HEALTH CARE IN THE 21ST CENTURY
You may have noticed the emergence of some unique kinds of medical practices over the past few years -- for instance, concierge practices, micropractices and, most recently, online medical services. I thought it might be helpful to review some of these new business models for medical practices, in order to examine the pluses and minuses for each. I spoke with Jessie Gruman, PhD, founder and president of the Center for Advancing Health, an independent, non-profit Washington-based policy institute, for her insights.
First and foremost, Dr. Gruman stressed how important it is for consumers to understand what kind of care they actually will receive from each type of service -- what you are buying and what the limits are. She urges patients to read the fine print and ask plenty of questions. Apart and aside from the quality of care, make sure you are clear on such practical matters as...
- Whether or not the practice accepts your insurance.
- The qualifications, training and hospital affiliations of the physicians and other health professionals.
- The amount of the annual fee, if any, and what it does and does not cover.
- The contractual obligations of the doctor and the practice -- for example, your doctor's role if you are diagnosed with a serious illness.
- The hospital with which the doctor is affiliated and whether your insurance is accepted there.
- What happens if your physician leaves the practice before your contract expires.
- The process to follow if you have a complaint about care or services.
NEW MODELS OF MEDICAL CARE
Personalized/concierge practices are designed to give you extended and personalized care and greater access to your doctor -- including 24/7 pager/phone access and same day and longer appointments. Patients sign a contract and pay a monthly or an annual fee, typically in addition to other charges (i.e., your normal co-payments and deductibles). These fees are highly variable depending on the level and type of service, but generally do not cover specialist visits, laboratory tests, medical procedures, prescriptions, hospitalizations or emergency room visits. The leading company in the field, Florida-based network MDVIP (www.mdvip.com), has a typical annual fee of $1,500 per adult patient and an upper limit for practice size of 600 patients per physician. In upscale communities like New York City many doctors with a concierge practice charge twice that or more... luxe boutiques in places like Miami Beach and Beverly Hills may have fees that exceed $100,000 (and include extravagant perks). Critics charge that concierge medicine is exclusionary and elitist, since not everyone can afford it, but Dr. Gruman points out that our medical system is already multi-tiered. If you can afford it and believe you would benefit from this kind of certain, focused medical attention, it is worth exploring the options available to you locally, she said.
Medical home practices are a new model of primary care that also attempts to address the problems concierge care was developed to solve -- simplifying, centralizing and supervising what would otherwise be complicated, chaotic health care delivery. The concept was originally developed by the American Academy of Pediatrics in 1967 as a way to coordinate children's medical records in a central location... the term is now more broadly applied to describe a health care setting that provides "accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective care."
A medical home provides both preventive and sick/urgent care, similar to a concierge practice but without the annual fee, explains Dr. Gruman. The goal is to offer patients an ongoing relationship with a personal primary care physician who knows you and your medical history, provides as many services as possible at a one-stop location and coordinates care with other physician specialists as necessary. This is a specialized niche at present -- primary care medical homes are a relatively new phenomenon, not widely available. Some medical home practices focus on people with one or more chronic conditions, while others are gaining popularity due to interest of large companies for their employees.
Micropractices describe medical offices committed to delivering patient care via a high-tech, low overhead model. Doctors may answer their own phones and give patients their cell phone number and e-mail address to expedite communication. One doctor does it all -- sometimes with the help of a nurse or other medical assistant and lots of technology, such as electronic medical records, automated billing, e-prescribing, e-mail reminders for appointments, lab tests and prescriptions and sometimes even online consultations for non-urgent concerns. Dr. Gruman says this type of practice may be a good choice for healthy, relatively young people who only have minor complaints, such as occasional colds or earaches -- but she believes older people, families with young children and those with one or more chronic health conditions are better served by a general practitioner, family doctor or pediatrician who can provide stability and continuity of care.
The "mobile medical practice" has roots in the time when doctors traveled by horse and buggy to visit patients in their homes. Such house calls have made a (small) comeback today, since Medicare increased allowable reimbursement for them in 1998. In many cases, there's no physical office at all -- doctors can run their business from a home office, utilizing a specially equipped vehicle to bring tools and technology to patients in their homes. Demand for this type of care is likely to rise as our population ages, and proponents say that in the long run, home care for this group will cost less than repeated visits to the emergency room, hospitalizations and nursing home care. One of the leading house-call medical practices in the US is Visiting Physicians (http://www.visitingphysicians.com/), which provides primary care through home visits in Michigan, Texas, Kentucky, Florida, Wisconsin and Ohio.
Online or telemedicine medical services offer a variety of ways for patients to interact with physicians via the Internet -- these may or may not be covered by health insurance. One company, called American Well (at present available only in Hawaii), connects patients whose records are posted on Microsoft's Health Vault to physicians through [online video or chat or by telephone.] Doctors use the technology to provide follow-up care, referrals, advice or even to prescribe medication at a fee of $10 for a session for patients enrolled in Hawaii's Blue Cross Blue Shield, $45 for non-members. Other companies, including SwiftMD and TelaDoc, offer similar "telemedicine" programs in other states. Perhaps there is a role for this type of medical care, but Dr. Gruman cautions that little is known about the quality of care patients receive with this model.
Whatever type of health care delivery you choose, your goal should be to forge a strong and long-lasting relationship with a primary care practitioner you trust and respect and who has your interests at heart. Especially in this uncertain era, access to skilled, consistent and coordinated care is what's most important.
Note: Even in more traditional medical practices, an increasing number of doctors will provide an e-mail or phone consult to patients on a fee-for-service basis. Inquire about the fee and insurance arrangements before you commit.
Jessie Gruman, PhD, founder and president of the Center for Advancing Health, (www.cfah.org) an independent, non-profit Washington-based policy institute. Dr. Gruman is on the faculty of the School of Public Health and Health Services at The George Washington University and serves on the Advisory Panel on Medicare Education of the US Department of Health and Human Services and the Public Health Institute. She is author of AfterShock: What to Do When the Doctor Gives You -- or Someone You Love -- a Devastating Diagnosis (Walker).
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