The Evolution of Personalized Care

“In earlier conversations, Curmudge, you described family medicine in 1940 based on your personal experience. Back then, personalized care was the norm. Most docs were in solo practice with little or no supporting staff, they knew their patients well because they had delivered many of them, and they were willing to make house calls—sometimes in the middle of the night.”

“Seventy years ago, Jaded Julie, the financial side of solo practice was also pretty straightforward. Our family doctor’s patient load (panel) was kept low by the village’s low population. He charged what he felt was reasonable, my parents paid the bills, Dr. Arnold had a successful medical practice, and we enjoyed personalized care.”

“But now, Curmudge, a solo-practice doc is likely to be a preferred provider for an insurance company and he/she also has Medicare patients. Because of the level of reimbursements, his panel must expand to keep the practice viable. If the all-by-himself doc can’t expand his time to fit his panel and still get even a little sleep, there goes personalized care out the window.”

“That would seem be the case, Julie. In addition, think about how much more technically complex primary care has become. The advances in medicine itself are mind-boggling. Even small clinics have lab and radiology facilities, and the primary care docs have seemingly become the gateways to specialists for every disease, organ, and appendage. Then there are all of the externalities of health care delivery—insurance, Medicare, and regulations that change almost daily.”

“(Externality? I’m not sure what this is, but it sounds like more work.) You have described a rather unenviable plight for today’s primary care docs. So what, Ancient Oracle, do you suggest to get them out of it?”

“Suggest? No way! That’s beyond my salary grade. We must classify any statement that sounds like my judgment as pure conjecture. All I do is report what I find in the literature. Here’s an example, a Dr. Iliff, who sounded in 2003 as if he had done everything right in his solo practice (1). Seemingly everyone on his staff is a long-term employee: ‘My nurses have worked with me so long they know what I am going to say without my saying it.’ He has a long-time friend, a physician’s assistant, who also operates a solo practice; he helps smooth out the peaks in the doctor’s daily workload. Thus it would appear that the doctor has surrounded himself with surrogates who contribute greatly to his patients’ satisfaction. Perhaps we can call his practice ‘augmented solo.’”

“Curmudge, most docs that I know are, by nature, inclined to provide all of the personalized care that their patients desire. Their biggest constraint is lack of time. Dr. Iliff’s professional staff—because of their high quality and long service—make up for the doctor’s time limitation. But how does the doctor handle those externalities that you mentioned? Things like insurance, lab reports, reports from specialists, and Medicare?”

“He didn’t address many of these in his article, but he did emphasize that he limits his practice and keeps his office as simple as possible, with all records stored on site almost at arm’s reach. One might suspect that he has adequate—but minimal—clerical help who match the quality of the rest of his staff.”

“Well that’s one way to achieve personalized care. Are there others?”

“Sure thing, Julie. One is called ‘Concierge Medicine’ (Wikipedia calls this ‘Direct Care’). ‘Here are the basics: The patient pays an annual fee, ranging anywhere from $1500 to $10,000 a year for 24/7 access to her doctor. That means calls in the middle of the night, immediate, hour-long appointments, hospital visits, even house calls in some cases. Sometimes the fee includes appointment charges, but sometimes those are added on. Tests cost extra. Referrals get paid for separately’ (2). By significantly limiting his panel (100 to 1,000 patients), the physician is able to spend more time with each patient as needed. Typically, the concierge medicine practice does not become involved with insurance externalities; a patient with insurance handles that on his own.”

“I understand, Curmudge, that there are several business models for direct care.”

“One, apparently attractive to the uninsured, gets away from the pretentious connotation of ‘concierge’ by using the more descriptive term, ‘retainer practice.’ They charge $99 to join and then a flat monthly rate of $39 to $119 (3). Apparently however, retainer physicians are facing legal obstacles in some states (4). Primary care is certainly dynamic, Julie. Stay tuned for the latest news.”

“At your torpid tempo, Speedy, we could spend all year talking about primary care. When are we going to get to the medical home concept?”

“Never fear, Julie. The next time we talk about primary care, the medical home will be center stage.”

Affinity’s Kaizen Curmudgeon

(1)Iliff, D. Solo practice: the way of the future. http://www.aafp.org/fpm/20031000/23solo.html
(2)Trisha Torrey. Patient empowerment blog. http://patients.about.com/b/2008/03/21/your-doctor-on-call-247-for-a-price.htm
(3)Seattle doctors try flat-rate, no-limit primary care. (July 7, 2009)
http://www.medscape.com/viewarticle/705446
(4)Retainer physicians help uninsured but face legal obstacles. (June 4, 2009).
http://www.medscape.com/viewarticle/703900