July 21, 2017

Concierge Medicine …. What the heck is that?

I’m writing this from Newport Beach, CA. I call this neighborhood “Medical Mecca.” One big medical building after another. Hundreds of doctors. All largely feeding off federal and state medical programs and private insurance plans, of course. And everybody involved is interested in his full share. Including our good Dr. Rubinacci

Have you noticed how the practice of medicine is changing? Gosh, I have.

There’s a significant new trend. It started 10 years or so ago. It’s still small, but it’s growing. Controversial, some feel. It comes by various names.

VIP medicine. Platinum practice. Boutique medicine. Retainer medicine.  Executive health care. Concierge medicine. There’s no shortage of imaginative ways in which interested MDs have been choosing to sell it to their patients.

It even has its own professional association. AAPP. That stands for the American Academy of Private Physicians (www.aapp.org).

I heard about it via our mail carrier.  I’m in beautiful Newport Beach, California, as usual waiting out the cold and ice and snow of a Connecticut winter. Well, not too much snow this year. That’s only fair considering last winter’s incredible downfall.

Milady Annabelle showed me a letter.  “What do you think of this?” she said. It came from our esteemed primary care doctor, Thomas A. Rubinacci, M.D.

I looked at the envelope. Letters from him were very rare. Usually only his name and address appeared in the top left corner.

I spotted something very different—the label “Concierge Medical Care.”

What oh what is this, I wondered.

Inside was an attractive two-color folder on nice coated paper. It had his photo on the front. He’s a good-looking guy. But it’s the first time I was seeing him in a suit and white shirt and tie. Usually I see him in the office with slacks and a golf shirt and loafers.

I like that. Sets a tone I appreciate. Casual and relaxed. Never, never with a white jacket and a stethoscope looped around his neck à la TV–the favored style for many docs these days.

With the folder came a letter. A long letter. Single-spaced. It ran all the way down the first page and down half the second page. Dr. Rubinacci had a lot to tell us about, whatever it was. I gave it immediate attention.

By the way, Dr. Rubinacci is not his real name. I’ve changed it. (If there’s a real Dr. Rubinacci somewhere, it’s an extreme coincidence!) Before I get into all the letter’s details, let me tell you a bit about him.

Doctors, doctors everywhere. Most of them trying to maximize their practice. How to do that? Dr. Rubinacci is going about it in a very different way

He’s about 45. To me that’s the perfect age for your doctor. He’s had plenty of experience and is on top of all the marvelous new technology. But he’s not thinking yet about hanging up his stethoscope. He still has plenty of energy and enthusiasm. By the way, “he” could well be “she.” Nowadays half the students in medical school are women.

(As some of you know, two years ago I completed a full hitch in the Peace Corps. I was a university teacher in Ukraine. Ukraine was part of the Soviet world till that fell apart 20 years ago. One thing I saw was that most doctors in those countries were women, even now. Medicine was considered a women’s profession—the way we used to look at teaching school. And still do quite a bit. And it’s similarly poorly paid.)

Dr. Rubinacci has top credentials. Credentials that would be envied by many other doctors. He is a graduate of a fine California state university, and of the highly regarded medical school of another state university. More than that, in college he made Phi Beta Kappa—the prestigious fraternity honoring distinguished academic work–and he graduated summa cum laude—that’s Latin for “ with very highest honors.”

He served his residency at a top-quality hospital, and then a two-year fellowship at another. He began practicing 12 years ago and set up his office nine years ago.  Now he shares office and staff with another internist with significant credentials, Dr. Anna Kraviska. I’ve changed her name, too.

He’s a Diplomate of the American Board of Internal Medicine. “The” professional society for that specialty. It doesn’t accept doctors into its ranks until they have passed its very stiff examinations. Not all of them pass it. I saw that for myself when I checked it online. Some doctors take it again and again. He passed it on the first try, and again with top grades.

I go to Dr. Rubinacci while I’m here because Annabelle introduced me to him. She’s had him several years, referred to him by a friend. So in a sense, for several years I’ve had two doctors, one in California during the winter, and one in Connecticut the rest of the year. Truth is, a few times I’ve talked with Dr. Rubinacci while in Connecticut because I wanted his input.

We like him because he’s smart, personable, and we can really have a good chat with him. So important. Some doctors can’t afford the time to chat, I’ve found out. We consider him not only our doctor, but also a friend. Of course, we’ve noticed that his time increasingly is at a premium.

Now about his letter. First, that expression, “Concierge Medicine.” That certainly has uppity overtones. Well, it does to me. Concierge is a new word in our dictionary. (By the way, it’s a French word meaning “building superintendent.”):

What’s a concierge to us Americans? A forever smiling and bowing fellow in a spiffy suit at a mahogany desk at an expensive hotel. He’s there to give you expert advice on anything you approach him about. You may be familiar with concierges.

You go to the concierge with your needs, problems, or concerns, as a guest. He’ll take care of it. Again, maybe she. Buy you tickets to a hit play. Give you sightseeing recommendations. Make a reservation for you at a hairdresser’s. Direct you to a Spanish restaurant if that’s what you want. Do just about anything legal. No fee, but tips are definitely welcome. Fat ones preferably.

