Concierge medicine gaining ground: competition forces medical center into 'boutique' business. (Innovation).

MUCH IS BEING WRITTEN and said these days about concierge medicine.

Also described in the media as "boutique," "retainer," "platinum," "gold-plated," "premium," "old-style," "Main Street" and more recently, "luxury primary care," (1) the concept generates considerable debate.

At issue are patients' rights to purchase more time and attention from their physicians, the physicians' moral and ethical obligation to treat all patients, and the potential emergence of a two-tiered, and some say multi-tiered, (2) health care delivery system.

But in today's health care climate, can large health care organizations afford not to seriously examine the social and economic potential of this type of practice?

Two Seattle general internists established the first concierge practice in 1996. Similar private practices now exist in Florida, Massachusetts and California, and are planned in many other states.

Large medical centers avoided this practice model, choosing instead to offer patron patients luxury hospital suites that provide specially prepared meals and other amenities. VIP patients are often given prompt side-door access at the request of the CEO's office or foundation.

Competition in Seattle

Initially, Virginia Mason Medical Center in Seattle, where I have practiced for 25 years, chose not to participate in concierge medicine, as well. Then, three years ago, a number of dedicated benefactor patients quietly departed and the idea gained new respect. Competition played a part.

Two popular, local internists had opened the original concierge practice just two blocks from the doors of our medical center. Like other large cities, Seattle had experienced the usual turf battles for patient loyalty over the years, with "quality" topping everyone's list of potential advantages. No organization easily and consistently differentiated itself.

But this threat was different. Our patron patients were hearing from friends who joined the new practice that service now meant 24/7 cell phone access to their doctor, who actually answered his own phone. The doctor made house calls and business office calls, had time for longer appointments and paid more attention to their questions and requests.

Suddenly the common buzzwords "access," "patient-centered" and "quality" took on an entirely different meaning. Some of my long-term patients apologetically left my practice, often with a note claiming, "Dr. K, it's nothing against you personally, but the service in your medical center just isn't what it is at _____."

After responding to one too many requests to forward a patient's medical records and after hearing legendary tales about the service these docs provided, it became clear that we had a significant problem.

However unappealing the idea of charging patients premium prices for extra time and attention was our medical center could not afford to lose so many of its most devoted patrons, especially when achieving a positive bottom line was an increasing challenge.

Getting our organization to approve concierge care seemed an onerous task to many and nearly impossible to most. But with the aggressive help of some committed and loyal patients, the endorsement of a retired Virginia Mason administrator with a national reputation, and the support of both our CEO and president, a year-long debate over the relative risks and merits of such a program finally concluded with the decision to move forward to establish the first premium service program within a major medical center.

Concierge arrives

Our program began in January of 2000 with two primary care internists, two capable nurses and a talented medical assistant. Nearly three years later, our program is thriving.

We have achieved a rare win-win-win feat, satisfying patients, physicians, staff and our medical center leadership. Patients are happy with the 24/7 phone access and appreciate the service package we offer that includes:

* Same-day appointments

* Longer appointments

* Housecalls

* Business office calls

Our patients get more time and attention from a less harried physician and a staff with the time to help. The staff appreciates the benefits of supporting fewer patients. They feel less stressed and enjoy greater flexibility and more autonomy, taking pride in giving truly personalized attention to each patient as he or she walks into the clinic.

Gone is the need to apologize to patients for lengthy waits, delays and the incomplete or unintentional miscommunication inherent to overloaded systems.

Communication in all areas is enhanced.

Physician pay-off

Participating physicians are equally enthusiastic. They are able to spend more time with each patient in their panel, with less production pressure and reduced paperwork. And they are experiencing the old-fashioned joys of house calls.

Physicians also report unanticipated educational opportunities as they accompany patients to specialist appointments and procedures and they are finding more time to keep up with medical journals.

For the most part, specialists enjoy these interactions with the primary physician as well, because the primary care physician is then better-equipped to answer specialty questions after having heard the recommendations first-hand.

An older physician in our group, once considering retirement in the current health care climate, has been rejuvenated and now enthusiastically looks forward to going to work each day.

Finally, the organization is pleased with the retention of its experienced doctors and nurses, the strengthening of loyalties to patron patients and the significant revenue the program generates to help the bottom line.

Problems to overcome

There are some pitfalls.

A few patients now expect everyone in the medical center to give them the same service provided by our team, something that is not possible in the current system. Staff members sometimes experience disappointment at being unable to satisfy all patient requests related to specialty care.

Although most patients are respectful and communication is key, physicians can also be frustrated by requests from patients regarding their family and friends, who also have higher expectations for immediate answers and availability.

Some of these demands are intrusive and can disrupt the physician's private life. The organization can also have trouble with the public's perception of this type of program and the internal conflicts that can arise when such issues are first addressed.

Mango points out that "the public and the organization must get over the notion that because a few will get this premium service, the rest will get inferior service and care." (3) The same great standard of care that a medical center is known for can still be given to everyone, despite the service level being somewhat different.

As a Seattle Times editorial commented, "The quality of care for the general public will shape the reputation of the institution, not the first-class care for the lucky few." (4)

Leaders must convince the entire medical center that their work defines the institution, while walking the delicate tightrope of providing extra service for the small percentage who pay the enrollment fee.

Satisfying statistics

So fax, Virginia Mason has been very successful. Now in its third year, the Lewis and John Dare Center at Virginian Mason Medical Center has five physicians practicing in three different locations around the greater Seattle area.

Over 850 patients are enrolled, generating nearly $2.5 million in gross receipts. The attrition rate is less than 5 percent and standard patient satisfaction surveys show that 98 percent of our patients are extremely satisfied with the program.

The average age of our patients is 72, with each patient visiting an average of six times per year and calling or e-mailing about seven times per year.

One of our physicians has made over 150 house calls, saving an estimated 75 emergency room visits.

We have helped some of the busiest general internists in our medical center by removing some of their most demanding patients, who take extra time with excessive questions and requests.

Net productivity for the internists in our program increased two to three times and take-home salaries improved. The net margin in 2001 for our program was 29.7 percent.

It is no secret that despite major research advances and a promising new generation of high-tech equipment and procedures, medical centers around the country today are plagued by declining reimbursement, disengaged and disenchanted physicians (5) and staff, and dissatisfied patients.

Concierge practices are springing up in many cities as word of the success of various models spreads. If a successful pair of internists or a medical center near you is rumored to be considering this style of practice, you may need to consider getting better acquainted with its merits.

The alternative may be losing many of your important patron patients as they hear from enthusiastic participants about the high-service benefits of belonging to a concierge practice.

References

(1.) Brennan, T. "Luxury Primary care." New England Journal of Med. 2002, 346:1165-1168.

(2.) Parrish, M. "A New Day Dawns... When Patients Buy Their Own Health care." Medical Economics. Mar. 5, 2001. p. 106.

(3.) Mango, PD. The case for "Boutique" Health care." McKinsey Quarterly 2002, 2.

(4.) Seattle Times editorial. January 4 2000.

(5.) Kassirer, JP. "Doctor Discontent." New England Journal of Med. 1998, 339:1543

John Kirkpatrick, MD, is co-founder and section head of The Lewis and John Dare Center of the Virginia Mason Medical Center in Seattle, Wash. He can be reached by phone at 206-3411557 or by e-mail at jobn [e-mail].