Synopsis: Many primary care doctors are unhappy with the “factory medicine” they have to practice. Some are creating “concierge medicine” practices in response, cutting patient roles and asking for retainer fees from those that remain. Patients receive much longer appointments, greater access, and more personal care for these higher fees. Two concierge doctors and a patient discuss.

Host: Reed Pence. Guests: Dr. Uday Jani, internist, Lewis, DE; Dr. Jeffrey Puglisi, Glenville Medical Concierge Care, Greenwich, CT; “Suzy,” concierge patient

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 16-10 Concierge Medicine

Reed Pence: Many of America’s doctors are unhappy. To a great degree, they suffer from burnout. Surveys show that more than 40% of them are dissatisfied with their work and nearly 60% of them wouldn’t seek a career in medicine if they had it to do over again. The dissatisfaction seems to be most painful for doctors in specialties like family practice and internal medicine– primary care physicians who do the lion’s share of day to day healthcare. Seeing patient after patient on what seems like an unending assembly line.

Dr. Uday Jani: As the insurance companies and Medicare and Medicaid and everyone started tightening, we were forced in primary care to see more and more patients because it became a number game and it was not about what care you’re giving, what quality of care you’re giving, it was how many patients you are seeing.

Pence: Dr. Uday Jani is an internist in Lewis, Delaware.

Jani: That’s the only thing that brought the revenue in because in primary care, you just see patients, you don’t have big procedures that, you know, bring the revenue in. And then all the restrictions of, ‘You need a medicine, you need prior authorization. You need a CAT scan done, you need to pause.’  So you needed more and more staff members now, so your overhead is going up and then you had to see a lot more patients. You want to spend more time, everyone has diabetes, hypertension, or a stroke, coronary disease and you can’t do it in 7 minutes time that you are given so you run from room to room and you can’t concentrate on the problem.

Dr. Jeffrey Puglisi: You’re constantly pushing the envelope in terms of volume-related care.

Pence: That’s Dr. Jeffrey Puglisi, an internist and partner at Glenville Medical Concierge Care in Greenwich, Connecticut.

Puglisi:  Seeing more patients brings more revenue into the practice, allows you to pay for your bills, pay your staff, etc. And the more insurances and Medicare dollars that need to be spent on that type of care pushes physicians to really make of their lives this type of factory of medical care. And that’s something that I’ve seen over the past few years so that after maybe 10 years in practice it just became so difficult to give the level of care that I wanted to give to my patients.

Pence: Many patients in traditional practices rarely see their doctor. They may be more likely to see a nurse practitioner or physician’s assistant instead. Eventually both Puglisi and Jani reached a breaking point. For Jani, it came while he was trying to juggle two patients who each needed far more attention than he had time to give, and whose health might crash if he did business as usual.

Jani: I typically went in, I always took care of the lab works, gave him the refills he needed, and asked him, ‘Do you have any problems?’ and he said no. And I walked out of the room and I walked back in and I’m like, ‘No you have a lot more problems. Let’s talk about your diet, let me talk about your exercise program. What are you doing?’ There’s all these things we did not touch because I didn’t have time and he was not asking for it. So I sat down, I was already two hours behind, I became two and a half hours behind by the time I finished with him and then I walked into the next room and there was my 85 year old elderly patient who was really sick and had pneumonia and I said, ‘Why didn’t you call me earlier and come in?’ And she said, ‘Oh I didn’t want to bother you, you are so busy all the time,’ and that day I decided I did not go into medicine to run numbers, I went into medicine to practice medicine, to take care of the patient.

Puglisi: If that’s truly your mission in your practice then you have to do something, something has to give in order to be able to find the time to do that. And the days of six-minute visits, in my opinion, are over in this practice.

Jani: The benefit of concierge medicine is that we can spend more time on prevention and wellness and those are the two things we are missing in America today. So what is happening is it has become, ‘What’s the problem? Here is a pill,’ that’s the philosophy we are running on. And that is the problem we are never, ever going to solve it because we really need to sit, spend time on prevention and wellness so that the patients don’t get sick. But because we have no time, we can never do it. You go to a doctor and the physician says, ‘You need to do this, this, this, and this’ and you’re walking out the door. Instead, it is about sitting with the patient and saying, ‘Let’s talk about your problems and let’s see what you are going to do for it.’ Because if I am going to just tell you, it’s not going to work, we need to partner and find out what you want to do for it.

Pence: What makes concierge medicine possible is a yearly retainer each patient pays out of pocket in addition to the usual office visit fees typically paid for by insurance. Jani charges patients 45 and older $1,600 per year. Those who are younger pay $1,200 annually. “Suzy” is a patient of Dr. Puglisi’s concierge practice and she thinks the extra fee is well worth it.

Suzy: It’s almost like another insurance policy that, you don’t know when something’s going to happen. You don’t know when it’s going to change and when you’re going to need somebody a lot. I don’t want to wait until something really bad happens and then be more involved with physicians. I’m really happy to be able to see this person and make sure they know we really well so that they will know when something comes up, ‘That’s not normal for her. That’s not normal for him.’

Pence: However, Puglisi says what patients get most for their fee is access. Many concierge doctors say patients can get an appointment within 24 hours and for emergencies, they give patients their private email and cell phone numbers.

