I retired before the concierge model came onto the scene but imagine I would have used it if still in practice. I learned of it through a friend who told me he was buying access into the medical care system. It seems to me to be a reasonable free market response to many of the undesirable aspects of medical care that came with the corporate takeover. Many quite rightfully fear having an emergency and being assigned a hospitalist that knows nothing about them.
Good piece, thank you for writing it. I'm struck by the juxtaposition of "failure to invest" in a "public" model and the grassroots nature of direct primary care. The fact is that "we" (through government) have "invested" billions in a system that does not work. Sure, we could tweak it, reform it, whatever... But the fact that it is so dysfunctional is testament to the fact that a top-down, D.C. driven system will always fail to provide what spontaneous order driven by free people will naturally provide. Let's give thanks for DPC. It may be what saves primary care.
I know several colleagues who are happy in direct primary care and say that it kept them from retirement or leaving the practice of medicine. Agree we should learn from the experience and not disparage it. I also think the system needs to compensate primary care better and provide solutions to the practice burdens - some progress is being made, but not fast enough.
I very much appreciate this thoughtful post. The value of concierge medical practices aside, what strikes me most is that this very clear and recognizable description of the work overload comes, not from the trenches of a private hospital system or group practice where profit is the explicit motive, but from a senior member of a major, non-profit, academic medical center - one that routinely and loudly congratulates itself on its progress in improving working conditions for its faculty (i.e., reducing “burnout”, whatever that is). If it’s this bad in the academic setting (and my personal experience is that it absolutely is), I can only imagine how much worse it is in the private sector. The allocation of hospital and University resources to high billing specialties and the systematic deprivation of some units of critical resources, simply because they know we will work harder to protect our ICU newborns puts the lie to the lofty goals and ideals of the senior administration.
Well said! Concierge practice likely deals with both extremes- over testing and "under-testing?" - if that's a thing. We take a minimalist approach and our concierge doctor matches our energy. There's no quality metrics pressure on her to get us to do random screenings or to see her annually. We reach out when we need help and she's there for us. The regular practice we were with before was horrible in comparison (the reception, the rooming, the wait...); we could only reach the doctor via my chart and he needed a 24h response time window. And he was forced to be cookie cutter in his approach because the practice enforced strict processes for screenings. Concierge medicine works really well for the minimalist mindset and I honestly wish it was more accessible and that we could use HSA dollars to pay for it.
Well said. At one point I considered converting my practice to concierge but I considered it to be selling out. I no longer view those who leave for concierge to be sellouts. I was sad when a colleague of mine left for concierge recently but understood that it was an indictment of the current state of primary care and not a reflection of her values. Concierge medicine is an indictment of the existing system but at the same time it is an affirmation of how much people who can afford it value and are willing to pay for access to a long term trusting relationship .with a PCP
I do believe Dr. Lisa Rosenblum is a gifted writer and I've learned a lot and enjoyed reading her New England Journal pieces over the years ...I'm a little taken aback by her current series on the demise of primary care. She herself is s cardiologist. So is her mom. And her father is from a prominent speciality family in Portland Oregon. Her sister is an endocrinologist.
Although she interviews primary care doctors...she promotes concierge care as the solution....which is like" let them eat cake"
And Dr. Glaukenflecken..... an opthalmologist....is relentlessly cruel in his portrayal of primary care. I have heard that medical students have said watching his clips have discouraged them from pursuing primary care
After my primary care physician retired, I had a heck of a time finding a doctor who was taking new patients and with whom I could connect. I saw two doctors who were robotic, rushed, and one literally had one foot out the door as I was ripping through a list of 5 questions, in under 20 minutes. I ended up making an appointment with a physician at One Medical. I googled, googled, and GOOGLED to find a reason not to see her, but couldn't find anything compelling. I found out that she left her original practice because she wanted more control over her patient load to provide the care she said her patients deserve. Additionally, she has more control over her day and can spend more time with her young family. She is so incredibly thorough, thoughtful, and has time for me. I am not saying that physicians in traditional practices do not possess the same qualities. Still, as a patient, I am tired of feeling rushed, being given some lab orders, and wondering if something was missed because there was barely any time to examine me or have a conversation. That said, having worked in healthcare for 20 years, I feel for everyone involved.
