Thursday, January 5, 2012

Retainer, Concierge and Boutique Medicine are Not the Same Thing

Health care is in crisis. Reimbursements from insurance companies continue to dwindle, while the expenses of running an office continue to rise.  Looming cuts in Medicare are only weeks away, and many physicians may stop taking Medicare.  If these cuts go into affect, it is possible that primary care physicians could lose up to 50% of their salary.  Just recently CNN reported that some doctors are going bankrupt.

How to fix our health care system is an ongoing debate, but not surprisingly, many physicians have decided not to wait for the government to solve this problem and have taken matters into their own hands. One solution is to simply stop taking insurance altogether.  “Cash only” doctors are now commonplace in many major metropolitan areas.  Another solution is charging a regular, out of pocket fee (usually) in addition to what insurance will pay for treatment.  A version of this model that is becoming popular is called retainer medicine.  Sometimes, retainer medicine is referred to a “boutique” or “concierge” even by physicians and others involved in health care (as evidenced by this article in the AMA News, which prompted me to post on this topic).

However, “retainer”, “concierge” and “boutique” are not the same thing. Names are important, and the terms “concierge” and “boutique” tend to have negative connotations. Thus, it is important to describe the differences.

In a retainer model, patients pay a fee (not covered by insurance) to be part of a physician’s practice.  This is similar to clients paying a retainer fee to hire a specific lawyer.  With reimbursements from insurance companies being so low, the only way an insurance based physician can increase revenues is to increase the volume of patients they see.  Unfortunately, when physicians increase the number of patients they see, it leads to rushed patient visits, long waits in the waiting room, and decreased access to physicians including difficulty in getting appointments or responses phone call messages.  By accepting a retainer fee, the physician no longer needs to rely on insurance revenue alone, and in fact can decrease the amount of patients he or she sees on a regular basis. This allows for increased access (usually same day or next day appointments and 24/7 phone access) and longer appointment times (usually 30-60 minutes) for patients willing to pay a retainer fee.  The typical insurance based primary care physician has about 2500-3000 patients in their practice, and sees about 25 patients a day.  The typical retainer physician has about 500 patients and sees only a handful of patients each day.  Retainer fees and the amount of access patients get for what they pay vary widely, but the average retainer fee is about $1500 per year. 

Some have argued that retainer medicine is unethical because not everyone can afford $1500 a year.  First, the typical retainer fee amounts to about $4 a day, which is what many Americans pay (or more) for a Starbucks coffee. Secondly, one could also argue that it is also unethical for insurance based physicians to see complex patients in brief visits and/or not being able to see them in a timely fashion due to lack of access. 

Concierge medicine is somewhat different, and in my opinion, should not be used synonymously with retainer medicine. 

According to Wikipedia;
“A concierge is an employee who either works in shifts within, or lives on the premises of an apartment building or a hotel and serves guests with duties similar to those of a butler. The term "concierge" evolved from the French Comte Des Cierges, The Keeper of the Candles, who tended to visiting nobles in castles of the medieval era.”

Just like the concierge at a hotel, who can get you good seats at a ticketed event, a reservation at a popular restaurant, or even run an errand; a concierge physician can get you timely appointments with the best specialists, usually doing the scheduling themselves.  Many concierge physicians will even accompany patients to procedures or diagnostics tests, and some will even make house calls. Though some retainer practice physicians may perform concierge services (usually the ones charging well over the usual $1500 fee), the terms are not the same.  Many retainer physicians will assist in coordinating specialist appointments, but this is as far as they go. In fact, some “cash only” physicians perform concierge services to attract more patients, and some doctors (even insurances based physicians) will charge an extra-fee for some concierge services, such as a house call.

Boutique medicine is also completely different. Again, from Wikipedia:

“A boutique is a small shopping outlet, especially one that specializes in elite and fashionable items such as clothing and jewelry. It can also refer to a specialised firm such as a boutique investment bank or boutique law firm. In the strictest sense of the word, boutiques would be one-of-a-kind but more generally speaking, some chains can be referred to as boutiques if they specialize in particularly stylish offerings.”

I think the key words in this definition are “specilalized” “stylish” and “elite.” The first word is something commonplace in medicine, but the later two words are something usually not associated with medical practice. “Luxury” is also implied in the word “botique.”  Thus, in my opinion, a boutique doctor is one that specializes in unique, often luxurious services, that are not offered by others and which will therefore cost a little extra.  These services include, but are not limited to, cosmetic procedures (botox, laser hair removal), medical spa services, comprehensive screenings (i.e. body scans), and herbs or supplements.  Though both retainer and concierge physicians may provide boutique services, this is generally not the norm.  In fact, many insurance based primary care physicians have started to add these services as a way of keeping their practice running. (Ethics could be questioned here as well).

I am not arguing that retainer medicine is the solution for all of our nation’s health care woes. It certainly is not.  However, given that it solves some of the issues with 3rd party payors, is a model that continues to grow, and patients and providers enrolled seem to be very satisfied; it is something that deserves attention.  Another model that is garnering some attention is direct access primary care.  In this model, patients pay a monthly fee (usually about $70/month) and receive enhanced access and communication as well as primary care and urgent care services. Though the cost is slightly less ($1500/yr vs. $840/yr) and access to your personal may not be 24/7, this is a similar model to the retainer concept. (Proponents have called this retainer medicine for the masses).

Thus, using terms “concierge” and “boutique” that have connotations of elitism, luxury and unnecessary care synonymously with retainer medicine discredits a potentially viable health care model for many Americans.  I would request that physicians, policy makers and journalists no longer use these terms as if they were the same. 


Daniel Ginsberg said...

Good description of the various practices. Unfortunately, having sent two kids to orthodontists, I associate "retainer" with expensive!

Anonymous said...

Interesting blog Dr. Mintz. We have a serious problem here. Given the high cost of a medical education and malpractice insurance plus all the other various expenses to BE a doctor it's a wonder anyone wants to get into the profession at all. As healthcare costs go up and insurance reimbursement goes down things are only going to get worse.

So if insurance, medicare and medicaid get so bad that doctors refuse to accept them how will that make things any better? Patients are already struggling to pay when they have insurance. How will they do better without it AND how can a doctor have a large enough practice to offset the losses if his unsubsidized rates are more expensive?

The retainer idea is intriguing but consider this. If you are looking to collect from insurance and use the retainer to bring in more money how will that increase your clientele? And once the insurance companies see this practice how soon before they try to get some piece of that revenue?

The way I see the first thing that needs to happen is a fundamental change in the operating expenses of a medical practice. Everything from college loans to malpractice insurance need to be looked at.

So far everything falls on the doctor or the patient while insurance companies go on to make more and more. You don't really hear about insurance companies going bankrupt?