PHYSICIANS IN RETAINER PHYSICIANS IN RETAINER PRACTICEPRACTICEA NATIONAL SURVEYA NATIONAL SURVEY

Presentation to the Presentation to the Society for Innovative Medical Practice DesignSociety for Innovative Medical Practice Design

Matthew Wynia, MD, MPH, FACPMatthew Wynia, MD, MPH, FACPDirector, The Institute for EthicsDirector, The Institute for EthicsAmerican Medical AssociationAmerican Medical Association

May 5, 2005May 5, 2005The Institute for Ethics at the American Medical Association

Copyright 2005, American Medical Association. All rights reserved.

DisclaimerDisclaimer

The views expressed in this presentation are my own and,maybe, mine alone. That is to say, it could be that no one else agrees with me, let alone any of the very thoughtful and rational people I work with at the American Medical Association.

In occassional instances my views may seem eerily similar to policies of the AMA, but that can happen purely by chance. Furthermore, just because I say something that seems eminently reasonable, does NOT mean it is a policy of the AMA.

In fact, nothing I say should be construed as a policy statement of the AMA unless I specifically say otherwise (like, for example, if I say, “Here is what the AMA policy on this is…”).

No patient rush to 'concierge' practices

Tired of rushing through 25 to 30 appointments a day, Dr. Rick Versace thought he'd found the perfect solution: In October 2002, he opened a ''concierge" medical practice, spending $100,000 on radio ads, brochures, and other start-up costs and promising a smaller number of patients more time and attention in return for an annual fee.

But Versace's leap into a new kind of medical service didn't work out. Patient enrollment was stagnant and the patients he did have needed his attention at all hours and on weekends, so in February, he shuttered his Cape Cod practice. Now, Versace is employed working a regular shift treating hospital patients.

Dr. Rick Versace, shown with his son Joseph, 8, saw enrollment fall short after hiring a marketing expert to evaluate demand. (Globe Photo / Julia Cumes)

Boston Globe, April 15, 2005

BackgroundBackground

Physicians’ and patients’ frustrations Physicians’ and patients’ frustrations with health care are mountingwith health care are mounting

Frustrating factors for physicians Frustrating factors for physicians include time pressures, include time pressures, reimbursement hassles, providing reimbursement hassles, providing worse quality care than might be worse quality care than might be possible, and declining incomespossible, and declining incomes

To alleviate these frustrations, some To alleviate these frustrations, some physicians are establishing physicians are establishing “retainer” or “concierge” practices“retainer” or “concierge” practices

Retainer PracticesRetainer Practices

In retainer practices patients pay an In retainer practices patients pay an extra fee directly to the physician, extra fee directly to the physician, which covers special amenitieswhich covers special amenities

Fees range from several hundred to Fees range from several hundred to thousands of dollars per yearthousands of dollars per year

Amenities may include extra-long Amenities may include extra-long patient visits, preventive services, patient visits, preventive services, immediate access, private waiting immediate access, private waiting areas, and othersareas, and others

Ethics & Retainer Ethics & Retainer PracticePractice “…“…it is important that a retainer it is important that a retainer

contract not be promoted as a contract not be promoted as a promise for more or better promise for more or better diagnostic and therapeutic diagnostic and therapeutic services…”services…”– American Medical Association American Medical Association

Council on Ethical and Judicial Affairs Council on Ethical and Judicial Affairs (H-140.893)(H-140.893)

Ethics and Retainer Ethics and Retainer Practice, cont’dPractice, cont’d Ethical guidance on retainer Ethical guidance on retainer

practice also calls on retainer practice also calls on retainer physicians to specifically seek physicians to specifically seek opportunities to provide charity opportunities to provide charity carecare

And to ensure continuity of care And to ensure continuity of care for patients during time of for patients during time of transition to retainer practicetransition to retainer practice

Retainer Practices and Retainer Practices and the Lawthe Law Recent OIG Alert warns ofRecent OIG Alert warns of

“…“…potential liabilities posed by billing potential liabilities posed by billing Medicare patients for services that Medicare patients for services that are already covered by Medicare… are already covered by Medicare… [such as] ‘coordination of care with [such as] ‘coordination of care with other providers,’ ‘a comprehensive other providers,’ ‘a comprehensive assessment and plan for optimum assessment and plan for optimum health,’ and ‘extra time’ spent on health,’ and ‘extra time’ spent on patient care…” patient care…” OIG Alert March 31, 2004

