually, depending on the patient’s age. He says that range is much lower than what is charged by similar practices on the coasts. “It’s less than the cost of one Starbucks drink a day,” he notes.
The additional time and services he is able to provide allow Stein to offer above average care, he says. He prefers to label his practice style ‘personalized’ rather than ‘concierge’ so as not to deter a diverse patient group. While his practice does bill insurance carriers for services, they are expanded, he says. “Our normal visits are half an hour, and our physicals are a full hour,” he explains. “The blood tests we do are more specialized than at the Mayo Clinic. I take all of my own calls. When I travel, I have other doctors who cover for me while I’m en route, but I start taking calls right when I land.” His practice membership will be capped, he says. “When we are near the point that I can’t get people in the same day or next day, I will know I am full.”
traditional practice
>> Fee-for-service model
>> Insurance billed for services with patient co-pays
>> Evolving Traditional service model
“A concierge practice may have 400 or 500 patients, and a typical practice like mine may have 2,000,” Ihnat says. But he explains that many of those patients seldom need care. “I would probably see a patient with well-controlled diabetes or hypertension every six months,” he says. “If the condition is not well-controlled, I might see them every month. My appointments typically last 20 minutes for an established patient and 40 minutes for a new patient. The concierge model makes sense for people who are wealthy enough to afford it, but that’s not the majority. And the number of practicing doctors would have to quadruple if everybody was going to get concierge treatment.”
A larger traditional practice offers its own benefits, Ihnat adds. “We are able to provide excellent medical care using an electronic medical record,” he says. In addition to record-keeping, electronic communication keeps patients in better touch and improves the accuracy and reliability of pharmacy interactions. “The patient portal allows patients to view test results and make and cancel appointments,” Ihnat explains. “If they have medical questions, they can send an email that we usually will answer within one business day.”
Ihnat’s office also offers telehealth visits over computers or cell phones equipped with cameras for $45. Insurance does not cover those visits. “I can’t feel their belly over the phone if they have pain, but I can do follow-up treatment for depression or take a look at a rash,” he says.
