American Journal of Law & Medicine

From concierge medicine to patient-centered medical homes: international lessons & the search for a better way to deliver primary health care in the U.S.

I. INTRODUCTION

Primary care is crucial to the United States health care system. It is essential to the provision of high quality care; including the ability to reach health outcomes, ensure patient satisfaction, and facilitate efficient resource use. (1) Primary care also places strong "emphasis on health promotion, disease prevention, and care of the chronically ill." (2)

Physicians have introduced two business models in their attempts to improve the delivery of primary care: Concierge Medicine ("CM") and the Patient Centered Medical Home ("PCMH"). Both models provide personalized, comprehensive preventive care services.

CM is a private medical practice in which the physician charges patients an annual fee to be a patient in the practice. In exchange, the physician limits the number of patients in order to offer more personalized services and amenities such as: direct access through email or cell phone, same day or next day appointments, longer, more personalized appointments, house calls, and physician accompaniment to a specialist. (3)

PCMH is defined by six characteristics: "(1) personal physician, (2) physician-directed medical practice, (3) whole-person orientation, (4) coordinated care, (5) quality and safety, and (6) enhanced access." (4) In the PCMH model, the personal physician ensures that patients have access to coordinated and managed care that is continuous, comprehensive, preventive, and evidence-based.

For a significant portion of the U.S. population access to primary care services is provided through government programs. (5) The United States Congress is responsible for designing, implementing, and overseeing Medicare, Medicaid, and SCHIP--the governmental programs that pay for health care services for the elderly, disabled, poor, and children. Congress' chief goals in these programs are to ensure improved health and to control costs. Congress' response to CM and PCMH has been diverse. Several bills were introduced to prohibit the use of CM, while legislation has been enacted and proposed to begin demonstration projects in Medicare, Medicaid, and SCHIP using PCMH. (6)

The congressional decision to test the ability of the PCMH to deliver quality, cost-effective care to the Medicare, Medicaid, and SCHIP populations through demonstration projects is the better health policy decision. Widespread adoption of the PCMH is better than CM as a model to deliver primary care in the U.S. from a quality, cost, and access perspective. This conclusion is based on the World Health Organization's Health for All agenda and the experiences of the Netherlands, the United Kingdom, and Belgium. (7)

This paper will proceed in eight parts. Part II explores why primary care is a critical component of a country's health care delivery system. Part III describes patient and physician dissatisfaction with the current state of primary care delivery in the United States. Parts IV and V describe physician-designed solutions and Congress' responses to them. Part VI describes the role of primary care in the delivery of health services in the international context by focusing on the World Health Organization's Health for All policy and the policies supporting primary care in the United Kingdom, the Netherlands, and Belgium. Part VII identifies the international health policies that are consistent with those of the PCMH. Part VIII identifies and analyzes the lessons that can be learned from the international context that demonstrate that widespread promotion of the PCMH model is sound health policy. Finally, Part IX provides recommendations for future legislation to maximize the benefits that will result from using the PCMH to improve beneficiary health outcomes and provide cost-effective health care.

II. PRIMARY CARE, ITS MEANING AND ITS BENEFITS TO THE HEALTH CARE SYSTEM

The term primary care was first introduced in 1961. (8) Primary care is "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." (9) The four main features of primary care are "(1) first-contact access for ... new [health care] need[s]; (2) long-term person focused care (not disease focused); (3) comprehensive care for most health needs; and (4) coordinated care when it must be sought elsewhere." (10)

Empirical evidence shows that primary care improves "the overall performance of a health care system" by making it more efficient, effective, and accessible. (11) Primary care improves the population's health through: increasing access, especially among the disadvantaged; improving quality; emphasizing preventive services; identifying and beginning early health management to prevent hospitalization or use of emergency services; and decreasing the need for specialist care. (12) Primary care lowers disparities in the population's health and generally reduces aggregate health expenditures. However, expanding primary care does not necessarily lead to lower costs because previously unmet needs are identified and expanded access can lead to increased utilization of services (13)

With respect to individuals, primary care is valuable because it provides a place where:

   patients can bring a wide range of health problems for appropriate
   [care] ...; it guides [the] patients through the health system; ...
   it facilitates an ongoing relationship between patients and
   clinicians ...; [and] it helps build bridges between personal
   health care services and patients' families and communities. (14)

III. U.S. HEALTH CARE SYSTEM: DISSATISFIED PHYSICIANS & PATIENTS

The benefits of primary care are not being fully realized because of problems that exist within the United States health care system. Some chief concerns include fragmented delivery of services, high prevalence of medical errors, (15) and high health care expenditures. (16) For primary care physicians in particular, residual problems exist because of the unintended consequences of implementing managed care to control costs. Managed care was initially viewed as a means to "manage care and organize a fragmented and wasteful health care system." (17) The system was intended to emphasize primary care and be structured around the family physician and other primary care providers. (18)