Study Aims - 1Study Aims - 1

To describeTo describe– physicians entering into retainer physicians entering into retainer

practicepractice– patients in retainer practicespatients in retainer practices– services offered by retainer services offered by retainer

practices, including charity care practices, including charity care – the process of transition to retainer the process of transition to retainer

practicepractice

Study Aims - 2Study Aims - 2

To describe how physicians in retainer To describe how physicians in retainer practices and not in retainer practices practices and not in retainer practices perceive the risks and benefits of this perceive the risks and benefits of this new practice modelnew practice model

To assess whether these practices To assess whether these practices offer more and better diagnostic and offer more and better diagnostic and therapeutic services to enrolled therapeutic services to enrolled patients compared to non-retainer patients compared to non-retainer practicespractices

MethodsMethods

Snowball sampling of retainer practicesSnowball sampling of retainer practices

Comparison with sample of 1200 non-Comparison with sample of 1200 non-retainer physiciansretainer physicians

Mail survey, 4 waves, small incentivesMail survey, 4 waves, small incentives

Descriptive statistics, examined impact of Descriptive statistics, examined impact of clustering of physicians within practicesclustering of physicians within practices

MethodsMethods

National random sample mail National random sample mail survey of primary care physicians survey of primary care physicians (N=463), response rate 50% (N=463), response rate 50% (n=231)(n=231)

Sample of physicians in retainer Sample of physicians in retainer practice (N=144), response rate practice (N=144), response rate 58% (n=83)58% (n=83)

Survey ItemsSurvey Items

Study Goals 1:Study Goals 1:– Survey items addressed:Survey items addressed:

Demographic and practice characteristics of the Demographic and practice characteristics of the physicianphysician

Health and demographic characteristics of the Health and demographic characteristics of the physician’s patient panelphysician’s patient panel

– All physicians were asked about “special services” All physicians were asked about “special services” they provide for their patientsthey provide for their patients

– For retainer practice physicians, additional items For retainer practice physicians, additional items asked about asked about

The process of transition to retainer practiceThe process of transition to retainer practice How many patients in current practice are not paying How many patients in current practice are not paying

retainer feeretainer fee What proportion of former patients joined the retainer What proportion of former patients joined the retainer

practice practice

Methods, cont’dMethods, cont’d

Study Goals 2Study Goals 2 Survey items addressed:Survey items addressed:

Potential benefitsPotential benefits of of retainer practice, retainer practice, includingincluding

– Reduce administrative Reduce administrative hassleshassles

– Provide more time with Provide more time with each patienteach patient

– Increase physician Increase physician revenuerevenue

– Offer more diagnostic Offer more diagnostic and therapeutic and therapeutic servicesservices

– Offer better quality of Offer better quality of carecare

Potential risksPotential risks, including, including– Peer or community Peer or community

disapprovaldisapproval– Loss of diversity in Loss of diversity in

one’s practiceone’s practice– Loss of clinical skillsLoss of clinical skills– Harm to patients Harm to patients

unable to afford unable to afford retainer feeretainer fee

– Create a tiered system Create a tiered system of access to health careof access to health care

– Legal challenges to this Legal challenges to this mode of practicemode of practice

Overall assessment of whether retainer practices should be encouraged or notOverall assessment of whether retainer practices should be encouraged or not

Responding Physician Responding Physician CharacteristicsCharacteristics

RETAINERRETAINERPHYSICIANSPHYSICIANS

(N=83)(N=83)

NON-RETAINER NON-RETAINER PHYSICIANSPHYSICIANS

(N=231)(N=231)

P-VALUEP-VALUE

Age, mean, yAge, mean, y 4848 4949 0.510.51

Male, %Male, % 7373 7272 0.910.91

Years in practice, meanYears in practice, mean 16.816.8 18.418.4 0.250.25

Specialty, %Specialty, % General Internal MedicineGeneral Internal Medicine IM subspecialtyIM subspecialty Family PracticeFamily Practice OtherOther

626288

282811

27272828404055

<.0001<.0001

Patient panel, mean (median)Patient panel, mean (median) 835 (330)835 (330) 2303 (2000)2303 (2000) <.0001<.0001

Patients/day, mean (median)Patients/day, mean (median) 11 (10)11 (10) 22 (20)22 (20) <.0001<.0001

Charity/month, mean (med)Charity/month, mean (med) 9.14 (8)9.14 (8) 7.48 (4)7.48 (4) 0.220.22

Geographic distribution of physiciansGeographic distribution of physicians

Size of box indicates number of physicians sampled from a single zip code.

