Family Practice going member only Pros & Cons?

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ChinchillaWhiplash
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Family Practice going member only Pros & Cons?

Post by ChinchillaWhiplash » Tue Aug 13, 2019 10:05 pm

My personal physician is switching to a membership model. Not sure of the details yet and have no knowledge of such a business structure. She will be only taking on about 1/3 of current clients. Hate to switch doctors after being with her for over 10 yrs. is this a good thing or bad? Don't know how much it costs yet either. There will be some meetings about the details soon. Existing patients have 1st chance to join before it is opened to the general public.

mhalley
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Re: Family Practice going member only Pros & Cons?

Post by mhalley » Tue Aug 13, 2019 10:12 pm

Depends on how often you need to go see her and how much she will charge per yr, plus how much your insurance pays now. Most likely not worth it. If you have chronic health conditions and high deductible plan, MIGHT be worth it, but not enough info in your post.
https://www.consumerreports.org/healthc ... -and-cons/

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ChinchillaWhiplash
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Re: Family Practice going member only Pros & Cons?

Post by ChinchillaWhiplash » Tue Aug 13, 2019 10:39 pm

Actually the later does apply. I have ongoing health issues currently with oxygen saturation and sleep apnea. Had a lot of visits this year. Also have a $2500 deductible plan with HSA. So guess I need to wait and see what the fees will be.

randomguy
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Re: Family Practice going member only Pros & Cons?

Post by randomguy » Tue Aug 13, 2019 10:55 pm

mhalley wrote:
Tue Aug 13, 2019 10:12 pm
Depends on how often you need to go see her and how much she will charge per yr, plus how much your insurance pays now. Most likely not worth it. If you have chronic health conditions and high deductible plan, MIGHT be worth it, but not enough info in your post.
https://www.consumerreports.org/healthc ... -and-cons/
And if you were a doctor, isn't that exactly the patient you wouldn't want to invite into your club?:) At a high level, you are going to be paying more (my place wanted 3k) and might not get much (i.e. I was always seen within 24 hours) in return.To a large extent it is about doctors wanted to get paid more (who can blame them) and not have to see as many people (again who can blame them). If they could get away with it (i.e. have enough people sign up) almost every family practice doctor would do this. Most people though aren't willing to pay thousands of dollars for a service that they were paying 100s (i.e. a couple of copays/year). You need an upper class clientele to pull it off.

toofache32
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Re: Family Practice going member only Pros & Cons?

Post by toofache32 » Tue Aug 13, 2019 11:02 pm

Could be a DPC model. Cutting out the middle man with costs known up front can have significant savings and value, depending on your needs.

https://www.dpcare.org/about1-ccz5

sawhorse
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Re: Family Practice going member only Pros & Cons?

Post by sawhorse » Tue Aug 13, 2019 11:04 pm

One thing I've learned over many years of health problems is that a primary care doctor who can handle practically any problem on their own is worth their weight in gold.

My doctor at one of my former locations handled pretty much everything without referring me out to specialists. Psychiatric, dermatologic, neurological, you name it, she knew how to treat it. She was also super-responsive and had great bedside manner. Just an exceptional doctor all around.

My other primary care doctors have referred out a lot of problems that the old doctor handled herself, and that's been a huge inconvenience because of wait times for specialists and the additional time and money to see specialists.

So for my excellent old doctor I would definitely be willing to become a member, for my other doctors I wouldn't.

Another thing to consider is house calls if you have mobility problems. My grandmother had a doctor who not only handled basically everything on his own, but he also made free house calls. When my grandmother lost mobility late in life, her doctor's house calls saved her so much suffering in the brutal Canadian winters. I don't know if such practices exist in Canada, but if her doctor had one, it would definitely have been worth it.
Last edited by sawhorse on Wed Aug 14, 2019 12:07 am, edited 1 time in total.

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onthecusp
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Re: Family Practice going member only Pros & Cons?

Post by onthecusp » Tue Aug 13, 2019 11:07 pm

My doc tried this a few years ago. Didn't get enough takers and cancelled the plan, he finally went into administration at the hospital next door. He was a good doctor, miss him but he moved on.

I have a good doctor now but her support staff sucks. PA never answers her phone. Answering machine message is vaguely threatening that repeated messages will slow response, but I don't see how that is possible.

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Re: Family Practice going member only Pros & Cons?

Post by mountains » Tue Aug 13, 2019 11:28 pm

If you have ongoing health issues it could be quite good for you. Models vary but often you pay a fixed monthly fee plus you may or may not pay for each office visit in addition. If your provider takes insurance, it will probably cover the office visit part but not necessarily the monthly fee.

What do you get out of it? You should expect more time and better responsiveness from your provider. I.e., it should be easy to schedule same day or next day appointments. Your provider should give you more time for each office visit (i.e. 30min or 60min instead of 15). Finally, your provider will also often be available on the phone, online, facetime, etc. -- potentially including the weekend and holidays too. The exact level of service will depend on your provider obviously (and the fee).

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Re: Family Practice going member only Pros & Cons?

Post by Swansea » Wed Aug 14, 2019 5:42 am

My former PCP went to such a practice. The plan was to get 600 patients each paying $1800 annually as a retainer.
I did not sign up, and ended up with a better PCP.

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Re: Family Practice going member only Pros & Cons?

Post by ScubaHogg » Wed Aug 14, 2019 6:16 am

We use a service like this. We pay $120/mo for wife and myself and it’ll be another $40/mo when we have our first baby next month. The PCP doesn’t take any insurance of any kind, but the fee includes all our visits. It’s awesome. I wouldn’t do anything else.

Sick? Need a same day appointment? No problem. Want to email the doctor a question? No prob. She responds personally. No long waits in waiting rooms with a million sick people. Appointments are on time and *not rushed.*

Wife accidentally poked herself with a used needle one weekend. Called the doctor answering service and the on call doc called back within an hour. I had a minor skin thing and instead of making an appointment for two weeks from now then spending a couple hours going to and from the clinic I simple texted a photo. She uploaded a solution via their portal within an hour. Problem solved.

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?

