Concierge Care: Basketball, Hotels & the Future of Rheumatology

Freeograph / shutterstock.com

I wouldn’t normally look to professional basketball as a model for healthcare, but sometimes answers come from unexpected places.

The observation that elite athletes are not like you and me—medically speaking—is not new. In the second century AD, the pontifex maximus in Pergamum recognized this fact and appointed Claudius Galen physician to the gladiators, making him the first team physician in the Western world.¹

The importance of sports medicine as a medical specialty became obvious during the 1968 Summer Olympics. The competition was held in Mexico City, which is 7,350 feet above sea level—the first time the games had been held at such a high elevation. We now know that athletes engaged in sports that require quick bursts of effort are unaffected by altitude, but high elevations take a toll on those who engage in prolonged stretches of aerobic activity.² We know this in part because the Inter­national Olympic Committee, prior to the Games, commissioned a study on the impact of altitude on the performance of elite athletes. The researchers concluded that athletes should be allowed to move to Mexico City a month before the games to acclimate to the thinner air.

Of course, the science was ignored.

Valuing the image of the amateur athlete, the Olympic organizing committee declared that any athlete who moved to Mexico City a month in advance to train would no longer be considered an amateur and would not be allowed to compete.³

The impact of altitude sickness on the athletes who competed in the 1968 Sum­mer Olympics brought a renewed recognition of the importance of having physicians on hand with expertise in dealing with medical issues peculiar to high-performing athletes. Thus, a group of 13 physicians accompanied the Canadian team to the next Summer Olympics in 1972, ushering the concept of team physicians into the modern era.⁴

This model spread to professional sports, and team physicians quickly became commonplace. Nowadays, some institutions will, ironically, pay local sports teams to become their official physicians.⁵ Presumably, the money lost in such arrangements is returned tenfold by referrals of weekend warriors who want to receive care from the doctors who also minister to their local heroes.

One of these doctors was Howard Maron, MD, who was the team physician for the Seattle SuperSonics, a National Basketball Association team now known as the Oklahoma City Thunder. As a team physician, he noticed the tremendous advantages that came from dedicating oneself to the care of a small number of patients, both in terms of quality of care and personal satisfaction.

In 1996, he decided to share this model of care with non-athletes, and founded MD² International. In this new practice model, each physician cares for 50 families. Not 50 families per week, 50 families, total. The company’s website notes, “This affords them the luxury of time to give every patient the very best: their full energy and focus, their absolute availability, and their true potential. It’s an unparalleled standard of care built upon a powerful relationship—the one between you and a truly exceptional physician.”⁶

How much does the very best cost? An individual pays $15,000 annually, while a family of four pays $25,000.⁷ Although this price tag may be too steep for the average patient, lower cost versions of this practice model have been developed by others.

Thus, concierge medicine was born.

What’s in a Name?

Merriam-Webster defines a concierge as “a usually multilingual hotel staff member who handles luggage and mail, makes reservations, and arranges tours.”⁸

Already, you can start to see how the word is a particularly apt description for what we do. More than most physicians, we are multi­lingual: We speak neurology, oto­laryngology, orthopedics and nephrology with greater fluency than other practitioners speak our dialect of medicine. We make reservations for our patients when we refer them to other specialists. Also, arranging for a direct admission is not all that different from arranging for a quick jaunt through southern Spain.

The evolution from concierge to concierge medicine, however, is somewhat more difficult to parse. Trying to pin down a definition for concierge medicine, I was reminded of scanning labels in my local supermarket. Like natural and low fat, concierge medicine can mean whatever you want. It is essentially a marketing term, meant to signal to the consumer the availability of a higher standard of care in exchange for a member­ship fee.

Although the monthly fees for some concierge practices can be breathtaking, the average cost of joining a concierge practice may not be more than what you pay for your cell phone or a good cable package.