To me, “boutique medicine” has similar connotations. Upscale. Luxurious. Expensive. Exclusive.

What did all this have to do with medicine?

Dr. Rubinacci was straightforward.  He was transitioning into a new type of medical practice on March 1. Same office. Same staff. But with a much reduced number of patients. That way he would be able to give more time. He’d be more relaxed with them, and that would be nice. He would continue to accept Medicare and other usual government insurance as well as private insurance and continue to process all those forms and assume the headaches of that whole process and accept those payments.

It was clear this was a difficult decision for him, and he had given it plenty of thought.

Why was he doing this?  His letter explained it in detail. And at the bottom of it, he invited his patients to come and attend a question and answer and session.

Annabelle and I phoned that we were coming. We were four couples in his wafting room at 6 p.m., the announced hour, and to my eye not one of us was under 70.He didn’t appear till 6:20, as he escorted his last patients out—an elderly man and woman, the man leaning on a cane.

He quickly sat down, and smiled, He didn’t apologize. We understood. And he got right down to business. No white jacket. No stethoscope. Again the golf shirt and the slacks. The Dr. Rubinacci we really knew. And oh, no cookies. No soft drinks. Which is what you expect at the very least when somebody is pitching you something.

Here’s what we learned. Right now he had some 3,000 patients. More than half of them were seniors.  And the seniors were the more active patients. Many of them came to him regularly, even often. Younger ones came much less. Sometimes just once every two or three years, for a physical.

His office hours were super-charged. He felt he was running from one patient to the other. He wanted to have a relationship with each of his patients, but in many cases impossible, despite his best efforts.  He was increasingly frustrated.

Medicare and the other government programs and private insurers were making more and more demands and requiring more forms to be filled out. He felt he was running a factory, though he never used that word. And he was making less money.

At one point, he said, “My wife is a dentist. And she makes more money than I do. And far fewer forms to process.”

I had checked some things.  Internists—primary care doctors–even those with the most difficult credentials to achieve, on average make less money than most specialists—cardiologists, radiologists, dermatologists, surgeons, and so on. Their practice is more of a rat race. And I believe that all this rankles.

What was he transitioning to? Concierge medical care.  He would have 250 patients, 350 tops. And they would pay a fee: $2,000 per year for one person, $3,500 for a couple..

He would give each patient all the time required. He would do a better job of handling the inevitable phone calls and emails. Even same-day appointments. And there would be more flexibility in the appointments.

His patients would sign a contract, but they could opt out at any time. They would sign up for a year at the stated price, and pay the annual fee in advance. II necessary he would accept semi-annual and quarterly payments. He said that he had not changed his prices since the start of his practice, and he did not anticipate he’d have to increase these annual fees.

He recognized that many of his patients would drop out. He didn’t say this, but of course they would have to. One of his goals was a much smaller practice. He had lined up another fine internist or two, younger of course, and they had agreed to take on the ones who left, if these agreed to these doctors, of course. Their records would be transferred for them.  One point he made was that older patients require more and more care. That seems natural. And he said he felt a moral obligation to serve his new “members” as long as necessary, always with the same high care.

Numerous questions were asked, and he answered them generously. He said he had had the idea a long time. He had worked under a doctor who was a pioneer in this concept at the very start of his practice.

He said that in the few days since his letter had gone out, his staff had signed up 50 patients. His letter said he had an Enrollment Coordinator. Dr. Rubinacci was confident that his starting goal of 250 would be met. And 350 definitely would be the max.

His letter made a strong point, “The first to respond will be the first to get in.” That sounded ominous. If anyone dilly-dallied, they might find themselves left out.

Afterward I did more research, all of it online, of course. I typed “concierge medicine” in Google’s search window and within a minute I got dozens of hits. Wow! There was plenty to read, plenty to think about.

I found that there are now lawyers who call themselves specialists in “boutique medicine law.” And I found that doctors thinking of this do need legal advice.

Medicare sets up rigid standards for what services can be charged for, and how. Every state has rules and regulations of its own. So does every insurance company.

No way can you charge more for “better quality service,” “better lab services or procedures.” And there are no-discrimination laws. And there’s the Hippocratic Oath—an oath that used to be usual for every new doctor but seems less so now. That oath mandates that the new doctor serve everybody who needs care, and care to the best of the doctor’s ability.

How do such traditional concepts fit in with these new concepts? Frankly, I’m not sure.

Some people find a selective practice like this repulsive. Unfair. They feel everybody is entitled to the same level of care. Others say, “More money can buy you a better car, education, house, retirement. Why not better medical care?”

To realists, this is the situation already, and has always been this way.

Dr. Rubinacci letter was a big surprise to me. I read it, then read it again. I knew immediately that Annabelle and I would be sitting in the front row at his introductory session. As it turned out, not necessary. We were just a small, friendly group. It was all quite relaxed. I sensed we were all there because first and foremost we esteemed Dr. Rubinacci. He was planning a series of these get-togethers.

