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Monday, May 2, 2011

How is concierge care different from capitation?

Long ago in the late 1900s, that is to say not long after I got out of my residency, wise people had the idea that medical care would be more affordable if patients had a primary doctor who would be paid to take care of that patient and who would act as a gatekeeper to specialty physicians.  Because specialty care was so expensive and often use of specialists fragmented medical care, a patient would see his or her primary doctor before being referred to the cardiologist or the surgeon or the dermatologist.  Emergencies were exempt from this process. The physician would be paid a flat fee, per year, to take care of each patient. Patients became dissatisfied with this model, feeling that it impinged on their autonomy, and doctors didn't like either the gatekeeper role, or the fact that, in situations where patients were unexpectedly sick, the system of capitation could lead to financial hardship for the physician. Managed care and capitation are not gone, but the words have developed negative connotations and these models are practiced only in a limited manner, often in health care coops such as Group Health or Kaiser.

Now, however, more and more doctors are opting out of fee for service and payment by insurance companies and opening "concierge" services, in which a patient will pay a certain sum of money in return for better than average primary care, including cell phone and e-mail access to the doctor and longer appointments.  The doctor is able to offer these services because eliminating the hassles of insurance billing means that the doctor can make just as much money treating significantly fewer patients.  Concierge practices run from low cost to high cost, with an average yearly fee of about $1500. Both patient and physician satisfaction is high in these practices.

So what is different about this than a capitated system of payment? Nothing, I think, other than that the contract in concierge medicine is entirely between the doctor and the patient, without a middle man or organization.  The patient decides for him or herself whether the price the doctor charges is worth the services offered.

There is some animosity that surrounds doctors with concierge practices, as they are accused of only offering care to patients who can afford to pay their fees out of pocket.  I wonder, however, how the out of pocket costs compare between traditionally insured patients and concierge patients.  I'm thinking that those costs are probably not that different, and that they might at times favor the concierge patients. 

As we shift our ideas of how medical care should be delivered, I think we need to consider the strengths of concierge medicine and combine its characteristics with concepts of capitation and managed care to capture the successes of both.  One of the most important issues is to keep patients involved in defining what care they find valuable.  No matter how we pay for medical care, it comes down to the fact that the costs are paid from the pockets of the patients, and so they should have direct input on determining what kind of medical care they receive.


HMS said...

My good Janice,

This is the type of rare, ideologically untainted, pricelessly useful material we can never get enough of in Alexandria, and, frankly, in the human world at large.

Too many are happy with playing at ideological or status quo Rock 'Em Sock 'Em Robots, while precious few, like you, are instead stubbornly trying to build the yet-unknowable new paradigms that will offer us the only way out of current no-way-out social predicaments.

Don't ever think you're not one of the most important minds on this contemporary front, the well known talking and blogging heads of our dreary Rolodex journalism notwithstanding.

Janice said...

Thanks, HMS. There are so many simple solutions and so few people in positions of authority interested in discussing them. Far more interesting to get into ideological arguments and predict our inevitable slide into chaos than to iron out mutually acceptable systems that will work.