Freefun
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Re: Family Practice going member only Pros & Cons?

Post by Freefun » Wed Aug 14, 2019 6:27 am

My doctor switched to MDVIP. I tried it but didn’t like the cost (around $300 per quarter) as it wasn’t covered by my insurance. I already pursued my own wellness goals prior to this so I had little to gain by this offering in the MDVIP program. In summary I ended up changing doctors.
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TomatoTomahto
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Re: Family Practice going member only Pros & Cons?

Post by TomatoTomahto » Wed Aug 14, 2019 6:43 am

Around here they call it concierge medicine. When we moved to the Boston area, we started with a doctor here. I would not go back to “regular” PCP.
Okay, I get it; I won't be political or controversial. The Earth is flat.

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Re: Family Practice going member only Pros & Cons?

Post by lazydavid » Wed Aug 14, 2019 8:55 am

TomatoTomahto wrote:
Wed Aug 14, 2019 6:43 am
Around here they call it concierge medicine. When we moved to the Boston area, we started with a doctor here. I would not go back to “regular” PCP.
The doctor my parents have been going to for 20+ years went concierge a couple of years ago, think the fee is $3k/year. Too rich for their blood, but he also sees non-concierge patients on Tuesday mornings. So they just schedule as best as they can.

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TomatoTomahto
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Re: Family Practice going member only Pros & Cons?

Post by TomatoTomahto » Wed Aug 14, 2019 9:13 am

lazydavid wrote:
Wed Aug 14, 2019 8:55 am
TomatoTomahto wrote:
Wed Aug 14, 2019 6:43 am
Around here they call it concierge medicine. When we moved to the Boston area, we started with a doctor here. I would not go back to “regular” PCP.
The doctor my parents have been going to for 20+ years went concierge a couple of years ago, think the fee is $3k/year. Too rich for their blood, but he also sees non-concierge patients on Tuesday mornings. So they just schedule as best as they can.
Ours was a bit less pricey, around $2k each. I find our doc much more proactive and involved than our previous doctors.

If your parents can schedule for Tuesday mornings, which I imagine is doable, they might have hit the sweet spot :D
Okay, I get it; I won't be political or controversial. The Earth is flat.

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dm200
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Re: Family Practice going member only Pros & Cons?

Post by dm200 » Wed Aug 14, 2019 9:17 am

No personal experience with "concierge medicine" - but find this interesting to follow.

What I notice (and conclude) is that most of the cited benefits to patients are things I get with being enrolled with our Kaiser (HMO) plan - whether Medicare (as now) or other types of enrollment (employer, ACA, etc.)

I get 24x7 access to and "advice line" staffed by nurses, who can consult Physicians when needed, as well as 24x7 access to local "Urgent Care" being seen by a Physician - who can consult with any needed specialty - and can access my entire medical record.

What I do not get is 24x7 or after hours access to my own PCP, but I have not experienced any real downside to that. My PCP at Kaiser is very accessible by email (she usually responds within 24 hours - business hours) and usually has in person or telephone or "smart phone" appointments readily available.

In many ways, the "concierge medicine" model for Primary Care is much like the "old days" when Physicians made house calls and handled many issues that today tend to be handled by Specialists.

What I also wonder about is whether there is a significant change of the mix of types of patients in this "concierge medicine" model. Are these sicker patients that get more services, justifying the added cost? Are they patients that want the added convenience - and are willing to pay for it? Are they patients that want the "extra attention" and lack of being "rushed" - and are willing to pay for it? The numbers I have seen cited indicate that the Physicians doing this end up with a lot fewer patients for the same amount of income.

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Re: Family Practice going member only Pros & Cons?

Post by TomatoTomahto » Wed Aug 14, 2019 9:27 am

^ I spoke to our physician about this. What she gets from the model is a much smaller set of patients, and no office manager hounding her to deal with patients more quickly.

She explains blood test results in detail, emphasizing which results we want to watch trending over the next few blood tests (even when they are within range).

There is no reason (other than time) that my previous physician couldn’t have done this. But, he didn’t.
Okay, I get it; I won't be political or controversial. The Earth is flat.

rich126
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Re: Family Practice going member only Pros & Cons?

Post by rich126 » Wed Aug 14, 2019 10:46 am

I'm not really fond of the prices for the concierge practices. I knew a doctor (internal medicine) back east. Probably mid 50s and enjoyed his job (told me he had no intention of ever retiring and rarely took vacations). I'd run into him in various restaurants and he went to a concierge practice and greatly reduced the number of patients and felt he could spend more time with each one.

As a patient while I want a doctor that actually listens to me (as an engineer I'm pretty good at adding up my symptoms and issues) but I really don't want a 2 hour physical or spend more time in a doctor's office than necessary.

I've been looking around for a doctor in Arizona and a number of them have gone this route. I think for a couple of reasons here, not enough doctors for the growing and aging population, and Scottsdale isn't exactly a low income area.

Maybe paying $500, but paying $1,500+ seems excessive for the handful of times I see a "family" doctor. If I go 5 times a year that would be a $300 surcharge. :shock:

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Re: Family Practice going member only Pros & Cons?

Post by dm200 » Wed Aug 14, 2019 11:06 am

TomatoTomahto wrote:
Wed Aug 14, 2019 9:27 am
^ I spoke to our physician about this. What she gets from the model is a much smaller set of patients, and no office manager hounding her to deal with patients more quickly.
She explains blood test results in detail, emphasizing which results we want to watch trending over the next few blood tests (even when they are within range).
There is no reason (other than time) that my previous physician couldn’t have done this. But, he didn’t.
Ah, yes - I did not think of the "office manager" issue! :)

In my (no medical credentials) opinion, I fully agree about following test results in such detail. I can do that myself with online access to just about all of my test results for the last eight years (when I switched back to Kaiser). Yes - "trends" are important - not just that results are "in the normal range". My wife, however, does not do this at all (my observation) and just depends on her PCP (we have different PCPs) to say normal range or not.

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Re: Family Practice going member only Pros & Cons?

