Without doubt healthcare is in an “age of transition.”  Healthcare reform is being pursued by the Federal government in order to increase access, to decrease the cost and to improve the outcomes of healthcare.  This is being done with the classic methods of reform, i.e., increased regulations, rules, restrictions, and requirements;, all of which exert pressure from the outside to reshape (reform) care.  Other healthcare changes are being motivated by transformation, which is coming from internal drives based on a new vision of healthcare adopted by healthcare providers in what is called patient-centered medical home.  Over 8,000 medical practices have been recognized or accredited as Patient-Centered Medical Homes.  Ultimately, we think, healthcare transformation will create more sustained change in healthcare than will reform.  However, whether reformation or transformation, both are driven by the professionalism which has classically been at the heart of healthcare providers’ efforts.

There is a third movement trying to change healthcare.  It is called “concierge medicine” or “subscription medicine”.  In this model, the physician dismisses 60-80% of his/her patients, requiring those remaining to pay a annual fee of $1,500 to $5,000 to received “personalized care” from the physician.  This payment is in addition to insurance premiums and other healthcare costs.  In this model, typically, the physician will retain 600 patients in his/her practice with significantly increased access, but typically with significantly decreased services.  Measuring only the care delivered to the relatively healthy and wealthy remaining patients, this new form of care boasts of improved preventive and screening care.  Of course, no mention is made of the thousands of patients who are now denied care because they can’t afford these new fees.

This movement is driven by the entrepreneurial spirit which began to grow in healthcare with the advent of Medicare in 1965.  The tension between professionalism and entrepreneurialism has driven some improvement in healthcare delivery but also has been at the root of some of the most difficult problems in healthcare.

In 2011, I received an e-mail from my life-long closest friend who lives in Colorado..  My friend’s wife’s physician is changing his practice to a plan where she would pay him $1,500 a year in addition to insurance payments. The physician will limit his practice to only 600 patients and will give her his cell phone number for instant, round-the-clock, access.  My friend’s question was, “Should she do this?”  I sent him my cell phone number and told him to send me $1,500.

There are a number of companies promoting “concierge” medicine, among them are:  MDVIP, MD2, Signature, Excel MD, PinnacleCare, ABC (Above and Beyond), Concierge Choice Physicians.  An ad promoting this entrepreneur access to healthcare stated:

“’Concierge medicine,’ now known as direct medicine, is emerging as the only solution for physicians to escape the failing health care system. Over 1,000,000 (editorial note:  this number is probably exaggerated) patients across the country are in a direct practice and according to the Physicians Foundation study 17,000 primary care doctors (also exaggerated) intend to transition to a direct practice in the next 5 years. Direct practice is a way to get back to practicing medicine without all of the interference of insurance companies and other third parties. Physicians simply can no longer increase volume and push patients through an assembly line to survive, and yet practice quality care, while enjoying being a physician healer.” 

This ad, like others, addressed provider motivations like: “fear of the future of medicine,” “promised increase in income: “control of your future”, “escape from intrusive governmental regulation” and more.  Interestingly, the better websites promised:

Same day appointments

• Longer appointments
• Screening care
• Preventive care
• Personalized wellness plan
• After-hours access
• Attention from your personal physicians
• The provider’s personal cell phone number

Many of these benefits sound strangely familiar, as they are similar to some of the principles of patient-centered medical home (PC-MH).  However, PC-MH does not require the payment of a significant “franchise fee” to the provider. While the concierge movement touts the restoration of the physician/patient relationship, they fail to mention that some of these franchises are owned by corporations with non-physician stock holders who expect to profit from their investment.  The plans also promise that the routine care of the patient will continue to be paid by their insurance company. 

In 2013, Johnny Mauffray, Associate Director, Physician Development, mdVIP, A Procter & Gamble Company, visited Southeast Texas Medical Associates, LLP.  Mr. Mauffray left two articles for my review:

• ”Personalized prevention care model versus a traditional practice:  comparison of HEDIS measures, “ The International Journal of Person Centered Medicine (Vol 2 Issue 4 pp 775-779).-- http://www.ijpcm.org/index.php/IJPCM/article/view/305
•  “Personalized Prevention Care leads to Significant Reductions in Hospital Utilization,” The American Journal of Managed Care, Vol. 8, No. 12, pp 3453-e460). -- http://www.ncbi.nlm.nih.gov/pubmed/23286675

It appears that MDVIP is establishing its own distorted medical literature to legitimize its so-called “model of care,” which MDVIP is promoting as superior to current practice models.  The following are disturbing things about MDVIP:

• At mdVIP’s website, all of the 650+ physicians listed who “belong” to mdVIP are Caucasian except for three African-Americans and a dozen or so Asian-Americans. 
• mdVIP pays Proctor and Gamble $500 a year per patient for services rendered by mdVIP.  In some indirect way these patients ‘belong” to Proctor and Gamble, which may be an illegal relationship in many states.  (see more on this in part III of this series)
• mdVIP claims to be patient-centered but creates their model by excluding all but the well-off and healthy from their model.
• mdVIP does not say what would happen to “their patients,” if they become unable to pay their annual fee of several thousand dollars. 
• In fact it appears that the patient does not have a professional relationship with a physician but has a financial contract which may be terminated if the patient cannot or will not pay their annual fee.

The following chart shows why mdVIP’s claim to be patient-centered is false.

With a workforce shortage in primary care, mdVIP and other concierge physicians eliminate all but a small percentage of their former patients, leaving the remaining patients without a “medical home.”  With only 600 or so patients, all of whom, by financial screening, is middle or upper class, mdVIP touts itself as the solution to healthcare quality in America.  The reality is, you cannot improve healthcare in American by excluding from your care all of those for whom there are financial barriers to care and/or those who need a great deal of care.  What happens to the patients who have been dismissed from the practice?   I would like to see the following information for  mdVIP’s patient population:

1. Ethnic distribution of those whom they keep in their practice and of those whom they discharge from their practices.
2. Socio-economic distribution of those whom they keep in their practice and the same information for those whom they discharged from their practice.
3. The mean and standard deviation of the risk adjustment factors for their patient populations which they keep in their concierge practice and the same information for those whom they discharged from their practice.
4. The education, gender, age and primary language of the population which mdVIP providers keep in their practices and the same for those whom they eliminated from their practices.
5. The number of patients dismissed from the mdVIP practice who could not find a new physician. And which were thereby functionally abandoned by their provider.
6. Do Texas physicians, who join mdVIP notify their patients who elect not to pay the additional fee that they are being dismissed, continuing to treat them for thirty days following the formal notice?

In the next two weeks, we will examine concierge medicine and the purchase of mdVIP in 2006 by Proctor and Gamble and their May, 2014 announcement that P&G is selling mdVIP.