"You are killing yourself. You're working too hard." Surprisingly, those were the admonishments from patients, advising their doctor. It was the reverse scenario from medicine-as-usual.
Indeed, Jeffrey H. Graf, MD, FACC, a Manhattan cardiologist and internists, had been struggling with the push and pull of his practice over the last few years. Like many doctors, the 57-year-old physician found his reimbursements were going down, and expenses were going up.
Consequently, his hours were extremely long, and the fun of being in practice was disappearing. Still, he loved his patients and wanted to keep helping them.
Graf thought about going into a full concierge model, where patients pay a flat fee per year. His conclusion: "I looked into the faces of people I knew for a long time and thought: 'I can't do this; it isn't right. So many of my patients would have to leave me, especially those who couldn't afford the program. It isn't the way I want to practice; I can't go [concierge] full-time," he says.
Instead, Graf opted for the middle ground. He is among a growing number of physicians who are dipping into concierge while maintaining a full-time practice, in a scenario that is aptly named "hybrid concierge." A hybrid model allows doctors to merge traditional and concierge programs. This gives them the option to care for patients who rely on Medicare or other government or private insurance programs.
Concierge itself has been growing in popularity, as reflected in a recent Merritt Hawkins' physician recruiters survey. The 2012 findings showed that 6.8% of 13,500 physicians say they will embrace direct pay or concierge medicine within the next three years. A fear of major reimbursement cuts is among the top threats cited by healthcare leaders in the HealthLeaders Media 2013 Industry Survey.
Wayne Lipton, founder and managing partner for Concierge Choice Physicians in Rockville Center, NY, which uses the hybrid model, says the field is growing, but he has no precise numbers. The hybrid model provides services not covered by the patients' traditional insurance by offering comprehensive preventative care and wellness visits, while also ensuring patients can continue to receive care from their chosen physician, Lipton says.
Graf, who has been in practice for 26 years, says he embraced the hybrid model so he could continue serving his longtime, insured patients, some of whom rely on Medicare and Medicaid. At the same time, he could offer specialized service for patients who pay a fee for concierge care, which entails more individualized attention such as longer office visits and more phone calls.
"I am very comfortable with the model," he explains. "I didn't feel like I was putting anybody against a wall, saying: 'You join my program, or you have to leave.'"
"People," he says, "are very happy I'm taking care of them and they are delighted with the options." At the same time, he's feeling the stress dissipate, as his workdays are getting shorter.
Like Graf, the "vast majority of physicians who choose the hybrid [do so] because they don't want to say goodbye to their patients," Lipton says. "Most physicians with us opting for the full model do so because it's a way to prolong retirement. They can slow down, yet still see patients. Or, [they choose it] because they have younger families or other personal needs, and a full model gives them the time they need."
Another compelling reason physicians are seeking concierge is because they are "worried about changes in the market, and they are looking to options such as cash-only models."
Because they don't exclude patients, the hybrid models may offer more options for physicians as well as patients, he adds. It would be up to patients themselves if they want to have the concierge fee plan, or continue regular services.
As doctors divvy up their days, the concierge generally takes more time for each patient, and offers physicians a chance to see fewer patients, and have a thus less stressful practice, Lipton says. That's what Graf is starting to see. Besides offering more comprehensive care, the concierge model has convenient scheduling and shorter wait times, as well as more immediate phone access to physicians, Lipton says.
But hybrid isn't for all doctors, says Lipton. "For a hybrid to be successful, you have to be a great doctor—the kind that patients like and respect so much that they are willing to pay an additional fee in order to access your services," Lipton says.
For Graf, it was, oddly enough, his patients who first came to him and suggested he change his practice model to consider concierge a few years ago. "The thing that got me was about 10 patients over a course of a couple of years who said to me, 'you are killing yourself. You are working so hard. You should think about doing this," Graf recalls.
"When I started in solo practice [in 1987,] it was very different then. Patients were satisfied and doctors were very happy," Graf says. "Reimbursements were reasonable and things went along very nicely. But that evolved over the years, in terms of lesser reimbursements, more and more overhead, less time, more stress. I was looking around and seeing at this point, every single one of my colleagues in solo practice, or at least most of them, either had sold their practices to a hospital, or joined a big group or had given up."
Despite the complications of a physician's practice, he wasn't entirely ready to walk away from it. Besides, he has raised four children. Graf kept talking to patients about the full-time concierge model, and he got differing opinions. Some patients wanted to remain with him, and others didn't.
"I have had a very long relationship with many of these patients," he says. "Offering the hybrid program was the best way to continue to care for all my patients and also ensure my autonomy, while providing my patients with real choices. I have a long way to go in medicine."
While many internal medicine physicians are exploring the hybrid model, specialists are only beginning to embrace the concept, he says.
Graf didn't reveal the number of his patients in concierge or hybrid models. "The number of patients in the Concierge plan is increasing slowly but surely," Graf says. "The hybrid model is working out well. I still have a greater number of patients in my traditional practice."
Graf anticipates that more patients may choose concierge and like the hybrid approach since healthcare reform may mean "many millions more patients and a major shortage of primary care MDs," as well as far fewer medical students choosing primary care as their career path.
"I'm not looking to work harder," Graf says with a laugh. "I want to work better for people. I feel I'm practicing good, old-fashioned medicine and that fits right with everybody."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