Post by TomatoTomahto » Wed Aug 14, 2019 11:29 am

dm200 wrote:
Wed Aug 14, 2019 11:06 am
In my (no medical credentials) opinion, I fully agree about following test results in such detail. I can do that myself with online access to just about all of my test results for the last eight years (when I switched back to Kaiser). Yes - "trends" are important - not just that results are "in the normal range". My wife, however, does not do this at all (my observation) and just depends on her PCP (we have different PCPs) to say normal range or not.
I also have online history of results, but she can explain things in a way that works for me. She has figured out that I’m a visual learner, and doesn’t treat me as a dummy. For example, we discussed my total cholesterol (a bit lower than she’d like, although it was in range), triglycerides, LDL, HDL, and a host of other lipid measures, and their levels relative to my metabolic markers, inflammation markers, etc. It was very interesting, and although it gets a bit “inside baseball” at times, I appreciate that she pays attention.

I think it makes a difference that the office manager is on board with the practice’s values.
Okay, I get it; I won't be political or controversial. The Earth is flat.

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dm200
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Re: Family Practice going member only Pros & Cons?

Post by dm200 » Wed Aug 14, 2019 11:46 am

TomatoTomahto wrote:
Wed Aug 14, 2019 11:29 am
dm200 wrote:
Wed Aug 14, 2019 11:06 am
In my (no medical credentials) opinion, I fully agree about following test results in such detail. I can do that myself with online access to just about all of my test results for the last eight years (when I switched back to Kaiser). Yes - "trends" are important - not just that results are "in the normal range". My wife, however, does not do this at all (my observation) and just depends on her PCP (we have different PCPs) to say normal range or not.
I also have online history of results, but she can explain things in a way that works for me. She has figured out that I’m a visual learner, and doesn’t treat me as a dummy. For example, we discussed my total cholesterol (a bit lower than she’d like, although it was in range), triglycerides, LDL, HDL, and a host of other lipid measures, and their levels relative to my metabolic markers, inflammation markers, etc. It was very interesting, and although it gets a bit “inside baseball” at times, I appreciate that she pays attention.
I think it makes a difference that the office manager is on board with the practice’s values.
Probably because I usually ask so many questions when I see her in person for any kind of issue, as well as my very detailed following of tests and test trends, in the last several years (I have been with her for over eight years), after giving me a diagnosis, making a recommendation or finding, etc. - she always asks me, "What do you think?" and seems to have a smile. Without getting too deeply "into the health/medical weeds", at an inperson office visit, discussing bowel movement issues, I told her that, in recent years, I have been a 3 or 4 (the best) on the "Bristol Stool Scale" . As usual, she was sitting at the computer as we spoke, and she immediately did an internet search on the "Bristol Stool Scale" and what a 3 or 4 meant. :happy We get along very, very well - and I believe that she tends to somewhat go out of her way when dealing with me and things I encounter. This, I believe, helps a lot in the few cases where I do not 100% follow her recommendations or advice. I always tell her and/or discuss these instances with her as well.

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Re: Family Practice going member only Pros & Cons?

Post by White Coat Investor » Wed Aug 14, 2019 12:13 pm

This is just what happens when you combine a free market with medicine. Those with money get a great product/service. Those without do not.

There are pluses and minuses both ways, but your view of it likely depends on whether you have money or not.

The truth is that health care in our country is rationed by your economic standing and has been for a long time. This just makes it a bit more explicit.
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Re: Family Practice going member only Pros & Cons?

Post by dm200 » Wed Aug 14, 2019 12:28 pm

White Coat Investor wrote:
Wed Aug 14, 2019 12:13 pm
This is just what happens when you combine a free market with medicine. Those with money get a great product/service. Those without do not.
There are pluses and minuses both ways, but your view of it likely depends on whether you have money or not.
The truth is that health care in our country is rationed by your economic standing and has been for a long time. This just makes it a bit more explicit.
I wonder what the "super rich" folks do about medical care? I presume there may be Primary Care type physicians (and perhaps some specialists) whose practices consist mainly (or exclusively) of such "super rich" or powerful folks. Or, if not "super rich" themselves, have companies that provide such "super rich" medical care for them.

Anyone here ever involved, in some way or another, with such "super rich" folks' health and medical care?

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Re: Family Practice going member only Pros & Cons?

Post by Artful Dodger » Wed Aug 14, 2019 2:30 pm

I think the pros have been well stated. Ease of getting an appointment, better care when you see them, more explanation of tests, better coordination of on-going treatment.

The cons as I see them - docs do this so they don't have to contract with PPOs, HMOs, etc. So any services you receive you will likely have to file with your insurer, and they will go towards a much, much higher out of network deductible and out of pocket. Nothing will go towards your in-network share. You better make sure they have a mechanism to refer any expensive care (MRIs, advanced testing, therapies, inpatient and outpatient hospital) and treatments to your in-network providers, so these can be can be covered in-network.

Regarding HDHP / HSA plans - you're basically just adding that amount they charge to your HDHP deductible as your responsibility.

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Re: Family Practice going member only Pros & Cons?

Post by randomguy » Wed Aug 14, 2019 2:54 pm

ScubaHogg wrote:
Wed Aug 14, 2019 6:16 am

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?
Would you buy this product from a car dealer? Would you prepay for a service plan that only makes financial sense if you get oil changes every month?:) If PCP care wasn't covered by health insurance, what do you think your premiums would drop? 400 year? Maybe 500? Want to bet that your baby in a couple months (congratulations) will cost more than both of your PCP visits in your life so far?:)

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Re: Family Practice going member only Pros & Cons?

Post by randomguy » Wed Aug 14, 2019 3:04 pm

dm200 wrote:
Wed Aug 14, 2019 12:28 pm
White Coat Investor wrote:
Wed Aug 14, 2019 12:13 pm
This is just what happens when you combine a free market with medicine. Those with money get a great product/service. Those without do not.
There are pluses and minuses both ways, but your view of it likely depends on whether you have money or not.
The truth is that health care in our country is rationed by your economic standing and has been for a long time. This just makes it a bit more explicit.
I wonder what the "super rich" folks do about medical care? I presume there may be Primary Care type physicians (and perhaps some specialists) whose practices consist mainly (or exclusively) of such "super rich" or powerful folks. Or, if not "super rich" themselves, have companies that provide such "super rich" medical care for them.