Age of retainer practicesAge of retainer practices

0

5

10

15

20

25

30

35

40

1996 1997 1998 1999 2000 2001 2002 2003 2004

Year*

# R

eta

ine

r p

rac

tic

es

sta

rte

d

Data for 2003 based on extrapolation of data through 9/2003.

Retainer Practice developmentRetainer Practice development

Months in retainer practice, mean (median)Months in retainer practice, mean (median) 17 (12)17 (12)

Practice development, %Practice development, % Started new practiceStarted new practice Converted or moved to retainer practiceConverted or moved to retainer practice

15158585

Patients not paying fee, % mean (median)Patients not paying fee, % mean (median) 17 (10)17 (10)

Patients joining practice, % mean (median)Patients joining practice, % mean (median) 12 (10)12 (10)

Amount of time given to find new physician, %Amount of time given to find new physician, % <31 days<31 days 31-90 days31-90 days >90 days>90 days

2236366363

Patient characteristicsPatient characteristicsRETAINER RETAINER

PHYSICIANS PHYSICIANS (N=83)(N=83)

NON-RETAINER NON-RETAINER PHYSICIANS (N=231)PHYSICIANS (N=231)

Medicaid patients, mean % Medicaid patients, mean % †† 5.85.8 15.315.3

African American, mean %African American, mean %†† 6.86.8 15.515.5

Hispanic, mean %Hispanic, mean %†† 4.54.5 13.613.6

Age 65 or greater, mean %Age 65 or greater, mean % 39.539.5 37.337.3

Patients with DM, mean %Patients with DM, mean %†† 16.916.9 23.923.9

Patients with CAD, mean %Patients with CAD, mean % 21.221.2 24.824.8

Patients with HTN, mean %Patients with HTN, mean % 30.430.4 34.734.7

Physicians with >5% of Physicians with >5% of Patients in Selected CategoriesPatients in Selected Categories

0%

10%

20%

30%

40%

50%

60%

70%

African-American*

Hispanic* Medicaid* HIV +*p<.001

RetainerNon-Retainer

Physicians with >25% of Physicians with >25% of patients in selected categoriespatients in selected categories

0%

10%

20%

30%

40%

50%

60%

70%

>65 y/o Diabetes* CoronaryDisease

HTN

RetainerNon-retainer

*p<.01

Hours of Charity Care/Mo.Hours of Charity Care/Mo.

0%

10%

20%

30%

40%

50%

60%

70%

0 1 to 10 11 to 20 >20

Retainer

Non-retainer

hours/mo.

Percent of Physicians Offering Special Services

0%10%20%30%40%50%60%70%80%90%

100%

*all p<.01

Retainer

Non-Retainer

Services Offered and UtilizedServices Offered and UtilizedRETAINER RETAINER

PHYSICIANSPHYSICIANS(N=83)(N=83)

NON-RETAINER NON-RETAINER PHYSICIANSPHYSICIANS

(N=231)(N=231)

Services offered, %Services offered, % Accompanied specialist visits Accompanied specialist visits ††

House calls House calls ††

24-hour physician access 24-hour physician access ††

Same-day appointments Same-day appointments ††

Coordinated hospital care Coordinated hospital care ††

Private waiting room Private waiting room ††

323270709696999995953434

11262640408383595933

Services utilized, mean #pts/3 monthsServices utilized, mean #pts/3 months Accompanied specialist visitsAccompanied specialist visits House calls House calls ††

24-hour physician access24-hour physician access Same-day appointments Same-day appointments ††

