Concierge Medicine: The Return of the House Call
Many physicians, frustrated by the bureaucracy of modern medical practice, the financial pressure to shorten appointments and limit face time with patients, and the delays and hassle of dealing with health insurers for reimbursement, are increasingly turning to concierge medical practices as an alternative. Under this business model, patients pay a set annual fee for unlimited (or nearly unlimited) access to a private primary care physician, many of whom will even make house calls for minor illnesses, injuries and physicals.
Although the fees for this service can be expensive, and while it does not replace the need for insurance in the event of more serious health problems, this system has some clear advantages, both for those who can afford it and for the doctors who can build a successful concierge medical practice. The physician in a concierge practice typically has far fewer patients, and does not depend on a certain volume of patients per day to generate sufficient revenue for the practice. This means that the doctor can spend significantly more time with his or her patients, and build a deeper rapport with each patient.
Additionally, since the number of patients per physician is much smaller in a concierge practice, patients do not have to wait days or even weeks for an appointment. According to a recent survey by Merritt Hawkins, a physician staffing firm, average wait times for new patients seeking non-emergency medical services in 2017 was 24.1 days, up 30% since 2014. With a concierge practice, depending on the doctor’s other commitments, a patient generally sees the doctor within hours, either at the doctor’s office or at the patient’s home.
As a result, concierge practices are becoming increasingly common in the Phoenix area, especially in wealthier enclaves such as Scottsdale and Paradise Valley. However, there are several issues that any practitioner should be aware of before starting a concierge medical practice.
Written Patient Agreement
It is critically important that you have a written agreement in place with your patients before you start a concierge medical practice. Not only will a written agreement provide both you and your patients with a clear understanding regarding the scope and nature of the relationship, it can also shield you against potential liability and disciplinary action.
As just one example, Arizona has a statute prohibiting charging or collecting excessive fees for services.[1] Although the amount you charge for your concierge medical services will likely be a reasonable amount, based on the services you provide, your availability, and the limited number of patients you will accept, you may still face a potential accusation from a disgruntled patient that your fee is excessive. A written patient agreement removes this possibility, since this statute does not apply if there is a “clear written contract for a fixed fee between the physician and the patient that has been entered into before the provision of the service.”
In addition to establishing fees, the written patient agreement should include a number of key provisions, such as the term of the agreement, included and excluded services, any renewal and billing provisions, limitations on the doctor’s availability, and appropriate disclaimers or limitations of liability,
Third-Party Payors
Generally, patients who use concierge medical services are encouraged to maintain their own private or employer-sponsored medical insurance as well. Concierge medical services are usually intended to provide general internal medicine and family practice care, not services like emergency medicine, surgery, or specialized medicine such as cardiology or oncology.
Although your patients will likely want to keep their insurance for these non-primary care services, you will need to determine whether you will contract with any insurers or participate in any other third party payment programs like Medicare. If you do, there may be restrictions on your ability to run a concierge medical practice. Insurers will often require you to bill any services that are covered under their plans at their specific rates, and may even expressly prohibit concierge medicine.
Therefore, signing up with an insurance company and remaining in the Medicare system can present significant challenges in setting up a concierge practice. As a result, many doctors in concierge medicine choose to disengage from the traditional insurance model altogether.
Other Considerations
Although it can streamline matters considerably, simply opting out of Medicare and cancelling all insurance contracts is not a panacea for all of the complexities in modern medical practice. In most cases, even if a doctor has opted out of Medicare and does not accept third party insurance, he or she will still be covered by privacy laws, including HIPAA, and must still comply with both the privacy and security requirements contained in those laws.
Similarly, other regulations can still apply in some circumstances, including the Stark Law and Anti-Kickback Statute. You will also still be subject to the jurisdiction of the Arizona Medical Board or Arizona Board of Osteopathic Examiners, and will be required to comply with all of the state regulations that apply to the practice of medicine. In more traditional practices, there is often a larger support staff that can help ensure compliance with laws, regulations, and standards; whereas, the concierge doctor may be responsible for these requirements by him or herself.
Starting a concierge medicine practice, and finding patients willing to pay a significant premium for medical services, can be a daunting task. For many practitioners, though, the flexibility, increased patient time, and stronger relationships that develop from this business model make it worth the risk. If you are ready to take the leap into concierge medicine, it is important to have an experienced and knowledgeable attorney assisting you to ensure legal compliance and protect your practice.
[1] A.R.S. § 32-1401(27)(w).