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History of Concierge Medicine (1996-2022)
By Concierge Medicine Today | Last Updated: Fall 2022
Bringing History Back To Life.
Doctors carrying a medical bag and coming into a Patient's home was standard into the late 1960s. Look at The Andy Griffith Show. Remember Marcus Welby, MD? That is what our grandparents know. Medicine became more and more government and insurance regulated and that started to end. It came in for a reason — there did need to be some amount of administration. But now regulation and administrative tasks have frustrated doctors.
The past 5 to 10 were some the most eventful years in the space of Concierge Medicine, private-pay and DPC as news and headlines continued to circulate across the wire. From The New York Times to The Wall Street Journal and everywhere in between, Concierge Medicine was becoming a familiar term that people are beginning to understand as an affordable healthcare option. Concierge Medicine Today and our sister-publication, The DPC Journal covered this industry and reached millions of new readers, Patients and others with headlines now being read regularly in over 130 countries and inside thousands of medical offices and homes across the U.S.
"There Should Be Absolutely, Unequivocally, No Necessary Tension or Conflict Between DPC and Concierge Medicine, regardless of price, perception, optics or even insurance or Medicare participation. Each Physician is doing what they feel is right for the Patient and at the end of the day. 'The Patient comes first!' And, there's nothing wrong with that in either niche, it's simply opinion and the loudest opinion rarely represents a majority. So, while these two models are similar in subtle ways, (eg. their subscription programming), they each have uniquely different offerings that make them attractive to different audiences and Physicians. No one Doctor should be villainized for following their dream in Concierge Medicine, nor the opposite. These models are simply different vehicles taking Patients to similar destinations on the road to health and wellness. These are Physicians following their vision for how healthcare could be and should be delivered now and in the future. I'm proud to know Physicians in both models whom are uniting heart and hands together and helping Patients like we've never understood or seen before. Yes, they may have some things in common, but they are also BOTH beneficial and special to those Patients that seek them out around the country for different reasons. Each Physician should be respected [by their peers] for their differences and their shared values. Never should we denigrate the practice of medicine and those Doctors who choose a path different from your own. The world has high expectations and seemingly impossible goals and harsh realities placed upon Doctors. We don't need more Physicians disparaging or discouraging one healthcare delivery model from another within any free market healthcare delivery space. As Truett Cathy, the CEO of Chick-fil-A once said, 'If someone is breathing, they need encouragement.' Let's be a group of healthcare educators in subscription-based healthcare delivery, that is known more for who and what we are for versus who and/or what we are against. We have more in common than we realize. So, let's be a group of people in medicine that is full of open-minded colleagues in the business of delivering great Patient care and which encourages Doctors to follow their passions, however unique or different it might from your own perspective and be the best Physician you can for your local community of Patients."~Editor, Concierge Medicine Today and The DPC Journal
Last Updated: Fall 2022 Edition
By Editor-in-Chief, Concierge Medicine Today/The DPC Journal
As the Editor of both industry healthcare trade publications for the subscription-based healthcare delivery market since 2007, both Concierge Medicine Today and our sister publication, The DPC Journal believe that both healthcare delivery models (eg. Concierge Medicine and Direct Primary Care) can and are great career lifelines for both Doctors and Patients.
However, let me be perfectly clear here … those of you that know me understand this and have heard it echoed before. "There is a difference between Concierge Medicine and Direct Primary Care (DPC)."
It may be subtle for some of you and glaringly obvious for others.
Is one better than another.
It's subjective, but our professional opinion as observers and advocates for both delivery models is that they both have inherent value.
We are of the persuasion that not one is better than another and anyone who may say different is of course, entitled to their opinion. But, that would be like saying one Doctor is better than another, and we all know what cyclical conversation that will lead to if we pull that thread in any conversation today.
So, it's subjective, right? We can agree on that.
So, that being said, the conversations, interviews, events and even our observations from all sides of the free market healthcare delivery marketplace over the years provide us with a unique perspective that isn't singular, nor is it biased or evangelistic. But based on interviews, exclusive conversations with both audiences and based on past, present and future observations in these niche markets, please feel confident that each model serves Patients and Physicians differently and in subtle, similar ways yet both are advantageous and provide wonderful services in unique ways to both Patients and Physicians.
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This article today is not meant to persuade or convince you that one subscription healthcare delivery business model is better than another. Each have pros and cons. Each provide unique services to Patients and have different features and benefits that bend to the Patient and Physician being more closely connected. With all of this being our common ground or thesis, it should also be known that we are not affiliated with any Doctor's office, consultant, medical group(s) or association(s), etc., which affords to us to critique and observe these subscription-based healthcare delivery models with an unbiased opinion and neutral context upon which to outline our opinions.
So, let's get started and unpack the suitcase here.
Understanding the Basic Terminology
First, if you haven't heard of these terms in healthcare, you're not alone.
Monthly and annual subscription fees for a primary care doctors service and expertise is becoming a popular and emerging business model in our free market economy that has gained tremendous popularity since 2008. As of 2022, more Physician Assistants, RNs, MDs, DOs and even telehealth programs have emerged using such a subscription business model.
They're all relatively new if you consider the event between 2009-2013 new. It's semantics. It is often confusing when you see the brand or terminology of one Physician using these terms interchangeably. It's confusing for the Patient, believe me! I know, because I am one.
Direct Pay vs Concierge Practices | Physicians Practice
I typically start by explaining it to novices new to the space in relative terms they are familiar with. Maybe it's because of my marketing and public relations upbringing and education. So by explaining the difference between Netflix billing and Amazon Prime billing, it starts to make sense. But, I also am careful to explain and educate that you need Internet too in order to make the services all work for your family. The Internet here is the metaphor for health insurance if you didn't catch that. 🙂
Years ago now, most of which many of you may not have even heard or had discovered these terms, I was interviewed by several healthcare publications and popular news outlets alongside some of the great Physicians in each of these healthcare deliver niches. The writer wrote something I really thought was great after our interviews were concluded. He wrote, The distinctions between concierge medicine, private medicine, and direct primary care may be ultimately meaningless, since some doctors call themselves whatever they feel sounds better, and there are so many practice variations, many overlapping, that it often isn't clear which is which.
Defining Direct Primary Care (DPC)
- According to the AAFP, they define Direct Primary Care (DPC) The Direct Primary Care (DPC) model is a practice and payment model where patients/consumers pay their physician or practice directly in the form of periodic payments for a defined set of primary care services. (Source: https://www.aafp.org/family-physician/practice-and-career/delivery-payment-models/direct-primary-care.html)
According to The DPC Coalition, Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. Patients have extraordinary access to a physician of their choice, often for as little as $70 per month, and physicians are accountable first and foremost their patients. DPC is embraced by health policymakers on the left and right and creates happy patients and happy doctors all over the country! Empowering this relationship is the key to achieving superior health outcomes, lower costs and an enhanced patient experience. DPC fosters this relationship by focusing on five key tenets: Service: The hallmark of DPC is adequate time spent between patient and physician, creating an enduring doctor-patient relationship. Supported by unfettered access to care, DPC enables unhurried interactions and frequent discussions to assess lifestyle choices and treatment decisions aimed at longterm health and wellbeing. DPC practices have extended hours, ready access to urgent care, and patient panel sizes small enough to support this commitment to service. Patient Choice: Patients in DPC choose their own personal physician and are reactive partners in their healthcare. Empowered by accurate information at the point of care, patients are fully involved in making their own medical and financial choices. DPC patients have the right to transparent pricing, access, and availability of all services provided. Elimination of Fee-For-Service: DPC eliminates undesired fee-for-service(FFS) incentives in primary care. These incentives distort healthcare decision-making by rewarding volume over value. This undermines the trust that supports the patient-provider relationship and rewards expensive and inappropriate testing, referral, and treatment. DPC replaces FFS with a simple flat monthly fee that covers comprehensive primary care services. Fees must be adequate to allow for appropriately sized patient panels to support this level of care so that DPC providers can resist the numerous other financial incentives that distort care decisions and endanger the doctor-patient relationship. (Source: https://www.dpcare.org)
- According to GoodRx Health, Since arriving on the healthcare scene in the mid 2000s, direct primary care has grown in popularity. As health insurance gets increasingly confusing, expensive, and frustrating, new models of care are rising. Patients without health insurance, or those fed up with paying skyrocketing monthly premiums, are turning to direct primary care as an option to afford basic medical care.(Source:https://www.goodrx.com/insurance/health-insurance/direct-primary-care)
- According to STAT, In a nutshell, direct primary care is a model for delivering primary care, and only primary care. The doctor charges each patient a monthly fee, generally ranging from $50 to $200, in return for timely, convenient access to him or her and a buffet-like menu of mostly basic primary care services. The amount of the monthly fee is presumably set in relation to the scope of services covered, though every practice may do it differently. For services that aren't covered under the fee, like more extensive management of a chronic disease, the patient's insurance — if he or she has it — must be billed to pay for the service or, in some cases, the physician or practice will charge the patient extra fees to cover those services. (Source: https://www.statnews.com/2018/09/06/direct-primary-care-doctors-patients/)
- Many direct primary care practices do not build in concierge medicine customer service and advanced testing and analytics components received by such tests. Additionally, there are some DPC practice programs that do not offer 24/7 care, cell phone text messaging, and instant or same-day appointments. And yet, some do.
- Of great benefit to the consumers, prices are dropping dramatically due to increasing competition among physicians entering the marketplace, retail medicine pricing, price transparency demand from Patients and continued uncertainty about the implications of the Affordable Care Act.
- In most DPC doctors' offices, Patients pay one low monthly fee, sometimes as low as $49-$99/mo. directly to their DPC physician for all of their everyday health needs. Like a health club membership, this fee (avg. $50-$99/indiv.) provides Patients with unrestricted access to visits and care. Patients can use the services as much or as little as they want. Many DPC practices are open seven days per week and offer same-day or next-day appointments. At many clinics, physicians are on call 24/7.