Coordinated hospital care Coordinated hospital care ††

Private waiting roomPrivate waiting room

4.14.18.08.041.741.786.786.712.412.452.352.3

2.02.04.14.1

60.460.4133.1133.135.235.21010

0%10%20%30%40%50%60%70%80%90%

100%

Less admin.hassle*

Less hoursworked**

More patienttime*

Better quailtycare*

Morediagnostics

andtherapetics

offered**

Morerevenue*

Retainer (n=81)

Non-Retainer(n=574)

*p<.001**p<.05

Physician agreement with possible benefits of retainer practices

0%10%20%30%40%50%60%70%80%90%

Peer orcommunitydisapproval

Tieredsystem ofaccess*

Harm topatients

unable topay fee*

Loss ofinsurance

contracts inpractice**

Loss ofpatient

diversity*

Possiblelegal

challengesto charging

fee*

Retainer (n=81)

Non-retainer (n=574)

*p<.001 **p=.01

Physician agreement with possible risks of retainer practices

0% 10% 20% 30% 40% 50% 60% 70%

Strongly encouraged

Somewhatencouraged

Allowed

Somewhatdiscouraged

Illegal

Non-retainerRetainer

p<.001

Physicians’ opinions on how retainer practices should be regarded

ConclusionsConclusions

Retainer practices are forming across Retainer practices are forming across the country, but primarily in the coastal the country, but primarily in the coastal states and large cities - ? current trendstates and large cities - ? current trend

Retainer practices offer numerous Retainer practices offer numerous “special services”, but none are “special services”, but none are universal and none are unheard-of universal and none are unheard-of among non-retainer practicesamong non-retainer practices– Some non-retainer practices appear to Some non-retainer practices appear to

offer amenities comparable to some offer amenities comparable to some retainer practicesretainer practices

Conclusions, cont’dConclusions, cont’d

Conversion to retainer practice takes timeConversion to retainer practice takes time Most such practices are new (~1 year old)Most such practices are new (~1 year old) When doctors convert to retainer When doctors convert to retainer

practices, the vast majority (>80%) of their practices, the vast majority (>80%) of their patients do not join the practicespatients do not join the practices

Most have some patients (~10%) not Most have some patients (~10%) not paying retainer feespaying retainer fees

Retainer practices might be in transition, Retainer practices might be in transition, though older practices also have ~10% of though older practices also have ~10% of patients not paying retainer feepatients not paying retainer fee

Conclusions, cont’dConclusions, cont’d

Patients in retainer practices seem to Patients in retainer practices seem to have slightly fewer patients with have slightly fewer patients with chronic diseases, especially DM. chronic diseases, especially DM.

Retainer practices serve very few Retainer practices serve very few ethnic minority patients ethnic minority patients – Most (~70%) have fewer than 5% African Most (~70%) have fewer than 5% African

American or Hispanic patientsAmerican or Hispanic patients Most retainer physicians (86%) provide Most retainer physicians (86%) provide

some charity care, and on average some charity care, and on average they provide slightly more hours of they provide slightly more hours of charity care than non-retainer primary charity care than non-retainer primary care physicianscare physicians

Conclusions, cont’dConclusions, cont’d

Practice transitionPractice transition– AverageAverage non-retainer practice = 2300 non-retainer practice = 2300

ptspts– AverageAverage transition to retainer practice transition to retainer practice

entails…entails… Transfer of care for 2025 patientsTransfer of care for 2025 patients Add 560 new patientsAdd 560 new patients Continue to see 140 patients not paying Continue to see 140 patients not paying

feefee

Conclusions, cont’dConclusions, cont’d

The majority of retainer and non-retainer The majority of retainer and non-retainer physicians believe that retainer physicians physicians believe that retainer physicians risk peer or community disapprovalrisk peer or community disapproval

Retainer physicians see countervailing Retainer physicians see countervailing benefitsbenefitsMore time with patients (98%)More time with patients (98%)Fewer administrative hassles (82%)Fewer administrative hassles (82%)Provide better quality care (88%)Provide better quality care (88%)Increased revenues (66%)Increased revenues (66%)Fewer hours of work (48%)Fewer hours of work (48%)More diagnostic and therapeutic services More diagnostic and therapeutic services

provided (47%)provided (47%)

