Concierge, Direct Pay, or Hybrid: Is One Right for You?

Leigh Page

Disclosures

April 06, 2016

In This Article

What About Specialists

Dr Sizemore-Ruiz is also venturing into specialty concierge care. Her cardiology patients can join the concierge practice. This makes sense, she says, because cardiologists follow patients for many years, and she thinks the extra attention would benefit cardiology patients.

"Easy access to care is very beneficial for patients who have, for instance, congestive heart failure," she says. "Often, these patients need to be watched very closely, or they could end up in the hospital for something that could have been managed as an outpatient. I can help to keep them out of the hospital by being more available to them for quick appointments."

Specialists can also prosper in direct pay arrangements, where physicians don't bill insurance, according to Josh Umbehr, MD, a young family physician who operates a direct-pay practice in Wichita, Kansas. "Specialties like endocrinology, cardiology, neurology and women's health are managing chronic conditions and are perfect for direct arrangements." he says.

Even specialties that don't follow patients, like orthopedic surgery, can drop insurance and accept cash only. Dr Umbehr points to the Surgery Center of Oklahoma, which is basically cash only and has been posting its rates on its website since 2009.[3]

But some specialties don't quite fit the mold. Some psychiatrists, for example, have had cash-only practices for years, and yet they aren't direct pay in other ways. They don't typically give out their cell phone numbers or give patients longer appointments.

The Growing Appeal of Direct Pay

Dr Umbehr reports that direct-pay practices have been growing faster than concierge practices in recent years, but there are still very few of them—just 500 nationwide, according to his count. One reason these doctors are still rare is that they must take a radical departure from traditional medicine.

Typically, direct-pay doctors reject all insurance contracts and even opt out of Medicare, Dr Umbehr says. To survive without insurance, they have to keep their rates lower than concierge practices, charging $40 or $50 a month for the average patient. This means offering all of the frills of concierge care and keeping their overhead very low.

They don't need to have a billing function, and they often rent office space and constantly seek out discounts for drugs, labs, and other services, he says. This bare-bones approach probably appeals more to young physicians. These physicians tend to gravitate to direct pay rather than concierge because they don't have an existing practice to convert.

On another level, however, direct pay appeals to any doctor who's frustrated with insurance and government regulations. Dr Umbehr gets his inspiration from the book Atlas Shrugged, by Ayn Rand. His practice, AtlasMD, is named after the book, and he launched it on September 2, 2010, the exact date when the 1957 futuristic novel opens.

In the book, the Greek god Atlas, who holds up the world, is a metaphor for the smart, creative people whom Ayn Rand thinks are being forced to support the rest of society. These "Atlases" have to free themselves by "shrugging" off the weight they have been forced to carry. On his website, Dr Umbehr writes: "AtlasMD represents my ideal medical practice where I'm able to shrug off the burdens and restrictions of government and insurance regulation so I can focus solely on my patients and their needs."

That view appeals to a much broader swath of doctors than just Ayn Rand fans. A 2014 poll[4] by the American Academy of Family Physicians found that while very few family physicians were in direct-pay practices, 28% were exploring the model.

Many people still have problems with membership-based care. It has been criticized for appealing a lot more to doctors than to patients. But this hasn't been the case for Dr Umbehr. He's been able to find many patients in Wichita, a small city with almost 400,000 people, and even add more doctors his practice. Since coming out of residency 5 years ago, he has expanded AtlasMD to 5 doctors, each with a panel of about 600 patients. They each make about $240,000 a year on a gross income of about $360,000, he says.

AtlasMD's monthly rates are on a sliding scale—from $10 for children up to age 19 years; $50 for adults ages 20-44 years; $75 for adults ages 45-64 years; $100 for adults ages 65 years and older; and $150 for patients who are homebound or in a nursing home. Dr Umbehr says that other practices may come up with different rates. "You adjust the model to your patient mix," he says.

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