Paying for enhanced service: comparing patients\' experiences in a concierge and general medicine practice

ORIGINAL RESEARCH ARTICLE

Patient 2009; 2 (2): 95-103 1178-1653/09/0002-0095/$49.95/0

ª 2009 Adis Data Information BV. All rights reserved.

Paying for Enhanced Service Comparing Patients’ Experiences in a Concierge and General Medicine Practice Justin M. Ko,1 Hector P. Rodriguez,2 David G. Fairchild,1 Angie Mae C. Rodday3 and Dana G. Safran1,3,4 1 Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA 2 Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington, USA 3 The Health Institute, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA 4 Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts, USA

Abstract

Background: Concierge medical practice is a relatively new and somewhat controversial development in primary-care practice. These practices promise patients more personalized care and dedicated service, in exchange for an annual membership fee paid by patients. The experiences of patients using these practices remain largely undocumented. Objective: To assess the experiences of patients in a concierge medicine practice compared with those in a general medicine practice. Methods: Stratified random samples of patients empanelled to each of the four doctors who practice at both a general medicine and a concierge medicine practice separately situated at an academic medical center were drawn. Patients were eligible for the study if they had a visit with the physician between January and May 2006. The study questionnaire (Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey, supplemented with items from the Ambulatory Care Experiences Survey) was administered by mail to 100 general medicine patients per physician (n = 400) and all eligible concierge medicine patients (n = 201). Patients who completed the survey and affirmed the study physician as their primary-care physician formed the analytic sample (n = 344) that was used to compare the experiences of concierge medicine and general medicine patients. Models controlled for respondent characteristics and accounted for patient clustering within physicians using physician fixed effects. Results: Patients’ experiences with organizational features of care, comprising care co-ordination (p < 0.01), access to care (p < 0.001) and interactions with office staff (p < 0.001), favored concierge medicine over general medicine practice. The quality of physician-patient interactions did not differ significantly between the two groups. However, the patients of the concierge

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medicine practice were more likely to report that their physician spends sufficient time in clinical encounters than patients of the general medicine practice (p < 0.003). Conclusion: The results suggest patients of the concierge medicine practice experienced and reported enhanced service, greater access to care, and better care co-ordination than those of the general medicine practice. This suggests that further study to understand the etiology of these differences may be beneficial in enhancing patients’ experience in traditional primary-care practices.

Background Concierge medicine, also known as retainer practice, boutique medicine, and independent personal care medicine,[1] emerged over a decade ago amidst an environment of increasing patient case loads,[2] dwindling reimbursement,[3] and rising practice costs.[4] Primary-care physicians (PCPs) who practice concierge medicine see this delivery model as a means to free themselves from the rising pressures of general medical practice. In part, this is accomplished by charging patients an annual fee for membership, which enables the physician to substantially limit the size of his or her panel, while promising patients more personalized care, longer and more comprehensive visits, and dedicated service and access. Concierge practices boast that this method of practice enables the patient-centered care that has been eroded by recent practice pressures, and enhances patient and physician satisfaction[5] in a time when both are waning.[6-10] Proponents of concierge care further contend that the ability to focus on wellness, preventative care, and care of chronic conditions[11] can ultimately result in cost savings for the system. However, the practices have been controversial in that they are seen as creating a healthcare elite and potentially exacerbating healthcare disparities, because patients unable to afford the practice may be forced to sever their clinical relationships and seek new care arrangements. To date, there has been little information about the performance of concierge practices, and, to our knowledge, no study has directly ª 2009 Adis Data Information BV. All rights reserved.

compared the experiences of patients seen in traditional primary care versus concierge practices. This study compares the experiences of patients empanelled to the four PCPs of an academic medical center who split their time between a general medicine practice and a concierge medicine practice. Both practices are located on the academic medical center campus. The organization of the concierge and traditional teaching practices differ substantially by patient caseload, office organization, systems for co-ordinating patient care, and appointment access (table I). However, quality of care, including clinical guidelines and algorithms, are consistent across the two sites and referral to laboratory testing, diagnostic imaging, and specialist care is the same between the general medicine and concierge medicine practices. Using well validated survey measures,[12] we compare the experiences of patients with respect to practice features, such as access to care, coordination of care, and office staff interactions, and quality of interactions with the physicians in the concierge medicine versus general medicine practice setting. Methods Stratified random samples of patients empanelled to one of the four PCPs who practice at both the general medicine and concierge medicine practices of the Boston-based academic medical center, Massachusetts, USA were drawn. Patients who had visited their PCP between January and May 2006 were eligible for inclusion in the study. For the general medicine practice, we Patient 2009; 2 (2)

