Direct Primary Care, More Affordable 'Concierge' Medicine, Is Hard To Scale Up : Shots - Health News The model, which gives patients direct access to their doctors and longer appointment times, is proving hard to scale up.

'Concierge' Medicine Gets More Affordable But Is Still Not Widespread

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Would you pay your doctor a fee to get perks - perks like same-day appointments, no waits on rushed exams? This is sometimes called concierge medicine. NPR's latest poll with the Robert Wood Johnson Foundation and the Harvard T. H. Chan School of Public Health found that more than 1 in 5 wealthy people do pay for these perks. NPR health policy reporter Selena Simmons-Duffin reports that concierge medicine is more affordable than it once was, but it's still not widespread.

SELENA SIMMONS-DUFFIN, BYLINE: Listen to this guy talk about his primary care doctor.

DAVID WESTBROOK: Well, Dr. Dunlap is a remarkable physician. He's not distracted when you sit down to talk with him. He understands your history.

SIMMONS-DUFFIN: That is David Westbrook of Kansas City, Mo., talking about his doctor, John Dunlap. The feeling's mutual.

JOHN DUNLAP: He is a wonderful, intelligent and very well-spoken individual who's highly thought of in the local community.

SIMMONS-DUFFIN: So basically, it's a lovefest with a contract behind it. All of Dunlap's patients pay him a monthly fee. And for that fee, they get a long, thorough annual physical, including lab work, home visits or visits in the hospital, same-day appointments. And all of his patients have his cellphone number.

DUNLAP: We have a certain group of people who only text before 6:30 in the morning or 6:30 at night. There are some people like that that, of course, push the limits.

SIMMONS-DUFFIN: Dunlap started out in medicine in 1980. He has a private practice. He's not in a physician group or affiliated with a hospital. In recent years, he says, with his patients getting older, it felt like he was working harder and making less. He became interested in trying to practice medicine in a new way.

DUNLAP: With the emphasis on more comprehensive care for a smaller number - the direct primary care model. And so little by little, I became more interested in it and saw the advantages.

SIMMONS-DUFFIN: Advantages like knowing his budget at the beginning of the year, knowing his patients better, being able to pay his staff more and taking insurance claims and billing codes and all the rest off their plates.

He decided to take the plunge and switch his practice to the direct primary care model. The whole thing happens outside of health insurance. His patients pay their monthly fees, and he uses that money to run the office. His practice is not connected with any of the national companies like MDVIP or SignatureMD. He came up with his own version, and the fees vary based on age - $50 a month for those under 40. It's $133 a month for David Westbrook, who's 70, and that is in addition to his monthly insurance premium. Westbrook says it's totally worth it.

WESTBROOK: People spend $200 a month at the golf course or couple hundred dollars a month on cable television.

SIMMONS-DUFFIN: He says he just spends his discretionary income on this great relationship with his doctor. Westbrook says he's privileged to have a great career. He's a hospital executive, and his income puts him in the 1%, defined in the NPR poll as making more than $500,000 a year. The poll found more than 1 in 5 people in this income bracket use some kind of concierge medicine. It's not a brand-new concept. It actually goes back a few decades.

ERIN SULLIVAN: Concierge medicine appeared in primary care in the 1990s with the purpose of providing luxury medical care.

SIMMONS-DUFFIN: Erin Sullivan of the Center for Primary Care at Harvard Medical School says there are really upscale versions of this that leave 130 bucks a month in the dust.

SULLIVAN: Patients could be charged up to $30,000 a month.

SIMMONS-DUFFIN: Thirty thousand dollars a month. In the mid-2000s, she says direct primary care came along as a way to bring personalized care to people at a lower price point. These days...

SULLIVAN: There are approximately a thousand practices in 48 states serving approximately 300,000 U.S. patients.

SIMMONS-DUFFIN: There's less known about how many patients receive care in true upscale concierge practices. There are also many patients seen at hybrid practices, which still bill your insurance like a regular doctor's office and charge you an extra fee for some of the same perks these other models offer.

Even so, most patients do not get their primary care this way. In our poll, less than 10% of low- and middle-income people say they do this. In fact, a recent study in the journal JAMA Internal Medicine found about a quarter of Americans don't have a primary care doctor at all.

Sullivan points out one barrier to scaling up. In these models, doctors generally see fewer patients. To get more patients access to this kind of thing, there would have to be more primary care doctors doing this. And that's a tall order, Sullivan says.

SULLIVAN: We have issues with access to primary care in this country. We don't have enough trainees and enough clinicians choosing primary care.

SIMMONS-DUFFIN: Still, she appreciates that the promoters of this new model of primary care are experimenting, trying to disrupt a system that needs improvement.

Dr. Jewel Mullen says disruption can be a good thing.

JEWEL MULLEN: The question that comes along with it is, for whose benefit?

SIMMONS-DUFFIN: She is associate dean for health equity at the University of Texas at Austin's Dell Medical School. She clearly sees the benefit of this type of model for the doctor.

MULLEN: Who manages to extricate themselves from, you know, all of the overhead and administrative red tape that gets in the way of taking care of people.

SIMMONS-DUFFIN: She's less convinced of the benefits to patients. And she says even if it works for some, it likely won't bring greater access to primary care at the scale needed for real change.

The doctor in Kansas, John Dunlap, says at first, he was reluctant to switch to the direct primary care model, knowing not all of his patients could stay with him.

DUNLAP: I had a lot of emotional baggage from those people who had to move on to other practices.

SIMMONS-DUFFIN: He ultimately decided it was the best way for him to continue to stay in practice, and he does scholarship in some patients who can't pay the monthly fees. Five years in, he says the model has exceeded his expectations. But please, he says, don't lump him in with the concierge medicine set.

DUNLAP: I think the term concierge medicine makes medical care sound like it is for an elite group.

SIMMONS-DUFFIN: He does know his patients, including David Westbrook, sometimes do call it that. He says if that means they're happy with the attention they get and the quality of care, he's fine with it.

Selena Simmons-Duffin, NPR News.


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