The MedPAC report indicates that retainer-based care has yet to catch on in some parts of the country, with a few states leading the way. Many of the retainer-based physicians cited in the report were in California (157), Florida (99), Virginia (53) and Texas (40). At the same time, there are states with few or no such practices, according to the report, and among metropolitan statistical areas with 10 or more, some have a relatively low number of retainer-based doctors relative to the population.
States with few or no retainer-based physicians included Iowa, Maine, New Mexico and Wisconsin. MSAs with relatively low numbers of retainer-based physicians per 100,000 population included Atlanta (0.2), Houston (0.2) and Chicago (0.2), while Naples, Fla., led the nation with a ratio of 5.1.
Support for these models seems to be coming from consumers who want it and doctors who want to provide it. An executive for a large chain, Concierge Choice Physicians, based in Rockville Centre, N.Y., says demand continues on both sides of the equation.
“There's no question the economy has had an impact,” says Wayne Lipton, managing partner and founder of Concierge Choice Physicians. But practices are retaining well over 90% of their patients, and more important, physicians want to offer Concierge Choice's hybrid style of care, in which a practice keeps the bulk of its traditional patients and has a smaller number in concierge care. Physicians want to try to boost revenue through such patients to help make up for lost reimbursement expected from the Medicare program, Lipton says.
The roots of concierge and retainer-based care go back to the 1990s, but didn't start to really take of until the early part of this century. A 2005 report from the Government Accountability Office estimated that the number of concierge physicians grew to more than 100 in 2004 from less than 20 as of 2001.
Medicare looms large in concierge medicine. One of the biggest reasons why is that in order to treat a Medicare beneficiary in a concierge medicine program, extra fees paid for 24-hour, easy-appointment care cannot be for any service covered by Medicare. HHS' inspector general's office reminded physicians about this in 2004 because of the rising popularity of concierge medicine.
“If participating physicians decide they want to charge patients additional fees, they should be mindful that they are subject to civil money penalties if they request any payment for already covered services from Medicare patients other than the applicable deductible and coinsurance,” said Dara Corrigan, then the acting principal deputy inspector general.
As a result, many retainer-based physicians say their fees, typically $1,500 to $2,000 annually, are for extra services, such as the extensive annual physical, that are a core part of concierge care, and not covered by Medicare, according to the MedPAC report. Concierge practices work to promote wellness programs also not currently covered by Medicare. Some, according to MedPAC, offer a personalized CD with medical information for each patient and personalized reviews of medications.
The report also notes a criticism of concierge care—that it is broadening the overall shortage of primary-care doctors.
“The availability of extended office visits is seen by some as improving quality of care, but commentators have noted that providing longer visits for a select group of patients that are not particularly sick does not necessarily advance the health of communities overall,” the authors wrote. “Even if the more extensive care offered by retainer physicians does result in better outcomes for retainer patients, it could be seen as discriminatory against those who cannot afford to pay the retainer fees.”