Members only: Is concierge care stealing docs for the rich or fixing a broken system?

Michigan Medicine in Ann Arbor was thrust into the national spotlight recently over Victors Care, the health system’s new concierge medicine program targeted to executives and wealthy potential donors.

The program doesn’t accept insurance. Instead, patients pay a $300 monthly retainer ($225 per month if they join before July) for unlimited primary care appointments, shorter waits, 24/7 access to their doctors, and “executive” physicals with extra tests.

More than 300 faculty, many of them physicians, signed a letter of protest sent to University of Michigan Medical School Dean Marschall Runge, saying Victors Care will create a two-tiered health system where the rich take priority over the rest. They worry the program will rob the health system of needed primary care physicians, reducing health care access for less advantaged patients.  

“There’s fear we’re going to be asked to let these people jump the line where there are already patients awaiting treatment …” said Dr. Praveen Dayalu, a Michigan Medicine neurologist who signed the letter.

These developments in Michigan are part of a much larger trend underway throughout the country. Concierge medicine began to take off in the U.S. in the 1990s, as doctors became increasingly disillusioned with the high caseloads and bureaucratic requirements of insurance-based medicine. Estimates of the number of concierge practices vary widely, but in 2017 the trade publication Concierge Medicine Today reported they’re growing by 3 to 6 percent annually.

Concierge practices are often marketed as luxury services for the rich, but a more recent iteration, called direct primary care, has found a niche with middle- and even low-income Americans who have high-deductible insurance and can’t afford routine medical care.

In Howell, Michigan, 60-year-old Marilyn Reardon neglected her diabetes for years because she couldn’t afford to go to the doctor. She was paying about $600 a month for federally subsidized insurance through the Affordable Care Act, but had a $5,000 deductible.

“I was putting all my money into the insurance, and I couldn’t afford the actual health care,” Savage told me. “My sugar got so out of control that I became insulin-dependent.”

In 2015, Reardon’s doctor, Chad Savage, M.D., of Brighton, Michigan, reconfigured his practice to a direct primary care model, where patients pay a set monthly fee for unlimited doctor appointments, depending on their age and health status, and get deep discounts on prescriptions and lab tests.

Now Reardon pays $59.99 per month for regular visits with Savage, and has been able to bring her diabetes under control. She backs that up with her membership, for $199 per month, in a health care sharing ministry that covers 70 percent of hospitalizations and other health care costs. (Health care sharing ministries were included in the ACA as an acceptable alternative to health insurance, but they do not have to guarantee solvency and can reject claims that traditional insurers are bound to honor.)

The model works well for Reardon, who can afford the $59.99 monthly fee. But critics say the movement toward retainer-based medicine jeopardizes health care for others at a time when the U.S. faces a projected shortfall of 40,800 to 104,900 physicians over the next decade, according to the Association of American Medical Colleges.

Retainer-based doctors typically limit the size of their caseloads to provide more time for their patients. Savage now has 700 patients, compared more than 3,000 he cared for previously as a primary care physician for a local health system.

“I’m still working just as hard, but do a better job for those people I treat,” Savage said, saying he “hopefully” breaks even with his previous income.

Runge, the University of Michigan Medical School dean, said Victors Care is expected to boost donations to the school, which can be used to improve care for patients who are economically disadvantaged. Stanford and University of North Carolina at Chapel Hill have similar programs.

“The program itself is not likely to create much of a margin, but the philanthropy will,” Runge said at a town hall held in December to address the controversy.

Scott Greer, a professor of health management and public policy and global public health at the University of Michigan, said the trend toward retainer-based medicine is fueled by dissatisfaction from both doctors and patients.

 “Any doctor is likely to be spending more than half their time dealing with electronic health records, whose benefits they might not see,” Greer said. “A lot of doctors in the U.S. would like to declare independence of the entire system and practice medicine the way they think it should be practiced for their patients.”

As for patients, “You pay a helluva lot of money, and in return you get you get distracted organizations, you get bills you don’t understand, you are increasingly suspicious of a lot of people who should be caring for you,” Greer said.

In Washington, federal legislation has been introduced that would let Americans use tax-free health savings accounts to pay for a direct-care membership fee, a change that would help accelerate the movement. And 23 states, including Michigan, have passed “enabling” legislation to clarify that direct primary care is an acceptable health care model and not to be confused with health insurance coverage under federal law, according to the Council of State Governments. 

As the movement progresses, observers like Toby Citron, director of the Center for Public Health and Community Genomics at University of Michigan, are watchful.

“The ACA had the impact of reducing disparities; this is going in the other direction,” he said. “It’s increasing the stratification and segmentation of people by ability to pay.” 

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