In broad strokes, the two most common forms of concierge medicine are fee for care (FFC) and fee for extra care (FFEC).⁹ In the FFC model, the patient pays cash for a limited number of services. Think of the executive health programs operated by many institutions. My institution, for example, offers The Standard Executive & Preventive Health Visit, in which patients undergo a physical examination, an electro­cardiogram, audiogram, eye examination, skin cancer screen, routine lab tests, and wellness coaching, in which a nationally board-certified health and wellness coach will work with you to identify values and desires and develop a plan in regard to your current physical and emotional state.¹⁰

In the FFEC model, the patient’s insur­ance is billed for covered services. The patient pays cash for additional services not covered by insurance, such as having a nationally board-certified health and wellness coach work with you to identify values and desires. Because providers are enjoined from charging Medicare patients an additional fee for services already covered by Medicare, the FFEC model is the only version of concierge medicine available to many older patients.¹¹

Some concierge physicians create a hybrid model, in which they continue to see some patients using a traditional model, while other patients pay a retainer fee to receive a higher level of service.¹²

A specific subset of concierge medicine is direct primary care (DPC). Although the two terms are often used interchangeably, they refer to slightly different practice models. In a concierge practice, ultimately, an insurer pays for services outside the actual clinic visit. A DPC practice avoids dealing with insurance companies altogether. Instead, the retainer pays for all services, often including incidents that might normally require a trip to the emergency department.¹³

So far, the concierge model may not seem all that different from what one might expect from a standard visit with a particularly well-connected primary care provider. What does the patient receive in exchange for their membership fee?

The answer is access. One of the providers from the Mayo Clinic’s Executive Health Program states, “Once you experience the Executive Health Program, you become like family. Our physicians stay connected with patients long after they leave and build a bond that keeps people coming back year after year for exceptional care and camaraderie.”¹⁴

Other concierge programs promise that your relationship with your doctor will extend far beyond your clinic visit, with higher fees leading to higher levels of access. Although the services offered may vary, most concierge physicians typically guarantee:¹⁵

• same-day appointments and prescription refills;
• unlimited office visits;
• minimal waiting time in the office; and
• immediate access to the physician, through phone or text.

Sounds awful, right? Not for the patient, of course—I’m sure my patients would love to be able to text questions to me when­ever they felt the urge. For the physician, however, it’s hard to imagine doing everything you’re already doing, plus all of the additional services outlined above.

That’s where the membership fee comes in. It pays for your time.

Most clinicians work in a volume-based practice, which is why we get so nervous when we see openings in our schedule.¹⁶ If those openings don’t get filled, then we don’t get paid. For clinicians in private practice, this is even more fraught because clinical revenue pays for everything from the front desk staff to the office lights.

Concierge medicine represents a move toward a value-based practice, in which patients pay for the quality of care they receive. The membership fee allows a more relaxed schedule, which can easily accommodate urgent visits. Because the membership fee covers the cost of all clinic visits with the concierge physician, in theory, patients will be less shy about showing up for preventive care, which should reduce overall healthcare use.

Although the term concierge medicine was developed by physicians, there’s no particular reason this model couldn’t be used by nurse practitioners, physician assistants or other healthcare providers.

Concierge Rheumatology?

When it comes to the rheumatology workforce, one thing is clear: We are running out of rheumatologists. The 2015 ACR Workforce Study predicts that by 2030, the total number of adult rheumatology providers (including physicians, nurse practitioners and physician assistants) will decline by 25%. At the same time, the aging of the baby boomer generation and increasing life expectancy is inexorably increasing the number of patients looking for a rheumatologist. Taken together, this means that by 2030, about half the patients in need of a rheuma­tology provider will not be able to find one. The problem will be even greater in rural areas, which are already having difficulty attracting rheumatologists.¹⁷

Will a proliferation of concierge rheumatologists leave an even larger number of patients without rheumatic care? Not necessarily.

One reason for the projected deficit in rheumatology providers is the high number of rheumatologists who are expected to call it quits. The pandemic has accelerated the burnout that has already affected our profession, the result of having too little time to meet too many demands.

For some, conversion to a concierge practice may help stave off burnout. Irene Kazmers, MD, a rheumatologist in Michigan, transitioned to a concierge-style practice, and notes:¹⁸

My office is still very busy, but in a much more satisfying way. Patients are being seen more promptly and responded to quickly with improved channels of communication. I am able to address their rheumatology concerns thoroughly and keep up with visit documentation and paperwork without devoting many nights and weekends. With stable revenues based on membership rather than sole reliance on third-party payer reimbursements, the viability of [my practice] has thankfully been restored. For me, the most important change has been the incredible lifting of work pressure, resulting in a much better quality of life. From the first night of transitioning to the concierge medicine model, I was able to sleep well, knowing my patients were being better served, my staff was happier, and that I could continue to practice as a rheumatologist within the changing and challenging landscape of medicine today.