- Fast-forward now years later (eg. 2013 to 2022) and DPC has taken on various pieces of legislation in a majority of states which help protect the Patient-Physician financial relationship, typically educating lawmakers that DPC or retainer-based medicine (in any form) is not considered an insurance product.
- Simply stated, the biggest difference between 'DPC' and retainer based practices is that DPC generally takes a low, flat rate fee whereas concierge models plans usually charge a slightly higher annual retainer fee and promise more time spent with a doctor. Also, services in concierge models tend to more service-focused and added-value oriented versus just providing access and more convenience to the practice.
- In its simplest form, Direct Primary Care, often termed DPC, direct care or private, direct medicine has been around some would say since the late 2000's. It truly hit its stride on or about 2012-2013. I can personally even remember the days when the terminology was in flux and a variety of terms were being used.
- With DPC, there are no insurance co-pays, deductibles or co-insurance fees. DPC doctors do not typically accept insurance payments, thus avoiding the overhead and complexity of maintaining relationships with insurers. This can save significant overhead expense as managing insurance relationships can consume as much as $0.40 of each medical dollar spent.
- DPC practices typically have monthly membership fees under $100 and serve a population of households earning $70,000 or less, according to The Concierge Medicine Research Collective. Monthly Concierge Medicine membership fees usually are slightly higher, about $135 per month and can include more in-office services. Despite the cost advantage, the DPC model may be hampered by low awareness among health plans and primary care physicians, resistance from some insurers, and resistance from competing hospitals and specialists. Although, significant efforts are underway to accelerate the DPC movement, so this disadvantage may disappear as awareness grows.
In a report published by the California HealthCare Foundation, five large DPC clinics in the U.S. using a DPC healthcare service model serve over 500,000 lives. These charge either direct fees paid to the doctor, the physicians practice, or via self-insured employers and health plans.
- DPC is primary and preventative care, urgent care, chronic disease management and wellness support through a monthly care fee patients (or an employer) pay to cover the specific primary care preventative care services.
- DPC practices are distinguished from other retainer-based care models, such as concierge care, by lower retainer fees, which cover at least a portion of primary care services provided in the DPC practice.
- Monthly fees at direct practices vary from $25-$85 per month or less. Patients prefer to pay monthly vs. quarterly or annually.
- DPC patients typically come from the Generation X and Millennial population and earn a combined annual HH income of less than $100k.
- A DPC health care provider charges a patient a set monthly fee for all primary care services provided in the office, regardless of the number of visits.
- No insurance plan is involved, although patients may have separate insurance coverage for more costly medical services.
- Because the insurance "middle man" is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.
Years ago I had the pleasure of speaking to a spokesperson at now closed, Qliance Medical Management based in Seattle, Washington. He described DPC is a 'mass-market variant of Concierge Medicine, distinguished by its low prices.'
We concur.
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Defining Concierge Medicine
According to WebMD, They're often physicians who choose to form a private practice to limit the number of patients they're responsible for — usually a smaller number compared to the volume of a more traditional office practice — and to minimize the amount of paperwork associated with insurance payouts. Concierge doctors can do everything a primary care physician can, including administer lab tests and conduct annual physical exams. They also typically provide diagnostic screenings and minor urgent care services like stitches or treatment for minor skin conditions. However, they can't provide many specialized treatments or major medical procedures, like surgery. (Source: https://www.webmd.com/a-to-z-guides/what-is-a-concierge-doctor)
- According to Medicare.gov, You pay 100% of the membership fee for concierge care. Concierge care is when: A doctor or group of doctors charges you a membership fee. They charge this fee before they'll see you or accept you into their practice. Concierge care may also be called concierge medicine, retainer‐based medicine, boutique medicine, platinum practice, or direct care. When you pay this fee, you may get some services or amenities that Medicare doesn't cover. Doctors who provide concierge care must still follow all Medicare rules: Doctors who accept assignment can't charge you extra for Medicare-covered services. This means the membership fee can't include additional charges for items or services that Medicare usually covers unless Medicare won't pay for the item or service. In this situation, your doctor must give you a written notice called an "Advance Beneficiary Notice of Noncoverage" (ABN) listing the services and reasons why Medicare may not pay. Doctors who don't accept assignment can charge you more than the Medicare-Approved Amount for Medicare-covered services, but there's a 15% limit called the " limiting charge." All Medicare doctors (regardless of whether or not they accept assignment) can charge you for items and services that Medicare doesn't cover. The membership fee is governed by the contract or agreement you sign with the doctor or doctor group. Additional state laws and consumer protections may apply. For more information, contact your state's insurance departmentor consumer protection bureau. (Source: https://www.medicare.gov/coverage/concierge-care)
- According to Forbes, For a flat monthly fee, you get unlimited office and telehealth visits that last as long as you need, as well as direct care from a doctor without worrying about copays and other charges. You also gain access to your doctor's direct phone line for medical questions and simple diagnostic and blood tests in their office. And if you have a major health problem, your doctor coordinates specialist referrals and/or hospital care as needed. With concierge medicine, there's no insurance or corporate health system interference—just doctors and patients. (Source: https://www.forbes.com/health/healthy-aging/concierge-medicine/)
- According to Definitive Healthcare, When the concierge medicine model first appeared in the mid-1990s with Seattle-based MD2 International, it introduced the idea of "luxury medical care" and came with a price tag to match—with patients paying up to $25,000 per year for the boutique healthcare experience. What's more, this cost was paid in addition to regular health insurance premiums and didn't cover the costs of hospitalization or specialist consultations. Though some patients still pay a five-figure fee for their care, the average fee for membership in a concierge practice nowadays is between $1,500 and $2,400 a year—or between $125 to $200 a month. (Source: https://www.definitivehc.com/blog/what-is-concierge-medicine)
- In its simplest for, Concierge Medicine, sometimes called Concierge Care, boutique medicine or private medicine has been around since the mid-1990's. It's actually much older, decades in fact but that's a story for another day.
Finding Common Ground
"It is no longer about being the best Doctor in the world anymore. It is about being the best Doctor FOR the world, FOR your Patients and FOR your local community." ~Editor, Concierge Medicine Today/The DPC Journal
- DPC practices, similar in philosophy to their Concierge Medicine lineage – typically bypass insurance and go for a more 'direct' financial relationship with Patients. But, it's not always the case. Both healthcare delivery models may also provide comprehensive care and preventive services for an affordable fee.
- Similar to concierge health care practices, DPC removes many of the financial barriers to accessing care whenever it is needed. There are generally no co-pays, deductibles or co-insurance fees. DPC practices also do not typically accept insurance payments, thus avoiding the overhead and complexity of maintaining relationships with insurers, which can consume as much as $0.40 of each medical dollar spent (Sources: Dave Chase and California Health Foundation).
- Under most Patient-physician contracts in DPC and concierge medical clinics, Patients (and workers at employer groups, small and mid-size businesses) pay no co-pay for services. In addition to the services that the doctor provides on-site and inside the practice, individuals and companies maintain lower cost insurance plans to accommodate major medical expenditures and more intensive procedures. In that sense, the model for healthcare is similar to that being pursued by many internal medicine, specialty physicians and family practitioners, who are today, reducing their Patient load by two-thirds, dropping insurance wrangling and adopting a DPC model paid with an (almost) all-inclusive, monthly, quarterly or annual subscription fee.
In summary, both terms are often globally used in this article and within our publications, events, Physician interviews and books as Membership Medicine. Or, as some outside of healthcare but business title, part of the subscription-based service economy.
Physician Thoughts and Perspectives From Both Angles
"Direct Primary Care (DPC) is not insurance, does not strive to replace health insurance, nor is it adversarial to it. On the contrary, many DPC practices are eager to work with insurance carriers to co-create blended plans which integrate DPC with high-deductible insurance and ultimately correct the perverse incentives which are rife in the traditional fee-for-service system." ~Dr. T., DPC Physician, Colorado
"We recognized back in 2000 that health care was moving from personal to a more institutionalized form, and it wasn't what we wanted to do," said Dr. J.B., Michigan, who operates a concierge medicine practice and a DPC-employer based program with offices in Michigan. "We felt we needed to have time with our patients, to have the excellence to have the time with patients. Health care has been cutting reimbursement to doctors, which has forced doctors to see more patients, so the time doctors have with their patients have declined. The average time today with patients for most doctors is only 10 minutes."
"Instead of viewing the status quo PCP model as the center of the universe. Maybe we should take some plays from the Retail Clinic playbook before we become obsolete." ~DPC Physician and CMT/DPC Journal Contributor/Writer, Dr. R.N.
