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Concierge Specialties

Scott MacStravic, PhD, for HealthLeaders Media, March 6, 2008
I have been closely following "concierge medicine" ever since the first practice opened in 1996 in Seattle. Although there is no official count of how many such practices exist, my personal files include 222 practices operating with their own names, and 624 physicians practicing in these or in practices with the doctors' names. There are many others who have concierge patients paying extra for specific services, such as same-day access, e-mail consultations, and risk or disease management packages, as well.

The initial concierge practices were all in primary care specialties--family practice, internal medicine, pediatrics--but there are a growing number that are in secondary specialties: 45 by my count, including "addiction medicine," cardiology, dermatology, general surgery, gynecology, and oncology just to name a few.

These specialty practices usually offer the same immediate access, longer appointments, and a proactive health focus as primary care concierge practices. Some also offer home visits. Specialists usually limit their practices to a smaller number of patients--150-300 compared to the more typical 500-600 patients for primary--and they more often deal with patients who already have a chronic condition to be treated.

Like their primary care concierge counterparts, the specialty care practices often attract patients who are not affluent, but who are willing to pay extra for proactive management of their risk conditions or chronic diseases, rather than waiting for the negative consequences of both. Anyone in the middle-income category can usually forego enough discretionary expenditures to afford $100-$200 a month in retainer for better health.

Why concierge medicine is spreading
Virtually all of these specialty concierge practices converted from the traditional practice model, rather than starting out as concierge operations. They cite the same reasons for converting as their primary care counterparts:

  • having too many patients to give the time and attention each deserves
  • wanting to provide a more holistic/proactive approach rather than just sickness care
  • wanting time to deliver the kind of quality and service patients need
  • burnout because of too many patients, emphasis on "billable procedures," and a focus on episodic, rather than continuous, care
  • hassles of dealing with insurance companies and third-party reimbursement systems, with resulting huge overhead costs
While physicians recognize the pain of switching practice models and forcing most of their former patients to find another source of care, physicians also realize that attempting to start from scratch would be far more difficult. Without a large practice to draw patients from, most physicians wouldn't have enough patients from the beginning to make the practice viable.

Many concierge physicians have converted gradually, offering a retainer option to all while retaining traditional-pay patients, or offering patient-paid fee-for-service as well as retainer to be sure they have enough patients to survive. But most seem to have eventually converted entirely to retainer-based payment, since this simplifies practice management and enables the most complete holistic health management.

A solution, rather than a problem?
The specialty practices tend to be subject to the same kinds of criticism about the unfairness of it all and the "abandonment" of former patients. But unlike primary care, where there is the possibility of a severe shortage, most secondary specialties aren't experiencing significant shortages, experts say. And with continuing expectations that the market for concierge practices of all kinds will be severely limited, there have been fewer dire predictions that a few physicians moving to concierge medicine will deprive patients of access to needed care.

In fact, many gurus are arguing that Americans are over-treated by specialists. When specialists only gain income by delivering procedures and specialty-specific treatments, specialists become subject to the "law of the hammer." Every patient they see tends to look like a nail, and the procedures they've been trained in is their hammer, and the only tool they have. With the option of gaining income from continuous, proactive healthcare, specialists will be less dependent on reactive sickness services income and more likely to have time to focus on proactive alternatives.

As a result, there could be strong arguments that the conversion of many specialty practices to the concierge mode, with attention to proactive risk and chronic condition management, would be a good thing for patients and payers alike.

In fact, the concierge model may already represent the kind of "medical home" approach that many insist is the most important healthcare reform needed to solve the cost crisis. And since it can be adopted in secondary specialties as easily as in primary care, with far less concern about depriving patients of access, it may be that the conversion should be encouraged, rather than criticized.


Scott MacStravic, PhD, has semi-retired to a life of freelance scholarship, consulting, and writing after 35 years as a health systems executive and professor of strategy and marketing. He has authored 10 books and 750 articles about a variety of marketing and strategy topics. He may be reached at scottmacstra@earthlink.net.

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