http://www.lef.org/news/LefDailyNews.htm?NewsID=12273&Section=DISEASE&utm_source=DailyHealthBulletin&utm_medium=email&utm_term=Disease&utm_content=Body+Title&utm_campaign=DHB_12218

Occasionally, it is appropriate to use B12 alone – it depends on the
individual! I really do love the biomedical approach to the
individual!

by MATTHEW MINTZ, MD | in POLICY | 40 responses

inShare23

Health care is in crisis. Reimbursements from insurance companies
continue to dwindle, while the expenses of running an office continue
to rise.  Looming cuts in Medicare are only weeks away, and many
physicians may stop taking Medicare.  If these cuts go into affect, it
is possible that primary care physicians could lose up to 50% of their
salary.  Just recently CNN reported that some doctors are going
bankrupt.

How to fix our health care system is an ongoing debate, but not
surprisingly, many physicians have decided not to wait for the
government to solve this problem and have taken matters into their own
hands. One solution is to simply stop taking insurance altogether.
“Cash only” doctors are now commonplace in many major metropolitan
areas.  Another solution is charging a regular, out of pocket fee
(usually) in addition to what insurance will pay for treatment.  A
version of this model that is becoming popular is called retainer
medicine.  Sometimes, retainer medicine is referred to a “boutique” or
“concierge” even by physicians and others involved in health care (as
evidenced by this article in American Medical News, which prompted me
to post on this topic).

However, “retainer”, “concierge” and “boutique” are not the same
thing. Names are important, and the terms “concierge” and “boutique”
tend to have negative connotations. Thus, it is important to describe
the differences.

In a retainer model, patients pay a fee (not covered by insurance) to
be part of a physician’s practice.  This is similar to clients paying
a retainer fee to hire a specific lawyer.  With reimbursements from
insurance companies being so low, the only way an insurance based
physician can increase revenues is to increase the volume of patients
they see.  Unfortunately, when physicians increase the number of
patients they see, it leads to rushed patient visits, long waits in
the waiting room, and decreased access to physicians including
difficulty in getting appointments or responses phone call messages.
By accepting a retainer fee, the physician no longer needs to rely on
insurance revenue alone, and in fact can decrease the amount of
patients he or she sees on a regular basis. This allows for increased
access (usually same day or next day appointments and 24/7 phone
access) and longer appointment times (usually 30-60 minutes) for
patients willing to pay a retainer fee.  The typical insurance based
primary care physician has about 2500-3000 patients in their practice,
and sees about 25 patients a day.  The typical retainer physician has
about 500 patients and sees only a handful of patients each day.
Retainer fees and the amount of access patients get for what they pay
vary widely, but the average retainer fee is about $1500 per year.

Some have argued that retainer medicine is unethical because not
everyone can afford $1500 a year.  First, the typical retainer fee
amounts to about $4 a day, which is what many Americans pay (or more)
for a Starbucks coffee. Secondly, one could also argue that it is also
unethical for insurance based physicians to see complex patients in
brief visits and/or not being able to see them in a timely fashion due
to lack of access.

Concierge medicine is somewhat different, and in my opinion, should
not be used synonymously with retainer medicine.

According to Wikipedia, “A concierge is an employee who either works
in shifts within, or lives on the premises of an apartment building or
a hotel and serves guests with duties similar to those of a butler.
The term “concierge” evolved from the French Comte Des Cierges, The
Keeper of the Candles, who tended to visiting nobles in castles of the
medieval era.”

Just like the concierge at a hotel, who can get you good seats at a
ticketed event, a reservation at a popular restaurant, or even run an
errand; a concierge physician can get you timely appointments with the
best specialists, usually doing the scheduling themselves.  Many
concierge physicians will even accompany patients to procedures or
diagnostics tests, and some will even make house calls. Though some
retainer practice physicians may perform concierge services (usually
the ones charging well over the usual $1500 fee), the terms are not
the same.  Many retainer physicians will assist in coordinating
specialist appointments, but this is as far as they go. In fact, some
“cash only” physicians perform concierge services to attract more
patients, and some doctors (even insurances based physicians) will
charge an extra-fee for some concierge services, such as a house call.

Boutique medicine is also completely different. Again, from Wikipedia,
“A boutique is a small shopping outlet, especially one that
specializes in elite and fashionable items such as clothing and
jewelry. It can also refer to a specialised firm such as a boutique
investment bank or boutique law firm. In the strictest sense of the
word, boutiques would be one-of-a-kind but more generally speaking,
some chains can be referred to as boutiques if they specialize in
particularly stylish offerings.”

I think the key words in this definition are “specilalized” “stylish”
and “elite.” The first word is something commonplace in medicine, but
the later two words are something usually not associated with medical
practice. “Luxury” is also implied in the word “botique.”  Thus, in my
opinion, a boutique doctor is one that specializes in unique, often
luxurious services, that are not offered by others and which will
therefore cost a little extra.  These services include, but are not
limited to, cosmetic procedures (botox, laser hair removal), medical
spa services, comprehensive screenings (i.e. body scans), and herbs or
supplements.  Though both retainer and concierge physicians may
provide boutique services, this is generally not the norm.  In fact,
many insurance based primary care physicians have started to add these
services as a way of keeping their practice running. (Ethics could be
questioned here as well).

I am not arguing that retainer medicine is the solution for all of our
nation’s health care woes. It certainly is not.  However, given that
it solves some of the issues with 3rdparty payors, is a model that
continues to grow, and patients and providers enrolled seem to be very
satisfied; it is something that deserves attention.  Another model
that is garnering some attention is direct access primary care.  In
this model, patients pay a monthly fee (usually about $70/month) and
receive enhanced access and communication as well as primary care and
urgent care services. Though the cost is slightly less ($1500/yr vs.
$840/yr) and access to your personal may not be 24/7, this is a
similar model to the retainer concept. (Proponents have called this
retainer medicine for the masses).

Thus, using terms “concierge” and “boutique” that have connotations of
elitism, luxury and unnecessary care synonymously with retainer
medicine discredits a potentially viable health care model for many
Americans.  I would request that physicians, policy makers and
journalists no longer use these terms as if they were the same.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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