"I have decided to adopt a blended model of concierge medicine. My current patients may continue their medical care at our clinic, and a well-trained and capable nurse practitioner under my supervision will be seeing them. When necessary, I will be brought in with the nurse practitioner to discuss and formulate the medical management plan. Those patients who sign up for the concierge service be seen by me and get to enjoy extended appointment time during their visits, have access to me via telephone 24 hour/7 days a week, same day appointments, and get detailed in-depth yearly physical that focuses on disease prevention and wellness. My motto is "Preventive Healthcare, A Smart Approach to Healthy Life". I believe that a healthy body and stable mind gives the opportunity to live an enjoyable and rewarding life." ~Dr. M.T., Concierge Medicine Physician, Baton Rouge, LA
"If Concierge Medicine is about super servant-hood, then it has nothing to apologize for. People deserve to have access to a physician who spends the time necessary to gather appropriate insight about patients. People deserve transparency. They deserve answers to difficult questions. People deserve accurate information, especially when it concerns their health. Simply searching the web in today's convoluted environment leads to inaccurate assumptions, misinterpretations, harms reputations and undermines the confidence that patients have in their physicians and local medical facilities they trusted. Concierge Medicine has been around for more than 20 years and it works to solve many of these problems. It has redefined healthcare delivery." ~Michael Tetreault, Editor-in-Chief, Concierge Medicine Today & The DPC Journal
"The road was much more difficult than I expected, but also much more satisfying. I spent much of my time learning what doesn't work, but in the end learned that most good ideas grow out of the remains of a hundred bad ones that didn't survive." ~Dr. L., MD, DPC Physician/CMT/DPC Journal Contributor/Writer
"We ask people to do really hard things: gluten and dairy free diets, mold remediation, massive amounts of targeted vitamin and mineral supplementation based on labs, calorie counting and exercise logs, meditation. When they are willing to do these things they usually get better. When they don't, they are wasting our time and their money. We coach them with a lifestyle coach included in their membership, we follow up with them via snail mail cards, phone and email, and we do everything to give them tools for success but if they are not willing to make the changes, we tell them that the relationship is not working and they need to seek another doctor." ~Dr. E.C., Concierge Medicine Physician, Cumming, GA
"What I found interesting was that when I left my old practice — I had a 10% Medicare population. That fraction has grown to almost half, suggesting to me that some of the folks most interested in this model are older patients." ~Dr. F., Northeastern United States
"This primary care business model [DPC] gives these type of providers the time to deliver more personalized care to their Patients and pursue a comprehensive medical home approach," said Norm Wu, CEO of the former Qliance Medical Management based in Seattle, Washington. "One in which the provider's incentives are fully aligned with the Patient's incentives."
What's does Concierge Medicine and Direct Primary Care have in common?
In both Concierge Care and DPC, people have inherent value. There's no class order … no first class or second class, just people for whom doctors serve each day. They've built clinics for children, families and people who are sick … and it is these visioneering physicians who are drawing attention to the cost of healthcare across the country and designing ways for it to be available and affordable for anyone.
For anyone looking at which model they want to choose, you must understand that the Doctor is the story here, not the delivery vehicle.
Physician's have a customer service problem. Healthcare has a price problem as well.
But both Concierge Medicine and Direct Primary Care help provide a solution to the victim whom is the Patient and the healer, the Physician.
I'm of the persuasion that Physicians are too &$#! important to close up shop because of a lack of business acumen that wasn't provided in medical school and poor performing financial margins.
Physician Knowledge Gaps and Accounting — "You cannot camp out in the land of DIY forever …"
You've heard us say it over and over but it is worth repeating.
"It is no longer about being the best Doctor in the world anymore. It is about being the best Doctor FOR the world, FOR your Patients and FOR your local community."
As a Patient, I would prefer never to know if my Doctor was one or the other. Frankly, I don't care. What I do care about is my health. Patients don't care how hard your life was before this job. That might not be fair, but it is true.
All of that bureaucracy you're complaining about, leave it in the break room. Or, the board room, which ever you prefer. It doesn't belong on a Twitter feed that your patients are going to read or in a blog post on your web site.
Patients don't care how much you know, they want to know how much you care.
Show, don't tell.
You and I don't need to justify why concierge medicine or direct primary care and/or other subscription-based healthcare delivery models are relevant, anymore than we need to explain to each other why it is relevant to our lives today.
Both have relevance, just in and of itself.
Both find unique and personal ways for Patients and Physicians to understand each other and allow the Patient to more confidently participate in each others decision-making process. You and I both know that these models find ways to bring the Physician and Patient closer together. And, that the care and treatment discussions now held knee cap to knee cap, for longer periods of time, keep you and the Patient connected in a very personal and unique way.
The Patient, finally gets the time to examine all of their options that the Physician has now unpacked for them. The Patient has a voice and seat at the table again on treatment decisions versus blindly following the treatment plan. They can now ask their Doctor without guilt 'Show me the evidence behind that therapy/drug or treatment.'
So you see, both healthcare delivery models are just plain relevant.
But I also don't get mad around certain language used either, nor should you. Be proud of the brand and model you chose, but not evangelistic or degrading to colleagues who opt for a slightly different path. Physicians already feel bullied and six inches tall after leaving medical school. We don't need that trait to continue into our 40's, 50's, 60's, 70's and 80's.
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I'm also not mute to the fact that when people hear the term 'concierge medicine,' what it triggers is ideas of wealth or opulence. Yet when we all pause, listen for a moment and learn from all of these Doctors, we see that their heart beat is about bringing the Physician and Patient closer together. I also don't believe in the altruistic idea that Physician's in Direct Primary Care should make no money or break even in DPC because that's just what everybody else, or the loudest voices in the crowd are doing. You see when 8/10 people surveyed inside your community and mine, don't care if their Doctor's Office closed at the end of the day today. Like, forever! We have a problem. We hear all of the time about Physician shortages and that narrative is a continuous drum beat that's not going away.
So please, don't under value yourself.
You are too important to our communities to do all of this wrong.
A lot of people like to compare Concierge Medicine to Direct Primary Care (DPC) and say … 'DPC is the less expensive alternative.'
The data, the patient interviews, the web site and service contracts we've all seen as well as the industry service offerings we continue to see plus, the trend lines say something completely different.
The distinguishing factor differentiating DPC and Concierge Care is not price … it's insurance participation of the doctor, monthly billing (seen at most DPC clinics) and the amount of services offered. Add to that, concierge medicine has put a significant focus on staff training, interior design and customer service and hospitality.
Still confused by this semantic hair-splitting? Join the club. Even concierge medicine and direct primary care physicians are still confused about which type of doctor they are. We see and hear quite frequently these terms used by the same Physicians interchangeably.
"The distinctions between concierge medicine, private medicine, and direct primary care may be ultimately meaningless, since some doctors call themselves whatever they feel sounds better, and there are so many practice variations, many overlapping, that it often isn't clear which is which." ~Neil Chesanow, Medscape/WebMD, May 2014
Please understand that whichever subscription-based healthcare delivery model you choose, please price your services and offerings in such a way (preferably with the help of a good consultant, attorney, financial planner and supportive spouse) that you have confidence in yourself and the team around you. Make sure you have a team that can show you your blind spots and tell you that 'You are worth more than you think you are.'
I adore what attorney Jim Eischen, Esq. said at an American Academy of Private Physicians conference (April 2015) in Phoenix, Arizona when he said from the stage …'Let's focus on substance, not labels.'
We couldn't agree more.
"It is no longer about being the best Doctor in the world anymore. It is about being the best Doctor FOR the world, FOR your Patients and FOR your local community."
Subtle Differences Between Concierge Medicine and DPC.
- Some would tell you (or rather, argue) it is insurance participation and/or Medicare participation with the added subscription. Others would tell you it's all about pricing of the subscription that determines the brand you identify with the most.
- For me (and I'm providing both a marketplace observation professionally and that of a Patient perspective), it is about price, insurance compatibility or utility, services offered beyond the membership and most importantly, the customer service and the friendly demeanor of the Physician and staff.
Overall, Concierge Medicine and DPC style clinics are thriving in major metropolitan markets.
- Concierge Medicine patients skew upper middle class, with typical household earnings between $125,000 and $250,000 a year. They also tend to be Baby Boomers, generally in their 50s to 80s, according to doctors interviewed.
- It is commonly understood and accepted that both subscription-based healthcare delivery models have a place in healthcare for different patient demographics. And Patient demographics is where we can kickoff these differences first. According to our study over the decades (and it is a lot), exclusive interviews with countless Physicians over the years, hosting industry conferences, speaking at conferences about these models and advocating for each, demographic patient populations in each of these respective models is where these two subscription-based healthcare delivery models part ways in our research.
- Is there some overlap? Of course, there always is.
- For example, Direct Primary Care, otherwise know as DPC or direct care is much younger than it's familial subscription-based healthcare delivery business model in healthcare, despite reports in the media citing the same dates as Concierge Medicine. Physicians entering DPC are also usually quite young (eg 30-50s). Is that always the case? No. But the more and more DPC practices we see hanging their shingle, the younger the Patients are. Inherently, patient demography usually follows. Meaning, you can usually expect 80% of your customer or patient population to be on or about 10+/- years of the age of the Physician.
- Conversely, we encounter in Concierge Medicine, that a lot of Physicians are in their 50's, 60's and even 70's. Inherently, patient demography follows a similar pattern whereabouts 80%+/- patients are within 10+/- years of their Doctor's age.
Services Offered
- One would want to believe that the services would be the same but they would be incorrect. You need only do a little Google search and visit a handful of each of these practices and you will quickly learn that the services offered are different.
- Once again, to each their own. Just because you offer less or more, isn't necessarily a negative or a positive. Each Physician and Patient should make their own choice about what works for them.
- However, we have discovered over the years, a greater breadth of primary care services are provided (which are not covered or considered covered by Medicare of health insurance) by the annual retainer contract fee structure and contract between the Physician's practice and that Patient Member.
Direct primary care providers help keep costs low by avoiding unnecessary referrals and by referring mainly to specialists willing to offer significant discounts. Despite this advantage, the DPC model may be hampered by low awareness among health plans and primary care physicians, resistance from some insurers, and resistance from competing hospitals and specialists. In recent years however, DPC Physicians have pivoted their practice to overcome this financial problem, educational and marketing gap and are now working with employers, where healthcare expenditures for a majority of employer dollars spent each year. Meaning, the employer now pays the member (eg Patient subscription) fee vs. the actual Patient/Member.
Insurance and/or Medicare Participation
- Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly "fee" is only for "non-covered" services. This results in two fees paid by patients — the concierge medicine fee, and their insurance premium.
- Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.
- Conversely, most DPC practices have chosen to opt out of all insurance/payor contracts and Medicare and rely just on the subscription fee as their primary/bulk form of revenue for the practice.
Patient Panel Size
- Annual fees at DPC practices may vary from $8-$170 per member, per year (PMPM). The average according to The DPC Journal from 2013 to 2022 is about $85/pmpm. Additionally, DPC Patients prefer to pay monthly vs. annually.
