It started as a little itch. In a 777 bumping from updraft to updraft above Central America, my forearm pricked. By the time we landed in Miami, I had a complete set of red dots scattered across my body.
It’s probably just lice, I thought, remembering the bus I’d shared with a few dozen chickens and baby guinea pigs. But by the time I hit Miami International’s baggage claim, my throat was burning and a fever had set in. Technically I’d been in a malaria zone of the Amazon. But I’d opted not to take the drugs since cases were rare—one to two per year max, said the guidebook.
What if I was that one case?
I needed to see a doctor. But as a 30-year-old “invincible” who’d only recently received health insurance (as a wedding present from my federal employee husband), I didn’t have a primary care doctor to see. I turned to Google and picked up my phone.
My first six calls were all met with the same response: “Oh, we’re a concierge practice; there’s an annual retainer fee. Would you be interested in joining?” When I finally found a nonconcierge practice, the wait time for a new patient appointment was three months.
Concierge medicine is booming, and my town is the capital of the movement. I live in Naples, Florida, the final resting spot of America’s one-tenth-of-one percent. With fat, former-CEO pensions and golden-age parachutes, the residents here want the very best medical care. And local physicians are happy to give it, but at a price. According to a 2012 Medicare Payment Advisory Commission report on retainer-based physicians, Naples has more concierge physicians per capita than any other place in the country. That’s why I can’t find a doctor.
Concierge medicine is an alternative medical model in which doctors see a reduced panel of patients, each of whom pays a monthly or annual retainer. Patients are granted more (sometimes even unlimited) access to the doctor. Weekends and evening phone consults and same-day appointments are the norm. So are expanded medical tests. Annual fees for this service run from $1,000 to $20,000.
Here’s the problem: The typical American family physician working on a fee-for-service model carries between 2,000 and 3,000 patients on his or her roster. A concierge physician however, has just 400 to 1,000 patients (and 1,000 is very rare). As the trend toward concierge medicine grows, more and more people will find themselves like me: feverish, itching, and unable to find care.
The numbers are grim. A 2012 survey of almost 14,000 physicians conducted by Merritt Hawkins, a physician recruiting firm, and the Physicians Foundation found that almost 7 percent planned to convert their practices to concierge in the next one to three years. In 2012, the American Academy of Private Physicians reported that there were 4,400 concierge doctors in the United States, which was a 30 percent increase from the previous year. That translates to about 1,015 doctors switching to concierge care in just a one-year period. If each of those doctors previously cared for 2,300 patients (a 2005 study published in the Journal of General Internal Medicine found that the average patient panel for family practice physicians was 2,303) and cut his or her practice to 600 patients (that’s the number that MDVIP, a company that helps physicians transition to a retainer-based practices, recommends as a cap), the result would be 1,725,500 Americans losing access to their health care providers.
Compounding the problem is an anticipated doctor shortage. The Association of American Medical Colleges released a report in March of 2015 predicting a shortage of 46,000 to 90,000 doctors by 2025. “This projection doesn’t include the rise of concierge doctors in the final scenario,” said Janis Orlowski, the chief health care officer for the AAMC. “Concierge physicians see fewer patients, so it likely would exacerbate the shortage, but we didn’t want it to look like we were just throwing in things that would make the shortage worse.”
To be clear, the physician shortage is primarily caused by a lack of funding for medical residencies, not gobs of physicians going concierge. The number of medical residencies available in the United States is directly tied to Medicare spending. Medicare picks up between 60 and 70 percent of the tab for educating new residents while a teaching hospital generally picks up the rest of the cost. In 1997, the Balanced Budget Act capped the number of medical residencies. “The cap was supposed to be temporary, but it’s now been in place for two decades,” says Orlowski. (The AAMC has suggested to Congress a $1 billion increase in funding for medical residencies.)
The Affordable Care Act is projected to exacerbate the doctor shortage. More people with insurance means more people will be able to see a doctor more regularly. In the AAMC’s report, the ACA increases the demand for primary care physicians by an additional 2 percent.
Of course, if you can afford it, there are benefits of concierge medicine. If you’ve ever been hurried in and out of a doctor’s office in 15.7 minutes, (the national average for a doctor’s visit) you can imagine the advantage of more doctor-patient face time. A study in the American Journal of Managed Care (the lead researcher of which was MDVIP’s medical director) found that MDVIP Medicare patients had a 79 percent reduction in hospital admissions compared with general population Medicare patients.