Anyone here ever involved, in some way or another, with such "super rich" folks' health and medical care?
From a couple years back: https://www.nytimes.com/2017/06/03/busi ... -care.html

When you have money to buy all sorts of luxury goods, you tend to buy them. This trickles down. The super rich are buying bentleys. The merely rich and upper middle class are paying to drive mercedes and BMWs instead of the standard honda with 1k-3k/year concierge medicine practices. I have no idea if it is the better doctors opting out (from skill at treating) or if it is more the more personable (you need people to like you to spend that money).

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Re: Family Practice going member only Pros & Cons?

Post by kenoryan » Wed Aug 14, 2019 3:11 pm

randomguy wrote:
Wed Aug 14, 2019 2:54 pm
ScubaHogg wrote:
Wed Aug 14, 2019 6:16 am

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?
Would you buy this product from a car dealer? Would you prepay for a service plan that only makes financial sense if you get oil changes every month?:) If PCP care wasn't covered by health insurance, what do you think your premiums would drop? 400 year? Maybe 500? Want to bet that your baby in a couple months (congratulations) will cost more than both of your PCP visits in your life so far?:)
If the PCP visit wasn't covered by health insurance, I bet the doctor would charge more for an office visit. Cash.

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Re: Family Practice going member only Pros & Cons?

Post by toofache32 » Wed Aug 14, 2019 3:17 pm

With several friends who are concierge doctors, their goal is to generally get away from the red tape and paperwork. They don't make more money, but they are able to practice without insurance telling them what they can and cannot do. It also lowers their overhead since they don't have to hire a room full of women to sit on the phone and argue with insurance. Very boglehead if you ask me.
I send my wife to a concierge doctor and she loves it.

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Re: Family Practice going member only Pros & Cons?

Post by fposte » Wed Aug 14, 2019 3:23 pm

For a differing data point--a couple I'm friends with signed up for one such service. The doctor was overstretched and out of her depth, and should have sent the husband to a specialist rather than attempting to manage his condition on her own. (My friends also fell prey to the sunk cost fallacy and were reluctant to go to a specialist off their own bat, even though his insurance would have covered it.) The result was a health downspiral that eventually killed my friend, and the doctor was completely unresponsive to any requests for information or guidance for the first several months of his illness.

The doctor's reviews are still generally good, and there's no way you've have seen this in advance. But by the time my friend needed to exercise independent judgment about seeking a different care model he no longer had that capacity.

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Re: Family Practice going member only Pros & Cons?

Post by TomatoTomahto » Wed Aug 14, 2019 3:27 pm

randomguy wrote:I have no idea if it is the better doctors opting out (from skill at treating) or if it is more the more personable (you need people to like you to spend that money).
Small anecdotal sample:
I liked my old doctor well enough in a social sense, but had reasons to question his medical wisdom/knowledge towards the end. Had we not moved, I would have replaced him regardless. Concierge doctor, in addition to having more involvement in my health, seems frankly to be more current (although that’s admittedly something I can only have an impression of, not being a doctor myself).
Okay, I get it; I won't be political or controversial. The Earth is flat.

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Re: Family Practice going member only Pros & Cons?

Post by toofache32 » Wed Aug 14, 2019 3:36 pm

fposte wrote:
Wed Aug 14, 2019 3:23 pm
For a differing data point--a couple I'm friends with signed up for one such service. The doctor was overstretched and out of her depth, and should have sent the husband to a specialist rather than attempting to manage his condition on her own. (My friends also fell prey to the sunk cost fallacy and were reluctant to go to a specialist off their own bat, even though his insurance would have covered it.) The result was a health downspiral that eventually killed my friend, and the doctor was completely unresponsive to any requests for information or guidance for the first several months of his illness.

The doctor's reviews are still generally good, and there's no way you've have seen this in advance. But by the time my friend needed to exercise independent judgment about seeking a different care model he no longer had that capacity.
Just curious if you think this was a function of the care model or of the doctor herself? Bad outcomes can occur in any setting.

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Re: Family Practice going member only Pros & Cons?

Post by fposte » Wed Aug 14, 2019 3:45 pm

toofache32 wrote:
Wed Aug 14, 2019 3:36 pm
fposte wrote:
Wed Aug 14, 2019 3:23 pm
For a differing data point--a couple I'm friends with signed up for one such service. The doctor was overstretched and out of her depth, and should have sent the husband to a specialist rather than attempting to manage his condition on her own. (My friends also fell prey to the sunk cost fallacy and were reluctant to go to a specialist off their own bat, even though his insurance would have covered it.) The result was a health downspiral that eventually killed my friend, and the doctor was completely unresponsive to any requests for information or guidance for the first several months of his illness.

The doctor's reviews are still generally good, and there's no way you've have seen this in advance. But by the time my friend needed to exercise independent judgment about seeking a different care model he no longer had that capacity.
Just curious if you think this was a function of the care model or of the doctor herself? Bad outcomes can occur in any setting.
I think the care model played a role, yes, and it's also an indication of what impact poor performance can have in a model where you're staking so much on an individual practitioner at a primary level. The doctor was, I think, concerned about invalidating the model by directing a patient to a specialist, and as I said my friend was invested in not going elsewhere after having paid the concierge fees. And while one could say that's on them, I think it's a response that kind of plan predisposes people to.

That doesn't mean I think the model is inherently bad; I can see a lot of use for it. it's just that first, as you say, bad outcomes will occur in every setting and the possibility for bad outcomes hadn't been mentioned yet; second, every model will have fault lines, and no one had mentioned the fault line of overanchoring on a particular practitioner that this model especially encourages.

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Re: Family Practice going member only Pros & Cons?