- "Direct primary care practices, because they charge a lower fee, need more patients on their rosters. They typically have under 1000 patients but numbers on DPC patient panels vary widely from 150 to 1,200 patients under subscription.
- Concierge practices composed exclusively of concierge patients (most practices include a mix of concierge and traditional patients) generally limit their panels to 600 or fewer patients per physician and according to Concierge Medicine Today, the average PMPM is approximately $225/pmpm.
In Summary
It's not easy doing either one.
Don't let anyone tell you different.
Furthermore, don't let anyone tell you what you're worth or that 'You should just pick the [salary] figure what you want to make each year and go from there …'
Don't let people tell you that some prefer to think of DPC as the less expensive or generic alternative to Concierge Medicine or that any reference to Concierge Medicine in healthcare is only targeted for the ultra-wealthy Patient.
Most of the Doctors that I've known in my career and I have known a great many will tell you they went into one model or another based on a great deal of research, wise counsel and great ideas that they wanted to see become a reality. Fewer, went into one model or another because of frustration with bureaucracy.
Regardless of the reason, there's inherent value and truth in either path.
What you're about to read is what I hope is an open minded editorial which I welcome readers to share their insights and experiences as well. Furthermore, I always welcome an open open minded conversation to anyone willing to have a discussion about the pros and cons around each of these subscription-based healthcare delivery models. If at the end of our discussion, neither path is in your future, then we've done our job as well.
Do Membership Medicine Models Have Competition?
It's not lost on me that Concierge Medicine is not for every Doctor, nor every Patient.
It's also not lost on me that Direct Primary Care (DPC) is not for every Doctor, nor every Patient.
There's similarities to be sure. There are also polarizing differences. The goal of each however is to provide a lifeline for Doctors and Patients that allows them to have a closer, more transparent and convenient connection with one another.
Most of your peers as you know move into medicine for the same reason most physicians do. Because their family was connected to medicine somehow. It tends to move along like that line. A sort of family business or as some might say, a patrilineal descent into the career known as medicine. It's what your father or mother did. Or maybe there was a friend of the family who was in medicine that you encountered at a young age that forever changed what you wanted to do. It's simply who you are, you're a Physician, first and foremost.
It's also important to note that most future and current Doctors were introduced to medicine as an act of love for human kind. I love that.
I know that might sound suspicious to some people given how they think of healthcare today as multi-tiered, impersonal and fraught with bureaucracy and high costs.
Though I have no illusions, there will always be a rift between people's understanding of what concierge medicine is and does and the rest of what healthcare could be and should be. I believe personally that concierge medicine has become the conscience of our healthcare marketplace and the stories we share, show and tell her now for years at CMT prove that to be true. These Physician's are truly doing great work and will continue to do so in the future.
I'm also open to discuss Concierge Medicine, subscription-based healthcare delivery, DPC and even the impact of retail healthcare and the concept of patient fatigue with anyone who will listen.
A common misconception out there is that every Concierge Doctor who does it is in it for the money. That's just simply not true. That argument has created a removed perspective.
What the doctor-patient relationship currently looks like today is a relatively new experiment in our human history. When we're long gone and Millennials, Gen Y and Z's are using Google glasses and asking their grandkids if they texted or video chatted with their Doctor we'll soon see the Patient-Physician relationship hopefully in a far more connected place than Patients are experiencing today.
To say that Patient Fatigue and the stress of the unknown for a Patient is not an issue both mentally and physiologically for the Patient and Physician to deal with in the future is to also understand why these subscription models in healthcare today exist.
Horst Schulze, former executive at the Ritz Carlton and now respected author and speaker says it best in his book, Excellence Wins: A No-Nonsense Guide to Becoming the Best in a World of Compromise, "An organization can't please every human being every time. But it never hurts to try."
He also says later in the book, "No sound on earth is as sweet to a person's ears as their own name."
Those words reverberate in the hearts and minds of the Concierge Medicine Doctors that I know and have known.
I respect a Doctor who pursues his or her passion to help people.
But I'm naturally drawn as most people are to find, follow and befriend a Physician who has the kind of personable qualities that we all look for in a friend. I want to find a Physician for myself and my family who looks you straight in the eye and says "How can I help you today … " or "It's okay. We're going to get through this together …" Furthermore, what we all want is a Physician who isn't distracted and doesn't let his or her circumstances or station in life dictate his or her bedside manner.
Author and speaker Jeff Henderson said "Every relationship has a climate—sunny, stormy, or even icy. And the current climate dictates the forecast. The problem is that many of us are unaware of the emotional climates we carry around with us."
We shouldn't have tribalism in healthcare. Sure it's nice to celebrate and commiserate the hardships of our journey with friends and colleagues but the one thing I see both critics of Concierge Medicine and advocates of it have in common is that they all want to see the Patient and Physician brought back together in a way that's satisfying to both the Doctor, the Patient and ultimately, the community.
In my personal opinion, there's no room for tribalism in healthcare. There's no room for the criticism of Doctors following their entrepreneurial inclinations that will help their community become healthier. Whatever form, brand or term that may be.
Today the tribalism in healthcare is evident. As an observer of this space and other healthcare delivery innovations, it's easy to see.
Professional tribalism is an attachment of health professionals to their respective medical, nursing and allied health groupings instead of collaborating and identifying as cross professional team members (Weller, 2012).
For critics of Concierge Medicine, the tribalism can get pretty esotheric. Oxford Dictionary defines the adjective esoteric … as intended for or likely to be understood by only a small number of people with a specialized knowledge or interest.
I'd like to see that tension remember the common ground. It's the patient. He/she, they're right there. They're sitting right there. And we all agree that the Physician and Patient need come closer and closer together.
The British Medical Journal (BMJ) researchers even went so far as to study tribalism in healthcare recently.
- The Results: At baseline, there were few significant differences between the professions in collective orientation, most of the personality factors, Machiavellianism and conservatism. Teams generally functioned well, with effective relationships, and exhibited little by way of discernible tribal or hierarchical behaviours, and no obvious differences between groups (F (3, 31)=0.94, p=0.43).
- Conclusions: Once clinicians are taken out of the workplace and put in controlled settings, tribalism, hierarchical and stereotype behaviours largely dissolve. It is unwise therefore to attribute these factors to fundamental sociological or psychological differences between individuals in the professions, or aggregated group differences. Workplace cultures are more likely to be influential in shaping such behaviours. The results underscore the importance of culture and context in improvement activities. Future initiatives should factor in culture and context as well as individuals' or professions' characteristics as the basis for inducing more lateral teamwork or better interprofessional collaboration.
Source: https://bmjopen.bmj.com/content/6/7/e012467
Most of the Doctors that I've known in my life and I have known a great many, struggle in some way with how to design a practice, a career in medicine that focuses primarily on the Patient-Physician relationship without a lot of hassle.
It's a process. There's no perfect model, despite the rhetoric of some who are more tribal in their beliefs than others.
As a Physician you strive to make a difference each day. You struggle with the time you can't spend with your Patient. You are fatigued by the bureaucracy, the control but yet an internal voice drives your vision to truly care for your patients inside an unfair ecosystem.
Concierge Medicine is only one way to help Physicians find a lifeline in their career and help with Physician Burnout. It's not the only way.
Direct Primary Care (DPC) is another great way, but it's also not the only path. For the few …. the conversation around the differences between Concierge Medicine and DPC illustrates that central paradox between Do no harm … and Treat Others as You Want to be Treated.
When wrestling with this, I believe it's important to remember that many of our most influential Doctors had a love of medicine at the beginning of their journey that inspired in them to save the world and help humanity.
My personal hope is that more Doctors will continue to wrest with their own frustrations about the delivery of medicine while at the same time not become tribalistic and develop an optimism that fuels their vision to ultimately marry The Hippocratic Oath with The Golden Rule.
So which ever path you choose, Concierge Medicine, DPC, hospitalists, executive in healthcare, advisor, etc., make the decision that's right for you. Don't be persuaded that one path is the only way. Someone recently said and we don't know who so the credit here is not ours, The goal is not perfection, the goal is progress.
Communicator and author, Andy Stanley recently asked this question in one of his Podcasts to listeners which I think resonates with today's article. He said, "Is it more important to be fair . . . or to do good? Do for one what you wish you could do for everyone. Because if we all did for one what we wish we could do for everyone, it might change the world. But certainly, it would change one person's world. It may even change your world."
In Closing
We may have different perspectives on what you might be comfortable hearing about at niche industry conferences. Notably, we have observed DPC events since 2014 to present, are often marked by great collegial networking but or at times, unbridled enthusiasm and evangelistic excitement that desires to persuade young and middle-aged (and up) Physicians into starting a DPC practice and that it's as easy as 'Decide how much you want to make and back into your subscription price this way, and begin.'
Again, it's not lost on me that Concierge Medicine is a polarizing term and unpopular among some Physicians. That's okay. I welcome anyone who is willing to learn to have a conversation about it and DPC.
Conversely, we're also aware of the rising young Doctors need for independence to start and strike out on their own in DIY-DPC. And at times, we see seasoned DPC Physicians whose rising enthusiasm to break away from bureaucracy and control to start a Direct Primary Care (DPC) practice is as much a statement against all things that hold the Physician and Patient away from each other as it is a personal mission to serve the Patient.
Each of these subscription-based healthcare delivery models are doing great things.
As we look to the future, particularly the future of DPC, we see closures going unreported and Physician's moonlighting and DPC practices vanishing. While another may pop up quickly somewhere else, that's great. However, these DPC practices we are observing over the past several years now are in need of business training and leadership development education that is simply not being taught in medical events, CME curriculum, medical meetings, industry events or webinars of any real value to the Doctor.