Later I asked to see the contract we would be asked to sign, and he showed it without hesitation. I quickly noted that the contract was with both Dr. Rubinacci and Dr. Kraviska.  I picked up details. Besides husband and wife, he would include children—between the ages of 12 and 25—for an additional fee of $500 each per year.

People would pay up front. He listed several plastic cards. I paid attention to one stipulation that had not been mentioned: he retained the option of suspending any patient, even during the term of the contract.

If he did this, he would give a pro-rated rebate. He would have no need to explain his decision. I was sure he would not do this lightly. Nevertheless, it disturbed me. Some people might consider it “being dumped.”

And I added up the numbers.  The 50 patients already in hand would provide him nearly $100,000 in fees per year (remember, a spouse would pay $500 less). With his goal of 250, the fees would bring in close to $500,000. Nearly half a million!

Plus he would collect the customary Medicare and private insurance payments plus the co-pays and full fees of any patients without coverage.  And with his significantly reduced patient roll, his office overhead might be substantially cut. Maybe his insurance premiums cut also. On the other hand, for the same reason his various sources of insurance income would be diminished.

It would be interesting to find out how all this would balance out.

One new thought popped up.  Under his present set-up, if he takes a day off for any reason, he loses that day’s “take.” With his new set-up, the collected fees would eliminate this concern.  But if he and his partner, Dr. Anna Kraviska, cover for one another when one takes time off, this would not apply.  This is undoubtedly what they intend to do.

I know that when doctors and such retire, they often find another doctor to sell their practice to.  Dr. Rubinacci would be transferring hundreds of patients to one or more other doctors. Would he collect a fee for each? Nothing wrong with this, of course. But interesting to speculate about, don’t you think?

Of course, Dr. Kraviska will be doing the same thing. In fact, I believe she’s had a head start. So whatever I say here about Dr. Rubinacci applies to her also, it seems.

If Concierge Medicine can succeed anywhere, it’s right here. This is a very affluent community, by and large. One of the most affluent in the U.S. (Also one of the most Republican, not surprisingly.)

Many people here make tons of money. Many wealthy people retire here. Driving around and seeing some of the houses—thousands of them—many built high on the landscaped slopes with gorgeous views of the Pacific, can be a startling experience. Many are in gated communities—something in Connecticut that we are not really familiar with. Yet.

And there are numerous country and yacht clubs, so the concept of paying annual membership fees for such is well accepted. What’s one more membership? Especially one that will assure you more attention from your doctor!

I have seen a lot of changes in medicine over the years. When I was a little boy, I remember our family doctor making a house call to see my ailing grandpa. He walked into his bedroom with his scuffed black doctor’s bag. He had bandages and ointments and scissors in there. He took out a thermometer and a stethoscope. And those were the two high-tech instruments of those times! Oh, yes, I believe our little hospital did have an X-ray machine.

I was still in grammar school when I had to have an operation. A small one. I think it was to have my tonsils removed. I do have a bad memory of the doctor putting a paper cone over my nose and dripping ether onto it.  What a terrible experience! That awful smell. But I didn’t get to feel any pain. That was the height of anesthesiology back then.

Forty years ago I had to have my gall bladder removed. I was in the hospital more than a week. Good experience. No complaints. Today I’d be there two or three days, if that long.

A year ago I made a frantic visit to hospital emergency. I had called Dr. Rubinacci and he commanded me to do that. I had symptoms that made me think–and him!–of a possible heart attack. That’s when I encountered my first “hospitalist” ever.

Do you know what a hospitalist is? I didn’t. A hospitalist is an MD who is a credentialed primary care doctor who works in the hospital. Just the hospital. Your doctor orders you to the hospital, and at that point he the hospitalist (or again, maybe she) takes over. Makes all the decisions. Orders everything you need. Supervises every step. All while reporting back to your own doctor. When you leave the hospital, you return to your own doctor’s care.

That’s a new trend, too, far more advanced than that of concierge care, however. But like everything else, a trend that has plus and minus features.

I thought I had a good hospitalist.  But not many years ago, it’s Dr. Rubinacci who would be visiting me in the hospital, during rounds after his hours in the office. I remember when doctors made rounds twice a day. Sometimes seven days a week. That’s something that has just about totally disappeared.

Oh, my heart problem turned out to be a false alarm. My heart seems to be fine.

With the goings-on in Washington, plus new developments in the healthcare industry, we can expect many more changes, of various kinds, despite the loud protests of many groups. And now word is that our economy is improving. Wonderful. More people will have better incomes Maybe this Concierge Medicine will really catch on.

This is all encouraged by our American free-enterprise spirit. Some people get rewarded for being innovative and taking chances. And we admire that. But it hurts others, Can leave them behind. Squeeze them out.

I know you’re wondering, “What are Annabelle and you going to decide?”

All I can tell you right now is, “We’re still mulling this over. But for sure we would hate to lose Dr. Rubinacci?”

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