Concierge practices are not intended for the masses. There is no need to scale them to benefit those who cannot afford a membership fee. They are the response to and opposite of the corporate practice health system associated practices with administrative driven metrics of productivity and throughput. They are intended to isolate physicians ( and NPs/PAs) from the perverse and capricious incentives of insurance companies.
They exist to put humanity into the life of physicians. A return to the business model of many years ago when the relationship of physician to patients did not involve third parties in the care team. I have several friends who have changed to this approach (as both physicians and patients) and they have been very happy with the results. Not because of financial reasons, but because of the control of relationships that result.
Ironically, the prevalence of Hospitalists for inpatient care has been instrumental in the resurgence of the direct care practice. Physicians are freed from the time and constraints of medical staff membership, and have more time to devote to their patients in the clinic.
This is not an answer to large volume patient care, government and corporate interests have already chosen NPs/PAs AI and technology as winners in that arena. It will not replace academic practices as much of the time spent on teaching and research lead to de facto smaller patient panels.
But it does reflect a failure of the current dominant practice systems to address the needs of patients and physicians.
Reading this brought me back to missing my favorite primary. She was one of a kind but sadly got so burned out being in a practice that controlled her every move that she left. I tried to find her thinking maybe she opened up her own practice but I wasn’t successful. I have often looked into direct care but unfortunately it’s cost prohibitive for most of us. The medical system is so disappointing however it always gives me hope reading your articles. You should be proud of yourself. It seems to me you chose the right profession.
One of the things that concierge medicine does, is enable the physician to limit the number of patients in their practice. It enables them to practice the way that they want to. They don't feel like they are seeing patients on a conveyor belt. They run their own practice instead of being controlled by a corporation. I don't blame them one little bit.
I retired before the concierge model came onto the scene but imagine I would have used it if still in practice. I learned of it through a friend who told me he was buying access into the medical care system. It seems to me to be a reasonable free market response to many of the undesirable aspects of medical care that came with the corporate takeover. Many quite rightfully fear having an emergency and being assigned a hospitalist that knows nothing about them.
Good piece, thank you for writing it. I'm struck by the juxtaposition of "failure to invest" in a "public" model and the grassroots nature of direct primary care. The fact is that "we" (through government) have "invested" billions in a system that does not work. Sure, we could tweak it, reform it, whatever... But the fact that it is so dysfunctional is testament to the fact that a top-down, D.C. driven system will always fail to provide what spontaneous order driven by free people will naturally provide. Let's give thanks for DPC. It may be what saves primary care.
I know several colleagues who are happy in direct primary care and say that it kept them from retirement or leaving the practice of medicine. Agree we should learn from the experience and not disparage it. I also think the system needs to compensate primary care better and provide solutions to the practice burdens - some progress is being made, but not fast enough.
I very much appreciate this thoughtful post. The value of concierge medical practices aside, what strikes me most is that this very clear and recognizable description of the work overload comes, not from the trenches of a private hospital system or group practice where profit is the explicit motive, but from a senior member of a major, non-profit, academic medical center - one that routinely and loudly congratulates itself on its progress in improving working conditions for its faculty (i.e., reducing “burnout”, whatever that is). If it’s this bad in the academic setting (and my personal experience is that it absolutely is), I can only imagine how much worse it is in the private sector. The allocation of hospital and University resources to high billing specialties and the systematic deprivation of some units of critical resources, simply because they know we will work harder to protect our ICU newborns puts the lie to the lofty goals and ideals of the senior administration.
Well said! Concierge practice likely deals with both extremes- over testing and "under-testing?" - if that's a thing. We take a minimalist approach and our concierge doctor matches our energy. There's no quality metrics pressure on her to get us to do random screenings or to see her annually. We reach out when we need help and she's there for us. The regular practice we were with before was horrible in comparison (the reception, the rooming, the wait...); we could only reach the doctor via my chart and he needed a 24h response time window. And he was forced to be cookie cutter in his approach because the practice enforced strict processes for screenings. Concierge medicine works really well for the minimalist mindset and I honestly wish it was more accessible and that we could use HSA dollars to pay for it.