A recent story entitled Thousands of Doctors' Offices Buckle Under Financial Stress of COVID, written by Laura Ungar in Kaiser Health News (KHN) should be sobering to all of us that proves this futuristic hypothesis.
At both CMT and The DPC Journal we have been talking about and addressing the lack of business education and support for Doctors and Physician-CEOs now shuttering their doors, forgoing the terms of their real estate leases and so on for years.
There's truly little in the way of support to course correct the ship by medical groups, medical associations or even medical event CME organizers and medical office managers when these practices run into financial trouble. It's clear that even in the niches of Membership Medicine, particularly the closures in DPC over the past few years that are not tracked, that still little support is being directed towards Physician's when they face closure.
Laura Ungar at KHN further proves this out as well when she writes on November 30th, 2020 … Although no one tracks medical closures, recent research suggests they number in the thousands. A survey by the Physicians Foundation estimated that 8% of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn't break them down by type, but another from the Virginia-based Larry A. Green Center and the Primary Care Collaborative found in late September that 7% of primary care practices were unsure they could stay open past December without financial assistance. And many more teeter on the economic brink, experts say.
We start with all of that to emphasize that there are not perfect business models in healthcare.
As enthusiastic and excited as DPC is, it's not the pathway for every Physician. I get it.
Furthermore, Concierge Medicine isn't the path either for some Physician's either. We understand that too.
But as someone wiser and who has obviously sold more books than I have recently said, 'The goal is not perfection, the goal is progress.'
DISCLAIMER AND USE: In no event is this information considered medical, legal, tax, financial, accounting or other professional advice (Please see full disclaimer below). This Publication, it's article(s), opinions, Podcast, the content provided herein, etc., Is Subject to the Terms and Conditions of Use (https://conciergemedicinetoday.org/tcpp/) and is recorded/hosted/written by Concierge Medicine Today, LLC. Concierge Medicine Today, LLC., our representatives, agents or employees accept no responsibility or liability for direct, indirect, special, incidental or consequential damages or financial costs or claims made by the Physician(s) interviewed or our guests.
Abridged History Of Concierge Medicine And The DPC Healthcare Marketplace.
1996: Dr. Howard Maron and Scott Hall, FACP established MD2 (pronounced MD squared) located in Seattle, Bellevue, WA and Oregon. They charged an annual retainer fee of $13,200 and $20,000 per family.
1999: Medical Professionalism Project-consisting of members of the internal medicine community, including representatives of ACP and the American Board of Internal Medicine, set out to draft a charter that could serve as a framework for understanding professionalism.
1999: Institute of Medicine releases the now famous report of medical errors, Patient safety, and professional integrity that caused further probing in physician exam rooms.
2000: Virginia Mason Medical Center in Seattle, WA began operating concierge medical services within its facilities and used some of the profits from the 5 physician practice to subsidize other programs and indigent care services.
2000: MDVIP, founded by Dr. Robert Colton and Bernard Kaminetsky, in Boca Raton, FL. A brand of Concierge Medicine practice and management firm which has set-up more than 700 concierge medical practices with offices in almost every State across the U.S. Update: In April 2014, Procter & Gamble announced the sale of MDVIP to a private equity firm, Summit Partners.
2001: American Medical Association writes concierge physician guidelines: PRINCIPLES OF MEDICAL ETHICS.
2001: July 04, 2001 · Seattle Post Intelligencer Seattle Post Intelligencer In Retainer Medicine, the Doctor is Always In; The idea started five years ago when Dr. Howard Maron, former team doctor for the Seattle SuperSonics, started MD2 (pronounced "MD squared") with his partner, Dr. Scott Hall …
2002: ACB Foundation , ABIM Foundation and the European Federation of Internal Medicine defines ethical principles and responsibilities contracts between Patient and physician, which is in a language that suggests both parties have equality, mutual interest and autonomy.
2002: Medicare addresses Concierge Medicine and retainer fees.
2002: Centers for Medicare and Medicaid, CMS, outlined its position on concierge care in a March 2002 memorandum. The memorandum states that physicians may enter into retainer agreements with their Patients as long as these agreements do not violate any Medicare requirements.
2002: Pinnacle Care establishes Patient care with a one-time membership fee for access to VIP service.
2002: The AMA counsel on medical services issued a report in June 2002 on Special Physician-Patient contracts. It concluded that retainer medicine was a very small phenomenon.
"When you think of Andy Griffith-style medicine, the doctor had a clinic in the local town. It'd be strange for him to say, 'What kind of insurance does Opie have?'"
~Michael Tetreault, Editor in Chief, Concierge Medicine Today
2003: American Society of Concierge Physicians was founded by Dr. John Blanchard. The association later changed its name to SIMPD, Society for Innovative Practice Design.
2003: AMA issued guidelines for boutique practices in June 2003.
2003: Department of Health and Human Services rules the concierge medical practices are not illegal and the federal government the OIG, Office of the Inspector General, takes a decidedly hands off approach.
2003: American College of Physicians writes doctors struggle to balance professionalism with the pressures of everyday practice.
2003: June 2003 the AMA Council on Ethical and Judicial Affairs outlines guidelines for "contracted medical services". The AMA House of Delegates approves these guidelines.
2004: GAO, General Accountability Office writes 146 concierge physicians in the U.S.
2004: Harvard University study finds that 55% of the respondents are dissatisfied with their health care, and 40% of that 55% agreed that the quality of care had worsened in the previous five years.
2005: The AOA, American Osteopathic Association adopts not to recommend and an official policy on concierge care.
2006: MDVIP, a concierge physician practice management firm, reports that 130 physicians within their network treat up to 40,000 Patients worldwide.
2007: Concierge Medicine Today, a concierge medical news agency opens its doors to be an advocate for news pertaining to the Concierge Medicine, retainer-based, boutique, private medicine and direct care industry.
2007: The term "direct practice" was first used in legislation in Washington in 2007 that clarified these practices were not insurance companies under state law-but they do provide basic, preventive medical care.
2008: Boasting an estimated 35 concierge physician practices, Orange County, CA appeared to be a leading hub of Concierge Medicine.
2008: Concierge Physician of Orange County (CPOC) – a non-profit group of existing concierge physicians was founded.
2009: Concierge Medicine Today (CMT) announces the formation of The Concierge Medicine Research Collective, a analytics and advisory arm of CMT based in Atlanta, GA USA.
2009: Concierge Medicine Today reveals that concierge medical practices across the U.S. are thriving in a recession.
2009: Procter & Gamble Acquired MDVIP in 2009 – No less a respected corporation than Procter & Gamble (NYSE: PG) has staked out a major presence in Concierge Medicine. In 2007, P&G acquired a 48% stake in MDVIP, a Concierge Medicine company that was formed in 2000. Then, in December 2009, Procter & Gamble acquired 100% ownership in MDVIP for an undisclosed sum. This acquisition was reported by Dark Daily. (See "Boutique Medicine Venture Generates Marketing Intelligence for Procter & Gamble," April 5, 2010.)
2010: SIMPD reorganizes, expands its vision, and rebrands itself the American Academy of Private Physicians (AAPP).
2010: Concierge Medicine Today reveals the affordability of concierge medical and private medicine practices across the U.S. stating that over 62% of the programs offered to Patients cost less than $135/mo.
2010: American Academy of Private Physicians (AAPP) forms first local chapter in Orange County, California called AAPP,OC (formerly CPOC)
2010: According to a 2010 American Academy of Family Physicians survey, three percent of respondents practice in a cash-only, direct care, concierge, boutique, or retainer medical practice.
2012: December 2012 – Study Proves Dramatic Reduction in Hospitalizations & $300 Million Savings for MDVIP's Personalized Healthcare Model
2013: Three Year Analysis of Concierge and Direct Care Medicine Shows Encouraging Signs For Boosting Primary Care In U.S. Economy. Data collected from Concierge Medicine and DPC doctors show encouraging signs across the U.S. from December of 2009 to December of 2012.
2013: New Data on Concierge Medicine Physician and DPC (DPC) Clinician Salaries and Released by Concierge Medicine Today. Data also looks at career satisfaction among Concierge/DPC physicians.
2013: On August 2, 2013, the Dare Center, Seattle, WA, invited concierge physicians, hospital administrators and medical center executives from across the country to participate in a roundtable discussion. This inaugural event took place at the Washington Athletic Club in Seattle.
2013: Family Physicians, Patients Embrace DPC … AAFP Recognizes Benefits, Creates DPC Policy
Is it worth it?
Since concierge medicine is not insurance (it wouldn't cover a trip to the hospital) many patients combine it with a high-deductible plan. Tetreault suggests that consumers think of health insurance more like auto insurance or fire insurance; it should be used for emergencies, not the day-to-day. You wouldn't use car insurance to change your oil, rotate the tires or buy wiper blades. In the best-case scenario, the sum of the concierge fee ($150/month, for example) plus the bare-bones premiums for a high-deductible plan ($110-ish, theoretically) would pencil out to less than $328 per month, or what the Department of Health and Human Services cites as the "average" cost of health care.
~Comstock's Magazine, April 1, 2014
2013: The DPC Trade Journal Launched. The DPC Journal works directly and indirectly with physicians, businesses and leaders, journalists and the media in the healthcare marketplace to help promote the distribution of news and information, policy initiatives and to reach out to physicians throughout the United States. DirectPrimaryCare.com.
2013: First National Gathering Focused On DPC (DPC) Held In St. Louis: October 11-12, 2013.
"This is the first national gathering of businesses and individuals interested in DPC," says Dr. Erika Bliss, a Family Physician at Qliance Medical Group of WA and President/CEO of Qliance Medical Management Inc. "DPC is quickly becoming an important contributor to the transformation of our nation's healthcare system. This conference will bring together key stakeholders to learn more about DPC and discuss its place in the future of medical care delivery."