Maybe better care was a part of achieving this result, but confounding variables were surely at work in this study. For example, concierge patients are generally rich and well educated. They’re also the people attentive enough about their health to cough up a big retainer fee for around-the-clock access.
They’re people like my mom, a retiree who changed to a concierge practice after a scary heart incident put her in the intensive care unit. Her original physician had been all but inaccessible in the months leading up to her hospitalization, and she had mysterious symptoms—dizziness and chronic fatigue—that he seemed too busy to address. But one of the doctors in the practice offered a concierge option. For a fee, she could have unlimited access to another, very experienced physician. My mom paid the retainer and made her first appointment.
She described her symptoms. The doctor listened. He ordered some tests. She returned for a few more visits, and she always got to see the doctor—usually on the same day she called.
But he completely missed her diagnosis. He maintained that she was simply feeling the effects of being middle aged and overweight. She was sure something was wrong. After another heart incident and another stint in the ICU, my mother left the practice. Eventually, a blood test resulted in a diagnosis of Lyme disease and Rocky Mountain spotted fever. Because the two diseases were left untreated for so long, she had an enlarged heart. Aggressive antibiotic treatments have improved her symptoms considerably, but she will likely need treatment for years to come. Even though she was with the concierge practice for only a few months, she never got her annual retainer fee back.
The point of that story is this: More attention doesn’t always equal better care. Furthermore, having a doctor at your beck and call is actually kind of silly, even wasteful. When someone joins a concierge practice, he or she generally expects to interact exclusively with an M.D. But we don’t have a deep enough pool of M.D.s to have them giving flu shots and advising patients about how to responsibly take antibiotics. Concierge medicine has scarce, highly trained doctors doing the work that nurses, nurse practitioners, or physician’s assistants could do.
At the heart of the debate about concierge medicine is a question about whether medicine is a business or a service or a bit of both. With the average medical school grad entering the workforce with $180,000 in student debt, it’s hard to imagine a model in which medicine isn’t at least part business. But as the granddaughter of a small-town family physician, who occasionally delivered babies in return for eggs or avocados, I have a hard time not seeing medicine as part service, too—especially considering that 60 to 70 percent of the bill for residency training is footed by the American public.
Still, medicine has changed dramatically since my grandfather practiced. He was generally happy with this work, but today primary care physicians are some of the unhappiest of all doctors. In a 2014 Medscape survey, only 47 percent of internal medicine doctors said they felt satisfied with their jobs. In the same study, only 27 percent of internal medicine and 32 percent of family practice doctors said they’d choose their specialty again if they could do it over. Seventy-seven percent of dermatologists, on the other hand, said they’d do it all again.
The current model for primary care doctors clearly isn’t working. Patients don’t feel like they get enough time with their doctors, and doctors feel just one rung up the ladder from “sheer misery.” (Really, a medical think tank called Geneia just released its 2015 “Physician Misery Index,” which says that we’re at a 3.7 out of 5 on the “misery” scale.)
“I get it, there’s less and less time to see more patients,” says Tasha Bielby Wallace, a doctor who runs a family practice in Lehigh Acres, Florida, about an hour from where I live. “I get the appeal of going concierge, I really do.” But Wallace also knows the sting of getting kicked off your doctor’s roster when he or she becomes a concierge practice. Last year, Wallace got a letter from her doctor stating that he was making the switch. “I wasn’t going to enroll, so it meant I had to find a new doctor,” she says. (Interestingly, a few months later, Wallace got another notice saying her doctor had changed his mind; he would remain open to the general public.)
“I see it like this: I work in an area where the people couldn’t afford it if I became a concierge practice,” says Wallace, adding, “and there aren’t that many doctors where I’m located. It just wouldn’t be right.”
As the income gap continues to grow, concierge medicine is likely to be viable for more and more doctors. But it’s not viable for the country as a whole. There’s an irony in the fact that millions of Americans are set to gain health care over the next few years, only to find out that there aren’t going to be enough doctors to see them.
As for me, after a dozen calls I found a doctor—a crusty, sour, ancient man who lacked the bedside manner needed to coddle the patients in a concierge practice. He told me I’d been bitten by bed bugs and caught a cold. “You’re going to be fine,” he barked.
Once upon a time I would have taken my topical crème prescription and complained about his grumpy demeanor. But instead, I found myself grateful for his old-school ways: his belief that any patient should be able to be seen and that “do no harm” means being available to more than just the elite.
