The doctor won’t see you now

I had a terrible case of insomnia. It was early October, and I had gone four nights without ever falling into a deep sleep. I was exhausted, terrified I would never sleep again, and desperate for some help. So I called Reno Family Physicians to schedule an appointment with my doctor, Paul Smith, to find out what was happening to me.

But when I asked to schedule an appointment with him, I was told some surprising news: Dr. Smith, who had been my primary care physician since 1999 and my daughter’s doctor since she was born in 2009, had joined a program called MDVIP. Through this more personalized program, the scheduler explained to me, Dr. Smith would be providing more one-on-one patient care. Each appointment would be a full half hour.

“That sounds great!” I said, thinking back over the many times in recent years when our appointments had lasted all of five minutes.

“The practice is limited to no more than 600 patients,” the scheduler continued, “and the cost is $1,650 per year, which is not billable to insurance.”

“That’s in addition to the cost of the services?” I asked.

“Yes, and insurance would apply to those,” she explained.

It didn’t take long to do the math. Because I’m self-employed, I pay for individual insurance that covers me and my daughter, and I could barely pay for that each month. Despite the fact that we had loved Dr. Smith, we would not be following him to MDVIP.

The practice fortunately has several other doctors, one of whom was available to see me that day. But I was officially in the market for a new primary care doctor and, perhaps, a pediatrician for my daughter. I started collecting recommendations from friends, one of whom mentioned that I was the third person she’s spoken to that week who had lost a doctor to “one of those VIP plans.”

It was then that I became really nervous. Could I potentially run into this issue with any doctor I found a connection with? Fewer patients and a steep annual fee seemed like a nice deal. Would doctors soon be dropping like flies from standard practices as they too chose what seemed obviously to be a more appealing option?

I felt a rise of panic in my chest. Now that the law said everyone would have insurance, it seemed as if insurance would no longer be enough. And with doctors already being in short supply, who would that leave for the rest of us?

Turns out, the more I started sharing my experience with others, the more people I found who'd had experiences similar to mine. In fact, one friend introduced me to a co-worker, April Flynt, whose whole family had also recently lost their longtime family physician, Dr. Merritt Dunlap of Carson Medical Group in Carson City, when they simply couldn't afford to follow him to MDVIP.

“It was heartbreaking,” said Flynt, 40, whose husband and two children all had seen Dr. Dunlap. “It was a tough decision, because we felt we had a good relationship with that doctor, and the philosophy [of MDVIP] sounded like something we would benefit from—additional care and more time with the doctor.”

Nonetheless, she couldn’t find a way to make the annual fees work.

“As a young family, we could spend that $3,300 in a much better way. (The cost is $1,650 per adult—kids up to age 26 are included under MDVIP’s family plan.) I don’t spend that much on medical care. We’re healthy, we get regular check-ups, and we just go in for the occasional allergy shot or flu. So it doesn’t seem beneficial to me.”

Meanwhile, Flynt is frustrated at having to start all over with a new doctor. And until they select a primary care physician, they’re unable to get certain kinds of care, such as her husband’s allergy shot, even from other doctors at Carson Medical Group. Right now, the family is actively seeking a physician with whom they feel a connection, and they haven’t found it yet.

I find myself in the same boat.

“Concierge medicine,” as it is being called, is growing by leaps and bounds. And this growth is expected to continue as a response to the Affordable Care Act.

“Concierge medicine is several different ideas rolled together,” Larry Matheis explained to me by phone from Las Vegas. Matheis has been executive director for the Nevada State Medical Association for the last 25 years, and says this shift in health care has been brewing for a while. “It’s about doctors dropping out of the current system and developing their own book for business, in effect, with select patients to whom they give more service and are more available, without having to deal with insurance or, in some cases, Medicare or Medicaid. They tailor their practices to a relatively small number of patients who are willing to pay on a monthly or quarterly basis, for services they need or for routine care.”

In 2012, the Physicians Foundation published “A Survey of America’s Physicians: Practice Patterns and Perspectives.” The national, biannual survey, which had 13,575 respondents, addressed issues such as morale, opinions on health-care reform, and the state of medical practices today.

The numerous findings of the study are alarming:

• Physicians are seeing an average of 16.6 percent fewer patients per day than they did in 2008.

• More than 60 percent of respondents would retire today if they could.

• More than 26 percent have closed their practices to Medicaid patients.

• In the next one to three years, more than half of respondents planned to cut back on patients, transition to part-time hours, switch to concierge medicine, retire or take other steps that would reduce patients' access to care.