But instead, managed care has brought an erosion of trust between the physician and the patient. The envisioned role of primary care provider as gatekeeper eroded trust because the physician was not seen as acting in the best interest of the patient and as being a gateway to appropriate care, but instead viewed as the managed care organization's agent charged with limiting care to control costs. (19) A second consequence was disruption of sustained physician-patient relationships. Here low managed care prices and employer decisions to change benefit plans encouraged patients to switch from health plan to health plan, and from provider to provider. Third, the low reimbursement rates generally paid to primary care physicians, the discounted rates imposed during the managed care era, and "fiat or declining fees from public and private payers" required physicians to seek higher volumes of patients in order to maintain profitability. (20) Higher volumes led to rushed appointments and more focus on disease treatment instead of prevention. (21) With the exception of the gatekeeper issue, primary care physicians still encounter many of these problems.

In the managed care environment, primary care physicians could not deliver health care in a manner that was professionally or financially (22) rewarding. Many physicians became dissatisfied and physicians reported being "frustrated, angry, and overwhelmed." (23) A survey published by the Kaiser Family Foundation in 2006 noted that forty-seven percent of physicians reported that their enthusiasm for practicing medicine had lessened over the last five years and eighty percent noted that the overall morale of physicians had decreased. (24) Another thirty-eight percent would not recommend the practice of medicine to a young person. (25) Dissatisfaction also affected medical students' residency selections. From 1998 to 2002 there was a decline in the enrollment of family practice residency programs. Additionally, a significant number of physicians over 50 years of age left the practice of medicine or retired early. (26) This decreased physician satisfaction, the decision by medical students to reject primary care as a specialty, and the early retirement of many physicians over 50 has created primary care physician shortages that are likely to persist in the future.

Dissatisfaction with the current state of health care delivery extends to patients as well. Typical patients want "easy, quick, reliable access to a source of care seven days a week, twenty-four hours a day." (27) They also want the health care provider to "know [them], have [their] records, care about [them], take continuing responsibility for [them], and guide [them] through the labyrinth" of the healthcare maze. (28) This type of access is rare in our present system. (29)

Patients' chief complaints include long waits to schedule appointments, long stays in the waiting room, and rushed appointments. (30) In 2006, a survey of United States residents found that fifty-one percent of respondents were dissatisfied with their healthcare. (31) Based on an earlier survey, forty percent agreed that the quality of care had worsened in the previous five years. (32)

IV. PHYSICIANS PROPOSE TWO SOLUTIONS: CONCIERGE MEDICINE AND THE PATIENT-CENTERED MEDICAL HOME

Physician frustration led to the creation of a new business model: concierge medicine ("CM"), and revitalization of an old model: the patient-centered medical home ("PCMH"). Both models focus on providing personalized primary care that is comprehensive and emphasizes preventive care. Both models feature enhanced and convenient access to health care services

A. CONCIERGE MEDICINE (CM)

Concierge medicine is a private medical practice in which the physician charges patients an annual fee to be a patient in the practice. In exchange, the physician limits the number of patients he or she accepts in order to offer more personalized services and amenities. (33) In concierge practices, physicians focus on addressing patients' chronic and acute health care issues while providing preventive health care services and working to change patient behavior to facilitate better health. Given the comprehensive focus of concierge medicine, a wide range of patients benefit from use of this delivery model, including health conscious individuals, urban professionals, those with complicated medical conditions, the wealthy, and those that choose to allocate their resources to focus attention on health issues (34)

Dr. Howard Maron started the first concierge practice, MD2, in 1996. Dr. Maron was the former physician of the Seattle Supersonics basketball team and was in charge of VIP medicine at the 1990 Seattle Goodwill Games. (35) Dr. Maron's business model for MD2 was to provide custom medical care in which the doctor, equipment, pharmaceuticals, and staff are brought to the patient to meet the patients' unique needs. (36)

In 2001, a Florida company, MDVIP, expanded the availability of concierge medicine by providing custom medical care at a significantly reduced rate (37) As of 2004 there were at least 145 concierge physicians in the United States. (38)

Concierge Medicine is an urban phenomenon, occurring mostly on the east and west coasts. Practices are in 25 states and concentrated in California, Florida, Washington, and Massachusetts. (39)

Concierge physicians are largely primary care physicians, most commonly from disciplines like internal medicine and family practice. The physicians are also generally seasoned, averaging about 19 years of practice. (40) While the traditional primary care practice has 2,500 to 5,000 patients, (41) the typical concierge practice averaged 491 patients in 2004. (42) The cost of concierge services varies from $60 to $15,000 per year, and the most frequently reported annual fee was $1,500. (43)

