Imagine opening a letter like this from your doctor:
“I'd love to keep you as a patient, but to stay with me you'll have to pay an extra annual fee of $2,500.
“Please let my office know if you will be paying the fee. If not, we'll help you find another primary care doctor.”
Although it might be worded more politely, that's the gist of the letter you could receive if your doctor adopts a style of primary health care known as concierge medicine.
Its backers say the concept can attract and retain more primary care doctors by improving their lives and enabling them to practice medicine the way they want, rather than under the time-constrained demands of the typical doctor's office.
But the concept also raises philosophical and ethical issues. Concierge physicians limit the number of patients they see by charging annual fees, which wealthy people can more easily afford. Also, this kind of medicine could reduce the number of primary care doctors at a time when demand already exceeds supply.
Nationally, the practice of concierge medicine is still small — perhaps 400 primary care physicians out of about 250,000 nationally — but in some regions it is firmly established.
The largest concierge company, MDVIP, has more than 300 doctors nationwide and recently was purchased by Procter & Gamble. It's been more than 12 years since the first such practice opened in Seattle. There's even a cable TV program, “Royal Pains,” about concierge medicine.
But the approach has only recently arrived here. Nebraska's first, a two-doctor practice, opened last month near 90th Street and West Dodge Road in Omaha after a three-year trial at the University of Nebraska Medical Center.
It's affiliated with a new Omaha management company, Members.MD, whose chairman is former Burger King franchise owner and cancer survivor Mike Simmonds.
“Primary care is broken,” said Dr. Joel Bessmer, who is medical director of Members.MD and who opened the new practice with partner Dr. Robert Schwab. “It allows us to step off the treadmill and spend time with patients. This is a different world of trying to provide primary care.”
Physicians get to know patients thoroughly and become their health partners, he said. The doctor's office becomes the patients' comfortable, easily accessible medical home, instead of a hurried place full of other sick people and doctors who have no time to spare.
But Dr. John Goodson of Harvard Medical School said concierge medicine could worsen a system that to some degree already dispenses care based on whether people can afford insurance.
“Do we as physicians hang together and maintain our commitment to access?” he said. “That really ought to be a fundamental principle of medicine. We're there to help people, and we're not going to discriminate against people because of their economics.”
Goodson said primary care doctors should supervise their patients' hospital stays as part of normal care, not for an extra fee. Members.MD offers hospital supervision only with its upper level of care.
Eliminating people from a medical practice by charging a fee is “abandonment,” he said. Even if a patient's records transfer, the new doctor doesn't know all the information that the first doctor learned about the patient.
Yet the rise of concierge care, he said, shows that as a profession, primary care “is on the ropes and dying fast. It's like the polar ice cap, starting to fracture. It ought to be a wake-up call to everybody.”
He said that the start of a practice in Omaha indicates the concierge model, although marginal in most regions, isn't going away. “It makes me sad as a professional that my colleagues are doing this sort of charging.”
Simmonds, the chairman of Members.MD, agreed that a rapid spread of concierge medicine would worsen the supply of primary care doctors.
“On the other hand, if it improves life for physicians, maybe more young people will want to go into internal medicine and will not suffer that burnout,” he said. “The only way they survive today is by seeing ever more patients in a given amount of time. And they (doctors) hate it because they really care about wanting to help people. They don't have time to spend with people to give them the quality time they need.”
Simmonds, who was inducted in the Omaha Business Hall of Fame last year for his success in the fast-food business, said the concept is “sort of the talk of the town, at least in my circles.”
Simmonds said he heard about Bessmer's practice from a fellow airplane traveler, called Bessmer the next morning, interviewed him over lunch at Charleston's and “hired him” as his doctor. Simmonds' former primary care doctor was good and even a friend, but Simmonds couldn't call or e-mail him whenever he wanted.
“When I don't feel good, I like to talk to somebody right now,” he said. “Joel spoiled me,” including supervising his care when he was hospitalized and providing other care over the past year and a half. He was diagnosed with cancer several years ago.
Simmonds, Bessmer, Schwab and Gary Glissman, a former nurse and medical administrator, formed Members.MD to help other doctors convert their practices, with a goal of forming 10 to 20 such practices in the Midwest in the next three or four years. Besides Omaha, target markets might include Lincoln, Des Moines, Kansas City, Mo., and Milwaukee.
Glissman said the annual fee of $2,500 for the basic service and $4,000 for the higher level of care amounts to about $7 or $11 a day, amounts which are within reach of many people, not only the wealthy.
In Omaha, Bessmer, who continues to work part time at UNMC, could handle about 300 patients in the concierge practice; Schwab can accept about 400. So far the practice has about 200 patients.
Simmonds said doctors could make the switch themselves, but for a percentage of the fees Members.MD assumes responsibility for the business activities, including advertising, setting up a clinic, pricing, even hiring employees and buying supplies.
Doctors “went to medical school, not business school. We take the business work away from them,” Simmonds said.
In a typical primary care practice of 2,000 patients, about 80 percent would decide not to pay the additional fees for concierge service, Simmonds said. That would leave 400 patients, which he said is “perfect.”
Besides individuals, Members.MD is targeting corporations that pay for physical examinations for their executives. For about the same cost as a one-day exam, Simmonds said, a concierge doctor makes a health plan and is available every day for a year.
The new practice is an outgrowth of the “personal services medical program” which Bessmer started at the medical center about three years ago.
Dr. Lynell Klassen, chairman of UNMC's department of internal medicine, said trying out new ideas is a proper role at a teaching medical center. But after the trial proved that the concept would work, he said, “we also felt that it really didn't fit within our core activities as an academic department of medicine. For that reason, Joel decided to take it into the private sphere.”
The practice met the objectives of giving people access to good medical care, Klassen said, but fell short on affordability and didn't fully meet UNMC's education and research missions.
“The financial aspect of paying for access to a physician has its own set of questions that many people raise,” Klassen said.
And if every primary care doctor adopted the model, the state would need about three times as many physicians, he said.
“Right now you already have an absolute and relative deficiency in the number of primary care providers. When people talk about this there are some positive things on an individual basis. There are some things that may not be so positive on a societal basis.”
Bessmer, a native of Plainview, Neb., said only a few doctors are likely to adopt the concierge model. But more doctors may choose primary care if they can practice the kind of personal-contact medicine they want, he said.
Concierge medicine is not for every doctor, he said. For example, it requires doctors to be continually on call, ready to respond quickly to each patient's phone call or e-mail, plus house calls or office calls for some patients.
But Bessmer, who has 12 children, said the practice helps him balance work and family. In a standard practice, he said, “that was a constant challenge for me.”
His patients average 60 or 61 years old and are evenly split between men and women. About 10 percent are younger than 40.
Bessmer said emergency room visits and hospitalization decrease substantially, and hospital supervision by the primary care doctor can avoid unnecessary tests or treatments that don't work. That saves money for the patient and for firms providing their employees' insurance.
The Bessmer-Schwab PC office resembles a plush law office. Patients wait by themselves in a small room with a couch, flat-screen TV and other amenities.
Simmonds, who has sold his restaurants, said he is excited about the concept and his newest venture.
“It's like everything in life,” he said. “You can drive a Mercedes or you can drive a Toyota, and in America you get a choice as to what you want to do. This is the Mercedes of health care.
“It's obviously not affordable for everyone, but for those who can afford it, it's a wonderful alternative.”
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