• More than 62 percent reported providing patients with at least $25,000 in uncompensated care each year.

The majority of physicians reported being unhappy in their work, wouldn’t choose to practice medicine again if they were starting out today, wouldn’t recommend the profession to their children, and were not optimistic about the effects healthcare reform would have on their practices.

“The practice of family medicine and general care has changed a lot,” said Dr. Daniel Spogen, chair of the Family Medicine Department at the University of Nevada School of Medicine in Reno. “It used to be that families paid cash unless it was an extraordinary kind of visit. But it was affordable. When I started practicing medicine [in 1983], I think it was $35 for an office visit.”

But then came managed care in the mid ’90s.

“It took the patient-physician decisions, in terms of cost, out of the picture and left it all up to insurance,” Spogen said. “Then there were administrative costs. So you not only had insurance dictating payments, but they required certain data. We had to document certain things, send information. … There were administrative hassles that largely expanded to become 30 to 40 percent of the cost of care for a patient. So for a $100 doctor bill, $40 is administrative costs. So doctors wondered, ’Is there a way to do things better?’ That’s where concierge medicine came in.’”

In addition to the hassles of managed care, said Matheis, there was another blow to physicians.

“In 1999, Congress passed a bad piece of legislation, which included a formula for paying out Medicare claims,” Matheis said. “In 2002, it blew up on them, and every year since then, the formula has spit out an amount that leaves us with a negative number. Everyone admits it’s an error. Congress should never adopt a mathematical formula that’s over their heads. And each year that they’ve failed to fix it, the cost to fix it has gone up.”

The result, he explained, is the yearly need to pass a piece of legislation, a “patch,” which makes budget cuts and prevents raises [for administrators] just so that the government can afford Medicare each year.

Twelve years ago, the combination of increased administrative compliance laws and frustration over Congress and corporations making medical decisions led to many physicians finding their goodwill stretched to the breaking point. That was when concierge groups, including MDVIP, were born.

Nationally, we’ve seen a steady decline in the number of primary care physicians, resulting in patient rosters that may number up to 3,000 and hour-long wait times for five-minute appointments.

Regarding his move to MDVIP, Dr. Smith said that he believes his own patient roster had numbered at least 3,000, and was likely more.

“I think the biggest thing for me was a desire to practice medicine the way I thought it should be practiced and has been done in the past,” he said, explaining that through MDVIP, he’s limited to 600 patients, though he’d actually prefer to have fewer.

“Medicine has drifted away from what it used to be. I thought, ’There’s got to be something better than this, this unpersonalized cattle call-type of medicine we’re forced into practicing.”

Smith said he actually considered making a move five years ago, and looked at several concierge models, including MDVIP.

“I saw the trends even then. My dissatisfaction came from the idea that I wanted to spend more one-on-one time with patients. That’s the heart of better medicine, and that’s not what traditional medicine and reimbursement models are supporting. … My goal was to give better care, have a better lifestyle, and find something that I can continue to do for my career.”

MDVIP is one of several models providing concierge care. (Currently, Smith is the only Reno-area doctor to be part of MDVIP, and he and Dunlap are the only two in Northern Nevada.) Each program is unique and has its own fee schedule. Some charge annual fees—which, in some cases, may be as steep as $5,000 to $10,000—in addition to billing insurance and/or Medicare and Medicaid (if accepted) for actual services (the fee is just so you can call them your doctor). Some others simply charge flat fees for service and skip the whole insurance thing altogether.

Here in Northern Nevada, concierge models include Medical Direct-Gorski, a South Reno non-urgent-care clinic accepting walk-ins that charges a flat fee for services and does not bill insurance. And Renown Health’s Premiere Care Program, in some ways similar to MDVIP, is a primary care practice intended to provide more one-on-one physician-patient time and guaranteed same-day appointments, by limiting its number of patients and charging monthly ($35-$55) or annual ($395-$595) fees.

For those fees, programs such as MDVIP and Renown Premiere Care not only promise same-day and longer appointment times, but in some cases, they give patients unprecedented access to doctors’ cell phone numbers and email addresses, create wellness and nutrition plans, design customized patient websites to chart progress with certain goals or conditions and may even offer house calls.

According to Dan Hecht, CEO of MDVIP, which is headquartered in Florida, its national network currently has 675 physicians on board who see more than 200,000 patients across the country: “In today’s chaotic health-care system, patients are saying, ’I’m looking for a system that meets my needs.’ People want a physician that knows them, one who is their counselor, who will help them navigate a complicated health-care system. … I think that’s why it’s continued to grow across the country.”

