Roberta Greenspan

Converting to a fee-based concierge practice may be the answer to all your problems. But it's not for the squeamish. 

Something is very wrong with primary-care medicine today. Physicians who entered the field because it was supposed to give them time to get to know patients as people, not just as lists of symptoms, are increasingly frustrated with the business side of their practices. They are exhausted; they're fed up. In a Web poll three years ago, 73 percent of primary-care physicians said they regretted their choice of specialty.

The primary-care physicians I consult with every day keep asking me the same questions: 

1. How can I regain my autonomy and release myself from the control of managed care?

2. How can I keep my practice afloat despite decreasing insurance reimbursement and increasing malpractice insurance premiums?

3. How can I regain my passion for medicine? I used to love being a doctor, but today I am forced to see too many patients in too little time, just to stay in business. 

4. How can I deal with the overwhelming time demands imposed by paperwork and phone calls?

5. How can I change patients' perception of me as rushed and impersonal, and my office as hectic and unwelcoming? 

These types of questions are disheartening, both for doctors and patients. Once pillars of the community, primary-care physicians have lost some of the public's esteem. Until the 1990s, in polls ranking trusted professions, physicians were always at the top of the list -- viewed as ethical and compassionate with a single-minded commitment to patient care. No longer. Today, physicians face scrutiny and mistrust. Many patients have concluded that their doctors are disengaged and uncaring. It's no wonder the primary-care specialties are less popular with American medical students than ever before.

What's the solution? There's no magic bullet. But concierge medicine, in which patients pay an annual fee in exchange for special services not covered by Medicare or commercial health plans, is one idea that is growing in popularity. 

The reasons are clear: for physicians, the concierge model holds out the possibility of practicing medicine the way it should be practiced. The membership fees allow a concierge physician to reduce his patient load by as much as 75 percent. That means the patients he sees will get a doctor who once again enjoys his work, who will spend more time with them, and who will offer a more personal level of service. It also means the physician can get his life back. 

Some concierge practices offer a Ritz Carlton-like approach, with everything from valet parking to terry-cloth robes and continental breakfasts. The more typical concierge practice of 300 to 600 patients, though, has less opulent but certainly immeasurably attractive features. These may include same-day appointments, timely return of phone calls, unrushed office visits, and 24-hour-a-day access to the physician's home phone and private cell phone. In some cases, the physician may do house calls and accompany patients on visits to consulting specialists.

Concierge medicine is distinct from cash-only. A cash-only practice offers service for a direct fee, paid by the patient; it accepts no insurance. This model disengages the practice from insurance hassles but not from the need for large patient volumes. A concierge practice may still bill insurers for covered services, generally as an out-of-network provider, though the rules vary by state law and plans' policies. Medicare forbids practices from including in a concierge fee any service for which the government normally pays, but does not prohibit an annual fee for noncovered extras. 

But how do you get there? Many physicians in conventional practices wish they could do something different, and dream about switching to a concierge model. But is it practical? It is for many physicians. Even so, concierge medicine requires a substantial change in the way one thinks about medicine. 

The practice transition process to a concierge model can be daunting. It requires a leap of faith, and most importantly a dogged commitment and determination to reach the ultimate goal. 

One concern is the potential loss of longstanding patients who might not be able to afford the concierge fee. It's tough to leave patients; some of them will resent it, and will tell you so. You may feel guilty. You may even be surprised and hurt to find that some longstanding patients, with whom you thought you had an excellent relationship and whose financial station permits them to afford the fee, decline to stay with you. 

In practical terms, however, you're counting on most of your patients declining. In moving from 3,000 patients to 600, obviously many must decline to sign on. 

But you'll be pleasantly surprised by those who choose to stay, and you don't need to walk away from all of your needy patients. Indeed, you can -- and should -- maintain a list of patients you'll hold onto without charging the concierge fee. It's the right thing to do, and will help assuage any lingering guilty feelings.

