Concierge FP

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
DIce3 I take it that you do not run a Concierge practice… So I would appreciate it if you do not insult my patientsfor my practice.

I don't have a single patient that feels entitled to their care. In fact, I considered my patients friends and family and I passionately enjoy being their Physician.

So I would appreciate that you leave the misconceptions behind. However, I am more than happy to answer any questions.

Respectfully,
Josh
 
AtlasMD said:
DIce3 I take it that you do not run a Concierge practice… So I would appreciate it if you do not insult my patientsfor my practice... So I would appreciate that you leave the misconceptions behind.
Click to expand...


I cross-covered with a concierge internist for five years. I worked in a high net worth city with many concierge internists with whom I talked frequently about my switching over (I did not). Concierge medicine deals with by definition a very different group of patients than a standard primary care pool. Your specific FP practice in Kansas may be different than what I have personally experienced. The typical concierge practice I have seen is an internist with 250-300 patients total charging an annual retainer fee of around $5000/pt/yr. Patients in these practices are very demanding on average.

The advantage is a gross revenue of 1-1.5 million per year with a smaller overhead. There are definite drawbacks, however. When patients want controlled substances, it becomes difficult to say no. Home visits at 3 AM are done promptly and with a suit on. Usually there are three adult daughters all from different states that want daily updates about their ex-Fortune 500 CEO father. More money, yes. Worth it for me, no.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Interesting but clearly the exception and not the rule. I have plenty of wealthy patients and they get treated like everyone else.
 
DIce3 said:
I cross-covered with a concierge internist for five years. I worked in a high net worth city with many concierge internists with whom I talked frequently about my switching over (I did not). Concierge medicine deals with by definition a very different group of patients than a standard primary care pool. Your specific FP practice in Kansas may be different than what I have personally experienced. The typical concierge practice I have seen is an internist with 250-300 patients total charging an annual retainer fee of around $5000/pt/yr. Patients in these practices are very demanding on average.

The advantage is a gross revenue of 1-1.5 million per year with a smaller overhead. There are definite drawbacks, however. When patients want controlled substances, it becomes difficult to say no. Home visits at 3 AM are done promptly and with a suit on. Usually there are three adult daughters all from different states that want daily updates about their ex-Fortune 500 CEO father. More money, yes. Worth it for me, no.
Click to expand...

How many people ran that practice? If it's 1-1.5 mil revenue per practitioner, then he/she SHOULD be making home calls with a suit on. And it better be at least a Hugo Boss suit...:D:D
 
These practices are a dying niche - sure they'll always be someone out there who pays too much for care, like all things in life. But the $5-50k models are inherently limited in potential client reach.

Thankfully the mainstream movement is in a direction that everyone can afford and every doc can see themselves doing. Good care for a fair price.
 
Is there any way to find these "direct" or cash based practices in a certain state/city?
 
AtlasMD said:
INSURANCE WILL SQUASH THIS - nope, wrong again. we've shown insurance companies how to rethink their business model. they save so much $$$ when they work with us that its silly. They are working WITH us now b/c it lets them lower their premiums. Ok ok, by now if you're still reading, you think i'm drunk on my own koolaid (flavor: delusions of grandeur). True.
Click to expand...

Interesting relationship you have with the insurance companies. How exactly are they working with you?
 
Fonzie - our working relationship with insurance companies is what I would call an "arm's-length agreement." we are not interested in a contractual relationship with the insurance companies. That is part of the complications occur model.

Rather, we have been able to document our significant savings to the system over the last 2 1/2 years and this has attracted their attention. By decreasing their payouts for outpatient visits, administrative costs, laboratory testing costs, medication costs, emergency care usage, urgent care usage, hospitalizations, specialty referrals, and hospitalizations we have significantly decreased their risk and improve their profit margins. As their profit margins increase they will compete by lowering their premiums. A current example of this is the competitive car insurance market.

Thoughts?
 
Atlas, thanks for sharing and revealing your identity. Your contributions are a very rare glimpse into concierge/direct primary care. I commend you for taking over the reigns and providing excellent primary care!

