The Retainer Model or Single Payer -- What Will Save Primary Care?

Robert M. Centor, MD; Charles P. Vega, MD


March 20, 2008

In This Article

Point: The Retainer Model May Stimulate a Rebirth of Outpatient Internal Medicine

Robert Centor, MD

Outpatient internal medicine has joined the endangered species list, or at least so many commentators have opined. Fewer internal medicine residents are opting for outpatient jobs. Many outpatient internists are leaving practice, either for fellowships or for hospitalist jobs.

As I consider the medical student's choice of internal medicine for his or her career, I note that the fascination with internal medicine usually results from the complexity of the field. Internists champion the care of complex patients. We love diagnostic and management puzzles.

In the 1970s and 1980s, many internists embraced a definition of primary care that the Institute of Medicine (IOM) codified:

"A set of attributes, as in the 1978 IOM definition -- care that is accessible, comprehensive, coordinated, continuous, and accountable -- or as defined by Starfield (1992) -- care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness."[1]

Training programs produced internists who could care for complex disease and also handle a wide variety of clinical issues, including episodic care and preventive medicine. Over the following 30 years, our society apparently has redefined primary care to a definition that degrades the original concept. The American Heritage Dictionary in 2006 provides this definition for primary care: "The medical care a patient receives upon first contact with the healthcare system, before referral elsewhere within the system."

I believe that most insurers and other physicians no longer consider comprehensiveness when they think of primary care. I would argue that internists do not want and are not trained to do this limited conceptualization of primary care as defined by the American Heritage Dictionary; rather, we are trained to add primary care services to our comprehensive care. Such distinctions underlie the angst of many practicing internists. We have trained a generation of internists to provide comprehensive care, including episodic and preventive care, and yet insurers and especially health maintenance organizations complain that internists are not good at providing quick, efficient primary care. Family physicians are in a similar situation. We have a problem of semantics and thus our discussions about primary care remain confused.

Our reimbursement system also does not pay internists sufficiently to provide high-quality comprehensive care, although our patients are too complex and require more time than what insurers believe constitutes a standard office visit. Specifically, patients need various levels of intensity. A 30-year-old mother with a sore throat has different physician needs than a 55-year-old man with chronic obstructive pulmonary disease, heart failure, and type II diabetes mellitus. Clearly, the latter patient will need longer and more frequent visits. Moreover, our current system does not reimburse out-of-office continuity. We have no reimbursement for telephone calls or emails, although patients often have questions for their physicians. They would like to call their physician for advice, or to discuss a possible new symptom. And, conversely, we would often like to check on our patients to find out, for example, how they are responding to a new treatment.

Our current arrangements are slowly killing the outpatient practice of internal medicine. With this backdrop, some enterprising physicians re-created the retainer model. They imagined a practice and created a model that would both satisfy patient desires and improve physician satisfaction.

The idea is simple. The patient pays a fee for physician access, which allows same day appointments, telephone access, and email access. Physicians regularly call these patients and even make house calls when necessary. The physician's panel size has a much lower limit than most internists currently have. Although the retainer model has variations, the above principles represent the core concepts.

When interviewed, retainer physicians emphasize their professional satisfaction with this arrangement. They can spend enough time with each patient because they no longer have the pressure to see 20 or 25 patients each day. Patients apparently love this model. They want convenient access and are willing to pay for that access. Despite retainer fees, which generally range from $1000 per year to $4000per year, approximately 90% of patients renew their contracts each year.

Many have criticized these practices on ethical grounds and on the assumption that primary care physicians should care for a large panel of patients. I believe that retainer medicine may save outpatient internal medicine. I doubt that all patients will enter a retainer practice, but I do suspect that increasing numbers will join such practices because patients recognize the value of access to their healthcare.

Perhaps these practices, if they continue to flourish, will stimulate a resurgence of outpatient internal medicine. We will be able to continue to train internists who understand the spectrum and complexity of disease, because the retainer model provides an option for those who prefer the outpatient setting but also want complexity and comprehensiveness. Whereas many critics are concerned with the finances of this model and worry about inequities, supporters emphasize the retainer physician's ability to provide the level of care and attention that patients deserve.

The retainer model originated and is succeeding because of classic market forces. Physicians and patients find our current arrangements undesirable, thus this new alternative model gives them an interesting choice. Perhaps it will save outpatient internal medicine.


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