Concierge practices offer a variety of services which can be grouped in three categories: (1) services not covered by insurance or services subject to coverage limitations; (2) access to the physician and patient convenience; and (3) amenities. Services included in concierge practices that are not covered by insurance or subject to coverage limitations typically include periodic preventive care physical examinations, wellness planning, exercise management, nutrition, weight loss programs, smoking cessation, and stress reduction counseling. 44 Patient convenience and access services include: telephone 45 and email consultations; priority, same-day, or next day appointments for non-urgent matters; longer, more personalized appointments that allow the physician to interact more fully with the patient; (46) house calls or workplace consultation; accompaniment to specialist appointments; transportation to and from the office; and prescription delivery. (47) Amenities can include a waiting area that provides coffee, cake, and fruit for the patients, (48) or they can be upscale and include private waiting areas, monogrammed bath robes, and marble hallways. (49)

B. PATIENT-CENTERED MEDICAL HOME (PCMH)

A PCMH provides a "continuous relationship with a personal physician" who cares for the whole person. (50) There are six characteristics to the PCMH model of delivery: "[(1)] a personal physician, [(2)] physician-directed medical practice, [(3)] whole-person orientation, [(4)] coordinated care, (51) [(5)] quality and safety, and [(6)] enhanced access." (52)

"The American Academy of Pediatrics ("AAP") introduced the [first] medical home [model] in 1967" to improve the care provided to children with special needs, (53) In 2004, the Future of Family Medicine Project expanded the model to create the patient-centered medical home and "called for every American to have a 'personal medical home." (54) Today, four primary care physician organizations encourage use of the PCMH: (1) the American Academy of Family Physicians, (2) the American Academy of Pediatrics, (3) the American College of Physicians, and (4) the American Osteopathic Association. (55)

In a PCMH, each patient in the practice is assigned to a team of health care professionals who are responsible for that patient's ongoing care. (56) The team is directed by a personal physician. The personal physician provides acute, chronic, and preventive care, as well as care for all stages of life, including end-of-life. (57) The personal physician coordinates care across providers and in the patient's community. (58) To ensure clinical quality, physician decision-making is evidence-based. (59) In addition, patients are involved in their treatment decisions and trained to manage their health conditions. (60)

Current fee-for-service payment systems create barriers to use of the PCMH model by paying each provider separately and emphasizing treatment for acute conditions and face-to-face care. (61) In fact, the current reimbursement system in the United States does not reimburse physicians for the time that they or their staff provide coordinating care between the practice, specialists, ancillary health care providers and community resources. (62) In this environment many patients do not receive recommended care and suffer harmful consequences such as unnecessary hospitalization. (63)

Studies show that coordination of care across clinicians and settings improves efficiency and produces better clinical outcomes. (64) Accordingly, efforts are being made to amend Medicare reimbursement legislation to compensate physicians for care coordination and care management. (65) Additionally, private insurers are launching pilot projects that "pay participating physicians a per-member-per-month care management fee in addition to fee-for-service payments." (66)

V. CONGRESS RESPONDS DIFFERENTLY TO THE PRIMARY CARE DELIVERY MODELS

The congressional response to these two primary care models has been diametrically opposed. Several bills were introduced to prohibit the use of concierge medicine with Medicare beneficiaries while legislation has been enacted and proposed to begin demonstration projects in Medicare, Medicaid, and SCHIP using the PCMH.

A. CONGRESSIONAL RESPONSE TO CONCIERGE MEDICINE

Several congressmen were concerned about the use of the concierge business model to treat Medicare beneficiaries because of the potential financial burden imposed on elderly patients and the possibility that the model would limit access to care. (67)

Third-party payers use charge limitations to help control the cost of health care services paid by insured-patients. Charge limitations are designed to control the reimbursement rate that physicians receive from third-party payers. Charge limits also can prevent balance billing. Balance billing occurs when a physician contractually agrees with a third-party payer to be reimbursed at a certain rate for providing a medical service and then attempts to collect the balance of the amount charged from the patient. (68)

For example, in the Medicare program the two primary methods of reimbursement for physicians place limits on what physicians may charge Medicare beneficiaries. Physicians can agree to an accepted fee as a participating provider. Alternatively, the physician can choose to be a nonparticipating physician and be limited to charging a percentage of the Medicare fee schedule. (69) The only way physicians are not limited in what they charge the beneficiary is by not participating or opting out of the Medicare program. (70)

Given the Medicare reimbursement limits, concerns about concierge medicine and its use with Medicare beneficiaries were raised explicitly in a letter from several congressmen to then Secretary of Health and Human Services, Tommy Thompson. …

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