I am currently setting up an out-of network psychiatric clinic (There are some significant differences. It's interesting to hear your perspective). I wish you were closer to the west coast so we could establish a referral network!
 
Members don't see this ad :)
I just want to say that I really wasn't interested in primary care until I read this thread because it seemed like a hopeless situation. I am afraid of NP encroachment, poor reimbursement, and dealing with an entrenched bureaucracy, but I really see no reason why direct care won't take off, and I don't think people will be willing to pay a monthly fee to see anyone but a physician. I'd be much happier in AtlasMD's position than stuck as a hospitalist or subspecialist in the system. I'm definitely going to keep a more open mind going forward.
 
xenotype said:
I just want to say that I really wasn't interested in primary care until I read this thread because it seemed like a hopeless situation. I am afraid of NP encroachment, poor reimbursement, and dealing with an entrenched bureaucracy, but I really see no reason why direct care won't take off, and I don't think people will be willing to pay a monthly fee to see anyone but a physician. I'd be much happier in AtlasMD's position than stuck as a hospitalist or subspecialist in the system. I'm definitely going to keep a more open mind going forward.
Click to expand...

That made my whole week....

Family Medicine is a beautiful specialty and it doesn't have to be mired in misery like it is today.

NPs CAN'T compete with a well trained FP.
There is no bureaucracy in our model - what is best for the patient is our barometer
DPC has a bright future ahead b/c its able to fix so many problems for patients and for the system a like

Congrats on seeing the potential of a bright new future :)
 
Blue Dog said:
Related article:

Local doctor changes healthcare; Charges monthly rate instead of insurance, Medicare or Medicaid
http://www.nbc26.tv/story/22147084/...ate-instead-of-insurance-medicare-or-medicaid

http://doctorlamberts.org
Click to expand...

This is one of the best sites for a doc that I've seen. Simplicity goes a long way. I look forward to hearing about the possible prescription and imaging rates that can be negotiated.

Reading about this type of model is exciting. Hopefully this catches on in the future.
 
This might be a stupid question. One of the biggest criticisms is that the reason primary care has become boring and easy is the high rate of referrals for common problems. In a concierge practice where you have 30min or more with each patient, would the number of times you refer out decrease significantly compared to typical 15min or less visits? Would patients themselves demand fewer referrals?
 
xenotype said:
One of the biggest criticisms is that the reason primary care has become boring and easy is the high rate of referrals for common problems.
Click to expand...

I've honestly never heard that outside of SDN.

Referrals actually involve a fair amount of uncompensated work for us (scheduling, follow-up, coordination of care, etc.) Referrals are also potentially lost revenue as opposed to treating the problem yourself (assuming you could). It's definitely not something you'd want to make a habit of doing without a good reason.
 
AtlasMD said:
Great thread and interesting conversation.

The best that I can tell, i'm the only "concierge physician" thats commented so far (skipped a few posts in the middle ;-)

my 2 cents - concierge family practice will grow to become the standard, drop the concierge, and will be the new "family medicine". Health reform will drive this b/c the current insurance based model (regardless of who resides in the oval office) is unsustainable and unaffordable.

my model of "concierge" is more aptly described as "direct primary care":

by going 100% ins free, and working directly with the patients, then the incentives are appropriately aligned so that my first and last responsibility is to them. now that doesn't mean i rx pain meds or abx when they don't need them...the customer is usually right...and the patient is usually wrong about abx.

The avg practice has 7-10 employees per doc to play the ins game. crazy! http://goo.gl/FvPBu

We have 1 staff/RN for 3 doctors. Overhead is less than 30% and income is up 40%.

