0
Editorials: Point and Counterpoint |

POINT: Is It Time for Pulmonary Concierge Practices? Yes FREE TO VIEW

Neil Freedman, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Department of Medicine, Northshore University Health System, Evanston, IL

CORRESPONDENCE TO: Neil Freedman, MD, FCCP, Department of Medicine, Northshore University Health System, 2650 Ridge Ave, Evanston, IL 60201


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(2):255-257. doi:10.1016/j.chest.2016.09.041
Text Size: A A A
Published online

First let me start by saying that I truly enjoy practicing pulmonary, critical care, and sleep medicine. I entered the field of medicine for all of the same reasons that most other individuals chose the profession: The ability to make a difference in the lives of others, intellectual curiosity, and lifelong learning. I have experienced the practice of medicine in several different clinical settings, including a brief career in academic medicine, 12 years in private practice, and currently as an employed physician.

During this time I have observed the transformation of the practice of pulmonary medicine. Although it was previously a common expectation for many fellows to obtain a job in private practice, those opportunities are rapidly evolving. Now > 50% of physicians are employed by a hospital or a group while only 35% are in private practice, and these trends are expected to continue. Thus, all physicians, including those specializing in pulmonary medicine, will need to continue to explore alternative practice models as the health-care landscape continues to change. One option that is not commonly pursued by specialists is concierge medicine.

Depending on the source, concierge medicine (also known as boutique medicine) has varying definitions. According to the journal Concierge Medicine Today, concierge medicine is defined as a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer in return for enhanced care. In addition to the annual retainer fee, many concierge practitioners may also bill insurance because the retainer fee is only for “noncovered” services such as increased physician access and longer office visits. Most concierge primary care practitioners charge an annual retainer ranging between $1,500 and $2,500 and limit their practices to 400 to 600 patients.,

There is actually very limited peer-reviewed literature on the topic, and much of the literature on this practice model is based on model-specific trade publications.,,, In 2014, there was an estimated 12,000 concierge and direct pay practices in the United States. Most of the existing concierge-type practices have been primarily expanding in the specialties of internal medicine and family practice medicine, although there is precedence of hybrid concierge-type models in some of the medical subspecialties, including endocrinology, cardiology, and neurology. MDVIP Inc, a company that operates a network of concierge physicians, reports that 20% of their 650 concierge physicians have a subspecialty in a field other than primary care but they predominantly practice as a primary care physician in their model. Although there are few data related to pulmonary concierge practices, approximately 3% of pulmonary practices identify themselves as concierge and another 2% to 3% are cash-only practices.,

Why Should Pulmonary Physicians Consider Alternative Practice Models, Including Concierge Medicine?

Changes in Economics and Oversight

The current drivers of health-care economics and government oversight have resulted in several common themes: reductions in reimbursement, increases in overhead, and an intensified “hassle” factor (due to increases in paperwork, need for precertification, and documentation for meaningful use). In addition, changing payment models (eg, bundled payments and accountable care organizations) and competition from nontraditional providers (eg, Walmart, CVS, Walgreens) make predicting the future of practicing medicine more difficult.

These economic forces have led to several expected outcomes. To maintain their incomes, physicians are seeing more patients per day and spending less time with each patient. In pulmonary medicine, median salaries between 2011 and 2015 have remained relatively stable, although the median productivity required to achieve these salaries has increased. A 2016 survey of pulmonary physician compensation and productivity found that 61% of pulmonary physicians spend > 45 h per week in direct patient care activities, with 13% spending > 65 h per week. Thirty percent of pulmonologists see between 76 and 124 patients per week with 7% seeing > 150 patients in 1 week. The majority of outpatient visits (69%) are ≤ 20 min in duration, which is increased from 62% in 2011. In addition to their clinical time, most pulmonary physicians (65%-75% depending on their employment model) are spending between 1 and 14 h per week on paperwork and administrative activities, with 36% spending 10 to 14 h per week on these nonclinical activities.,

Reduction in Job Satisfaction and Physician Burnout

Overall, physician job satisfaction is declining as levels of perceived burnout are on the rise., A recent Mayo Clinic survey of 35,922 physicians found increasing trends of perceived physician burnout (54% noting at least one symptom of burnout) and declining satisfaction with work-life balance. Another recent survey looking specifically at physician lifestyle showed that the majority (55%) of physicians who practice critical care medicine and 43% of pulmonary physicians have feelings of burnout as defined by loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. These findings tend to be driven by several factors, including duration of work hours, number of bureaucratic tasks, and an increase in computerization of practice.

