At the beginning of this year, I received an email from my doctor, who informed me her practice would be switching to a membership model.
“I have found myself at a crossroads—to either continue practicing high-volume medicine or evolve my practice to deliver more personalized medical care via the concierge model,” she wrote in the announcement email. Concierge health is a type of practice that promises patients more time with their doctor and more comprehensive healthcare. My doctor wrote that she would see fewer patients more consistently under the new arrangement. To get in, I would have to pay a yearly fee of $1,850 in addition to my health insurance.
The pandemic has put an incredible strain on primary care doctors. Approximately 16,000 physician practices closed because of COVID-19, according to a survey from Physicians Foundation. The same survey found that 58% of physicians were experiencing signs of burnout. As the pandemic wears on, more doctors are exploring how they can work less intensely. Some doctors are shifting to online practices. Others are exploring concierge medicine and direct primary care. Where concierge health requires an annual fee and insurance, direct primary care requires only a monthly fee and does not accept insurance. There are also blended practices such as One Medical, which has an affordable annual fee ($199) and bills insurance.
Elation Health, an electronic health record company that serves small practices, found that the number of direct primary care practices and concierge health practices on its platform grew 38% last year. “If you really want to spend more time with your patients and not be stuck in paperwork all the time . . . change your business model,” says Kyna Fong, CEO of Elation Health. “For a lot of DPC docs, it’s a mantra of, ‘We just want to focus on our patients—we just want to deliver great care,’ and unfortunately the United States healthcare system leaves them no option to be able to do this except to opt out of the dominant insurance-based system.”
To get in, I would have to pay a yearly fee of $1,850 in addition to my health insurance.
The problem with concierge health and direct primary care is that not everyone can afford to pay the extra monthly or yearly fees on top of health insurance. While direct primary care doesn’t require insurance, patients would still need to have insurance to cover emergencies and more complicated health problems that require specialists. Critics say that the growth in direct primary care and concierge health effectively creates a two-tiered health system. Since both concierge and direct primary care practices see fewer patients, it means there are even fewer doctors available for Americans who can’t afford such elite care. This compounds the existing dearth of primary care physicians, and the Association of American Medical Colleges expects that there will be a primary care physician shortage of between 21,400 and 55,200 doctors by 2033.
Another concern is that patients with more health problems will be left out of the benefits of concierge health. Concierge and direct primary care physicians have been criticized for attracting or even selecting healthier patients. “The primary care physician may ‘cherry-pick,’ inviting the most healthy to join their concierge practice. Some studies have shown that concierge practices include fewer patients with diabetes or hypertension,” wrote two doctors and professors from the University of Arizona College of Medicine at Tucson on the rising phenomenon in the American Journal of Medicine.
Though concierge and direct primary care are growing, it’s still a small fraction of the healthcare system. There are 1,450 direct primary care practices in the U.S., up by a little over 200 in the last year, according to data from industry tracker Direct Primary Care Frontier. In 2019, there were only around 12,000 physicians practicing concierge medicine, according to Concierge Medicine Today. However, companies such as One Medical, Parsley Health, and Eden Health, which recently raised $60 million, are trying to expand the model more broadly.
The rise in interest in direct primary care and concierge health highlights how physicians are pushing for a change in the way they work. Getting paid per treatment has made the business of medicine hard, and this was especially true early in the pandemic, when the rapidly spreading novel coronavirus had no known treatments. Doctors may spend time talking patients through how they can self-isolate and monitor for severe symptoms, but they may not always get paid for that care. This is also true for comprehensive care: helping someone become healthier doesn’t always require a billable treatment. Sometimes, it just requires expert planning and recommendations.
That’s why doctors increasingly want to practice a different kind of care, known as value-based care. The idea of value-based care is that patients or payers pay doctors to make patients healthy rather than treating them for individual ailments. This often means charging a monthly or annual flat fee in exchange for comprehensive care. Essentially, doctors use those dollars to care for a patient however they see fit. In some models of VBC, doctors can suffer penalties when patients don’t get better. It’s the foundation of direct primary care and Medicare Advantage, a version of Medicare that’s becoming more popular, wherein the government pays doctors a fixed amount each month to manage a patient’s care. It can also cover fitness programs, dental, vision, and hearing. In September, the Centers for Medicare and Medicaid Services put out a plan to bring value-based care to Medicaid recipients as well.
As value-based care gains in popularity, both through public health options and a growing cadre of private ones, there is a chance that people who make too much to qualify for Medicaid, but not enough to afford additional monthly fees for direct primary care, will get left out of this new model of care. Add to that a creeping physician shortage and a desire among doctors to take on fewer patients, and the result could be even fewer healthcare options. As for me, I’ll be able to see the physician assistant at my doctor’s practice until her concierge panel becomes full. Then, if I don’t want to pony up, I’ll have to find a new doctor.