Puglisi: Many patients always ask me, or residents that I’m teaching ask me, ‘What’s the difference between a good doctor and a great doctor?’ And I always say that the difference is accessibility. When a patient is sick and in need, whatever that issue may be, whether it’s acutely life-threatening or otherwise, whether it’s two in the morning or two in the afternoon, I think that physician needs to be available.

Suzy: I can text him, I can email him, which he likes because he can then answer something really quickly that’s just something small. ‘Oh, Dr. Puglisi, when was my last tetanus shot? Do you know?’ He can have that looked up and get back to me really quickly. And if it’s something more urgent, I don’t feel uncomfortable calling him on his cell phone. And I’ve never had this kind of access direct to a physician before in my life. And I did have a situation before the holidays and it was 10 o’clock on a Saturday night, something arose and I texted Dr. Puglisi. I was a little skittish about doing it because I’m not used to it and he called me back within 60 seconds at 10 o’clock on a Saturday night, that’s amazing to me. You’re not going through a service, do you know what I mean? An answering service. You’re going, texting directly to him.

Pence: However, if a doctor is handing out his phone number to all his patients, doesn’t that defeat one of the purposes of a concierge practice– giving doctors their lives back? Puglisi says not at all.

Puglisi: For me, even though there’s a 24/7 open policy with my patients, there’s such tremendous respect on the other end with my patients in terms of knowing when the right time is to reach out to me and understanding that even though they have that capability of contacting me at 2 in the morning, that they’re going to do it respectfully. I can’t think of one episode or one occurrence where that hasn’t been the case.

Pence: Many concierge practices include one complete physical each year for free–and Puglisi figures on spending 90 minutes with the patient on each one. Then he often schedules another visit, sometimes on weekends or evenings, to talk it over.

Puglisi: The beauty of this practice now for me, and one of the most rewarding aspects of it, is that I feel like at the end of the day, when I speak to a patient about their care, and about their health, I feel like at the end of the conversation, we’re done. There isn’t the lingering question, because much of all of what the patient was concerned about was discussed thoroughly. And how many times have you been in a doctor’s office and you have eight minutes with the physician or the nurse practitioner and at the end of the visit, you forgot the four things that you really came in there to ask and then there’s really no time to be able to circle back and do that? For this type of practice, that’s where the value really becomes, is that ability to get that thorough care but also to have follow-up care following.

Pence: Without time, Puglisi says most doctors miss a lot of diagnoses or at least the real problem facing the patient. No matter what symptom the patient comes in with, he says about 30% of the time there’s something else behind it– things like stress, relationship difficulties, anxiety, loss of sleep, or something else.

Puglisi: And I think if you have six minutes to spend with a patient, you’re never going to be able to scratch the surface of that and I don’t think you’re going to adequately treat that patient. So what ends up happening is you dissect someone’s symptoms, you put a diagnosis code next to it and you give them the medicine hoping that they’re going to feel better. And to me, I just think that that’s what we’re seeing more and more in this factory-driven type of health care environment that we’re in which I think needs to stop. And the way you stop that is that you slow down, physicians have to slow down. If they don’t slow down, they’re going to miss the enjoyment of practicing medicine, which is no doubt one of the things that pushed me into this type of concierge practice is that you got to a point where were you enjoying it as much as you thought you would be?

Pence: Puglisi says he’s never enjoyed medicine as much as he does now. But traditional medicine is scaring desperately needed new primary care doctors away. 

Puglisi: They’re wondering if a career in primary-care medicine is really something that they want to do. They’re coming out with $300 thousand dollars worth of loans from college and med school and they’re looking at the salaries of different types of specialists and physicians and they’re wondering if it’s not the better idea to go on for two or three more years of fellowship training, get into a sub-specialty, you will allow yourself to really focus in on one discipline of medicine and perhaps be able to pay back your loans a little bit easier, etc. And I think that’s wrong. I think that at the end of the day, we are the first line of defense for patient care, we are in the trenches with patients. Primary care doctors are the physicians, we need our best and our brightest in this field of medicine.

Pence: Puglisi says getting more doctors into concierge care could be the key to solving the doctor shortage.

Puglisi: If you can have conversations with insurers, with the federal government, and particularly with employers, to say to a small business owner or to a large employer that this type of medicine, this preventative aspect of medicine, having a relationship to a physician who is there for you 24/7 is really the way to do it. I think you can have more patients demand that this type of a practice exists. There’s no reason a concierge practice can’t be on every street corner in the future and then when you have a young physician who is looking down the road to what they’re going to do in the future, I think primary care becomes a huge option for them.

Pence: But despite the satisfaction experienced by many concierge care doctors, Puglisi says a lot of physicians won’t even consider making the transition themselves. In part, that’s a reflection of a major criticism of concierge medicine– collecting an annual retainer of a thousand dollars or more makes it medicine for the rich.

Puglisi: A lot of doctors are fearful of making this change. They’re fearful that, you know, being looked down upon that they’re just shifting over to a concierge practice for the money or that they don’t have to work as hard. And I’ll be honest with you- I work as hard if not harder, than I ever have. The difference is that it’s more rewarding. The difference is that I’m making a difference.

Pence: Jani says concierge care may even be more cost effective than traditional practices because of its focus on prevention and wellness. Puglisi says he has many people of relatively modest means on his patient list, people who really care about their health. But he says it’ll take buy-in by insurers, employers and Medicare to make concierge care more widespread.

You can find out more about all our guests through links on our website, You can also find archives of our segments there, as well as on iTunes and Stitcher.

I’m Reed Pence.

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