Model: low monthly membership, $10-100/mo/pt based on age only (not on pre-existings) for unlimited home/work/office/tech visits, no coapys, all procedures free and up to 95% discount on medicines and labs = then they can find insurance up to 30-50% cheaper.
doesn't work? too good to be true? drunk? yes only to #3 :)
simple math: $50/pt/mo x 600 pt x 12 mo = $360 - 30% overhead - 240k - employer taxes/benefits - $200ish take home per doc.

oh and does it help that i only saw 25 pts last week? WEEK

wholesale meds = HUGE value, more than pays for the membership for many patients. the poor need this the most. prilosec is $2.49 per month. HCTZ is $0.01/pill. Zofran $3.75/bottle. leflunomide $11 mo for us, $120 generic at pharm and $950 brand at pharm.....uhhhhh...easy call for every pt [with RA that is]
wholesale labs = cbc $2, cmp $4.5, lipids $3, tsh $3, T3/4 $4/ea, etc etc.

included procedures: laceration repair, bx, joint injections, ultrasound (non-dx ob), ekg, holter, spiro, audiometry, UA, rapid strep, dexa (yup, i bought a dexa in residency, long story), home sleep apnea screening, minor surgical procedures, medical laser treatments (aerolase.com).----think about it, all that stuff is cheap to do after you have the equipment. If it keeps the pts coming back, who cares how often they get a $0.40 ekg?!

THEY ABUSE IT -- i'll just address it now b/c it'll be asked. No. They. Don't. they have my cell phone, they text, they tweet, they facebook, [few] skype, they email. But they DON'T abuse it. For 1) its only 600 people, 2) they are very gracious in returning the trust you give them. 3) it drops in their chart (mind blown?)

INSURANCE WILL SQUASH THIS - nope, wrong again. we've shown insurance companies how to rethink their business model. they save so much $$$ when they work with us that its silly. They are working WITH us now b/c it lets them lower their premiums. Ok ok, by now if you're still reading, you think i'm drunk on my own koolaid (flavor: delusions of grandeur). True.

ONLY FOR THE RICH - really? come on, now you're not even trying. $10/mo/kid for unlimited care? for the rich?

ok, thats good for now
thoughts?
Click to expand...
Hey great thread.

Just a premed visiting but I am amazed that this type of model is sustainable much less profitable especially given the extremely low cost to the patient, wow.
 
"primary care has become boring and easy"

Wrong


I am never bored. I consult only for procedures/chemo/radiation. Taking care of DM, COPD, CHF, cirrhosis, CKD by myself requires significant domain knowledge and takes years past residency to do "well."
 
I don't see how FM could ever be easy given its breadth. I've actually heard internists say they didn't do FM because they thought it would be too difficult. True story.
 
Count me as one of them. I am oversaturated with general internal medicine. I don't think I could handle adding pediatrics and obstretrics to my plate.
 
Smokemont said:
I look forward to hearing about the possible prescription and imaging rates that can be negotiated.
Click to expand...

Hi and happy to answer those questions:

Prescriptions - Wholesale - www.practrx.com is the easiest. Almost all states allow it actually (see link below) and the price savings are amazing. 1000 omeprazole 20mg for $55, 30 zofran generic $3.80, etc. amazing savings for your patients and very easy to do.

http://www.pointofcaredispensing.net/dispensing-faq/ is a good source for info about states that allow physician dispensing

Imaging - easy to negotiate, but looking around $20 for plain films, $100-150 for ultrasounds, $300 for CTs and $400 MRI (knee)

Labs - same "physician purchasing agreement" CBC $2, CMP $4.5, Lipids $3, TSH $3
 
ToldYouSo said:
Hey great thread.

Just a premed visiting but I am amazed that this type of model is sustainable much less profitable especially given the extremely low cost to the patient, wow.
Click to expand...

As a pre-med, you're ahead of the curve, even many of your teachers and docs won't understand how the direct primary care model works. Congrats!
 
A few more questions. What is the incentive for healthy patients to pay the monthly fee? I would think this practice model only attracts patients who are chronically ill or think they are chronically ill because most people don't spend money on healthcare unless it is unavoidable. How often do your patients typically visit? And how do you handle call overnight- how often do you get woken up for a housecall at 3am?
 
xenotype said:
A few more questions. What is the incentive for healthy patients to pay the monthly fee? I would think this practice model only attracts patients who are chronically ill or think they are chronically ill because most people don't spend money on healthcare unless it is unavoidable. How often do your patients typically visit? And how do you handle call overnight- how often do you get woken up for a housecall at 3am?
Click to expand...

Great questions!

