Caught in "too big to care"?

 There have been two compelling articles in the “New York Times” over the past few weeks focused on healthcare. The first article dated Tuesday, October 30, 2018, is entitled “A Sense of Alarm as Rural Hospitals Keep Closing1 and the second article dated November 14, 2018, entitled “When Hospitals Merge to Save Money, Patients Often Pay More2. These two articles are really bookends of the same set of issues emerging in our healthcare delivery system.


"Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so." 1 In many communities these hospitals are amongst the largest employers in the area. Because of the availability of medical care, communities establish a sense of stability that sustains existing businesses and presents opportunities for new commercial enterprises. The reality is that the cost of delivery of healthcare, which continues to accelerate, makes these rural institutions less capable of sustaining the level of quality of care emerging in this era of rapidly expanding technologies.


Do you stay or go?


These rural community hospitals are relegated to providing primary care services and very few of the specialty services that are available in centers of medical excellence in metropolitan cities. This situation continues to increase the need for patients to migrate to larger communities in order to obtain the specialized services their healthcare will require. This raises an interesting paradox addressed in the second article focuses on increased consolidation of healthcare services in huge healthcare systems with almost monopolistic power in key healthcare markets. "The latest giant hospital consolidations continue to stir concerns. Dignity Health and Catholic Health Initiatives, two large chains are expected to become one of the nation’s largest groups ---- with 139 hospitals in 28 states--- by the end of the year. And two of Texas’ biggest systems, Baylor Scott & White Health and Memorial Herman Health System, recently announced plans to combine.” 2

Piggy bank and stethoscope resting on pile of dollars on white background


"In the national analysis, a third of the metropolitan areas experienced increases in the cost of hospital stays of at least 25% from 2012 to 2014, from roughly $12,000 to at least $15,000.”2 Thus, these hospital system consolidations are doing exactly the reverse of what was anticipated as they are continuing to accelerate the cost curve rather than bend the curve with additional savings.



When you look at this emerging picture of healthcare from the perspective of the individual from a rural community who needs specialized care, the system is fraught with confusion, anonymity and increasing costs. We at Curus referred to this as the "What do I do now? syndrome". In order to seek out the highest quality of care, patients are left to their own ingenuity to figure out what are the best options that are most cost-effective and are in network? This is where the doctor-patient relationship is devolving into an impersonal process where the patient is on the conveyor belt of healthcare delivery. Further complicating the decision-making in this scenario is the fact that physicians are becoming part of the "corporate practice of medicine". While legally that phrase has certain implications in the real world, it represents the fact that physician affiliations to these monolith healthcare systems or to huge practice groups dictate much of the decision-making with regard to the referral patterns to specialists. 

 New call-to-action

A patient coming from a rural hospital is at the mercy of the system in which he/she seeks specialty care. They no longer have the familial relationship with the provider that is the historic bedrock of care in rural communities. When we started Curus, we were often confronted with the question of, “What do I need a healthcare manager for?” As we see the continuing consolidation of the healthcare delivery system where the patient has ceased to be the focal point of the care delivery process, the question has begun to answer itself. Without a dedicated team of skilled healthcare professionals who understand the nuances of the healthcare process, patients are directed rather than engaged by the healthcare professionals. They are part of the system, a process.  As one physician told me recently - when the healthcare systems are run by “bean counters”; the role of both the patient and the doctor suffer.    


In 2007 and 2008, the nation talked a great deal concerning the financial industry about the problem of "Too Big to Fail". Well, surprise! That is exactly what's happening in healthcare today. Systems of tremendous power are centralizing the delivery process and the patient has become a commodity in the system. In our Curus model the patient is the center of the universe. That's what being patient-centric means. Our role is to ensure the best possible choices so that our members can make value judgments that we can assist them in implementing. Our fundamental goal is to return control of the health care process to the recipient of that care. The reason one needs Curus to coordinate, navigate and evaluate all aspects of the continuum of care is to ensure that the human side of the healthcare experience is one of top quality care, compassion and concern.  


