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Since the advent of Medicare in 1965, there has been an increasingly entrepreneurial element in healthcare. The infusion of tens of billions of dollars into the healthcare industry has created opportunities both for healthcare professionals and for business men and women to profit from seemingly endless, uncontrolled healthcare dollars.
Many changes have come to healthcare over the 49 years of Medicare’s existence. We have seen health maintenance organizations and managed care, integrated delivery networks, Medicare Advantage and its predecessors, hospitals buying medical practices which failed in the 1990s but which is being tried again, healthcare providers buying or building hospitals, targeted care for subsets of our populations such as the Veterans Administration, Medicaid for the poor, accountable care organizations, and many others.
A new form of medicine emerged at the turn of the century. It was called concierge medicine and referred to healthcare providers, who for a fee, allowed unfettered access to themselves twenty-four-hours-a-day. Appealing mainly to the wealthy patient due to the annual cost, according to Proctor and Gamble (P&G), concierge medicine also appealed to healthcare providers who were frustrated with their practices and were looking for a way to maintain their incomes while decreasing their work load.
It was not long after the emergence of concierge medicine that for-profit companies saw another opportunity for profit. In 2000, mdVIP was founded and in 2007, P&G bought a minority interest in the company, acquiring full ownership in 2009. In May, 2014, P&G proposed to sell mdVIP to another for-profit company from whom P&G had originally bought mdVIP. While the structure of the relationship is not public information, the most recent figures are that with approximately 212,000 patients being treated by 700 mdVIP physicians, produced a $16 million profit.
In 2009, P&G said that “mdVIP’s proactive approach leads to lower hospitalization rates and significant cost savings to patients, employers and the health-care system as a whole.” No evidence is offered in support of these contentions. In the literature being promoted by concierge medicine, it is unclear whether there is any “real” improvement in care, or just an appearance of improvement created by the decrease in the number of patients being cared for and with a probable elimination of sicker patients in the concierge provider’s panel of patients..
It would be interesting to examine the cost of care of the mdVIP subset of patients while in the previous practices’ populations and the cost of that same group after the change of the provider to a concierge model of care. In a 2011 study done by RTI International for the Center for Medicaid and Medicare Services (CMS), the results for SETMA showed a 37.4% lower cost than for a benchmarked practice of similar size and complexity. This was not a subset of SETMA’s fee-for-service Medicare population but all of them.
Concierge literature touts that concierge and mdVIP “doctors also provide preventive, personalized health-care to patients, not just the detection and treatment of disease.” This implies that non-concierge doctors don’t provide preventive care and that practices transforming themselves into patient-centered medical home do not provide personalized health-care.
P&G makes the following assertions, again without evidence, about the quality of care being provided by mdVIP:
- “Concierge health-care providers, which pride themselves on knowing their patients so well they can detect medical conditions early on.”
- ‘mdVIP is highly valuable, rapidly growing, and the undisputed leader in personalized and preventive health care.’”
- “ mdVIP's approach to primary care places the emphasis on ‘wellness’ care, not just ‘sick’ care.”
Three assertions are made here: concierge medicine “knows their patients so well they can diagnose illness earlier,” concierge medicine and particularly mdVIP is the undisputed leader in preventive health care,” and that “mdVIP places an increased emphasis on wellness rather than sickness.”
Personality Based Medicine
Vocabulary requires a dictionary in order to know what someone means by what they are saying. Increasingly, the concept of “personalized healthcare” refers to the use of the genome in care. The way concierge medicine and mdVIP uses the concept of “personalized” care, they are really referring to “personality” care. “Personality” care means that you see the same provider each time you go to the clinic. That may or may not be a good thing, but it certainly ignores the concept of a “team approach” to healthcare, which if concierge medicine wants to claim to be a “medical home,” it must provide a team approach to that care.
In my career, the weakest healthcare provider I knew had a small practice and he knew everyone very well. The only problem was that he knew very little medicine. He did know however his limitations and never hurt a patient because for any serious problem he referred his patients to others. I suspect that most of the concierge providers are bright, well-trained and knowledgeable healthcare providers. But, they cannot ignore the clear evidence that a team approach to care is the best approach to 21st Century quality care.
Undisputed Leader in Preventive Health Care
This is a claim without evidence and even if it is the case for the few patients being cared for by the concierge practice, it is not the result of excellence of care but of the selection of the population being measured. If the concierge model of care had designed and deployed a methodology which would bring excellent results to a larger population that would be something of value. But, if the only way to produce excellent results is to greatly reduce the size of your panel that is not a model which has public benefit.
The man-power problem in primary care is not likely to be solved by concierge medicine but only made worse. That is why SETMA has chosen to transform into a patient-centered medical home and to publicly report by provider name on over 300 quality metrics at http://jameslhollymd.com/public-reporting/public-reports-by-type. There you will find SETMA’s preventive care and general health measures which results are excellent. Where is the public reporting by provider name for mdVIP physicians?
Wellness rather than Sickness
mdViP’s and P&G’s claim to be more concerned with “wellness” than traditional primary care is self-serving and untrue. The focus claimed by mdVIP is not unique to this group of physicians. It is the focus of the American Academy of Family Medicine, the American College of Physicians, the American Association of Nurse Practitioners, and ever other board and agency in American healthcare. SETMA’s interest in and performance on “wellness” can be reviewed at: http://jameslhollymd.com/pat-index.cfm. Some of our prevention tools are listed below. I suspect mdVIP has a traditional and limited concept of preventive care. As can be seen here and on our website at www.jameslhollymd.com, SETMA does not have a limited concept of prevention.
- Fall Risk
- Pain Assessment
- Functional Assessment
- Wellness
- Stress
- LESS Initiative (Lose Weight, Exercise, Stop Smoking)
- Diabetes Prevention
- Hypertension Prevention
- Depression
- Annual wellness examination
- HEDIS -- Measures tracked on all patients
- HEDIS – Effectiveness of Preventive Care
- HEDIS – Effectiveness of Acute Care
- HEDIS – Effectiveness of Chronic Care
21st Century Health Care
Concierge medicine and mdVIP is moving in an opposite direction to the best of care in the 21st Century. Concierge medicine is moving toward a solo practitioner model and away from a team approach to healthcare. Before SETMA understood that Twenty-First Century medicine could not be practiced with pencil and paper (19th Century Medical Record Methodology), or with Dictation and Transcription (20th Century Medical Record Methodology), both of which drove SETMA to Electronic Medical Records in 1998, SETMA understood that the demands of 21st Century medicine would require a team approach to healthcare delivery.
Team Building - Risk Taking
Success can only take place in the face of the potential of failure, i.e., risk taking. In September, 1995, we addressed team building and risk taking with President Teddy Roosevelt’s 1887 observation about risk:
“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, and comes short again and again, because there is no effort without error and shortcoming; but who does actually try to do the deeds; who knows the great enthusiasms, the great devotions, who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who know neither victory nor defeat.”
SETMA’s formation did risk failure, but we were determined that if we failed, it would not be because we did not “try.” If we failed, it would not be because we did not set the standard very high and try to scale the wall to reach the standard! If we failed, it would not be because we sat on the sidelines and envied what others were achieving.
Concierge medicine may fail. If it doesn’t, it will not because its model is good for medicine and for the public but simply because it set a standard that is relatively easy to achieve but which does not contribute to the solving of complex healthcare problems.
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