Kate Johnson

May 26, 2012

May 26, 2012 (Philadelphia, Pennsylvania) — When 200 delegates crammed into a room at the American Association of Clinical Endocrinologists (AACE) 21st Annual Meeting and Clinical Congress to hear a panel discussion on how healthcare will affect their income, they didn't expect to hear about "concierge medicine."

But 3 hours later, the room was still full, the session was running overtime, and there was a long line behind the single microphone.

On the one hand, it was a chance to collectively express the growing frustration that is metastasizing across medical specialties — that of increasing costs and decreasing reimbursement. On the other hand, it was a rare opportunity to hear about solutions.

"My take home pay is about 350% what it was before.... It's just fun again," said David DeAtkine Jr., MD, who has discovered the world of concierge medicine. "Everybody in this room ought to be paid 3 or 4 times what you're currently being paid."

For Dr. DeAtkine, an endocrinologist and internal medicine specialist from Birmingham, Alabama, the story started when the good times stopped — in the early 1990s.

"For those of you who are just starting, it's hard for you to understand or appreciate what it was like to be in practice in the early 90s," he said. "When you wrote a prescription and handed it to the patient, it just got filled. When you put somebody in the hospital, it just happened; you didn't have to...kiss somebody's ass. It was remarkably fun."

But a few years later, he and a colleague became disillusioned in their multispecialty practice. "We were concerned about major inefficiencies; we felt we could be doing better. We were hoping...that we could make a decent living taking care of patients in a small, welcoming environment without the presence of a large ancillary apparatus."

Although he is doing that now, in the early 2000s it was an idea before its time. Setting up a "2-man" practice, even with diligence, efficiency, and the best intentions, "our practice overhead was high, and costs were going up.... Watching our income decline despite the fact we were working very hard was worrisome.... Reimbursement was stable or declining, costs were relentlessly increasing and, to my great consternation, administrative effort was logarithmically increasing," he said.

Lured by a 2002 article in the New England Journal of Medicine (2002; 347:1971-1975), Dr. DeAtkine started to investigate concierge medicine. In 2003, he joined MDVIP, a company that now has the largest network of concierge physicians in the United States.

"Although intellectually and spiritually rewarding, private practice endocrinology is a high-overhead and a low-reimbursement business. Reimbursement is completely dependent on hostile entities...creating an emotionally and physically exhausting cycle," he said. "Most important, the status quo is becoming a practice environment that is hostile to our patients, where the practitioner and patient are literally at odds."

"Our patients value our time and they want our time. The thing that you do not have to give is your time."

After switching to concierge medicine, Dr. DeAtkine went from seeing 35 patients a day, 150 new consults a month, and a fear of taking days off, to seeing 8 to 12 patients a day and a "normal" personal life.

"Unlike a traditional practice — I had 4300 active patients at the time... — [concierge] practices are limited to a maximum of 600 patients," he said. "In my mind, this is the perfect model for diabetes patients. I had so many patients who wanted me to be their primary care physician, and this was the opportunity to do that."

Each patient pays an annual fee of $1500 to $1800, which pays for a wellness/prevention plan and a physical. "That allows for a practice where you have same-day or next-day appointments and unhurried visits, where physician access is unparalleled, where there is enhanced coordination of referrals and, for the patient, more time with the physician."

"Even though I'm available supposedly 24/7, I get far fewer calls than I used to because people get taken care of during the day," he said. "I don't get calls at 3:00 in the morning about constipation or being vaguely itchy. The calls I get are when someone is having a myocardial infarction or diabetic ketoacidosis or vomiting blood — they're all legitimate — and it's rare because I only have 600 patients."

Dr. DeAtkine's story provoked a mix of reactions from the audience.

"We all feel the frustration," acknowledged Jonathan Leffert, MD, from the North Texas Endocrine Center in Dallas, and chair of the session. He also chairs the Legislative and Regulatory Committee of the AACE.

"We have more and more frustration because we continue to have reimbursements cut...and more and more expenses," Dr. Leffert said in an interview with Medscape Medical News.

"There's so much concern about what is going to happen in the future. The changing reimbursement models, the changing delivery systems are being talked about in Washington."

"Endocrinologists are a cognitive group of physicians; we don't have specific procedures. It's much more difficult for us to get a handle on what the payment models will be, other than a fee-for-service model. That's what we're used to; that's what our bread and butter is. We realize the new models may be very different from the current models," he explained.

But some participants were critical of the concierge approach.

"I really believe these people doing these concierge practices are cherry picking," said Richard Guthrie, MD, in an interview with Medscape Medical News. "They're taking patients who can and will pay. There are some people who simply can't. Somebody's got to take care of them; I'm the guy who takes care of them."

Dr. Guthrie, a 76-year-old endocrinologist still working full-time in Wichita, Kansas, said he should have retired, but hasn't "because there are people to be taken care of," many of whom do not pay him because "they can't."

"In my town, we have 10 endocrinologists. We take care of a population of a million and a half — that's 1 endocrinologist for every 150,000 people. If [Dr. DeAtkine] is only going to take care of 600 of those, who is going to take care of the rest?"

Dr. DeAtkine has heard these criticisms before, but is not convinced it's a problem.

"All those patients you say don't pay you, I'm willing to bet they pay the power company and they pay the sewer and water board, and they pay for their cell phone, they go to Las Vegas," he told Dr. Guthrie." It's just that you're a rich doctor and you don't really need the money, so they don't have to pay you. I got over that a long time ago. I do a certain percentage of my work for free, but I do it on my terms."

He says endocrinologists, as a group, are guilty of Stockholm syndrome. "We're so used to being abused by third-party payers and the federal government that we've begun to sympathize with them and we've begun to think we're really not worth anything.... If all of us got up as a body and said we're worth something, we could really do something. The reason...orthopedic surgeons are where they are is because they said all along they are worth something — an ACL is worth this amount of money; kiss my ass if you don't like it. And guess what? Everybody falls in line. But we, because we are born with a guilty conscience, say it's okay to not be paid. I think that attitude hurts our subspecialty. It does not do the patients any good to say what we do is worth nothing."

Dr. Guthrie said he agrees with the concept, and he agrees, as Dr. DeAtkine suggested, that endocrinologists should speak out.

"We should value our time. It is true that the surgeons have done that and the endocrinologists have not. It is time for us to stand up and say it's time to be reimbursed. The problem is that insurance companies and Medicare don't know how to reimburse for cognitive specialties. They know how to reimburse for procedures. We need to teach them, and they need to learn it. It needs to be more of a level playing field. But I would hope there's another way to do it in which we can still provide the care people need, because people still need to be taken care of."

Dr. DeAtkine's practice is affiliated with MDVIP in Boca Raton, Florida. Dr. Leffert and Dr. Guthrie have disclosed no relevant financial relationships.

American Association of Clinical Endocrinologists (AACE) 21st Annual Meeting and Clinical Congress. Presented May 25, 2012.

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