Limitations on Typical Practice Options for Later-career Pulmonary Physicians

In the past, pulmonary and critical care physicians had more options, especially as their careers progressed. Many mid-career and later-career pulmonary physicians reduced or opted out of critical care medicine and took on the practice of sleep medicine to maintain their productivity while improving their lifestyle and quality of life. Changes in technology and reductions in reimbursement for sleep-related services have limited this option, however.,, In addition, the option for the later-career physician to transition into an administrative role has become more difficult as the skill set required to navigate the evolving health-care environment has become more complicated. Thus, many physicians, regardless of their current employment model, will be faced with difficult choices as the pressures of practicing medicine continue to evolve.

Alternative Practice Models: How Might This Work in Pulmonary Medicine?

Although there are few data related to pulmonary concierge practices, approximately 3% of pulmonary practices identify themselves as concierge and another 3% are cash-only practices., Given the limited data regarding alternative practice payment models for pulmonary medicine, one could only propose how these practice options might work for a typical clinician. The ability for given practitioners to transition their practice into a concierge, or cash-only, practice would in part be limited by the area in which they practice and specifically the finances of the surrounding patient base. In addition, these types of practice models would likely be limited to mid-career to late-career physicians with an existing patient base and reputation within a given location. There is little precedence for a specialty-only concierge practice, and I believe it would be unrealistic to think that patients would pay an annual retainer for specialist care on top of their primary care and other medical bills. Thus, the more realistic concierge option for pulmonologists would be transitioning to a hybrid practice combining both specialty and primary care while limiting their inpatient consultative and critical care practices to their own patient base (because other commercially insured patients would be considered out-of-network).

The practice of medicine is rapidly evolving, challenging the status quo and survival of the standard private practice and fee-for-service models. The pressures of changing health-care economics and government oversight will continue to challenge most physicians regardless of their employment model. Thus, physicians need to consider alternative models of practice to maintain the quality of care they provide, improve their quality of life, and remain financially viable in this profession. Alternative practice models, including concierge medicine, should be considered for the pulmonologist.

The Physician Foundation Survey of America's Physicians in 2014: Practice Patterns and Perspectives.  2014;:- [PubMed] Merritt Hawkins Dallas, TXjournal
 
Tetreault M. . Specialty concierge medicine increasing…2015 and beyond. Concierge Medicine Today. 2015;:1-10 [PubMed]journal
 
Musslewhite R. . Concierge care for all? Why MDVIP thinks the model makes sense for execs, teachers and truck drivers. The Daily Briefing. 2015;:- [PubMed]journal
 
Johnson S.R. . Expanding VIP care. New concierge doc models focus on employers, with some offering specialists. Modern Healthcare. 2015;45:20-22 [PubMed]journal
 
Cornwell D. .Leatherwood S.M. . Direct primary care plans: PPACA's version of “concierge medicine”. J Med Assoc Ga. 2014;103:32- [PubMed]journal
 
Cascardo D. . Concierge medicine: is it becoming mainstream? Part I. J Med Pract Manage. 2014;29:362-365 [PubMed]journal. [PubMed]
 
Cascardo D. . Concierge medicine: is it becoming mainstream? Part II. Steps to developing a concierge practice. J Med Pract Manage. 2014;30:176-179 [PubMed]journal. [PubMed]
 
Page L. . The rise and further rise of concierge medicine. BMJ. 2013;347:f6465- [PubMed]journal. [CrossRef] [PubMed]
 
Peckham C. Medscape pulmonologist compensation report 2015.http://www.medscape.com/features/slideshow/compensation/2015/pulmonarymedicine. Accessed March 27, 2016.
 
Peckham C. Medscape pulmonologist compensation report 2016.http://www.medscape.com/features/slideshow/compensation/2016/pulmonarymedicine. Accessed April 3, 2016.
 
Burwell S.M. . Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med. 2015;372:897-899 [PubMed]journal. [CrossRef] [PubMed]
 
Oberlander J. .Laugesen M.J. . Leap of faith—Medicare's new physician payment system. N Engl J Med. 2015;373:1185-1187 [PubMed]journal. [CrossRef] [PubMed]
 
Medical Group Management Association (MGMA) MGMA Provider Compensation 2015: Based on 2014 Survey Data.  2015;:- [PubMed] Medical Group Management Association Englewood, COjournal
 
Oskrochi Y. .Maruthappu M. .Henriksson M. .Davies A.H. .Shalhoub J. . Beyond the body: a systematic review of the nonphysical effects of a surgical career. Surgery. 2016;159:650-664 [PubMed]journal. [CrossRef] [PubMed]
 
Shanafelt T.D. .Hasan O. .Dyrbye L.N. .et al Changes in burnout and satisfaction with work-life balance in physicians and the general us working population between 2011 and 2014. Mayo Clinic Proc. 2015;90:1600-1613 [PubMed]journal. [CrossRef]
 
Peckham C. Medscape lifestyle report 2016: bias and burnout.http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview. Accessed March 27, 2016.
 