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Table I. Comparison of characteristics of general medicine and concierge medicine practice at a Boston-based academic medical center Characteristics

General medicine practice

Concierge medicine practice

Panel size

2000 patients per FTE

300 patients per FTE

Cost to patient

Co-payments as per insurance fee schedule

Annual retainer fee of $US1800, which covers the cost of a comprehensive annual exam; for all other visits, co-payments as per insurance fee schedule

Physician compensation

PCPs who practice in both the general medicine and the concierge medicine practice are paid at the same salary scale as those practicing solely in the general medicine practice

PCPs who practice in both the general medicine and the concierge medicine practice are paid at the same salary scale as those practicing solely in the general medicine practice

Teaching

Attending physicians teach medical students and precept residents

No teaching occurs

General

Office environment and staff Office space

General clinic space

Separate clinic space with private entrance

Office staff

Selected from same human resource pool with the same pay scale and comparable levels of turnover

Selected from same human resource pool with the same pay scale and comparable levels of turnover

Patient orientation

No policy on answering missed calls

Concierge practice nurses see concierge patients who are on the inpatient service. Guideline exists for missed calls to be returned within 15 minutes

Follow-up

PCP responsible for follow-up letter to patients

Office staff responsible for incorporating copies of laboratory test results, relevant reports, and visit note for follow-up letter to patients For yearly physicals, patients are provided a CD of their personal health information

Specialist co-ordination

PCP responsible for providing relevant medical information or notes to specialist prior to patient visit and for following up on referral

Prior to visit, office staff send over relevant medical information to specialist. Office staff responsible for tracking referrals and compiling information into chart after the visit

Phlebotomy services

Patients go to a central hospital blood-draw service for phlebotomy, which necessitates an additional wait

Phlebotomy service provided at the concierge practice

Visit length

Follow-up visits scheduled for 20 minutes, annual/new patients scheduled for 40 minutes

Follow-up visits scheduled for 30 minutes, annual/new patients scheduled for 60 minutes

Office wait time

No guidance regarding wait time to see PCP exist

Providers and staff strive to have no patient wait >15 minutes to see their physician

Co-ordination of care

Access to care

FTE = full-time equivalent; PCP = primary care physician.

randomly sampled 100 patients for each physician (total n = 400) with the aim of obtaining at least 40 completed surveys per physician from this site. Since the concierge medicine practice (established in 2004) had fewer patients, all patients meeting the visit eligibility criteria and with a valid mailing address were included in the sample (n = 201). A multi-stage mail survey protocol was followed to enhance patient response. Reminder postcards were mailed 2 weeks after the initial survey mailing, and a second survey ª 2009 Adis Data Information BV. All rights reserved.

packet was sent to non-respondents 2 weeks after the postcard. Data collection proceeded over a period of approximately 8 weeks. The survey questionnaire consisted of the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CAHPS C/G) supplemented with validated items from the Ambulatory Care Experiences Survey (ACES).[12] The study questionnaire measured patients’ experiences of care across two domains: (i) quality of physician-patient interactions; and (ii) organizational Patient 2009; 2 (2)

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Table II. Adjusted Ambulatory Care Experience Survey (ACES) scores:a concierge medicine vs general medicine practice Parameter

General medicine

Concierge medicine

Quality of physician-patient interaction summary score

91.7

95.0

p-Value 0.20

Physician explains clearly

93.5

96.8

0.33

Physician listens

92.8

95.5

0.45

Physician gives clear instructions

92.3

94.5

0.38

Physician knows medical history

88.5

91.5

0.73

Physician respects what patient says

93.8

97.2

0.40

Physician spends enough time

90.3

94.4

0.003

Care co-ordination summary score

79.6

83.7

0.005

Physician follows up with test results

75.9

80.0

0.003

Physician up-to-date about specialist care

84.4

88.9

0.26

Access to care summary score

79.6

86.3