Pricing - its the old 80/20 rule...where 20% of the people make 80% of the work. But the other 80% WANT access to care too! So instead of selling one chunk of time to one patient (fee for service model) you're selling all of your time to all of your patients. Sure, the odds are great that all 600 won't need you every morning at 9am. My practice is proof of that. But you price the model to attract the 90% that are healthy b/c if its still a value to them then its an EASY sell to everyone else.

Plus, the more affordable the model, the EASIER it is to provide more savings than you cost. Just the objective savings of no copays, all procedures free, wholesale pricing on labs is a huge savings. But add in the savings on medicines (every month) and people, even healthy ones, can actually be MAKING money each month.

Now thats a business model that makes for great care.

But know what? Even the sick ones are that much trouble once they know they can see you. Sure maybe upfront they are more work, but its a far cry better than seeing your bad diabetics every few weeks/months and spinning your wheels. I can see a sick patient daily until they are controlled and then they coast with less attention. Its just better medicine that way.

Typical visits per year? wow, a huge range but anything from zero to weekly but both are on the ends of the bell curve. The people who never use it are still happy they did b/c they felt they had peace of mind (similar to insurance i guess) and the ones who use it a lot save a ton of money. But $120/yr for kids and $600 for young adults is easy to overcome in savings. Sutures free. UTI testing free. EKG free. No copays. CBC $2. Thats a 48$ savings locally for just the CBC! Do yearly blood work once and you save them almost their years membership. Starting to see?

Late night calls - I probably get called 3-5 times a YEAR between the hours of midnight and 6/7 am. the rest of the time they text, email etc. The last few i can think of, 1/2 NEEDED the ER (chest pain, GB attack, r/o appy) the others were migraines and/or N/V and i can fax out a script to a 24hr walgreens in <10 clicks and be asleep :)

Again, great questions and happy to answer anything.
 
Thanks so much for being so open, you truly are a pioneer and an inspiration!
 
Thanks and my pleasure. Medicine has a grand tradition of sharing advancements with each other to further improve all patient care.
 
Smokemont said:
I don't see how FM could ever be easy given its breadth. I've actually heard internists say they didn't do FM because they thought it would be too difficult. True story.
Click to expand...

I agree, I think FM is actually really hard to master just because of the sheer volume of information you need to know.
 
AtlasMD said:
Hi and happy to answer those questions:

Prescriptions - Wholesale - www.practrx.com is the easiest. Almost all states allow it actually (see link below) and the price savings are amazing. 1000 omeprazole 20mg for $55, 30 zofran generic $3.80, etc. amazing savings for your patients and very easy to do.

http://www.pointofcaredispensing.net/dispensing-faq/ is a good source for info about states that allow physician dispensing

Imaging - easy to negotiate, but looking around $20 for plain films, $100-150 for ultrasounds, $300 for CTs and $400 MRI (knee)

Labs - same "physician purchasing agreement" CBC $2, CMP $4.5, Lipids $3, TSH $3
Click to expand...

With costs coming down for things like ultrasound and plain films have you ever considered adding them to your practice? And if you did would you charge a small fee for them or just lump them into the included free services? Or charge till it was paid off then include it?

Also how does vacation time work for you in a practice model like this? Do you have someone cover for you, or are your patients ok with having you out of touch for a week or two a year?

FYI I am an MSIII (IV in a month) going into FM and very interested in your model for when i am some day actually practicing :)
 
Great questions!

We have ultrasound. Included free. My advice to students and residents = get more sono training! :)

Medical laser www.aerolase.com. Free

Free. EKG. Holter. Spiro. Dexa. Home overnight pulse ox. UA. audiometry.

Plain films are $20 contracted w an ortho group.

Vacation - works fine. Fwd calls to partners. No problem.

Share this w the other students bc
FM Needs a grass roots movement.
 
AtlasMD said:
Great questions!

We have ultrasound. Included free. My advice to students and residents = get more sono training! :)

Medical laser www.aerolase.com. Free

Free. EKG. Holter. Spiro. Dexa. Home overnight pulse ox. UA. audiometry.

Plain films are $20 contracted w an ortho group.