Parish J.M. .Freedman N.S. .Manaker S. . Evolution in reimbursement for sleep studies and sleep centers. Chest. 2015;147:600-606 [PubMed]journal. [CrossRef] [PubMed]
 
Freedman N. . Rebuttal from Dr Freedman. Chest. 2015;148:311-312 [PubMed]journal. [CrossRef] [PubMed]
 
Freedman N. . Counterpoint: does laboratory polysomnography yield better outcomes than home sleep testing? No. Chest. 2015;148:308-310 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

The Physician Foundation Survey of America's Physicians in 2014: Practice Patterns and Perspectives.  2014;:- [PubMed] Merritt Hawkins Dallas, TXjournal
 
Tetreault M. . Specialty concierge medicine increasing…2015 and beyond. Concierge Medicine Today. 2015;:1-10 [PubMed]journal
 
Musslewhite R. . Concierge care for all? Why MDVIP thinks the model makes sense for execs, teachers and truck drivers. The Daily Briefing. 2015;:- [PubMed]journal
 
Johnson S.R. . Expanding VIP care. New concierge doc models focus on employers, with some offering specialists. Modern Healthcare. 2015;45:20-22 [PubMed]journal
 
Cornwell D. .Leatherwood S.M. . Direct primary care plans: PPACA's version of “concierge medicine”. J Med Assoc Ga. 2014;103:32- [PubMed]journal
 
Cascardo D. . Concierge medicine: is it becoming mainstream? Part I. J Med Pract Manage. 2014;29:362-365 [PubMed]journal. [PubMed]
 
Cascardo D. . Concierge medicine: is it becoming mainstream? Part II. Steps to developing a concierge practice. J Med Pract Manage. 2014;30:176-179 [PubMed]journal. [PubMed]
 
Page L. . The rise and further rise of concierge medicine. BMJ. 2013;347:f6465- [PubMed]journal. [CrossRef] [PubMed]
 
Peckham C. Medscape pulmonologist compensation report 2015.http://www.medscape.com/features/slideshow/compensation/2015/pulmonarymedicine. Accessed March 27, 2016.
 
Peckham C. Medscape pulmonologist compensation report 2016.http://www.medscape.com/features/slideshow/compensation/2016/pulmonarymedicine. Accessed April 3, 2016.
 
Burwell S.M. . Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med. 2015;372:897-899 [PubMed]journal. [CrossRef] [PubMed]
 
Oberlander J. .Laugesen M.J. . Leap of faith—Medicare's new physician payment system. N Engl J Med. 2015;373:1185-1187 [PubMed]journal. [CrossRef] [PubMed]
 
Medical Group Management Association (MGMA) MGMA Provider Compensation 2015: Based on 2014 Survey Data.  2015;:- [PubMed] Medical Group Management Association Englewood, COjournal
 
Oskrochi Y. .Maruthappu M. .Henriksson M. .Davies A.H. .Shalhoub J. . Beyond the body: a systematic review of the nonphysical effects of a surgical career. Surgery. 2016;159:650-664 [PubMed]journal. [CrossRef] [PubMed]
 
Shanafelt T.D. .Hasan O. .Dyrbye L.N. .et al Changes in burnout and satisfaction with work-life balance in physicians and the general us working population between 2011 and 2014. Mayo Clinic Proc. 2015;90:1600-1613 [PubMed]journal. [CrossRef]
 
Peckham C. Medscape lifestyle report 2016: bias and burnout.http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview. Accessed March 27, 2016.
 
Parish J.M. .Freedman N.S. .Manaker S. . Evolution in reimbursement for sleep studies and sleep centers. Chest. 2015;147:600-606 [PubMed]journal. [CrossRef] [PubMed]
 
Freedman N. . Rebuttal from Dr Freedman. Chest. 2015;148:311-312 [PubMed]journal. [CrossRef] [PubMed]
 
Freedman N. . Counterpoint: does laboratory polysomnography yield better outcomes than home sleep testing? No. Chest. 2015;148:308-310 [PubMed]journal. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543