The future of health care delivery
To provide comprehensive preventive care, and to adequately coordinate the care of patients with chronic illnesses, some physicians have decided to bill the patient directly for services and not accept commercial insurance or Medicare. Others have opted to convert their practices to "retainer-based" practices, or "concierge" practices, which are, in effect, a type of capitation without the intermediary of the insurance company. The patient pays a fixed annual fee (usually $1,500-$2,000) for all care provided by the physician. In turn, the physician drops the practice size to about 500 patients; guarantees appointments within 24 hours; provides 24/7 cell phone access; and offers appointments that last as long as necessary, the option of e-mail conversations, and visitations in the hospital and emergency room.
Physicians operating such retainer-based practices report working as many hours as they did before, but say that they are giving superior care and that their patients are reporting a much greater level of satisfaction. The total costs of care come way down because the physician now has the time needed to thoughtfully sort out issues, resulting in fewer referrals to specialists, more lifestyle modifications instead of prescriptions, and fewer tests and x-rays. Hospitalizations are reduced by one-half, and unplanned readmissions after hospital discharge also are significantly reduced.
These changes, while quite disruptive, are, in the long run, bright spots on the horizon. While the cost of joining a retainer-based practice is out of reach for some individuals, the retainer system gives proof-of-concept to insurers and the government, who thus far have been too short-sighted to pay more per patient for primary care, and consequently have paid more across the entire spectrum of care. If such models could be adapted for wider use through the reallocation of insurer dollars, it would improve value for everyone.
The extent to which the retainer model will prevail in terms of physicians’ desires and expectations – as opposed to the options of becoming employed or joining large group practices – is uncertain. It is likely that we will see multiple shifts. Certainly, however, the future for delivering care to complex, chronically ill patients lies largely in multidisciplinary team-based care, with primary care physicians – including ob.gyns – serving as the quarterbacks.
Ultimately, key players will need to make it all happen so that we can have a delivery system that serves us well and costs us less. In the meantime, just as is happening in many large clinics, in certain specialty care centers, and in some primary care practices today, there is much that individuals and a combination of the leaders in medicine can do to keep the transformation moving.
Dr. Schimpff is the former chief executive officer of the University of Maryland Medical Center, Baltimore, and is a voluntary professor of medicine at the University of Maryland School of Medicine. He consults for the U.S. Army, medical startups, and Fortune 500 companies. Dr. Schimpff said he has no financial disclosures.