Hecht emphasized MDVIP’s proactive approach to healthcare—spending time on wellness exams and preventive care as opposed to the typical fix-it-when-it’s-broken model often seen in doctors’ offices. And he says the results of this approach are overwhelmingly positive, with a 79 percent reduction in hospitalizations for Medicare patients and 72 percent reduction for those with commercial insurance plans. According to the MDVIP press kit, these reductions meant an overall savings to the health-care system of $300 million.

And not only are there benefits for patients, but physicians are happier, too, Hecht said.

“Physicians love spending more time with patients,” he said. “Broadly, primary care physicians are leading medicine, so we’re saving primary care physicians in this way.”

In general, concierge medicine only fits with family medicine or internal medicine physicians. Hecht explained that MDVIP has a rigorous screening process, and turns away nine out of 10 doctors.

“We’re generally looking for physicians who are great clinicians as well as good patient communicators and collaborators, with a focus on patient care as a keen interest,” Hecht said, adding that patients are surveyed extensively to determine whether doctors are the right fit for MDVIP.

Hecht believes that this care model is a good fit for all types of patients, and that the cost, when broken down by month or day, is not exorbitant.

“Ninety-four percent of patients renew their contracts after the first year. That shows that 94 percent of patients are saying that this delivers,” Hecht said. “I think it may not be for everyone, but it’s affordable for those who prioritize their health.”

But what about people like me, who prioritize their health but can’t afford to add an extra $137.50 per month (or even more) to our monthly bills?

Hecht said that this breaks down to less than the cost of a cup of coffee per day, and that MDVIP offers several payment plans.

He added that roughly two-thirds of the fee goes to the doctor, helping to maintain a salary close to previous levels, which on average falls around $125,000 per year. This is not a way to get richer, he insisted.

In fact, Dr. Smith indicated that he would likely be taking a pay cut, but that it was worth it to him.

“For me, it was extraordinarily difficult, and it makes me sad to lose patients, either because they can’t embrace the process or simply can’t afford the program,” Smith said. “I don’t like that part at all. But I don’t like the alternative of being dissatisfied with my career and work life, and it was a hard choice.”

Though the reasons behind concierge medicine may be understandable, recent anecdotes about the “unaffordability” of the new plans available through the Affordable Care Act make the prospect of spending additional money simply to keep your doctor unthinkable. So around the country, families like Flynt's and mine, who cannot afford to join such plans and are left behind, are added to an already burdensome physician caseload.

In Nevada, our situation is worse than most.

“We’re very near the bottom in terms of doctors per population,” Matheis said. “We fell woefully behind in the last 10 to 15 years as the population grew. We didn’t train enough physicians and we have one of the fewest numbers of medical residency programs in the West.”

Nevada also struggles with a recruitment problem—after all, who wants to join an overloaded system?

According to Dr. Spogen, Nevada only adds five primary care physicians into the Las Vegas workforce each year, and six to Reno’s.

“That’s not nearly enough. We could double that and probably still need more,” said Spogen.

The problem, he said, is income.

“For primary care, it isn’t bad, but compared to other specialties, it’s low. A lot of students come out of med school in huge debt, $300,000 or more, so a specialty can help them pay that off quicker. And the other issue is that there’s a pay-per-volume approach to primary care. You get paid more to see more patients. So who cares about quality of care?”

Spogen added that one piece of Obamacare legislation includes investigating payment models and their relationships to quality of care. “Doctors are more content when they don’t get paid for volume. It gets them off the treadmill.”

Spogen and Matheis agree that Obamacare, though well-intentioned, has many flaws, including the fact that it makes no provisions for adding physicians to the system, meaning that guaranteeing insurance could merely create an even more untenable burden. And with nearly 7 percent expecting to switch to concierge or cash-only practices in the next three years (according to The Physicians Foundation), physician scarcity will get much worse before it gets better.

Still, both insisted that concierge medicine will evolve as physicians search for solutions. Neither expects this model to grow to the point where it leaves patients stranded and doctor-less, simply because it’s for outpatient care only, and doesn’t cover testing, procedures or specialized exams such as MRIs.

“I don’t believe that concierge medicine is going to flood the market,” Spogen said. “It’s just one model of care. [Its patients] aren’t getting full access to health care; some things aren’t covered. So they can’t be the only model for outpatient medicine. Most doctors will stay at their posts and do the best they can in this changing environment.”

And perhaps knowing that might help me sleep at night.