Post by White Coat Investor » Wed Aug 14, 2019 3:50 pm

toofache32 wrote:
Wed Aug 14, 2019 3:17 pm
With several friends who are concierge doctors, their goal is to generally get away from the red tape and paperwork. They don't make more money, but they are able to practice without insurance telling them what they can and cannot do. It also lowers their overhead since they don't have to hire a room full of women to sit on the phone and argue with insurance. Very boglehead if you ask me.
I send my wife to a concierge doctor and she loves it.
Don't kid yourself, most of them make more money by going DPC/Concierge. That's a major driver. Perhaps not the main driver (dealing with insurance stinks), but not insignificant. Even for the few that aren't making more overall, they're certainly making more per patient visit. Less work, more money, what's not to like?

I like seeing doctors owning their practices/businesses. I like doctors reducing their burnout/enjoying their practice/practicing better medicine. I like patients being able to get in to see their doctor.

The only downside is less opportunity to see a doctor, especially among those with limited means. It's really the same mixed feelings I have about free standing emergency departments.

My parents also stuck with their PCP when he went concierge. The alternative was seeing a PA/NP in a low income clinic as that was the only place that was taking new Medicare primary care patients in their town.

https://www.medpagetoday.com/blogs/prof ... tice/48459
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

mervinj7
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Re: Family Practice going member only Pros & Cons?

Post by mervinj7 » Wed Aug 14, 2019 4:04 pm

It's hard to tell from your post, what exactly the new scenario will be and what the forward costs are. In my case, I joined a membership based practice for my primary care visits. I enjoy talking directly to my doctor over email, same-day appointments, no one else in the waiting room, no triage nurse, doctor personally comes to the waiting room to get you, and the front desk coordinates any appointments I need with outside facilities. Most importantly, appointments start on-time. That is invaluable for visits during a workday (no more taking the morning off for 20 minute visit).
Membership is $200/year. I would not go back to a "regular" practice again.
https://www.onemedical.com/faq/

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TomatoTomahto
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Re: Family Practice going member only Pros & Cons?

Post by TomatoTomahto » Wed Aug 14, 2019 4:11 pm

The doctor was, I think, concerned about invalidating the model by directing a patient to a specialist, and as I said my friend was invested in not going elsewhere after having paid the concierge fees.
I am very sorry for your friend. Not knowing the details, but based on what you said, the doctor didn’t act responsibly. While your friend might have contributed to the tragedy by being under the spell of the concierge fees, it was the doctor’s job to overcome the resistance (or make it clear how critical it obviously was).

My doctor acts as my endocrinologist/nephrologist, which she is perfectly able to do given my improvements in those areas, but has me see a cardiologist and Retinologist. That doesn’t invalidate the model. A good clinician has a sense of their competence and limits.
Okay, I get it; I won't be political or controversial. The Earth is flat.

UpperNwGuy
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Re: Family Practice going member only Pros & Cons?

Post by UpperNwGuy » Wed Aug 14, 2019 4:12 pm

White Coat Investor wrote:
Wed Aug 14, 2019 12:13 pm
This is just what happens when you combine a free market with medicine. Those with money get a great product/service. Those without do not.

There are pluses and minuses both ways, but your view of it likely depends on whether you have money or not.

The truth is that health care in our country is rationed by your economic standing and has been for a long time. This just makes it a bit more explicit.
Well written. Thank you.

sawhorse
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Re: Family Practice going member only Pros & Cons?

Post by sawhorse » Wed Aug 14, 2019 4:17 pm

mervinj7 wrote:
Wed Aug 14, 2019 4:04 pm
It's hard to tell from your post, what exactly the new scenario will be and what the forward costs are. In my case, I joined a membership based practice for my primary care visits. I enjoy talking directly to my doctor over email, same-day appointments, no one else in the waiting room, no triage nurse, doctor personally comes to the waiting room to get you, and the front desk coordinates any appointments I need with outside facilities. Most importantly, appointments start on-time. That is invaluable for visits during a workday (no more taking the morning off for 20 minute visit).
Membership is $200/year. I would not go back to a "regular" practice again.
https://www.onemedical.com/faq/
$200 a year? That's amazing! A practice around here wants $6k a year, and they don't even do home visits.

One thing to consider is that you basically have to have a PPO as specialist visits with HMOs would require referrals from a primary care doctor in the network.

mervinj7
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Re: Family Practice going member only Pros & Cons?

Post by mervinj7 » Wed Aug 14, 2019 4:22 pm

sawhorse wrote:
Wed Aug 14, 2019 4:17 pm
mervinj7 wrote:
Wed Aug 14, 2019 4:04 pm
It's hard to tell from your post, what exactly the new scenario will be and what the forward costs are. In my case, I joined a membership based practice for my primary care visits. I enjoy talking directly to my doctor over email, same-day appointments, no one else in the waiting room, no triage nurse, doctor personally comes to the waiting room to get you, and the front desk coordinates any appointments I need with outside facilities. Most importantly, appointments start on-time. That is invaluable for visits during a workday (no more taking the morning off for 20 minute visit).
Membership is $200/year. I would not go back to a "regular" practice again.
https://www.onemedical.com/faq/
$200 a year? That's amazing! A practice around here wants $6k a year, and they don't even do home visits.
That's just my annual membership cost. My insurance covers the actual cost of visits and tests (after my deductible, of course). When I first joined, it was only $99/year and I almost canceled when they started raising membership rates. However, after getting used to it for the last 4 years, I would consider even $1k/year justifiable for the service. Just don't tell my doctor. :wink:

randomguy
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Re: Family Practice going member only Pros & Cons?

Post by randomguy » Wed Aug 14, 2019 5:38 pm

kenoryan wrote:
Wed Aug 14, 2019 3:11 pm
randomguy wrote:
Wed Aug 14, 2019 2:54 pm
ScubaHogg wrote:
Wed Aug 14, 2019 6:16 am

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?
Would you buy this product from a car dealer? Would you prepay for a service plan that only makes financial sense if you get oil changes every month?:) If PCP care wasn't covered by health insurance, what do you think your premiums would drop? 400 year? Maybe 500? Want to bet that your baby in a couple months (congratulations) will cost more than both of your PCP visits in your life so far?:)
If the PCP visit wasn't covered by health insurance, I bet the doctor would charge more for an office visit. Cash.
Maybe. Or maybe it would be lower. After all if you don't have to pay that billing person and deal with rejected claims, your overhead is lower. You can charge the same and end up with more money. Where the actual prices ended up would depend on who the doctor is trying to recruit as patients? Upper midddle class? Yeah prices will be higher. People without health insurance? Prices would probably be lower.