Vacation - works fine. Fwd calls to partners. No problem.

Share this w the other students bc
FM Needs a grass roots movement.
Click to expand...
Hi AtlasMD, I am currently in an internal medicine residency, and am greatly intrigued by your business model. I can honestly see it becoming a wave of the future, especially if you are able to offer the kind of prices you listed for your patients.
Are all your partners family medicine trained? What portion of your clientele would require pediatric knowledge? Do you think it would be equally feasible to do concierge without peds training?
 
Happy to help. Ill write back in a bit.
 
bronx43 said:
Hi AtlasMD, I am currently in an internal medicine residency, and am greatly intrigued by your business model. I can honestly see it becoming a wave of the future, especially if you are able to offer the kind of prices you listed for your patients.
Are all your partners family medicine trained? What portion of your clientele would require pediatric knowledge? Do you think it would be equally feasible to do concierge without peds training?
Click to expand...

Yes, all of my partners are FP trained. It works for our model b/c we can see the whole family which gives us an advantage when meeting with a company to sign up employees in bulk.

However, thats not necessary by any means. An IM doc could be very successful, more so even, b/c they don't have the lower children pricing to bring down the average. So they might make more money, seeing fewer patients etc.

Plus, you could always pair up with a FP or pediatric.
 
AtlasMD said:
Yes, all of my partners are FP trained. It works for our model b/c we can see the whole family which gives us an advantage when meeting with a company to sign up employees in bulk.

However, thats not necessary by any means. An IM doc could be very successful, more so even, b/c they don't have the lower children pricing to bring down the average. So they might make more money, seeing fewer patients etc.

Plus, you could always pair up with a FP or pediatric.
Click to expand...

Thanks for the response, AtlasMD. You may have already talked about this, but do you think the only way (or best way) into concierge medicine is to set up a traditional practice, then move into concierge model after you build a robust clientele base? I would think that it would be very difficult to be a new concierge doctor on the scene without any prior reputation in an area. Thanks.
 
bronx43 said:
Thanks for the response, AtlasMD. You may have already talked about this, but do you think the only way (or best way) into concierge medicine is to set up a traditional practice, then move into concierge model after you build a robust clientele base? I would think that it would be very difficult to be a new concierge doctor on the scene without any prior reputation in an area. Thanks.
Click to expand...

I'm glad you asked. I do NOT think you should start a traditional practice AT ALL. I started straight out of residency with zero patients in a town with NO "concierge" doctors. I added 300 patients in the first 9 months, brought on doc #2 at least two years ahead of schedule, at 32 months we have 1071 patients (as of today), i'm full, doc #2 has 500 pts and doc #3 started this week.

Believe me, its better to have no reputation and build it, then risk getting a bad reputation b/c of your work in a broken system.
 
In general when looking at setting up a new concierge practice in an area, what type of demographics should you look for? I would imagine that "demand" for such a practice would be low in a semi-rural area with a fairly low median home income.

So do you look for a certain amount of "wealth" in a community? What sort of factors make a particular area a good spot for concierge practice? Thanks.
 
Actually, this is a common misconception. The vast majority of my patients are low to middle income patients. Often blue-collar workers. Most people confuse The old model of concierge medicine for the rich with our new model of direct primary care for the masses.

The uninsured patients need our model the most because our model is the most affordable and offers them the most savings.

Their next would be great demand in a Rural facility because they need doctors as much as anybody. The doctor could charge a slightly lower price across the board because they would be more likely to get the bulk of the community.

But overall, this model would work in about any patient setting.

Again when patients can actually save more money per month on the medicines then their family membership costs, then you are truly helping them.
 
Thanks for the reply's, its great to hear about this type of model for practice. I'm only a 1st year student but it gets me excited thinking about the possibility of practicing this way. I enjoyed the links as well.
 
AtlasMD said:
Plus, the more affordable the model, the EASIER it is to provide more savings than you cost. Just the objective savings of no copays, all procedures free, wholesale pricing on labs is a huge savings. But add in the savings on medicines (every month) and people, even healthy ones, can actually be MAKING money each month.
Click to expand...

