Editor's Note: This is the second in a two-part series looking at the shortage of primary care doctors in western Massachusetts.
For about ten years, Michele Andrews saw the same primary care doctor in Northampton and was happy with the care, although she did start to notice it was harder to get an appointment.
“You’d call and you're talking about weeks to a month,” said Andrews.
That’s not surprising, as national surveys show the supply of primary care doctors has fallen well below the demand. Massachusetts’ Health Policy Commission says primary care is in a state of “extreme challenge.”
Michele Andrews knew all this. But she still wasn’t prepared for the letter that arrived from her doctor last summer.
“...writing to inform of this exciting change they'll be making in their internal practice,” Andrews read aloud from the letter. “And as of September 1st, they're switching to concierge membership practice.”
Concierge medicine is where a doctor charges a yearly or monthly membership fee to their patients, who are still paying insurance copays and deductibles. But in exchange for membership, the doctor has fewer patients overall so it’s easier to get more timely — and longer — appointments.
“The second paragraph tells me the yearly fee for joining will be $1,000 per year for existing patients, and that with couples she'll give a discount of $150,” Andrews read. “It'll be $1,500 for new patients. Some of the benefits will be the same or next day appointments, extended office visits.”
Andrews was floored — and in fact thought it was a scam. She called her insurance company, Health New England, who told her it wasn’t. According to one trade magazine, Concierge Medicine Today, there are about 12,000 concierge practices in the country.
Andrews and her husband were given three months to either pay or leave the practice. They left. The doctor who sent the letter, Christine Baker, did not respond to interview requests.
“Can we come up with a couple thousand dollars? Of course we can,” said Andrews, 56. “[But] I'm insulted and I'm offended and I don't want to give into this. I would never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”
“I knew I had to pay”
At the same time, Patty Healy — another patient of Dr. Baker’s — got the same letter but had a different reaction.
“I didn't question it,” Healy said. “I knew I had to pay.”
As a retired nurse herself, Healy knew she’d have a heck of time finding a new doctor. (In fact, her husband – who decided not to join the concierge practice – is still waiting for a new doctor.) Healy was willing to pay for peace of mind.
“And it might be to my benefit, because maybe I'll get earlier appointments and maybe I'll be able to spend a longer period of time talking about my concerns,” Healy said. “Instead of just talking about the pain in my right knee, I can also talk about the pain in my elbow.”
"It exacerbates the shortage"
This is the conundrum of concierge medicine. The quality of care may go up for those who pay, “but that means fewer people have access,” said Michael Dill, of the Association of American Medical Colleges.
“So each time any physician makes that switch, it exacerbates the shortage," he said.
Dill’s organization estimates the US will face a shortage of 21-thousand primary care doctors within the next decade. And he said the impact of concierge care is worse in regions like western Mass., which already has fewer doctors per capita than many other regions in the state.
“If you've got a community that doesn't have very many primary care physicians in it to begin with, and even one or two make that switch, you're going to feel it,” he said.
“I did feel a little torn”
But is it fair to demand that individual doctors stay with a stressed health system if they can serve their patients better in a membership model?
Geriatric care doctor Rebecca Starr recently started a concierge practice in Northampton. For many years, she consulted for a hospital group where patients only got 15 minutes with a doctor, “and that was hardly enough time to review medications, much less talk about acute concerns, much less manage chronic conditions,” she said.
When Starr decided to open her own primary care practice, she wanted two things: longer appointments and enough income to make the business work. To her, that meant the concierge model.
“I did feel a little torn," Starr said. "This is what I want to do and I can live my dream. But I have to do it in a way that I have to charge people in addition to what insurance is paying for.”
Starr said that money pays for quicker appointments and extra services for her patients. In a tour of her office, she pointed out one treatment room “for people to come in and have acupuncture or chair yoga or something like that.”
In another room, they may talk about nutrition after a regular appointment. “So we talk about green smoothies, eating right on a budget, plant-based diets, how to make sure you're getting enough protein.”
Starr said she’s capping her patient load at 200, which is much lower than the 1,000 to 2,000 that some doctors have. But she still has openings.
“Certainly there's some people that would love to join and can't join because they have limited income or it's not where they're able to put their money right now,” Starr said.
Joanne Rome, of Florence, Mass., would agree.
Rome was having trouble finding a primary care doctor for her 90-year-old mother, who had recently survived a stroke. Several people suggested Starr’s concierge practice.
“I got in touch with them and I asked what it would cost, and they said $3,600,” Rome said. (In our interview, Starr declined to say how much she charges for membership.)
Rome and her wife are retired and she didn’t think they could help her mother pay the fee, especially given all the medications she takes.
“Just her medical co-pays alone are so much money," Rome said. "And I just didn't know if we could handle $300 a month [for concierge membership.]”
“It’s a way to practice self-preservation”
Nationwide, membership fees range widely — between $1,000 and $50,000 dollars per year, according to some reports. But for many, charging for membership is the only way to turn back to the good old days of the family doctor.
“It's a way to practice self-preservation in this field that is punishing patients and doctors alike,” said Dr. Shayne Taylor, who recently moved from Tennessee to practice medicine in western Mass.
Taylor said many primary care physicians are tired of seeing dozens of patients a day, when they could see 15 or fewer under a membership model.
“I can't see 25 patients a day and continue in this career until I'm 65 or 70,” Taylor said. “It won't work. I'm going to burn out beforehand or leave medicine.”
So Taylor just opened what’s called a "direct primary care" practice in Northampton. It’s the same concept as concierge — charging a fee to be part of a small practice — but unlike concierge, direct care bypasses insurance altogether. Taylor’s patients still must have health insurance for things like X-rays or medications. But Taylor doesn’t accept insurance for any of her services.
“I can set my own rate. And I don't need to hire any staff to get reimbursements from insurance claims,” Taylor said. “And so it actually keeps my overhead much lower.”
She set membership at $225 per month, which she said is probably on the higher end of this model, “but I felt that the market that I was in could support it. I really wanted to be able to offer my patients 60-minute, 90-minute appointments, or home visits, if necessary.”
There are still glitches with direct care. For instance, Taylor doesn’t qualify as the primary care gatekeeper that many HMO’s require, so it’s hard to refer her patients to specialists.
And some critics say the membership model has an incentive to only take healthy patients who require less care, but Taylor said she would only refuse a patient if she felt their personality or expectations wouldn’t be a good fit. She can also choose to give discounts or scholarships to low-income patients.
“We get a lot of pushback because people are saying, ‘oh, this is elitist, and this is only going to be accessible to people that have money,’” Taylor said “But ultimately, the numbers don't work. We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company.”
“You're not fighting the system”
Some of that pushback comes from other physicians.
Paul Carlan runs Valley Medical Group, which has primary care practices in Hampshire and Franklin counties. He says the group already can’t meet patient demand, so concierge and direct care frustrate him.
“We all contribute through our tax dollars, which fund these training programs. And so, to some degree, the folks who practice health care in our country are a public good.” Carlan said. “And so we should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public.”
Michelle Andrews — the patient who did not follow her doctor into concierge care — managed to find a new doctor within a few months. But she’s still angry at the system and at concierge doctors.
“You're not fighting the system,” she said. “This is a workaround the system.”
That may be, but Shayne Taylor said it’s not fair to blame doctors for the health system’s dysfunction.
“It’s either we do something like this,” Taylor said, “or we quit.”
In other words, she said, serving only 300 patients is still better than serving zero.