I can assure with a 6k deductible, the health insurance company isn't planning on paying for much of my primary care and they still want 1k/month.:) That money all goes for tail end events (cancer, transplants, hernias, some really bad broken bones, NICO, ....) and like where you can run up a 20k bill easily.

fposte
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Re: Family Practice going member only Pros & Cons?

Post by fposte » Wed Aug 14, 2019 6:04 pm

TomatoTomahto wrote:
Wed Aug 14, 2019 4:11 pm
The doctor was, I think, concerned about invalidating the model by directing a patient to a specialist, and as I said my friend was invested in not going elsewhere after having paid the concierge fees.
I am very sorry for your friend. Not knowing the details, but based on what you said, the doctor didn’t act responsibly. While your friend might have contributed to the tragedy by being under the spell of the concierge fees, it was the doctor’s job to overcome the resistance (or make it clear how critical it obviously was).

My doctor acts as my endocrinologist/nephrologist, which she is perfectly able to do given my improvements in those areas, but has me see a cardiologist and Retinologist. That doesn’t invalidate the model. A good clinician has a sense of their competence and limits.
Yes, I agree, and as I said I don't think the model is inherently bad. I think every model of everything has its own particular weaknesses, though, and it's good to be aware of which ones you (the general you) might be susceptible to. I could see, for instance, there being a self-questionnaire to see if concierge medicine is a good fit or if you'd fare better playing the field, as it were.

toofache32
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Re: Family Practice going member only Pros & Cons?

Post by toofache32 » Wed Aug 14, 2019 10:11 pm

White Coat Investor wrote:
Wed Aug 14, 2019 3:50 pm
toofache32 wrote:
Wed Aug 14, 2019 3:17 pm
With several friends who are concierge doctors, their goal is to generally get away from the red tape and paperwork. They don't make more money, but they are able to practice without insurance telling them what they can and cannot do. It also lowers their overhead since they don't have to hire a room full of women to sit on the phone and argue with insurance. Very boglehead if you ask me.
I send my wife to a concierge doctor and she loves it.
Don't kid yourself, most of them make more money by going DPC/Concierge. That's a major driver. Perhaps not the main driver (dealing with insurance stinks), but not insignificant. Even for the few that aren't making more overall, they're certainly making more per patient visit. Less work, more money, what's not to like?
I'm sure they take home a little more, but it's not the lottery many think it is. I really believe it's mostly about lifestyle. Work smarter, not harder. Add value which doesn't exist in the insurance world where everything is the lowest bidder.

vested1
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Re: Family Practice going member only Pros & Cons?

Post by vested1 » Thu Aug 15, 2019 4:28 am

I had a PCP for over 20 years, definitely not the best, but one that would take our insurance. When he transitioned to MDVIP he wanted $3,600 a year for my wife and I to retain the privilege of being his patient. Same spiel you hear elsewhere, reducing the patient count to 600, individual care, Blah blah blah. When I declined he kept contacting me and lowering his patient count parameters until he got to 300 and still couldn't get enough takers.

The $3,600 yearly fee was not covered by insurance and all the other costs kept going up. During the ensuing 5 years or so before Medicare kicked in we had a number of PCP's, that is until they too transitioned to MDVIP. I spoke with several acquaintances who went that route and they were unanimous in their opinion that their care didn't improve.

I'm all for doctors being able to thrive financially, especially since many of the ones I've visited have no problem sharing tales about the rigors of their vast training and the time and expense of their education. What many of them fail to realize is that some of us have paid our dues as well, and don't demand an extra yearly membership fee for deigning to accept them as a client.

I have no special insight on how to fix our health care system, but I can recognize when it's broken.

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dm200
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Re: Family Practice going member only Pros & Cons?

Post by dm200 » Thu Aug 15, 2019 1:32 pm

vested1 wrote:
Thu Aug 15, 2019 4:28 am
I had a PCP for over 20 years, definitely not the best, but one that would take our insurance. When he transitioned to MDVIP he wanted $3,600 a year for my wife and I to retain the privilege of being his patient. Same spiel you hear elsewhere, reducing the patient count to 600, individual care, Blah blah blah. When I declined he kept contacting me and lowering his patient count parameters until he got to 300 and still couldn't get enough takers.
The $3,600 yearly fee was not covered by insurance and all the other costs kept going up. During the ensuing 5 years or so before Medicare kicked in we had a number of PCP's, that is until they too transitioned to MDVIP. I spoke with several acquaintances who went that route and they were unanimous in their opinion that their care didn't improve.
I'm all for doctors being able to thrive financially, especially since many of the ones I've visited have no problem sharing tales about the rigors of their vast training and the time and expense of their education. What many of them fail to realize is that some of us have paid our dues as well, and don't demand an extra yearly membership fee for deigning to accept them as a client.
I have no special insight on how to fix our health care system, but I can recognize when it's broken.
Interesting experience and perspective...

ScubaHogg
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Re: Family Practice going member only Pros & Cons?

Post by ScubaHogg » Thu Aug 15, 2019 4:01 pm

randomguy wrote:
Wed Aug 14, 2019 2:54 pm
ScubaHogg wrote:
Wed Aug 14, 2019 6:16 am

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?
Would you buy this product from a car dealer? Would you prepay for a service plan that only makes financial sense if you get oil changes every month?:) If PCP care wasn't covered by health insurance, what do you think your premiums would drop? 400 year? Maybe 500? Want to bet that your baby in a couple months (congratulations) will cost more than both of your PCP visits in your life so far?:)
I'm not sure I understand the question? My point is insurance should be to protect against tail events, not for very expected, relatively routine, and relatively inexpensive (a few hundred to a few thousand dollars, not a several hundred thousand dollar cancer scare) events. To use another example, I don't buy "gas insurance" to fill my car up, where I have some kind of "gas co-pay" and my "gas station" (is it in network?) has to file a bunch of forms and then I get confusing statements about my gas usage for the next six months. And yet somehow I manage to drive my car, even though I spend about $100/month on gas.