"The DPC National Summit will bring together physicians, business leaders, policymakers and others from across the country," added Bliss. "DPC providers and supporters share the common goal of contributing meaningfully to the improvement of healthcare for all, and by building connections among like-minded people; we hope to accelerate progress toward that goal."
Overall, Concierge Medicine and DPC are thriving in major metropolitan markets. Four states that have a huge lead in the amount of active concierge or private-pay physician's in practice as well as consumers seeking their care are: Florida, California, Pennsylvania and Virginia. Each of these States have a significant number of people, most are over the age of 50, seeking out Concierge Doctors and cash-only options. Fortunately, a sizeable number of Concierge Doctors are available to serve them, which is not the case in the more rural parts of the country.
Of great benefit to consumers, prices are dropping significantly due to increasing competition among physicians entering the marketplace, retail medicine pricing, price transparency demand from Patients and uncertainty about the implications of the Affordable Care Act. The Affordable Care Act has also created quite a bit of uncertainty among both Patients and doctors. The shoe has most certainly dropped and now more doctors than ever are considering a career in Concierge Medicine, DPC and retail healthcare.
2014: New Association Formed, American College of Private Physicians (ACPP): Group to Focus on Credentialing Doctors, Advocacy to Employers, Unions, Government and the like to benefit industry nationwide.
2014: P&G sells concierge medicine unit: P&G CEO — 'Since returning as CEO last year, A.G. Lafley has said P&G will exit ventures that won't help it grow.'
2014: MD² commemorates 18 years of practicing highly personalized care; March 7, 2014
2014: MDVIP to be Acquired by Summit Partners — 'MDVIP will continue to be run as a stand-alone company …' [May 2, 2014]
2014: IRS asked to clarify HSA rules in letter: On June 17, 2014, Members of Congress wrote Commissioner of Internal Revenue John Koskinen asking for clarification on how the Internal Revenue Service (IRS) treats DPC Medical Homes with regard to Health Savings Accounts (HSAs). Senator Maria Cantwell (D-WA), who authored ACA Sec. 1301 (a) (3), allowing DPC practices to participate in health exchanges with Qualified Health Plans, took the lead on the letter and was joined by Senate Budget Committee Chairman Patty Murray (D-WA) and Rep. Jim McDermott, MD (D-WA), ranking member of the Ways and Means Subcommittee on Health. The three WA state lawmakers point out that The ACA rules on the Establishment of Exchanges and Qualified Health Plans Part I (CMS-9989-F) promulgated by HHS, clearly state that DPC is not health insurance, and that the law has its roots in a provision in WA state law (48.150RCW) defining DPC as a health benefit outside insurance. IRS Continues to give guidance that DPC plans are considered health plans under Sec. 223 (c) of the Internal Revenue Code (IRC), which prohibits HSA account holders with high deductible health plans from having a second "health plan." DPC members have met with officials in the Department of the Treasury and continue to work with the administration and Congress to change the IRS definition so that DPC fees are qualified medical expenses under Sec. 213 (d) of the IRC and can be offered as a benefit complimenting Health Savings Accounts (HSAs) paired with high deductible health plans.
2014: Second National Gathering Focused On DPC (DPC) Held In Wash., DC. June 2014.
2014: DPC United, a new DPC Physician Association, launched by Dr. Samir Qamar of MedLion announces that it will provide resources for DPC physicians and consumers.
2014: Michigan DPC Bill Introduced as Louisiana Passes Law: On September 9, 2014, Michigan State Senator Patrick Colbeck (R-Canton) introduced S.B. 1033, a bill to amend the MI state insurance code to clarify that a DPC agreement is not subject to state insurance regulation. DPCC has provided resourced to Sen. Colbeck, and we are watching developments in state legislatures around the country as they prepare for the coming sessions. This summer, Gov. Bobby Jindal (R-LA) signed similar legislation; Senate Bill No. 516, making Louisiana the latest state to create law to define DPC practices correctly outside the scope of insurance regulation. Stay tuned for further updates as the legislative sessions kick off in this coming January.
2014: DPCC member Iora health recently announced an exciting new partnership with Humana to treat Medicare Advantage patients in Washington and Arizona. According to the Iora release, "The partnership launches Iora's unique health care model in Arizona and Washington where Iora Health will open four new primary care practices – two in Phoenix and two in Seattle – under the Iora Primary Care brand. The primary care practices are designed exclusively for Humana's Medicare Advantage members and will provide members access to affordable, quality care."
2014: New Study Conducted by Optum and MDVIP Finds Personalized Preventive Care Significantly Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
2014: September 2014, American Academy of Private Physicians (AAPP) Course Corrects Physician Association, citing that the industry's association is focusing on five key areas. Those include: legal compliance for doctors, innovative learning tracks at national meetings, physician networking, legislative and lobbying initiatives and staying up to date on new and emerging technologies…
Your ability to withstand the pressure and overcome the obstacles of uncertainty
and potential failure and see the other side before others do is what makes a successful concierge [direct-pay] physician
"There are no insurance codes for 'cure,'" says Dr. Garrison Bliss of Qliance, based in Seattle, WA.
2014: In October 2014, at the AAFP Assembly, a DPC Track is added to the agenda in Washington, D.C. It was called the "Health is Primary" initiative, a key business model for success touted by the AAFP (American Academy of Family Physicians).
2014: MD² Expands, Granting Access to Two New World-Class Medical Institutions; November 2014
2014: Washington State OIC issued DPC Outlook in Washington State. The OIC report insinuated that DPC is losing ground in terms of patients and that our monthly fees have been climbing (presumably as we head toward concierge medicine pricing).
2014: In reply, The DPC Journal assimilated a DPC leadership response to the Washington State OIC Report publishing for legislators, payers, physicians and the like: 'DPC Leadership Response To Washington State OIC Report: 'Outlook for DPC is bright throughout U.S.'
2014: The DPC Journal releases its industry-wide definition of DPC, the 5-Minute Guide: What Makes DPC Different From Concierge Medicine. Also releases 2-Year analysis of DPC marketplace data.
2014: (November 4, 2014) Hospitals Take Cues From The Hospitality Industry | By Kaiser Health News
2015: Michigan State Sen. Pat Colbeck, R-Canton, believes the path to providing Michigan citizens with access to higher quality, lower cost health care has been cleared following Gov. Rick Snyder's signature into law of Colbeck' s SB 1033 (Public Act 522 of 2014). The new law in Michigan assures physicians who adopt a direct primary care service business model that the administrative burden associated with insurance regulations will not interfere with their treatment of patients. Physicians who offer direct primary care services provide specified services for a monthly subscription fee that usually vary between $50 and $125 per month.
States with DPC Laws: Source: DPCare.org; Current as of January 22, 2015: Washington – 48-150 RCW; Utah – UT 31A-4-106.5; Oregon – ORS 735.500; West Virginia- WV-16-2J-1; Arizona – S.B. 1404; Louisiana – S.B. 516; Michigan – S.B. 1033
2015: Specialdocs, a pioneer and leading Concierge Medicine consulting firm says 'Cardiology, Endocrinology, Pulmonology, Pediatrics and OB GYN Practices Can Benefit from Conversion to Concierge Model.'
2015: The United Hospital Fund Releases A Report, Convenient Care: Retail Clinics and Urgent Care Centers In New York State.
This report is relevant to Concierge Care and the DPC healthcare space because: Although based on a small sample from a single group practice in Minnesota, the study found that patients who visited retail clinics had lower total costs than matched patients who visited the acute care clinic (Rohrer, Angstman, and Bartel 2009). A more recent study of adult primary care patients, also in Minnesota, found that the odds of return visits for treatment of sinusitis were the same whether patients received care at a retail clinic or in a regular office visit (Rohrer, Angstman, and Garrison 2012).
Perhaps more telling, a larger study of spending patterns of CVS Caremark employees found a significantly lower total cost of care in the year following a first visit to a retail clinic compared to costs incurred by propensity score-matched individuals who received care in other settings. In total, retail clinic users spent $262 less than their counterparts, with savings stemming primarily from lower medical expenses at physicians' offices ($77 savings) and reduced spending for hospital inpatient care ($121 savings). Retail clinic users also had 12 percent fewer emergency department visits than their counterparts (Sussman et al. 2013). The UHF saw nothing analogous on the impact of urgent care centers on total costs, but one study found that initial use of an urgent care center significantly reduced emergency department visits without increasing patient hospitalizations (Merritt, Naamon, and Morris 2000). Those results should be cautiously interpreted, however, given the study's design limitations.
Conversely, in September 2014, the MDVIP model also was shown to have saved some $3.7 million in reduced medical utilization for the 2,300 MDVIP Medicare Advantage patients over two years. Savings were $86.68 per patient per month in year one, and $47.03 per patient per month in year two, compared with patients who did not join an MDVIP practice. The two-year study explored preventive healthcare's ability to improve outcomes by creating a closer, personalized physician-patient relationship and focusing on disease prevention for Medicare Advantage.
2015: PinnacleCare, a leading health advisory firm, studied the impact of an expert second opinion on medical outcomes.
Researchers collected data on 1,000 cases over a three‐year period and found that almost 77 percent of medical interventions led to changes in diagnosis, treatment, and/or treating physician. PinnacleCare gathered data on patient outcomes from their interventions over a three‐year period. In a sampling of 1,000 cases with known outcomes from 2012‐2014, 41% resulted in transfer of care to a COE or expert provider with 34% resulting in a change in diagnosis, treatment, and/or course of care. A total of 18 patients were able to avoid unnecessary surgery as a result of a PinnacleCare intervention.
The data demonstrates the potential for health advisory services and second opinions to optimize outcomes and avoid needless expense. One of the persistent challenges in health care today is access to expert physicians. With consumer directed health care plans, the value of health advisory services becomes even more evident as consumers struggle with vetting appropriate providers and treatment options for their complex conditions while seeking timely access to the care that they need. PinnacleCare is committed to providing objective, concierge‐ level support with the expert resources and access needed to help consumers tackle these complex challenges.
