Wealth Care Reform

Call it primary care’s version of the gated community. As health care reform adds millions more Texans to state insurance rolls, wait times for appointments could creep from weeks to months. The new premium for patients who can pay? Simply getting in.

Some Texas physicians are charging retainers — yearly membership fees upward of $1,000 per patient — in return for capping their practice size and offering sick member-patients same-day appointments. Some refuse to accept insurance, limiting their practices to patients who can pay them directly. Others are being creative with the “health club” model, charging members an annual fee, then sending nurse practitioners out to make house and office calls when patients need care.

It’s not just convenient for the patient. Primary-care physicians who’ve left the traditional payment model say they can make more money and spend more time with patients when they’re not under financial pressure to see 40 or 50 of them a day.

“Each physician has to practice in the way that he or she believes will permit the best care of patients,” says Louis Goodman, executive vice president of the Texas Medical Association and president of the nonprofit Physicians Foundation. “Frankly, the new health law very well may force more physicians to consider restricted practice models.”

But at what cost to the patients who can’t afford them? And the doctors who continue to run traditional practices? There’s already a growing primary-care shortage in Texas. Health experts say that if more doctors head into so-called “concierge” care, low-income Medicare or Medicaid patients — some of Texas’ sickest — will face even longer waits for care from an ever-dwindling selection of physicians. And the doctors who continue to accept their insurance will be increasingly overburdened.

“Could it create an economic divide between people who can afford to access timely health care services and people who can’t?” asks Tom Banning, CEO of the Texas Academy of Family Physicians. “It’s an absolute possibility.”

Government officials expect the health care reform law that passed in Washington this year to eventually add 30 million patients to insurance rolls — perhaps as many as 4 million of them in Texas. At the same time, the primary-care physician shortage is only mounting. Experts anticipate the U.S. will be 100,000 family doctors short by 2025, leading to massive wait times for care.

Increasingly, primary-care doctors report being overwhelmed and underpaid — swamped with new patients and forced to see as many of them as possible to make up for slashed reimbursements. Already, the average patient in Dallas and Houston waits roughly 20 days to see a primary-care physician, according to a 2009 survey by the consulting firm Merritt Hawkins and Associates. The primary-care wait in Massachusetts leapt to 50 days in 2006 when the state passed a law requiring residents to have health insurance, as newly covered patients sought out doctors instead of emergency rooms for care. Texas has far more uninsured people than Massachusetts ever did, and they will soon be required to buy insurance or be eligible for Medicaid.  

The concierge model “is based on having many fewer patients, and you’re their personal physician,” says Dr. Lori Heim, president of the American Academy of Family Physicians. While her organization “doesn’t judge” doctors who use that business plan, she says, “in areas where there’s already a shortage [of primary care doctors], that will obviously limit others’ access to a physician.”

Dr. Chris Ewin, a family practice physician in Fort Worth, believes the retainer and direct-pay models are part of the solution, not the problem. He says that when doctors realize they can make more money, build better relationships and see fewer patients per day by having a “direct financial relationship” with them, more of them will go into primary care instead of entering more lucrative fields. That, in turn, will alleviate the primary-care shortage.

“We’re finding that if we can make our practices smaller but be financially viable, we can change health care and attract the youngest and brightest physicians back into primary care,” says Ewin, who charges an annual fee to his patients for unlimited access to care, including text messaging, e-mails and same-day service. “In my opinion, working directly with patients — no insurance, Medicare, Medicaid — is one of the only viable options left.”

Austin venture capitalist Bob Fabbio says he’s found another. He launched WhiteGlove House Call Health after a particularly frustrating trip to the doctor (he left the house at 9 a.m. and didn’t get home until 2 p.m.). Under his model, WhiteGlove members pay an annual fee of roughly $400 and get a nurse practitioner to make a house or work call when they’re ill for a $35 co-pay. Included in the visit are free generic prescription medications, an updated electronic medical record transmitted by wireless tablets and enough Gatorade and chicken soup to get through the next 24 hours of a cold or flu. The system is broken when “your ability to get care comes at the convenience of the provider,” Fabbio says. “We bring care to those who want it, on their terms.”

Private physician groups estimate that just 1,000 doctors nationally have moved into these alternative pay models. It’s a big risk: They have to believe their patients are willing or able to pay for it. But anecdotally, these groups say they’re hearing about more and more doctors embracing it. When the uninsured masses who have long avoided the doctor suddenly have health coverage, they expect the wealthy to pay for the convenience of having personalized “concierge” care.

Fabbio stops shorts of describing WhiteGlove as “concierge” medicine, which he says “connotes the affluent reserving a doctor.” Though he originally targeted baby boomers “willing to pay handsomely,” he quickly saw that WhiteGlove was as affordable as a gym membership. He now has as many uninsured customers as insured ones, he says, and offers his company’s services through several different insurance providers. “We’re concierge medicine on steroids, and catering to the masses,” he said. “Everybody can afford it.”