Out of curiosity, if a patient is looking for a cosmetic procedure, are those included? i.e. I had a mole removed off my head earlier this year because I shave my head.
Do you have a limit on what patients can request procedure wise?
 
We don't do "cosmetic" procedures like Botox or fillers.

We do have a medical/cosmetic laser, www.aerolase.com, which is free. We don't put any restrictions on it and its never been a problem.

As for all other procedures, like lesion removal, they are included free of charge. Mole removal is cheap and easy and would be hard for the avg person to "abuse".
 
xenotype said:
I just want to say that I really wasn't interested in primary care until I read this thread because it seemed like a hopeless situation. I am afraid of NP encroachment, poor reimbursement, and dealing with an entrenched bureaucracy, but I really see no reason why direct care won't take off, and I don't think people will be willing to pay a monthly fee to see anyone but a physician. I'd be much happier in AtlasMD's position than stuck as a hospitalist or subspecialist in the system. I'm definitely going to keep a more open mind going forward.
Click to expand...

AtlasMD said:
That made my whole week....

Family Medicine is a beautiful specialty and it doesn't have to be mired in misery like it is today.

NPs CAN'T compete with a well trained FP.
There is no bureaucracy in our model - what is best for the patient is our barometer
DPC has a bright future ahead b/c its able to fix so many problems for patients and for the system a like

Congrats on seeing the potential of a bright new future :)
Click to expand...

I basically second what xenontype wrote. My concerns were very similar, and as a pre-med and for much of my first year I have written off FP for those reasons. I had read about concierge as an alternative in the past, but felt it was too much of a niche/too vulnerable to whimsical regulation to bank my career on. Having a living, breathing example in yourself to demonstrate that it can 1) deliver affordable care to the average citizen 2)offer a reasonable lifestyle/compensation for the provider and 3) slash the red tape is truly exciting.

I was an econ major in undegrad so I've read A LOT about the healthcare industry and every time I've delved into the system I've gotten more saddened at just how hopelessly inefficient and ineffective it is. I've thought a lot about top down solutions, which would take enormous power to implement, but you've taken the bottom up approach which seems to work much better!
 
Thanks!! Docs are the ones who hold the majority of the control if they will just embrace models like DPC! :)
 
Atlas, need to ask... as a pediatrician looking more into this business model, how do you cover the costs of obtaining, storing, and administering immunizations?

Nardo
 
Very good question. As a family practice, low-volume pediatric, we struggle with this issue too.

In part because we cannot order the vaccines in the Limited doses that we need.

However we are working on a vaccine sharing program with another pediatrician which I think will answer this problem.

Patients will be able to be reimbursed by the insurance company
 
AtlasMd, thank you again for taking the time to answer these questions, it is an amazing resource!!

I was listening to NPR to a story about telemedicine and they were discussing how HIPAA regulations present some big challenges. As a provider that communicates via email, text, etc do you have to deal with any of that, or because you are cash only do you fall outside that regulation?

I apologize for my ignorance on the topic :)
 
No need to apologize! It's a very interesting topic. If you ask 3 lawyers you'll get 4 opinions on the topic.

Basically, our legal team says that patients have the option/right to communicate w their doctor any way they choose.

Our software is secure but it doesn't get in the way.

If you give a surgeon a better scalpel you'll make a better cutter. If you let FPs communicate easier, you create a better experience.
 
Hey AtlasMD, thanks again for answering all these questions. What would you say your biggest expenditure on overhead is? The rent? I think I saw that you said your current overhead is 30%. Do you think it is possible to get it much lower than that? Thanks!
 
You must log in or register to reply here.
Next unread thread

Similar threads

F
Strongly considering concierge
Replies
12
Views
3K
TableMD
TableMD
F
Your own health insurance when going DPC or concierge
Replies
7
Views
1K
hallowmann
hallowmann
ddjamb
FP Comprehensive Review
Replies
6
Views
5K
drake19
D
The Sports Doc
FP essentials Quiz- Sports Medicine
Replies
0
Views
658
The Sports Doc
The Sports Doc
S
FP jobs with pension plans
Replies
6
Views
2K
septoplasty
septoplasty
Top