Like HealthPoints?  Subscribe to more  Curus articles and news.  Click here

Filed Under: Insider, Traveling, Health Management, doctor shortages, healthcare quality, changes in healthcare, pros and cons of concierge medicine, medical access

Concierge Medicine Pros and Cons and a Little History

The Great Society

If you remember the time when physicians made house calls it was a period in American healthcare where the relationship between doctor and patient was both medical and economic. During the era of house-calls you received your services directly from your doctor and you paid for those services directly to your doctor. Along came the presidency of Lyndon B. Johnson and his “Great Society”. 


 Closeup portrait, overwhelmed, busy unhappy stressed female health care professional, funny looking doctor holding big clock running out of time exhausted, isolated red background. Healthcare reformThis aspirational vision began the disconnect on payments for physician services t patient and doctor. In this new emerging aspirational society, everyone was going to have comparable healthcare and both the government and private insurance would be the payment intermediary between patient and doctor. The patients purchased health insurance or if they were senior citizens they purchased Medicare insurance to cover the costs of their healthcare needs. As this phenomenon emerged and expanded, a total disconnect occurred between the patient and the physician. The patient no longer understood the cost or the value of the service being received.

As we fast-forward decades from the Great Society to today, we have a new emerging unique relationship being developed between physicians who provide primary care services such as internists or family doctors and their patients. This new relationship is occurring within the more affluent socio-demographic who seek to have preferred status with their primary care doctor to ensure immediate access and physician availability. We are in a time of increasing physician scarcity and access to a doctor can be weeks or more away from the time the services are sought.  These physicians are experiencing a reduction in the reimbursements provided by the third-party payer (insurance companies) for the services they have historically provided. As a result, the physicians have begun to look for alternatives to seeing more patients and reducing the amount of time available to each patient. 


New call-to-actionThe alternative that is emerging is that increasing numbers of well-trained primary care physicians are adopting a concierge medicine model. In this model, the physician caps the number of patients in his/her practice and receives an additional direct payment, in addition to the insurance reimbursement, from the patient. The norm for the average full-time primary care provider is to see between 1500-2200 patients annually. In concierge medicine, the number of patients seen by the physician is a sliding scale tied to the concierge payment made directly by the patient to the doctor. So what does concierge medicine cost? There are significant national groups that charge an additional patient payment, approximating $1800 annually, and the physician agrees to limit the number of patients in the practice to 600 patients. From this benchmark, there are practices that limit the number of patients to 50 patients annually and they are paid an additional $20,000 per year to have this very exclusive limited practice. Between these two extremes, there are a number of price points and patient numbered caps all along the continuum of concierge medicine. 


In a unique way, you can think of concierge medicine as a throwback to the doctors who made house calls. Photo of retired man on private medical consultation
The doctor provides much more hands-on direct access and the patient remunerates the doctor with an additional annual direct payment to have this accessibility. Do you really get good medical access with concierge medicine? The limiting factors that occur in this emerging concierge medicine model result from the fact that healthcare delivery has become much more complicated and specialized over the last five decades. Many of the illnesses that the traditional primary care doctor handled previously are now referred to specialist and sub-specialists. In this scenario, the exclusive access that exists with the PCP dissolves when the patient moves on to the specialists. The specialists, not being tied to a patient cap, has a full waiting room and the patient is again thrown in with the masses seeking, this time, a specialized physician. Further, the PCP develops a referral pattern that may result in the specialists recommended not being uniquely qualified for the specific medical issue or event, but more, a result of familiarity or network connections. Further, the complications of the billing processes in medicine and the document known as Explanation of Benefits (EOB) still remain within the purview of the patient as most concierge physicians continued to bill their patient’s insurance company.   When you decide that you are in the market for a concierge doctor, you need to focus on the doctor’s skill sets, referral patterns, and ability to navigate with you through the complex healthcare system we have. Just purchasing access for primary care in the complex healthcare world may not satisfy the experience your parents and grandparents had with their doctor who made house calls. 



There is a difference between concierge healthcare and concierge medicine. Which one are you really wondering about?

Click to Download a PDF on the Concierge HealthCare Management Model 

Filed Under: Insider, concierge medicine, concierge healthcare, why don't doctors do housecalls, changes in healthcare, lyndon by johnson, great society, pros and cons of concierge medicine