Some other transitional issues may include:

Legal concerns that each practice must clarify and resolve with legal counsel. A conversion is best conducted with the assistance of competent healthcare legal counsel. There are too many potential pitfalls, including patient abandonment, state insurance regulations, and Medicare rules, to go it alone. 

The struggle to manage 24-hour-a-day availability to patients and to find acceptable coverage when taking time away. The tough part is finding a physician to cover you while you're away who treats your patients with the same customer-service approach that you have. Beyond that, most concierge physicians find patients are remarkably respectful of their time. 

The ethical and personal dilemma of dismissing patients. Take heart: the furious protests physicians who converted once endured are waning as concierge medicine gains in popularity. 

The potential envy and resentment of nonconcierge physician colleagues. Not everyone who resents your transition will be patients. Some of your colleagues may have a problem with it. But this attitude, too, is waning. In the end, you can serve as a beacon of hope for other struggling primary-care doctors.

Concierge physicians nearly always report less stress than their colleagues in conventional practices, and believe they are finally practicing medicine the way they had once envisioned -- a type of old fashioned medicine in which physician and patient alike believe the medical care is the way it should be. The low patient load provides the freedom to focus on long-term health planning and wellness with patients, in contrast to the traditional focus on managing or resolving illness and dealing with managed care.

Still, the biggest challenge in converting from conventional to concierge medicine is that the new practice may fail. Some failures I've seen were of practices that never should have tried concierge medicine to begin with. Others could have been avoided by better up-front planning.

Consider the following success factors and make an honest assessment of yourself and your practice before deciding to take the leap:

The longer you've practiced in the same location the greater the likelihood of patients' loyalty and their desire to remain with the physician in the new practice. Thinking of moving to a new community where no one knows you and opening a concierge practice from scratch? That's not usually a great idea. 

In order to allow for an approximate 75 percent reduction in practice size, you should have at least 2,000 active patients -- those you've seen at least once in the past two years or so -- to start with. 

You must also understand the socioeconomics of your patient mix and the surrounding community. Unless you want to price yourself right out of business, you need a good handle on how much to charge and what kind of services to provide. 

You must have a reputation for being an excellent physician -- both as a clinician, and in your relationships with patients.

Beyond these items, what are the major reasons concierge practices fail?

Poor utilization of financial resources is a big one -- particularly when the transition struggles the first year. Some physicians spend money on things patients don't really care about. Spending too much money unnecessarily in the early going may cripple you.

Another item that trips up many new concierge practices: staff who are poorly trained, unqualified, or who just don't get the difference between a concierge practice and a traditional clinic. Patient satisfaction with both the physician and the support staff take on even greater importance and require staff who understand this and can step up to the plate.

You may have been tempted to make the conversion but eventually shied away, still wary of such a dramatic change in practice style. Maybe you're worried that you'll be seen as "greedy," or perhaps you're struggling with the debate over the development of a tiered healthcare system. 

I believe these arguments are beginning to give way to the current realities of the business of primary-care medicine. The American Medical Association's recent approval of ethical guidelines for concierge physicians and the continuing growth of these practices may ultimately serve to change the face of primary-care medicine in America. Clearly, concierge medicine has emerged as a reaction to, if not a revolt against, the managed-care system that has physicians spending 10 minutes or less with each patient. It's not right for everyone. But it's a chance to dedicate more time to individual patients while putting an end to your 14-hour days. Your patients deserve a doctor who loves being a doctor. And you deserve a life.

Roberta Greenspan is founder and president of Specialdocs Consultants Inc., a Highland Park, Ill.-based firm that helps primary-care physicians convert from conventional to concierge practices. She can be reached at 847 432 4502, 

This article originally appeared in the September 2005 issue of 

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Frustrated with traditional, volume-based medicine?  We may have just the ticket to enjoying work again.

Author | Roberta Greenspan

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