Possible ImplicationsPossible Implications

Case-mix and access to careCase-mix and access to care– Worried well vs. sicker, complicated patientsWorried well vs. sicker, complicated patients– Improved access for some ?overall impactImproved access for some ?overall impact– Don’t know if retainer physicians change their Don’t know if retainer physicians change their

patient mix at time of transitionpatient mix at time of transition

Segmentation and legality of Segmentation and legality of practicespractices– Increasing rationing by ability to payIncreasing rationing by ability to pay– More and better services and careMore and better services and care– Considerable overlap of special servicesConsiderable overlap of special services

Conclusions, cont’dConclusions, cont’d

Retainer physicians are less likely to Retainer physicians are less likely to perceive risks in retainer practice such perceive risks in retainer practice such asasHarm to poor patients (5%)Harm to poor patients (5%)Loss of diversity in practice (23%)Loss of diversity in practice (23%)Create tiered system of access to care Create tiered system of access to care

(40%)(40%) But are more likely to fearBut are more likely to fear

Loss of insurance contracts (51%)Loss of insurance contracts (51%)Possible legal challenges to this mode of Possible legal challenges to this mode of

practice (52%)practice (52%)

Possible ImplicationsPossible Implications

It may be unrealistic to assert that It may be unrealistic to assert that retainer practices can provide more retainer practices can provide more time, quicker access, and additional time, quicker access, and additional services, yet not claim to provide services, yet not claim to provide “more and better quality diagnostic “more and better quality diagnostic and therapeutic services”and therapeutic services”

Given diverse opinions on public policy, Given diverse opinions on public policy, legal and other policy challenges to legal and other policy challenges to retainer practices are likely to continueretainer practices are likely to continue

Persistent questionsPersistent questions

How can retainer physicians not perceive their How can retainer physicians not perceive their practices as contributing to a tiered health care practices as contributing to a tiered health care system and thereby harming poor patients? system and thereby harming poor patients? – Retainer physicians might see American health care Retainer physicians might see American health care

as already, and/or appropriately, tieredas already, and/or appropriately, tiered– Retainer physicians might see their practices as a Retainer physicians might see their practices as a

“drop in the bucket” of inequities in health care“drop in the bucket” of inequities in health care– Some retainer practices might be tied to specific Some retainer practices might be tied to specific

efforts to improve health care for the poorefforts to improve health care for the poor More research is needed on the degree to More research is needed on the degree to

which inequities in health care might be which inequities in health care might be worsened, or alleviated, through the creation of worsened, or alleviated, through the creation of retainer practice modelsretainer practice models

Possible ImplicationsPossible Implications

Vulnerable populations, including the poor and Vulnerable populations, including the poor and minorities, are dramatically under-represented in minorities, are dramatically under-represented in retainer patient panelsretainer patient panels Retainer practices might exacerbate racial and ethnic Retainer practices might exacerbate racial and ethnic

health disparitieshealth disparities On average, retainer physicians care for 1,427 On average, retainer physicians care for 1,427

fewer patients than other primary care physicians fewer patients than other primary care physicians Most retainer practices are in large cities, but if they Most retainer practices are in large cities, but if they

spread to smaller areas, they could reduce access to spread to smaller areas, they could reduce access to carecare

Physicians’ converting to retainer practices Physicians’ converting to retainer practices discontinue care for most of their patients (mean discontinue care for most of their patients (mean 87%), but most continue seeing some former 87%), but most continue seeing some former patients who do not pay the retainer feepatients who do not pay the retainer fee Some patients of physicians who convert to retainer Some patients of physicians who convert to retainer

practice might be having trouble finding appropriate practice might be having trouble finding appropriate carecare

AcknowledgmentsAcknowledgments

Caleb Alexander, Jacob Kurlander, Caleb Alexander, Jacob Kurlander, Karin Morin, Sara Taub, Amy Bovi, Karin Morin, Sara Taub, Amy Bovi, Jennifer Matiasek, Maliha Jennifer Matiasek, Maliha Darugar, Jeanne UehlingDarugar, Jeanne Uehling

MacLean Center for Clinical MacLean Center for Clinical Medical Ethics, University of Medical Ethics, University of ChicagoChicago