Increased job satisfaction and decreased workload may encourage some rheumatologists to remain in practice longer than they might have otherwise and to continue contributing to the rheumatology workforce.

The devil, of course, is in the details. Legislation governing concierge medicine is evolving, and the DPC model in particular may be illegal in some states, which consider this business model an ersatz form of medical insurance.¹⁹ Also, most patients who join a concierge practice will continue to need medical insurance to pay for hospitalizations, medications and services that cannot be administered by a physician in a standard medical office.²⁰

There’s also the ethical issue: the fear is that concierge medicine may create a two-tiered healthcare system in which only the wealthy can afford to receive the best care.²¹

I would argue that healthcare is already stratified. Anecdotally, the uber-wealthy are least likely to sign up for a concierge practice because they are accustomed to receiving concierge-level care simply by picking up the phone. Less affluent patients who have higher deductibles or patients who have complex medical issues requiring multiple clinic visits may stand to benefit most from this style of care.²²

I would also argue that many of us are already operating concierge practices and just haven’t adopted the sobriquet. Like you, I often spend part of my vacations and weekends checking lab tests, responding to patient questions and triaging emergencies. Unlike concierge physicians, however, we’re working for free.

Moreover, although the monthly fees for some concierge practices can be breath­taking, the average cost of joining a concierge practice may not be more than what you pay for your cell phone or a good cable package.²³

Rheumatic diseases are among some of the most complex that any physician may encounter and, more than most diagnoses, may require a particularly personalized approach. A transition toward concierge medicine may finally allow us to provide our patients with the care they deserve.

Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.

References

1. Snook GA. The father of sports medicine (Galen). Am J Sports Med. 1978 May–Jun; 6(3):128–131.
2. Acclimatization required for Olympic athletes in 1968 Mexico City Games. JAMA. 1964 May;190(11):31–32.
3. Andrews R. Altitude had major impact on performances at Mexico City Olympic Games. Global Sport Matters. 2018 Oct 11.
4. Teetzel S. Sports, medicine, and the emergence of sports medicine in the Olympic Games: The Canadian example. J Sport Hist. 2007;34(1):75–86.
5. Pennington B. Sports turnaround: The team doctors now pay the team. The New York Times. 2004 May 18.
6. MD². The MD² story.
7. Ruiz R. Should you dump your primary care physician? Forbes. 2009 Jan 14.
8. Merriam-Webster.
9. Concierge medicine: Next best thing or too good to be true? Amazing Charts.
10. Johns Hopkins Medicine.
11. Tomlinson K. Some doctors are charging both government and patients privately in illegal double-dipping practice. The Globe and Mail. 2017 Jun 10.
12. Ault A. Hybrid model combines concierge with traditional practice. MD Edge. 2010 Sep 28.
13. Direct primary care. American Academy of Family Physicians..
14. Executive Health Program. Mayo Clinic.
15. What is a concierge doctor? WebMD. 2021 Jun 29.
16. The healthcare imperative: Lowering costs and improving outcomes: Workshop series summary. 11. Payment and payer-based strategies. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. Washington (DC): National Academies Press (US); 2010.
17. Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology workforce study: Supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res (Hoboken). 2018 Apr;70(4):617–626.
18. Kazmers I. Concierge medicine: A rewarding option for rheumatologists. Rheumatology Network. 2021 Jul 8.
19. Direct Primary Care Coalition.
20. Castaneda R. Does health insurance cover concierge medicine? U.S. News & World Reports. 2020 Nov 23.
21. Question: Is concierge medicine ethical? Institute of Clinical Bioethics. Saint Joseph’s University. 2012 Apr 13.
22. Livingston S. Concierge care taking hold at some large, urban hospitals. Modern Healthcare. 2017 Oct 21.
23. Daily L. Before you pay extra to join a concierge medical practice, consider these questions. The Washington Post. 2019 Oct 22.