The Executive Suite: Concierge medicine vs. direct care: What's the difference?

So, I goofed. I assumed that my readers knew the differences between “concierge” and direct primary care (DPC) practices, but we’ve had a number of readers ask for clarification.

While there are many similarities between the two models, the differences are not only basic, but, in my opinion, they turn DPC from a curiosity or sideshow to a potentially huge player in the American healthcare marketplace. This article will compare and contrast the two practice models and conclude with a few thoughts on how DPC may have a much larger role in changing our entire system than many yet grasp.

By definition, direct care doctors:

Do not accept money from insurance;
Rely mainly on a monthly fee of less than $100 per month;
As a consequence of the above, they have larger panels, between 400 and 800 per provider; and
Focus more on saving money than on offering premium services.

On the other hand, concierge practices:

Often accept money from insurance;
Charge a higher monthly payment in addition to the insurance collection;
As a consequence of the above, they can have relatively small panels, between 200 and 300 patients total (sometimes less);
Tend to focus on “premium” services, such as vascular scans, “executive” lab panels, extended office visits, and even going along with patients to specialist visits.

There is a spectrum of services offered in both camps, but the general idea of DPC is to avoid insurance to lower overhead and keep cost down, while concierge care focuses on providing value-added services outside of the bounds of things usually covered by insurance. The danger for concierge practices is that they must be certain the extra fee does not duplicate the charges they are collecting from insurance, especially Medicare. Doing so would be (in the case of Medicare) illegal.

Similarities between DPC and concierge practices

1. Less patients, more time for each patient.

The most obvious similarity between the two models emerges when you walk into either a concierge or DPC practice: it’s far quieter and calmer than a typical fee-for-service practice. In my old life at a traditional practice, I had a schedule packed to bursting (25-30 patients per day) with little time for each person I saw. I spent 15 minutes on average with each patient, and typically ran between 30 and 90 minutes late by the end of the day. Much of my time was devoted to charting and coding properly for pay, so my patients received only a small amount of attention from me. It was not enough to take care of them.

By contrast, my DPC practice (of nearly 800 patients) averages between 6-10 patients per day, with 30 minutes given to each patient. A large percentage of the face-to-face time is devoted to actual care. My waiting room is usually empty, and my average wait time is still under 10 minutes. Obviously, this is even more the case in the lower-volume concierge practices. The obvious advantage to this is better care. There simply is more time to think about things, to listen to patients, and to educate them.

2. Less stress

After 18 years of facing the growing demand to see more patients, collect more data, document more thoroughly, make less mistakes, and do all of this in far less time, I was ready to quit. I was burning out. I was depressed, angry, and didn’t like my job. I wanted a way out.

This is the despair that gets most doctors to quit fee-for-service medicine (or the “hamster wheel” as I called it) for either DPC or concierge care. “Medicine as usual” is not sustainable, and it makes you go home each day questioning your decision to become a doctor in the first place. Changing to DPC has not only rescued me from the despair of unreasonable demand, but it has restored that initial love for medicine. I get to do what I became a doctor to do: take care of people. This change cannot be understated, and it is one that you hear echoed from any DPC and concierge doctors you talk with.

Differences between DPC and concierge medicine

1. Lower price

I considered starting a concierge practice, before I chose DPC. When I opened my practice six years ago, concierge medicine was a well-established business model, while DPC was just in its infancy. There were a number of companies willing to help me transition to a concierge practice, but there were only a few doctors across the country to discuss DPC with. Yet I chose to go to DPC because it allowed me to continue to serve my poor and elderly population. I knew that it was more reasonable to expect patients to pay $30-$70 per month.

There are significant price variations within the DPC community. Some start at $50 and go up to $100, while others (like me) keep the price lower. I find that the higher price point discourages the most desirable patients-those without any serious health problems-to join the practice, selecting instead for a sicker, more needy population. Regardless, the bottom line is that the goal of DPC is to offer affordable care, while concierge tends to (with the higher price) to focus on premium care.

2. No insurance billing

This is the definition of the word “direct” in DPC: doctors are paid directly by patients, not by third parties. In truth, there is a growing movement toward payment by employers, and this stands to be a huge potential market for the overall DPC community. There also are some doctors who have a “hybrid” practice, where they have some direct care and some insurance-based patients. This is fraught with risks, though, as many payers (especially Medicare) contractually obligate providers to accept the negotiated rates. This makes it a breach of contract (or in the case of Medicare, illegal) to accept payment from directly from the patient in lieu of insurance payment.

So how does concierge do it? Very carefully. Billing for “non-covered services” is tricky, as the list of covered services by each insurance provider varies and regularly changes. This is the reason many concierge practices are affiliated with a company (such as MDVIP) to both set up and manage the practice. DPC, in contrast, is very simple (I like to say it’s “so simple even a doctor can run it”), charging a monthly fee that covers a registration fee (if you choose to do require one) and the cost of labs, procedures, and medications.

3. Focus on less care, cost

Being paid by a set monthly fee means that doctors are rewarded for keeping patients healthy and decreasing their overall costs. My patients are grateful when I explain why they don’t need the MRI scan, the antibiotic, or the ED visit. If I can prevent problems from happening, the patient is happy, and my office schedule can be open for those who need my care on that day. DPC is one of the few business models where it’s preferable to be less busy.

Some of this may also be true with concierge care, but often these practices offer premium services, such as in-office carotid dopplers, bone densities, and specialty labs and medications. The focus is giving a premium experience similar to that of first class on an airliner.

The big-picture difference

Concierge care has been around for many years, while DPC has only become significant over the past five years. In that time, DPC practices have gained significant attention, being included in provision of the Affordable Care Act, featured on cable news, and recently offered as a recommendation for cost savings by Consumer Reports. While concierge care has carved out its niche, DPC is more like a movement, with significant excitement among liberals and conservatives, young physicians and those (like me) nearing retirement, insured and uninsured, and people of all economic classes.

Why is this? I believe it’s because DPC takes the primary care doctors out of the influence of the hospitals and insurance companies and gives them back to those who matter the most: the patients. This is something both doctors and patients have yearned for and could possibly stem the seemingly unstoppable rising cost of care. How? By no longer rewarding doctors for keeping patients sick, increasing care, and feeding the system. Pay doctors for better care, not more care and amazingly… you get what you pay for.