To answer your other question, my personal insurance wouldn't drop much if it didn't cover PCP (I obviously don't use it for PCP anyway), but one could realistically imagine that if a large percentage of PCPs had a slightly different business model that relied less on billing insurance companies health insurance as a whole would be less expensive. Maybe not a lot, but some.

This model is in many ways easier on the PCP (who doesn't have to set up a complicated billing system) AND me, since now I have to worry less about "what's covered / what's not covered / is this bill post-insurance adjustment or pre-insurance adjustment."

I'm sure the baby will cost a lot (thanks btw), but he is one reason we are willing to go this membership route. From what I understand babies tend to get sick and need to visit the doctor. With this model we can see our doc that day, not in two weeks, which is what many of our friends have experienced.

InMyDreams
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Re: Family Practice going member only Pros & Cons?

Post by InMyDreams » Thu Aug 15, 2019 4:10 pm

I see frequent turnover in PCPs. They move to another city/state; they change their clinic (and therefore, the insurance that will pay for the visit); they move out of clinical practice, and start doing computer work, quality assurance, research, and ???).

To me, it is a symptom of a bigger problem: physicians are less and less autonomous (an "employed physician") with bean counters who have their stop watches out and productivity calculators. All of which leads to burn out.

Personally, I'm tired of switching PCPs, and when my current one changed to an "out of network" status - I followed and pay out of pocket for visits. I would be tempted to pursue a different model (concierge or direct care) if I didn't have to keep changing the PCP.

I have seen a rheumatologist who moved to an independent practice, doesn't accept insurance, and provides patients with the forms with which to seek reimbursement from their insurers.

And while I'm sure there are concierge or direct care PCPs who are great, I've also watched one in practice that I wouldn't take me or mine to. If I needed a rheumatologist, I would go to the one that I've mentioned.

One problem to think about: if there's no one else in the practice, what happens in a catastrophic event - not for you, but your provider? Is there adequate coverage? What if they go on vacation for 2 weeks?

As usual, it means buyer beware - do your homework.

toofache32
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Re: Family Practice going member only Pros & Cons?

Post by toofache32 » Thu Aug 15, 2019 4:31 pm

ScubaHogg wrote:
Thu Aug 15, 2019 4:01 pm
randomguy wrote:
Wed Aug 14, 2019 2:54 pm
ScubaHogg wrote:
Wed Aug 14, 2019 6:16 am

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?
Would you buy this product from a car dealer? Would you prepay for a service plan that only makes financial sense if you get oil changes every month?:) If PCP care wasn't covered by health insurance, what do you think your premiums would drop? 400 year? Maybe 500? Want to bet that your baby in a couple months (congratulations) will cost more than both of your PCP visits in your life so far?:)
I'm not sure I understand the question? My point is insurance should be to protect against tail events, not for very expected, relatively routine, and relatively inexpensive (a few hundred to a few thousand dollars, not a several hundred thousand dollar cancer scare) events. To use another example, I don't buy "gas insurance" to fill my car up, where I have some kind of "gas co-pay" and my "gas station" (is it in network?) has to file a bunch of forms and then I get confusing statements about my gas usage for the next six months. And yet somehow I manage to drive my car, even though I spend about $100/month on gas.

To answer your other question, my personal insurance wouldn't drop much if it didn't cover PCP (I obviously don't use it for PCP anyway), but one could realistically imagine that if a large percentage of PCPs had a slightly different business model that relied less on billing insurance companies health insurance as a whole would be less expensive. Maybe not a lot, but some.

This model is in many ways easier on the PCP (who doesn't have to set up a complicated billing system) AND me, since now I have to worry less about "what's covered / what's not covered / is this bill post-insurance adjustment or pre-insurance adjustment."

I'm sure the baby will cost a lot (thanks btw), but he is one reason we are willing to go this membership route. From what I understand babies tend to get sick and need to visit the doctor. With this model we can see our doc that day, not in two weeks, which is what many of our friends have experienced.
+1
I have been preaching this for years. The problem is the entitlement mentality and how we want medical "insurance" to pay for every little thing. Can you imagine how expensive your auto insurance would be if they had to pay for oil changes? Insurance increases costs to the system by adding another middle man.

decapod10
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Re: Family Practice going member only Pros & Cons?

Post by decapod10 » Thu Aug 15, 2019 5:05 pm

ChinchillaWhiplash wrote:
Tue Aug 13, 2019 10:05 pm
My personal physician is switching to a membership model. Not sure of the details yet and have no knowledge of such a business structure. She will be only taking on about 1/3 of current clients. Hate to switch doctors after being with her for over 10 yrs. is this a good thing or bad? Don't know how much it costs yet either. There will be some meetings about the details soon. Existing patients have 1st chance to join before it is opened to the general public.
As others have mentioned, usually a membership fee like this usually implies increased access to the doctor ("concierge medicine"). The doctor will often give patients their personal cell phone number which they can call at extended hours. Easier clinic access time. These are the most common things. Some doctors even go as far as going with you to specialist appointments and things like that.

If there is no increased service, I probably wouldn't pay an annual fee personally. If there is, then you can decide whether you feel that it's worth it. Some do, some don't.

randomguy
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Re: Family Practice going member only Pros & Cons?

Post by randomguy » Thu Aug 15, 2019 5:13 pm

toofache32 wrote:
Thu Aug 15, 2019 4:31 pm
ScubaHogg wrote:
Thu Aug 15, 2019 4:01 pm
randomguy wrote:
Wed Aug 14, 2019 2:54 pm
ScubaHogg wrote:
Wed Aug 14, 2019 6:16 am

IMHO this is more like how the financial side of medicine should work. We don’t carry car insurance to have our oil changed. Why should we buy a lot of extra health insurance for routine PCP visits?
Would you buy this product from a car dealer? Would you prepay for a service plan that only makes financial sense if you get oil changes every month?:) If PCP care wasn't covered by health insurance, what do you think your premiums would drop? 400 year? Maybe 500? Want to bet that your baby in a couple months (congratulations) will cost more than both of your PCP visits in your life so far?:)
I'm not sure I understand the question? My point is insurance should be to protect against tail events, not for very expected, relatively routine, and relatively inexpensive (a few hundred to a few thousand dollars, not a several hundred thousand dollar cancer scare) events. To use another example, I don't buy "gas insurance" to fill my car up, where I have some kind of "gas co-pay" and my "gas station" (is it in network?) has to file a bunch of forms and then I get confusing statements about my gas usage for the next six months. And yet somehow I manage to drive my car, even though I spend about $100/month on gas.