Thank you! As a family doc,I can so relate!
Well said. At one point I considered converting my practice to concierge but I considered it to be selling out. I no longer view those who leave for concierge to be sellouts. I was sad when a colleague of mine left for concierge recently but understood that it was an indictment of the current state of primary care and not a reflection of her values. Concierge medicine is an indictment of the existing system but at the same time it is an affirmation of how much people who can afford it value and are willing to pay for access to a long term trusting relationship .with a PCP
Well said.
The business model of hospitals buying up PCP practices contributes to the demise. We need to go back to independent practices.
I do believe Dr. Lisa Rosenblum is a gifted writer and I've learned a lot and enjoyed reading her New England Journal pieces over the years ...I'm a little taken aback by her current series on the demise of primary care. She herself is s cardiologist. So is her mom. And her father is from a prominent speciality family in Portland Oregon. Her sister is an endocrinologist.
Although she interviews primary care doctors...she promotes concierge care as the solution....which is like" let them eat cake"
And Dr. Glaukenflecken..... an opthalmologist....is relentlessly cruel in his portrayal of primary care. I have heard that medical students have said watching his clips have discouraged them from pursuing primary care
Rosenbaum
Typo! Yes I know them all...Rosenbaum
After my primary care physician retired, I had a heck of a time finding a doctor who was taking new patients and with whom I could connect. I saw two doctors who were robotic, rushed, and one literally had one foot out the door as I was ripping through a list of 5 questions, in under 20 minutes. I ended up making an appointment with a physician at One Medical. I googled, googled, and GOOGLED to find a reason not to see her, but couldn't find anything compelling. I found out that she left her original practice because she wanted more control over her patient load to provide the care she said her patients deserve. Additionally, she has more control over her day and can spend more time with her young family. She is so incredibly thorough, thoughtful, and has time for me. I am not saying that physicians in traditional practices do not possess the same qualities. Still, as a patient, I am tired of feeling rushed, being given some lab orders, and wondering if something was missed because there was barely any time to examine me or have a conversation. That said, having worked in healthcare for 20 years, I feel for everyone involved.
Concierge practices are not intended for the masses. There is no need to scale them to benefit those who cannot afford a membership fee. They are the response to and opposite of the corporate practice health system associated practices with administrative driven metrics of productivity and throughput. They are intended to isolate physicians ( and NPs/PAs) from the perverse and capricious incentives of insurance companies.
They exist to put humanity into the life of physicians. A return to the business model of many years ago when the relationship of physician to patients did not involve third parties in the care team. I have several friends who have changed to this approach (as both physicians and patients) and they have been very happy with the results. Not because of financial reasons, but because of the control of relationships that result.
Ironically, the prevalence of Hospitalists for inpatient care has been instrumental in the resurgence of the direct care practice. Physicians are freed from the time and constraints of medical staff membership, and have more time to devote to their patients in the clinic.
This is not an answer to large volume patient care, government and corporate interests have already chosen NPs/PAs AI and technology as winners in that arena. It will not replace academic practices as much of the time spent on teaching and research lead to de facto smaller patient panels.
But it does reflect a failure of the current dominant practice systems to address the needs of patients and physicians.
What an outstanding summary of the reasons for the evolution of the concierge system.
Reading this brought me back to missing my favorite primary. She was one of a kind but sadly got so burned out being in a practice that controlled her every move that she left. I tried to find her thinking maybe she opened up her own practice but I wasn’t successful. I have often looked into direct care but unfortunately it’s cost prohibitive for most of us. The medical system is so disappointing however it always gives me hope reading your articles. You should be proud of yourself. It seems to me you chose the right profession.
I will be interested to see how concierge medicine can be scaled so that those who cannot afford a membership fee can benefit.
One of the things that concierge medicine does, is enable the physician to limit the number of patients in their practice. It enables them to practice the way that they want to. They don't feel like they are seeing patients on a conveyor belt. They run their own practice instead of being controlled by a corporation. I don't blame them one little bit.
Yes, by all means. Let’s prioritize the wealthy.