Concierge medicine keeps traditional practices afloat

An interesting twist is happening for concierge care, the controversial practice where doctors eschew insurance reimbursement and enter into private arrangements with patients who pay a lump sum to get longer appointments, more access and often around-the-clock availability.

The practice model works for the physicians who do it, and nationally, about 800 offices have gone to concierge care, according to this profile in the Philadelphia Inquirer. The practice hasn't always earned the respect of internists, though, who say the model drives the burden of community care to doctors in the traditional model. In this twist, however, revenue from concierge arm of the practice keeps the rest of the office in the black.

Labels: practice management, primary care

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posted by Ryan DuBosar at 11:59 AM   5 Comments

Internist asks patients to leave co-pay ... for the next patient

James S. Braude, ACP Member, of Atlanta, has started asking patients to leave a dollar (or any other amount) in an envelope at the front desk after a visit. That donation is applied toward the visits of patients without insurance--Dr. Braude comps the rest of the cost. The local TV report is here:



(The text version is here in case video is restricted on your computer.)

In May ACP Internist polled its readership how they handled uninsured patients, and doctors spoke of a variety of ways they help their patients who don't have insurance.

Labels: health insurance, primary care, recession

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posted by Ryan DuBosar at 8:00 AM   0 Comments

Primary Care "Provider"

I am ashamed to admit that I actually felt annoyed tonight over being referred to as a "primary care provider." It is hard to explain that after 21 years of education and another 23 years of practice as a specialist in Internal Medicine, I would be bothered by this.

One of my patients that I have cared for for 20 years was admitted to the hospital after going to the ER with abdominal pain. I was not informed of his admission and the hospitalist became the attending physician. The patient called me today from his hospital bed to inform me. He actually had a previously scheduled appointment with me in the office today and, good patient that he is, was calling to say he couldn't make it. He assumed I already knew he was admitted to the hospital. I asked him to have the attending doctor call me as soon as he/she made rounds.

I got the call from a young-sounding hospitalist who did not know my name and wondered if I was the "primary care provider." When I replied that I was his physician, she then said, "Oh, I don't usually call the primary care provider." That phrase just stopped me cold. It is so "insurance" sounding. So contrived and replaceable. Primary care provider ... delivery man ... vacuum cleaner salesman ... Roto-Rooter man. It's the doctor you can dismiss if you are a hospitalist, one or two years out of training.

"I don't usually call the primary care provider."

Guess I better get thicker skin.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: hospital medicine, primary care

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posted by Toni Brayer MD at 4:37 PM   16 Comments

Internists, FPs alike trying to help their patients through the recession

The economy is prompting internists and family physicians to increase charity care, discount fees and offer free screenings, according to a survey by the American Academy of Family Physicians.

ACP Internist reported its own poll results earlier in May asking internists how they handled patients who couldn't afford to pay. ACP members reported they most commonly offered free care or reduced payments (66.7%), offered free samples for prescriptions (61.1%) or referred to community clinics (34.7%).

Nearly 90% of the AAFP crowd reported their patients expressed concerns over their ability to pay, 58% had seen more appointment cancellations and 60% had seen more health problems caused by patients forgoing needed preventive care such as such as pap smears, mammograms and colonoscopies, or failing to return for follow-up visits or refills.

Also:

• 66% were discounting fees, increasing charity care, providing free screenings, and moving patients to generics;
• 54% have seen fewer total patients since the recession began in January 2008;
• 73% saw more uninsured patients;
• 64% of respondents reported a decrease in the number of employer-sponsored/privately insured patients; and
• 87% saw more patients with major stress symptoms since the beginning of the recession.

Labels: health insurance, primary care, recession

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posted by Ryan DuBosar at 11:40 AM   0 Comments

Your Thoughts Exactly: Handling patients who can't afford to pay

With the economy uncertain and unemployment rising, ACP Internist readers reported they are facing patients in their offices who are ill, but unable to pay for health care. The situation has left many physicians with the unexpected dilemma of how to treat such patients while also trying to manage a practice. Or worse, patients may not seek health care at all, an option suspected by virtually all respondents in our latest poll, Your Thoughts Exactly: Caring for unemployed/uninsured patients.

Results were collected anonymously throughout April. The results are not scientific and do not reflect any ACP policy, and are reported for their news value only.

When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
Options (respondents could choose more than one; n=73)

• I've offered free care or reduced payments. 66.7%
• I've offered free samples for prescriptions. 61.1%
• I've referred them to community clinics. 34.7%
• I've reduced or eliminated co-pays. 18.1%
• I've deferred billing. 16.7%
• I've had to refuse care to delinquent patients. 6.9%
• I've let the front desk handle it. 6.9%

Among those who offered other options, hospitalists who responded are generally able to refer to their own facilities. One reported, "As a hospitalist I try to take care of them as I do the others ... but I have the devil's own time getting consultants to see them, and arranging outpatient follow-up is often difficult or impossible."

Another respondent said, "I have the luxury of practicing in an academic setting where most of these decisions are made for me. I would hate to be faced with the situation of not providing care due to inability to pay. I can say that since our institution has implemented a co-pay policy, attendance at our resident teaching clinics has fallen off dramatically. I see a future where residents graduate with even less ambulatory care experience than they're already getting."

Office-based practitioners are setting up payment plans, steering patients toward low-cost or no-cost generic options through their local chain pharmacy or grocery. A few have some sort of sliding scale for payments; others suggested downcoding services, even comprehensive exams, so the overall cost would be less.

"I provide them information on how to shop for their prescriptions, explain the excessive cost of needless over-the-counter products, attempt to keep the costs of tests and other health care to a minimum, refer to the physicians who will provide the same level of care and concern that I have whenever possible; I also refer to the state."

Many are referring to local support groups or working at free clinics--in one case the doctor opened a free clinic. Many physicians are doing more chronic care management by phone, which as one person said, "I have done it in previous recessions."

Nearly all (72 of 73 doctors, or 98.6%) said that they know or suspect their patients are skipping needed care, while the other respondent replied he or she wasn't sure. Among the patients suspected of skipping care, they were thought to be rationing medications or not coming back for follow-ups. "I suspect this is a much bigger problem than any physician actually knows about," one physician added.

One doctor suggested a way to prevent losing patients to follow-up: "Be sensitive to proud patients who do not want to admit they are having financial troubles."

Labels: health insurance, primary care, recession

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posted by Ryan DuBosar at 3:23 PM   0 Comments

A helping hand or a snatch and grab?

Walgreens has announced a new plan that could be good news for patients but trouble for primary care providers. Under the Take Care Recovery Plan, patients who lose their jobs can get free basic care from the stores' minute clinics. That is, as long as the patients were clinic customers before they lost their jobs.

It's hard to criticize any program that provides care to the uninsured, but this plan does seem designed to use fear of the recession to lure insured patients away from their doctors' offices. Will this lift some of the burden of unpaid care from internists, or realize the concerns of the anti-minute-clinic crowd? Tough call.

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posted by Stacey Butterfield at 2:27 PM   0 Comments

When times look bad, focus on what's right

There's much to criticize about the current state of the nation's healthcare system but bloggers at Physicians Practice are reminding doctors to count their blessings. They've compiled a list of the Top 10 reasons to be happy you're a doctor. No. 8 on the list: "You relieve more than just physical pain," which goes on to explain:

"Particularly in primary care, you address your patients' vulnerability to not just disease, but also to loneliness, fear, and anxiety. True, a disturbing number are noncompliant with the help and advice you offer, but never doubt the effect you've had on people who survive and thrive simply because you bothered to listen."

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posted by Janet Colwell at 3:33 PM   0 Comments