2015: The DPC Journal to release its 2015 Annual Report and Market Trends Analyses In The First Quarter of 2015
2015: The DPC Journal releases physician insight gathered in a 2015 Industry Guidelines Proposal To Insurers and Legislators, Second Quarter 2015
2015: (December 2015) In 2015, fewer than half of the direct practices chose to report voluntary information. Some said they do not collect this information, and others simply did not respond to the supplementary questions. The bill requires the Office of the Insurance Commissioner (OIC) to report annually to the Legislature on direct health care practices. Under RCW 48.150.100(3), this includes but is not limited to "participation trends, complaints received, voluntary data reported by the direct practices and any necessary modifications to this chapter."
2016: (October 2016) National trade publication, Concierge Medicine Today issues industry-wide "Position Statement" on Outdated Physician Referral Methods to Surgeons and Hospitals on Behalf of Patients.
2017: (January 2017) Las Vegas' Turntable Health Closes | Jan. 2017 | ~Las Vegas Weekly | Leslie Ventura | Wed, Jan 11, 2017 (4:33 p.m.) Turntable Health, a membership-based primary care practice in Downtown Las Vegas, will close its doors on January 31. Touted as an affordable and comprehensive alternative to insurance-based healthcare, the Downtown Project-affiliated company notified its members in December that its services would no longer be available. The member-based model, in which patients pay a flat monthly rate of $80 to receive access to a "wellness ecosystem," including same- or next-day visits; 24/7 physician contact by phone, email or video chat; health coaching; nutrition, yoga and group therapy classes; and an on-site demonstration kitchen. Read Full Story … Source: https://lasvegasweekly.com/intersection/2017/jan/11/turntable-healths-closure-leaves-downtown-patients/
2017: (May 2017) UnitedHealth shutting down Harken Health May 16, 2017 – Harken Health was never a major player in the insurance market, but its demise ends an experiment that company officials believed would reduce healthcare costs. The company lost nearly $70 million during the first six months of 2016 and never recovered. The closure will be disappointing for those promoting alternative care models as ways to improve outcomes while reducing costs and perhaps increasing patient's satisfaction. In April 2016, then CEO Tom Vanderheyden told Healthcare Dive the company's care teams would be "empowered with the time to listen and build authentic and trusting relationship with members." ~HealthcareDIVE Insight | Les Masterson | May 16, 2017 Read More … http://www.healthcaredive.com/news/harken-health-closes-after-a-year-of-cuts-losses/442849/
2017: (May 2017) The DPC Journal has received multiple confirmations from various sources today [May 17, 2017] that reports from the Puget Sound Business (PBSJ) dated May 16, 2017 are confirmed … Qliance is closing their doors effective June 15, 2017. GeekWire reported today (May 17, 2017 @ 9:46 am) that … In an internal memo from Dr. Erika Bliss obtained by the PSBJ, she said the company was unable to find the funding to last them until they were able to find new contracts. The DPC Journal has confirmed this news as well.
2017: (August 2017) AAPP Board of Directors Votes to Suspend Operations and to evaluate AAPP's value proposition for 2018 and beyond. They issued the following statements … Article/Story Written By Michael Tetreault, Editor
AUGUST 10, 2017 In a statement released to Concierge Medicine Today by Dr. Pamila Brar, current President of the American Academy of Private Physicians (AAPP) stated "Due to evolving marketplace conditions in the private medicine conference space, our AAPP board of directors voted to suspend operations in 2017 and to evaluate AAPP's ongoing usefulness and value proposition for 2018 and beyond."
Formerly known as the Society of Innovative Medical Practice Design (SIMPD) for many years, the AAPP's presence, conferences and representatives served a limited, but engaged physician audience in unique ways. They focused on five key areas which included: legal compliance for doctors; innovative learning tracks at national meetings; physician networking; legislative and lobbying initiatives and staying up to date on new and emerging technologies. Although AAPP is suspending operations and evaluating the organization's future, other physician organizations involved in private direct medicine seem to be experiencing strong membership growth.
Throughout an entire career however, physicians are faced with recurring questions related to medical associations: Which associations should I join? Which should I retain membership in? How do you decide which associations to pass on altogether? Simply type in the words 'medical association' and 29,200,000 plus results are found on Google alone.
A recent story in Forbes noted that 'Nonprofits can be a great way for a community to mobilize around a cause, make an impact and deliver services to those in need.'
Following that, in November 2016, Becker's Hospital Review cited relevant physician association challenges and wrote that nationally, 57.4 percent of physicians are part of a state medical society; 73.8 percent of physicians are members of a national specialty society; 31 percent of physicians are a current Member of the American Medical Association; and finally, 10.1. percent of physicians are a Member of the American Osteopathic Association. [1]
However, even with so many options today and increasing annual dues, the membership of the American College of Physicians nearly doubled between 1995 and 2009, reaching 130,000 members. The American College of Surgeons, with 77,000 members, has also seen tremendous growth in the past three decades. In June, the American Academy of Family Physicians announced that its membership had reached an all-time high of 100,300. [2]
So what makes these groups different from others?
Most doctors join medical societies and associations for what they can get, not for what they can contribute. Maybe this paradigm should be reversed, like many antiquated processes in today's healthcare marketplace. Often the decision to join is influenced by a medical association's position on hot-button political issues, such as healthcare reform. Many medical associations' benefits are similar: access to discounts on medical devices; discounts on malpractice insurance; CME credit courses and webinars; hands-on help in choosing an EMR/EHR; participation at national or regional events and conferences; and advocacy for issues affecting members. It's the last benefit where the difference in associations is generally revealed.
Optimism regarding Concierge Medicine, the delivery of Direct Primary Care and other private medicine business structures remains high among both consumers, executive healthcare professionals and physicians alike. In fact, a recent career satisfaction poll of the private physician community [e.g. Concierge Medicine, Direct Primary Care, Micro Clinic, etc.], reveals that nearly 90% of physicians in this niche community of healthcare professionals are highly satisfied with their career move into these entrepreneurial healthcare delivery business models There are models in which patients pay either an annual membership or monthly fee to be a part of the doctor's practice.
"I think that this is an exciting time for private direct medicine," says attorney Jim Eischen, Esq. "With all sorts of stakeholders exploring private medicine solutions: this is no longer primarily a solo or small physician-owned medical practice space. Larger systems and providers, and even non-provider enterprises, are all exploring how to accomplish improved health outcomes with private consumer investment and expanded communication/connection. But there are challenges with how to integrate with the tax code, and with plan requirements."
However, the trend lines in Direct Primary Care (DPC) for example, reveal that the independent, solo physician is regrouping and possibly consolidating in its service line offering after two DPC groups announced their closures earlier this year [2017]. When asked, 'Will DPC Stay Small? Grow Big? Optimism? What's in store for Direct Primary Care?' more than 13% of physicians are hopeful HSA and FSA integration inside DPC will occur to help patients pay for their monthly memberships. Additionally, nearly 18% of respondents to the online poll stated 'I hope DPC Doctors Can Work/Partner With More Businesses to Save HC Costs …' and nine percent noted 'I hope to see the creation of DPC networks for Employer Use (sim. to MCOs) come into the market.' Self-insured employers are beginning to show interest in the ways in which these models can improve health outcomes and contain costs according to several industry insiders.
"There is no better strategy than a major issue campaign to increase the number of people in an association or professional society," said Catherine Sykes, Publisher of Concierge Medicine Today, The Direct Primary Care Journal and Concierge Medicine Canada. "If properly managed, associations will use a new issue campaign as an opportunity to expand their sources of information and the number of people involved in that aspect of the work. Most organizations focus on building a membership network and often underestimate the need to build the value of their own organizations while struggling to win on public issues. As in the case of the corn farmer from Iowa, the thought is 'if you build it, they will come.'"
When nearly sixty percent of physicians in 2017 cite that they took Less than 5 Business Education courses …, certainly associations and physician groups must adapt to the needs of its base. However, Concierge Medicine and its variants operating in the U.S. today work because so many people have made it work. Concierge Medicine and the like, work because a few visioneering physicians broke every standard delivery tradition they knew to embrace the mission of the Golden Rule: Treat others the way you would want to be treated.
"Since AAPP was originally designed to help support self-employed physicians seeking to convert to a private direct model, I think demand for live conferences focused on self-employed physicians limits the draw," says Eischen. "More web-based education, along with live conferences structured to integrate the entire range of stakeholders, is the probable downstream solution for moving private direct medicine conferences/education forward."
"Comprehensive Pharmacogenomics for example, is a powerful healthcare innovation," adds Sykes. "Concierge Medicine is seen by many as providing the ideal delivery model for the future of precision medicine. Used under the guidance and application of a Concierge Physician, these innovative tests can have a predictive effect on patient treatment outcomes. Whole genome sequencing, genetic testing and comprehensive profiling with more than 50 well-established pharmacogenomics genes in a single, cost-effective test can provide medically actionable and clinically relevant data, allowing Concierge Physicians, to make a more informed and thoughtful treatment recommendation for the health and well-being of each patient. Concierge Medicine Today strongly supports use of this innovative testing."
"Future growth of private direct medicine may not look like the past," concludes Eischen. "As a more diverse array of stakeholders need to come together to balance how to better integrate private health and wellness services with the traditional diagnosis and treatment services of plan-reimbursed healthcare."
