The Future of Access to Care: A down payment on tomorrow’s checkup

By Ann Chatfield | AZMedicine, June 2005

All the physicians interviewed for this story agree that a big plus in retainer based medicine is the freedom that both the provider and the patient have in choosing the “who, what, when and how” of individual medical needs without an insurance company as a go between. That, and much more time to spend with each patient to evaluate those needs. Steven Knope, MD, is an internist who has served as chief of Medicine, chief of Internal Medicine and director of the MICU at St. Mary’s Hospital in Tucson. He has attracted national attention as a self-described fierce opponent of the HMO industry.

“It evolved in steps,” Dr. Knope says of his current ‘concierge’ medical practice, which now accepts no HMO patients or managed-care contracts. Dr. Knope says he began dropping HMNs in 1998 and by 2000 had begun taking patients on a retainer basis. On April 1,2005, he opted out of Medicare, although he still takes some special clients for the $65 per visit fee normally charged under Medicare. Today, he sees about 1,000 patients who retain indemnity insurance coverage, but also sees about 40 private patients who pay $5,000 per person or $7,500 per couple annually for “unlimited visits, 24/7 , including house calls and emergencies.” Annual physicals and stress tests are included, important to a physician who is a nationally recognized exercise expert and whose practice stresses preventive healthcare. Access to a medically supervised exercise facility nearby is included in Dr. Knope’s fees. He treats a few patients at no charge.

Dr. Knope describes his new approach as “a phenomenal success.” As an example of the freedom he has in choosing how to care for his patients, Dr. Knope points to a recent case where he accompanied a patient suffering from a rare form of cancer on a trip to the University of Texas MD Anderson Cancer Center, something he could not have contemplated under managed care.

Andrew Carroll, MD, is a family physician practicing in Chandler. AzMedicine readers may recall recent artiles by Dr. Carroll describing his vision and experience with implementing a “cash-based” practice. His practice, called Renaissance Family Medical Care, offers “concierge care without the retainer.” As of today, Dr. Carroll says he is very pleased with the way things are going. Between December and February his practice doubled its patient flow, primarily by word of mouth, and also has reduced overhead. The practice currently serves 3,700 patients, and about one-third of those patients are cash-only. Renaissance retains contracts with only about 12 fee-for-service insurers, which has led to faster reimbursements. The practice serves patients at both ends of the income spectrum.

“I think most people who do not have insurance or who are underinsured are looking more for just good, comprehensive care at a fair price, (rather than) ‘guaranteed same day appointment’ or ‘cell phone access,” says Dr. Carroll. “Consumers who have the amount of money they pay anyway.” Dr. Carroll estimates that about 60 percent of his cash-only patients are middle-income wage earners who make too much for AHCCCS or are self-employed; 20 percent are high income; and 20 percent are low-income patients who don’t qualify for state aid. Renaissance has not needed to increase the $70 flat fee per patient visit for uninsured patients since last year, and is actually considering reducing fees in the coming months because of reductions in overhead. The flat fee includes any in-office testing (urinalysis, glucose checks, strep tests, flu checks, etc). Visits also include a 7-day guarantee, so that if the patient needs to return within one week for the same acute problem it only costs $15 for the revisit. Some changes the practice has made include reducing house calls to scheduled visits only, rather than acute visits, and eliminating the provision of pharmaceuticals to patients.

“We have been more strategic about informing patients about possible costs especially with testing not always covered by insurance such as PET scans etc.” Dr. Carroll says. “The thing that’s shocking people th most is medication copays, which have drastically increased to the point of absurdity. I have one patient with a $50 copay! For a visit I get reimbursed $52 for, I will get a check for $2. Insurance is obviously failing in its promise to keep people covered.”

Dr. Carroll has some words of advice for those considering a cash-based practice. “Be realistic. Do NOT expect to bring home a windfall,” he says. “Never forget this is a service industry – do your best for everyone, and patients will never forget you. Pick and choose the insurers you do business with. We still are able to maintain profitability and we take no AHCCCS plans. Keep your Medicare volume minimal. I would suggest no more than 1-2 percent of your practice due to Medicare billing stipulations for equal billing.

“You can do the concierge level care without the retainer,” Dr. Carroll adds. “It’s fair to patients, and it’ll be fair to you. Examine your costs, and adjust your pricing to those costs. For maerketing, use word of mouth – we spent a lot of money on print radio and yellow pages, and our strongest source of referrals was word of mouth – keep your patients happy; they’ll keep you busy.”