To answer your other question, my personal insurance wouldn't drop much if it didn't cover PCP (I obviously don't use it for PCP anyway), but one could realistically imagine that if a large percentage of PCPs had a slightly different business model that relied less on billing insurance companies health insurance as a whole would be less expensive. Maybe not a lot, but some.

This model is in many ways easier on the PCP (who doesn't have to set up a complicated billing system) AND me, since now I have to worry less about "what's covered / what's not covered / is this bill post-insurance adjustment or pre-insurance adjustment."

I'm sure the baby will cost a lot (thanks btw), but he is one reason we are willing to go this membership route. From what I understand babies tend to get sick and need to visit the doctor. With this model we can see our doc that day, not in two weeks, which is what many of our friends have experienced.
+1
I have been preaching this for years. The problem is the entitlement mentality and how we want medical "insurance" to pay for every little thing. Can you imagine how expensive your auto insurance would be if they had to pay for oil changes? Insurance increases costs to the system by adding another middle man.
My auto insurance would be about 40/year more if it covered oil changes. Maybe lower given the ability of large companies to negotiate discounts. FOr example my doctor wants 175 for a service and the insurance company got them down to 90. If they can do the same with jiffy lube, my cost would be like 25 bucks. Prepaid service plans have been around for decades and it is very easy to price out costs that come at fixed intervals and known costs.

But lets look at the examples. Do you think prepaying 1400/year for primary care for a couple that only tends to use 600/year (i.e. 6 office visits. Probably high)
a) buying insurance where you are spending an extra 800/year to cover your tail risk (i.e insurance)
b) buying goods as you need them (paying for gas)

Obviously the analogy breaks down a bit in that some of that 800 bucks goes for the luxury experience and not tail risk protection but I am not seeing much difference from a consumer point of view. Yes it technically isn't insurance. But the effect is the same.

It is easy to criticize insurance companies but without them, providers charge absurd prices. See any of the balancing bill threads where instead of taking the fair 1500 dollars they would for an in network patient, they bill out 10k+. There is power in collective bargaining especially when one party (patients) has no idea what things should cost.

Random Poster
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Re: Family Practice going member only Pros & Cons?

Post by Random Poster » Thu Aug 15, 2019 5:19 pm

toofache32 wrote:
Thu Aug 15, 2019 4:31 pm
+1
I have been preaching this for years. The problem is the entitlement mentality and how we want medical "insurance" to pay for every little thing. Can you imagine how expensive your auto insurance would be if they had to pay for oil changes? Insurance increases costs to the system by adding another middle man.
My car insurance isn’t $21,000 a year. If it were, I might reasonably expect for it to cover oil changes.

When medical insurance is priced more like car insurance, let me know.

Of course, I’m not sure that I want a medical insurance company to be able to declare me as a “total loss,” as I’m not sure that I’d like that outcome.

ETA: As a practical matter, there is going to be a limit as to how many doctors can really avail themselves of this concierge model. There are only so many people out there who can afford to pay the annual subscription fee, and if that price keeps increasing while wages generally aren’t, well, I suspect that the overall patient count will decrease over time. Alternatively, it is going to be the same number of doctors competing for the dollars of the same number of patients, and the subscription fee will decrease or remain constant.

vested1
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Re: Family Practice going member only Pros & Cons?

Post by vested1 » Thu Aug 15, 2019 5:42 pm

Random Poster wrote:
Thu Aug 15, 2019 5:19 pm
toofache32 wrote:
Thu Aug 15, 2019 4:31 pm
+1
I have been preaching this for years. The problem is the entitlement mentality and how we want medical "insurance" to pay for every little thing. Can you imagine how expensive your auto insurance would be if they had to pay for oil changes? Insurance increases costs to the system by adding another middle man.
My car insurance isn’t $21,000 a year. If it were, I might reasonably expect for it to cover oil changes.

When medical insurance is priced more like car insurance, let me know.

Of course, I’m not sure that I want a medical insurance company to be able to declare me as a “total loss,” as I’m not sure that I’d like that outcome.

ETA: As a practical matter, there is going to be a limit as to how many doctors can really avail themselves of this concierge model. There are only so many people out there who can afford to pay the annual subscription fee, and if that price keeps increasing while wages generally aren’t, well, I suspect that the overall patient count will decrease over time. Alternatively, it is going to be the same number of doctors competing for the dollars of the same number of patients, and the subscription fee will decrease or remain constant.
To add to this theater of the absurd, when we leased our new car recently I added an "insurance" policy that paid for oil changes, tire rotations, and incidental damage with no deductible for a set term. That policy has an expiration date, after which I am on my own for the aforementioned items. Not so with concierge medicine, the gift that keeps giving, or taking, I can't remember which. Perhaps a different analogy is in order.

Oh, and I would suggest that there may be other justifications rather than an "entitlement mentality" for not wanting to fork out another $3,600 a year for something of debatable value. It may be that the entitlement shoe is on the other foot.
Last edited by vested1 on Fri Aug 16, 2019 2:57 pm, edited 1 time in total.

sawhorse
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Re: Family Practice going member only Pros & Cons?

Post by sawhorse » Thu Aug 15, 2019 6:05 pm

With concierge primary care, do doctors ever fire unprofitable and time consuming patients, or raise their membership fee for those patients? You know, the patients with a gazillion ailments who are there every week, email all the time. With the standard model, the doctor gets paid for each office visit, but with a concierge, they pay a flat fee, so the doctor gets paid the same whether they see them once a year or 50 times a year.

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