[1] – http://www.beckershospitalreview.com/hospital-physician-relationships/112-statistics-on-physicians-under-45-years-old-practice-setting-finances-future-plans-more.html; 112 statistics on physicians under 45 years old — practice setting, finances, future plans & more Written by Laura Dyrda; November 02, 2016
2017: (August 10, 2017) In a statement released by The Direct Primary Care Journal, the trend lines in 2017 related to Direct Primary Care (DPC) for example, reveal that the independent, solo physician is regrouping and possibly consolidating in its service line offering after two DPC groups announced their closures earlier this year [2017]. When asked, 'Will DPC Stay Small? Grow Big? Optimism? What's in store for Direct Primary Care?' more than 13% of physicians are hopeful HSA and FSA integration inside DPC will occur to help patients pay for their monthly memberships. Additionally, nearly 18% of respondents to the online poll stated 'I hope DPC Doctors Can Work/Partner With More Businesses to Save HC Costs …' and nine percent noted 'I hope to see the creation of DPC networks for Employer Use (sim. to MCOs) come into the market.' Self-insured employers are beginning to show interest in the ways in which these models can improve health outcomes and contain costs according to several industry insiders.
2017: (August 2017) OCTOBER 27-28. 2017 | ATLANTA, GA USA | Concierge Medicine Forum in Atlanta to Showcase "Precision Medicine" Use, Utility and Innovation
2018: (January 2018) CMT, PHYSICIAN POLL, 2018: Does your Concierge Medicine Practice bill Medicare?
2018: (April 2018) CMT SURVEY SAYS … 1K+ PATIENTS SAY … "The Patient Experience Matters to GUESS WHO, THE PATIENT — and So Does Air Quality In Your Primary Care & Family Care Practice."
2018: (May 2018) Analysis, How Private, Concierge and Direct Care Doctors Are Taking A Lead In Ending Fees For Missed Appointments, Immunization Record Copies and a Copy of Their Last Sports Physical Form
2018: (June 1, 2018) Press Release, RANKED: Top 20 Web Sites In Concierge Medicine Revealed by Concierge Medicine Today, LLC. — 2018-2019
2018: (June 25, 2018) Press Release, ACEP, PHYSICIAN GROUPS: PRICE TRANSPARENCY MUST INCLUDE HEALTH INSURERS
2018: (June 27, 2018) New Study, MDVIP: The Grades Are In; Most Americans Score an 'F' on Fat IQ Test
2018: (Oct. 26-28, 2018) Concierge Medicine Today hosted the 2018 Concierge Medicine Forum in Atlanta, GA USA
2019: National Study Finds Americans Don't Know the Facts or Their Risk for Heart Disease; Jan 2019
2019: (March 6, 2019) Dr. Garrison Bliss writes a blog story entitled The Origin of DPC:Transformation, Simple Ideas, and Trojan Horses; Moving into Subscription medicine — Two of my partners from my original practice eventually left to set up MD2, the first monthly fee practice in the US. At $1000 per member per month, MD2 was also the first ridiculously priced primary care practice, so it attracted comments in the press about concierge care and boutique primary care. When I looked at financing an optimized primary care system, I was attracted to the monthly fee concept. Primary care is a fixed-cost business, so a monthly fee could replace the fee-for-service insurance model, with its foolish incentives and toxic costs. I calculated the lowest monthly fee that could support a 600-800 patient panel at $30-50 per patient per month (depending upon age). It worked both as a care model a
nd business model, so Mitch Karton and I launched the new Seattle Medical Associates in 1997, filling our practices in just over a year. Roughly 3 years later, I moved on to supporting a national movement through a board position in the American Society of Concierge Physicians, started by Dr. John Blanchard, which later became the Society for Innovative Medical Practice Design, and eventually the American Academy of Private Physicians.
2019: The X Factor: for Women, the Rewards of Concierge Medicine are Even Greater, According to Specialdocs; Aug 2019
2019: MDVIP Reaches Major Milestone of Over 1,000 Primary Care Physicians Nationwide; Oct 2019
2019: (Oct. 24-26, 2019) Concierge Medicine Today hosts the industry's annual conference, the 2019 Concierge Medicine Forum in Atlanta, GA USA
2020: Paragon And SignatureMD Merge To Establish Premier Provider Of Membership-Based Concierge Medicine Support Services; April 2020
2020: OFFICIAL, POSITION STATEMENT | Concierge Medicine Industry Leadership Share Their Opinions On the Critical Protocols and Best Practices Related to Resourcing and Distribution of COVID-19 Vaccine; April/May 2020
2020: MDVIP Membership Medicine Model Significantly Cuts Diabetes Care Costs; June 2020
2020: In the Wake of COVID-19, Specialdocs Reports Rapid Growth in Its Network of Independent Concierge Physician Practices; June 2020
2020: Pandemic is Disrupting Healthcare Routines, Challenging Psyche of Americans Across Generations, Reveals New Study from MDVIP and Ipsos; Aug 2020
2020: Study Finds Many Americans in the Dark About Dementia And Alzheimer's Disease, Uncovers How Pandemic Is Affecting Brain Health; Sept. 2020
2020: (Nov 2020) Concierge Medicine Today hosts the industry's first virtual conference due to the pandemic, the 2020 Concierge Medicine Forum in Atlanta, GA USA
2020: Specialdocs Informs and Inspires at Concierge Medicine Industry's Signature Event Nov. 12th – 14th
2021: Survey shows zero percent pandemic closure rate for membership-based medical practices; March 12, 2021; Dr. Dean McElwain; Dean McElwain is co-founder, president & CEO of Castle Connolly Private Health Partners.
2021: MDVIP Named to Fortune 2021 Best Workplaces in Healthcare & Biopharma™; March 2021
2021: SignatureMD Completes Merger with Cypress Membership Medicine; March 31, 2021
2021: MDVIP Primary Care Model Reduces Incidence Of Cardiovascular Events In At-Risk Patients; April 2021
2021: New Study Finds Alarming Gaps in Women's Health Knowledge and Healthcare Experiences; May 2021
2021: Concierge Medicine Pioneer Specialdocs Launches First Women Physicians Council; Aug 2021
2021: Goldman Sachs Asset Management and Charlesbank Capital Partners Complete Acquisition of MDVIP Primary Care Network; Oct 2021
2021: (Oct. 21-23, 2021) Concierge Medicine Today hosts the industry's annual conference, the 2021 Concierge Medicine Forum in Atlanta, GA USA
2021: Specialdocs Presents a Unique Perspective on the Future of Concierge Medicine at the Industry's Signature Event Oct. 21-23
2022: Aspiring "Docpreneurs" find solutions to industry challenges thru Concierge Medicine Today's Online & in-person opportunities, guiding you & your practice in enhancing the patient experience— Join the DocPreneur Leadership Academy; January 2022
Did We Miss Something? Do We Need To Add Something?
Editor's Note: This is by no means an all-inclusive, every single detail about all of the things that have occurred in this unique healthcare delivery space. It is a summary of many of the highlights however. When possible, we've tried to provide links to the stories, web sites, press releases, research, studies and organizations for you to learn more. We recognize a lot has happened in the past 20+ years. And, it's virtually impossible to capture every moment in one document or on one page. As you may be aware, this document is routinely updated by Concierge Medicine Today, LLC., and is routinely edited, corrected and updated. If we missed something or you think we should add something, please, let us know by emailing us directly at email@example.com. Thank you!


text:
You'll never hear us deny it: we're fans of just about every treat that comes out of Epcot's France Pavilion.
As it turns out, so are lots of other people! So much so, in fact, that the well-loved Boulangerie Patisserie outgrew it's original small space and reopened in early 2013 to better accommodate more guests… and more treats! (The original space, by the way, is now home to L'Artisan des Glaces.) Additionally, a large indoor seating area was added even while the charming outdoor seating remained.
When the Patisserie reopened in it's new space as Les Halles Boulangerie Patisserie, we were so excited to see (and even more thrilled to taste) all the goodness this spot had to offer.
By and large, reactions to the offerings – from sweet to savory – were positive. Many favorites from the old Patisserie made it over to the new, and the expanded options were varied, impressive, and flavorful.
One alteration, however, that displeased some guests was a change to a much-loved pastry: the Napoleon. It had been updated with the reopening to provide a more authentic French culinary experience. Upon learning that people were unhappy with the change, the chefs in the France Pavilion recently made an update…to the update 🙂 !
And here is the result:
The updated Napoleon is a
lovely blend of the new and old versions.
The filling – you may be able to tell from the photo above — is much closer to its original light cream consistency, as opposed to the more dense form it took upon the reopening (which was more like cheesecake).
The replacement of glazed sugar fondant over the original powdered sugar remains with this new update, in keeping with the vision for a more traditional French Napoleon. I MUCH prefer the fondant over the previous powdered sugar version.
The pastry is very flakey, making it messy to cut through; but that's my only complaint on this one. 😉
Overall, though, I think this updated Napoleon offers the best of both worlds, and am impressed that the chefs behind all the terrific creations in Epcot's France listened and responded to what guests had to say.
So, if you tried the Napoleon upon the reopening of Les Halles, you may want to return to taste it again and find out for yourself how it's different. We'd love to hear what you think!
Also, let the France pavilion know your thoughts at @ArtisandesGlaces on twitter!
Are you interested in trying the updated Napoleon? Please let us know your thoughts with a comment!

subset: commoncrawl


text:
Barnes & Noble still has a long way to go before it catches up to Amazon in the e-book war, but its latest e-reader has gained attention for non-reading reasons. While it is designed to be mainly an e-reading device, users have unlocked the interface to make it a full Android tablet. And now someone has taken that a step further.
This isn't an officially sanctioned use of the Nook, but someone was able to pull out his car's existing stereo system and replace it with an embedded Nook Color.
The Nook now serves as a touchscreen interface to view videos, listen to music, and, well, read. Although, we probably shouldn't recommend that while you're driving.
We have to say that this looks like a pretty rockin' device.
Something that could rival this would probably cost at least $500-$600 at Best Buy, and then you'd have to pay their techs to install it.
Of course, not everyone would have the uber abilities this guy has, and you'd have to have the right-sized stereo system to work.
In other words, don't try this at home. But do show all your friends, because this is pretty cool.
(Via UberGizmo)