EVERYTHING OLD IS NEW AGAIN

Ethan Bindleglas, MD, runs a Phoenix-based family practice called Arcadia Personal Physicians, where he works solo. He has always worked free of contracts, saying that he is only the second physician in the country to follow the retainer-based model straight out of residency. Dr. Bindelglas was interviewed last year by AzMedicine. One year later, he admits he is not getting rich monetarily, but that “quality of life is good” for both himself and his patients. He has increased his annual retainer fee from $900 to $1,100, which still covers five office visits. “Not everyone can afford it,” he says, “But not everyone can afford health insurance either. People are not getting enough of a break, (even in) catastrophic medical care coverage.”

Indeed, medical health savings accounts are much touted now. However, a tpyical HSA medical plan that charges a premium of $282 a month, for example, with a deductible of $2,400, means a total out-of-pocket cost of $5,784 per year before any insurance reimbursement comes into play. The premiums alone total $2,284 annually: more than double a retainer fee similar to that charged by Dr. Bindelglas. Of course, that doesn’t take into account the costs of tests, etc., and ongoing care, but because there is no prequalification for procedures by insurance companies, Dr. Bindelglas says his patients are happier. There is less “red tape” than in traditional practice.

Dr. Bindelglas’ patients file their own insurance claims, if they wish, or seek help from a third party. Those patients who require frequent evalluations and hospital testing may not find a retainer-based model practical, he said. In that case, it may simply be more convenient for the patient to seek more traditional care.

Time with his patients is a big plus for Dr. Bindelglas. Currently, he sees just under 150 patients- 50 more than last year. But he is still able to spend 40 minutes to an hour with each patient, especially on initial visits. He has not had to do any advertising. Most of his patients have come to him by word of mouth. “My retention (of patients) has been 90 percent,” he said. He doesn’t charge for preventative care, and provides lab work free of charge for his low-income patients, who comprise about 10 percent of his practice. He still deals with paperwork, he says, but electronic medical records (EMRs) have helped simplify things. “The bottom line is, I’m happy with what I’m doing,” he says.

MAKING THE TRANSITION
Helene Wechsler, MD, MD(H), founder of Scottsdale Private Physicians, is certified both in medical family practice and in homeopathy, and treats her patients with a mix of naturopathic and conventional medicine, seeking more natural and less toxic pharmaceuticals to treat illnesses whenever possible. That desire for a simpler and more holistic approach to medicine has transitioned to the business side of her practice as well. Since July 1,2004, Dr. Wechsler has, like Dr. Bindelglas been “flying solo.” From 12 employees in the previous practice she shared with other physicians, she is now down to two. She and her small staff moved into new offices on Scottsdale Road in April. A chiropractic physician sees patients at her office two afternoons a week.

After 16 years in practice, Dr. Wechsler also now sees patients on a retainer basis. “I’ve never been happier,” she said. “It’s a ‘win-win’ situation. The patients love it-they get more attention-and it’s really pleasant.” For an annual fee of $1,500 per person (or $500 up front and $90/month), patients receive 18 visits a year, which includes up to 6 hours of calls, up to 6 after-hour and weekend office visits and up to 18 hospital visits. Any additional care is charged at $20 per visit. As Dr. Wechsler says, physicians are indeed “borrowing from the past” in offering house calls.

Not only that, Dr. Wechsler’s practice is unique in that patients have 24/7 access to her, through either her private cell phone in emergencies, or by e-mail for non-emergency communications. So far, she says, her patients have not abused the privilege. “It would not be right for everyone,” she says of her practice. “Patients do demand more of your time-but they get a chance to express their wishes.” Most of her patients, she said, “know what they need and are willing to pay for it.” However, she also sees about 25 low-income patients free of charge, and hopes to increase that number as her practice grows and can support it.

Like the rest of her colleagues in concierge medicine, Dr. Wechsler enjoys the fact that she can spend more time with her patients, much as the old country doctors used to be able to do. She sees only 8-10 patients a day. “I now have 225 paying patients, not 3,000,” she said. “The pace is much more slow,” she said. “My stress level has been cut in half.” She enjoys the opportunity to keep her patients healthy. All patients receive “a complete, comprehensive, annual physical exam with specific, personalized recommendations for optimizing health and longevity.” Because of Dr. Wechsler’s “bundled” pricing scheme, she says it is not possible for patients to bill insurance for their medical visits, but most retain separate coverage for hospitalizations and major medical needs.

Perhaps the bottom line for all physicians who have embraced concierge care is that they have the time and the means to treat, in Dr. Wechsler’s words, “the human being at the center of each patient.”

Ms. Chatfield is a freelance writer living in Phoenix, Arizona.

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