Concierge-style medicine

According to a recent story in Businessweek magazine, around 17 percent of Californians don’t seek a doctor’s care because of the expense. Meanwhile, with physician shortages and challenging economic models, physicians aren’t always available to those who could afford them—insured or not.

Some medical offices have switched to the concierge (or direct-care) model, under which patients pay cash in the form of an annual fee for their care, often because insurance is not accepted (not accepting insurance can keep costs, such as administrative, lower for the physician, and consequently for the patient). In Chico, there’s a hybrid approach: Argyll Medical Group’s retainer service, called Argyll Advantage.

Argyll’s physicians do accept insurance for office visits. They also treat patients without insurance who must pay at the time of service (around $100 for a first-time appointment and $45 for a follow-up.) For other services, not covered by insurance but incurring a cost for the patient, most Argyll providers offer a voluntary program for patients willing to pay a small flat fee.

Those services, for established patients, above and beyond in-person appointments, include:

• Brief phone calls with the doctor, including weekdays after hours;

• Secure email communication with the doctor, as well as text-messaging;

• Forms and letters completed by the doctor;

• Late cancellation of appointments;

• Repeat refills of prescriptions;

• Same-day appointments with a health-care provider;

• Free CD copies of the complete electronic medical record sent to specialists and other physicians.

Many medical practices—Argyll included—charge individual fees for services like these. Argyll Advantage places these and other services under a single retainer fee of $20 a month. Unlike a concierge practice, this payment is not mandatory; nor is it covered by insurance. It is a supplement to in-person appointments.

“The basic reason is that patients want the convenience of ‘non-visit care’ and direct access to the doctor, but insurers do not pay for this—for now,” said Dr. Roy Bishop, CEO of Argyll Medical Group and one of the physicians offering Argyll Advantage. “We have over the years done a fairly good job of educating patients that office visits are paid for by insurance, [and] anything else is a la carte or they can sign up for the retainer. It is fairly standard; many practices are now offering retainers as an add-on option.”

Along with Bishop, four other practitioners participate in Argyll Advantage: Dr. Baran Onder, Dr. Brandan Stark, physician’s assistant Brent Hopson and nurse practitioner Jordan Frazer. Bishop estimates about 3 percent of Argyll Medical Group patients have enrolled in the program.

“I have two types of patients who sign up for the retainer,” Bishop said: “Very busy people who want access to me directly by phone, text and email rather than having to have office visits and go through my staff, [and] also some patients with multiple chronic problems who want enhanced access and care oversight by me personally, especially using the email access.

“Sometimes, for elderly patients, their children sign up for the retainer so that they can communicate with me about their parent who may be in Chico in a care home.”

Remote communication doesn’t supplant in-person contact—it’s a supplement. Sometimes the doctor’s reply is, “Come into the office.”

Explained Bishop: “We recommend all of our patients have an annual physical with lab work where we can assess their health status and order any preventative care needed; under health-care reform, the ACA [the Affordable Care Act], for most patients this can now be done at no cost to them. Usually when we hear about the problem by email or phone, we can assess whether the patient needs to be seen. Phone calls and emails do not replace office visits where an office visit is needed.”

At that point, though, Argyll Advantage patients have priority for appointments with their own physician or a guarantee of a same-day appointment with an available Argyll provider.

Bishop established Argyll Advantage two years ago—Jan. 1, 2011. He’d been reading about the American Academy of Family Physicians’ “Primary Care Medical Home” model, which incorporates information technology to coordinate health care. He also read about concierge doctors.

“I did not think Chico and Butte County would support a concierge practice,” Bishop said, citing the expense to patients (potentially hundreds of dollars a month). “But, being a pioneer with electronic-medical-record and email communication with patients at George Washington University in D.C., Sutter Health and then Argyll, I wanted to be able to offer additional means of contact and services for the patient as an add-on, without going concierge at a high cost to the patient and ceasing to accept insurance.”

In the future, Bishop predicts, insurance companies will change the way they reimburse to include non-visit services.

“Insurers and Medicare pay for office visits and work directly associated with that, and nothing else,” Bishop explained. “Unfortunately their payment systems have not evolved to change with changes in how people lead their lives and the technology like smartphones that we all use—and they need to do so. We could have better, cheaper health care if they moved in the direction that all other advanced countries use: ‘blended payment.’”

With only a small fraction of his patients on Argyll Advantage, how have the remaining patients reacted? Do they push back on the additional fees for additional services they may expect to be covered?

“We have not had any negative reaction,” he said, “because Argyll Advantage is an add-on service; it is not compulsory as in a concierge practice, and we do accept insurance. We see it as an added convenience. …

“Nearly all primary-care offices charge for non-visit care—insurance company and Medicare reimbursements [i.e., payments] have fallen by 30 percent in real terms in the past 10 years, while our costs are up by 25 percent due to inflation—and no health-care provider can afford to provide extensive free services for patients.”