Concierge Practices Even for Doctors Who Don't Like the Idea

Neil Chesanow


January 09, 2014

In This Article

Elitist Medical Practice?

Despite concierge medicine's reputation for being elitist, many doctors make the switch not because they want cushier lives but because they want more clinically challenging ones. In many cases, concierge practices enable them to better focus on their older, sicker patients, who rarely get the time they need in a conventional practice.

These are the patients, after all, whom many doctors presumably go into medicine to treat: those with complex diagnoses and complicated medication regimens -- the ones who give you a chance to practice at the top of your game.

Take Thomas W. LaGrelius, MD, a family physician and geriatrician in solo practice in Torrance, California, and internist Mario Ficarola, MD, the lead physician in a 5-doctor internal medicine group 38 miles away in Tustin, California. Both primarily see older patients with multiple chronic conditions. Both transitioned to concierge medicine -- LaGrelius in 2006, Ficarola in 2008 -- to be able to give these patients the time they need and were not getting elsewhere.

Many concierge physicians have cash-only practices, so it's commonly assumed that shunning commercial insurance or Medicare is the rule. Not so. Many concierge physicians take both. Ficarola is one of them. LaGrelius takes Medicare but is not on any commercial insurer panel. However, he does submit claims for patients as an out-of-network provider.

The doctors differ in one key respect. LaGrelius transitioned to a full concierge practice, in which all (in his case, most) patients pay an annual fee to be in the practice, and the overall number of patients is reduced so that the doctor has ample time to see those who remain. Ficarola transitioned to a mixed, or hybrid, concierge model, in which the panel remains the same, most patients are seen as they were before, and a smaller group are fee-paying concierge patients.

If you're considering a move to concierge medicine, how these doctors thought through their decisions -- from which practice model to choose to whether to hire marketing help -- can help to clarify your own thoughts on what's right for you.

The Making of a Concierge Doctor

Tom LaGrelius, 70, was a member of a multispecialty group of about 30 doctors in Redondo Beach, California, 21 miles southwest of Los Angeles, from 1974 to 1983. After completing his internship and residency at the University of Southern California Medical Center in Los Angeles, he joined the group, eventually rising to chairman of the board.

In the early 1980s, the group signed some HMO contracts. HMOs are often thought to have emerged in the 1990s, but in the early 1970s, almost 4 million Americans were enrolled in nearly 40 prepaid health plans, most of which were operating in California.[1] By 1980, about 8 million Americans were in HMOs.[1]

As chairman of the group, LaGrelius was given a seat on an HMO board, which he held for a few months. "I watched what they were doing," he says, "and it seemed to me something that I didn't want to do. They were in the business of denying care."

His gave his own board an ultimatum. "We joined an organization that I personally don't want to be associated with, and I want my name off the contract," he announced. His request was granted. "But when the group finally decided that everyone had to participate in the HMO, I resigned and opened a solo practice."

About half his patients followed him to the new practice: Skypark Family Medicine Group in nearby Torrance. LaGrelius has never joined an HMO and had resigned his last PPO contract decades before. Although he takes Medicare, "I am always considering opting out," he says. While the rest of his practice is cash-only, he submits claims for patients as an out-of-network provider.

"The practice was not initially terribly busy," LaGrelius admits. However, he had an established reputation in the community. He had privileges at local hospitals. And he did some marketing.

"I joined the hospital's public education forum and gave educational talks to the community," he says. "I passed out brochures to commercial businesses in the area. But by and large, it was mostly word of mouth from other patients in the practice that made it grow."

In 2005, when he decided to transition to a concierge practice, "I saw 1500 different individuals," LaGrelius says, "2400 individuals in the 2 years before. Most of those patients just came to me when they were sick."

Some of these patients had 20-30 medical problems. He was seeing 25 patients a day at his peak. He couldn't offer them the proper care in 15-minute visits.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.