When Annapolis resident Maria Pittarelli began pursuing concierge primary care for her mother, she quickly came down with an acute case of sticker shock.
The idea behind concierge is that primary care doctors can charge a membership fee so that they can see fewer patients for relatively the same amount of money, thereby allowing them to dedicate more time to each patient. However, as more practices adopt the business model, those fees can become a barrier.
Global revenue for concierge health care is slated to more than double within a decade, from $20.5 billion this year to $44.3 billion in 2034, according to Towards Healthcare, a Canadian health strategy firm. According to Johns Hopkins Bloomberg School of Public Health professor Dr. Gerard Anderson, the practices tend to show up in affluent areas, which he says pushed them more toward Central Maryland rather than out west or the Eastern Shore.
In Pittarelli’s case, she found several options in the Anne Arundel County and Baltimore area. One asked for around $2,000 a year, another asked for between $50 and $70 a month, while a third did not charge a membership fee per se, but rather charged anywhere between $300 and $500 per appointment. Many more, she found, made their fees difficult to find online, sometimes requiring inquiry or a consultation before she could find out.
In her own experience, she had to leave a physician in Greenbelt after she was told that the office was making the switch, and she would have to pay $3,000 to continue.
Wendy Sanhai, a professor of practice at the University of Maryland Smith School of Business, said that the concierge model can be compared to a boutique’s role in a retail space, constructed to deliver personalized service for a client.
Sanhai reeled off benefits such as more time spent with each patient, a potential reduction in insurance paperwork, shorter wait times for more frequent appointments, and a physician who is easily reachable.
Annapolis Family Medicine switched to concierge in 2019. Amy Ricker, one of its owners and a certified registered nurse practitioner, says that insurance, and the butterfly effects of it, forced the practice to make the change.
“As an independently owned practice, we don’t get reimbursed like the bigger conglomerates,” Ricker said, referring to how larger hospital systems have the bargaining power to get more out of insurance. “We’re too small. They don’t care. So, if we stayed in your typical model … we bill the insurance, we’re not making enough to sustain [the practice]. We’d have to see such a volume — like probably 25 to 30 patients a day, per person, per provider. The providers get burnout. The patients are mad.”
The membership fee, which is $1,000 at Annapolis Family Medicine, makes up that difference, allowing for more of a focus on every patient, she said. She also mentioned how some insurance rules allow physicians to care for only one issue per appointment, whereas now the practitioners have the freedom to use one appointment to treat all of a patient’s issues. She said the practice also uses the concierge model to offer more specialized services, like therapy, physical therapy, labwork and medicinal cannabis.
Gene Ransom, the CEO of MedChi, the Maryland State Medical Society, saw the emergence of concierge in Maryland around 20 years ago and has seen it rapidly grow ever since.
“I understand there are some people who are going to want to use concierge, and I hold no judgment on that. … If somebody wants to provide that niche service, that’s great, but that’s the symptom of the problem. That’s not the problem. The problem is that the insurance companies are not building out adequate networks,” Ransom said. “It’s a complete failure of the health insurance system.”
He estimates that the state is short around 1,000 primary care physicians, and says that the state’s physicians are some of the lowest paid in the country.
Anderson, when asked about this statistic, said there is actually a nationwide shortage of primary care physicians, and though Maryland is still in a shortage, it is better off than many other states, but also echoed that insurance can make processes difficult for both the practice and the patient, with prior authorization and billing requirements being commonplace.
A representative of AHIP, the trade association for the health insurance industry, did not respond to a request for comment for this article.
For some providers, using concierge is a way to break free from these systems and issues.
“There used to be a day in medicine when almost all the [primary care physicians] were entrepreneurial, independent,” said John Haskell, CEO of Sage Health, which has three concierge medicine offices in Baltimore. He argued that increased administrative complexity and regulatory oversight made it difficult to operate sustainably. “This is a great way for the primary care physician to kind of peel out of this health system machine, and be more independent again.”
Sage Health, unlike most concierge practices, offers its service without a membership fee, but only to disabled and senior populations on government health care programs in underserved communities. He said focusing on preventive care and homing in on the senior and disabled population’s specific needs make the business sustainable.
Though concierge care is a boon to practices, observers such as the University of Maryland’s Sanhai see drawbacks for consumers.
“This kind of brings us to … the ethical concerns about concierge medicine for people who cannot pay. [Concierge is] creating, I think, a further divide between the have and the have-nots,” Sanhai said. “I think, as a society, if we look to achieve the goals of decreasing the cost of health care, making health care more affordable, making it more accessible to the majority of patients, that we ought to look at other ways to do that.”
Availability for non-concierge primary care can be difficult to find. Pittarelli, who works at Anne Arundel Medical Center, said she has many times spoken with patients who decided to forgo primary care completely. Wait times for traditional primary care can be upward of six months, she said.
The Bloomberg School’s Anderson foresees those problems at scale.
“[People who can’t afford concierge] are going to have increasingly difficult times finding a physician that will take them,” Anderson said. “If they’re moving into the area or they need to change the doctor, it’s going to be a challenge, because there’s fewer and fewer primary care physicians already, and many of whom are getting locked up by concierge medicine. So the challenge of finding a doctor is increasingly difficult for people that can’t afford concierge medicine.“
Megan Pringle, communications director for the Anne Arundel County Department of Health, said in an email that a lack of insurance coverage and a low number of caregivers who accept medical assistance or income-based out-of-pocket compensation are partly to blame for gaps in care.
While Pittarelli was in her interview for this story, she received a text from her mother, who was in an appointment at an unnamed Glen Burnie traditional family practice. The doctor there was asking each patient the same thing: their opinion on the office switching to concierge in the future.
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