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Concierge Medicine Vizient Consortium GES Network 2018 Annual Meeting Gary W. Dorshimer, MD, FACP Penn Personalized Care Pennsylvania Hospital University of Pennsylvania Health System October 25, 2018

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Page 1: Concierge Medicine · 4 Concierge Medicine - Wikipedia Concierge medicine (also known as retainer medicine) is a relationship between a patient and a primary care physician in which

Concierge Medicine

Vizient Consortium GES Network

2018 Annual Meeting

Gary W. Dorshimer, MD, FACP

Penn Personalized Care

Pennsylvania Hospital

University of Pennsylvania Health System

October 25, 2018

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Objectives

Review of “Concierge” Models

Review of Penn Medicine’s Launch into Concierge Practice

Why Convert to a Concierge Medicine Practice?

Evaluating and Converting Established Medical Practices to Concierge Practices

Re-Enrollment and Membership Value

Lessons Learned

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My First Concierge Practice

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Concierge Medicine - Wikipedia

Concierge medicine (also known as retainer medicine) is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges. In exchange for the retainer, doctors provide enhanced care, including principally a commitment to limit patient loads to ensure adequate time and availability for each patient*

*Concierge Medicine: Greater Access for a Fee", PBS NewsHour,

PBS television, July 9, 2012

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Review of “Concierge” Models Concierge Medicine – Wikipedia Three Primary Types of Business Models

The Fee for Care ('FFC') is an annual retainer model, where the patient pays a monthly, quarterly, or annual retainer fee to the physician. The retainer fee covers most services provided by the physician in his/her office. Often, vaccinations, lab work, x-rays and other services are excluded and charged for separately on a cash basis

The Fee for Extra Care ('FFEC') is similar to the FFC model, however, the additional services are charged to Medicare or the patient's insurance plan

There is also a hybrid concierge model where physicians charge a monthly, quarterly, or annual retainer or membership fee for services that Medicare and insurers do not cover. For all covered services, these providers will bill Medicare and insurance companies for patient visits and services covered by the plans

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What are the Extra, Non-covered Services?

Same day access to your doctor

Immediate physician access

Unlimited office visits with no co-pay

Little or no waiting time in the office

Focus on preventive care

Unhurried atmosphere

Cell phone, text message and online consultations with your doctor

Convenient appointment scheduling

Specialty care appointment scheduling

Annual physicals

Extended visits

Comprehensive wellness evaluations and individualized wellness and preventive health plans

Newsletters

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Retainer Fee Based Model - Wikipedia

Care for fewer patients - ranging from 50 patients per doctor to 1,000, compared to 3,000 to 4,000 patients that the average traditional physician now sees every year*

Annual fees vary widely, ranging, on average, from $195 to $5,000 per year for an individual

Some include incremental savings when additional family members are added

Lower-cost concierge medical business models have also been attempted:

• GreenField Health in Portland, Oregon, which charged an annual fee between $195–$695 depending on age

• One Medical Group, the first major low-cost concierge medical group to attempt this model in a large scale, which requests a $199 annual membership fee

*“On Panel Size “physicians Practice Journal, June 2005

**”Concierge Medical Care With a Smaller Price Tag”, NY Times, January 31, 2011

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Direct Primary Care Model DPC is primary & 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 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, much of the overhead associated with claims, coding, claim re-filing, write offs, billing staff and claims-centric EMR systems disappears

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Trends in Retainer Medicine Unlike high-end concierge practices, which typically bill insurers for

medical services on top of collecting retainer fees, the lower-end practices usually don't accept insurance

They charge patients directly for treatment along with membership, often posting menu-style prices for services and requiring payment up front, which is why it is called "direct primary care"

Eliminating insurance billing cuts 40% of the practices' overhead expenses, enabling them to keep fees low, doctors say

Fueling the trend is a little-known clause tucked into the health-care law that allows direct primary-care to count as ACA-compliant insurance, as long as it is bundled with a "wraparound" catastrophic medical policy to cover emergencies

The rationale: Many of the new health plans have high deductibles that most members will never hit, meaning patients will still be paying thousands of dollars out-of-pocket anyway—possibly even more than what they'd spend on concierge medicine

*https://www.wsj.com/articles/pros-and-cons-of-concierge-medicine

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Trends in Retainer Medicine

People with deductibles of $5,000 or more

should think about how many times a year

they typically see the doctor and for what,

keeping in mind that annual checkups are

free under the ACA

If doctor visits typically cost $150 and the patient has six appointments a year, a concierge practice offering the same services for $40 or $50 a month might be cheaper

Direct primary-care doctors say that a patient's best bet is to select a high-deductible policy with minimal premiums for emergencies, and put the money they save up front toward the concierge retainer. High-deductible plans are often paired with health savings account. The IRS, however, doesn't recognize direct primary-care fees as eligible HSA expenses, so patients might not be able to spend pretax dollars at the clinics

*https://www.wsj.com/articles/pros-and-cons-of-concierge-medicine

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“A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.”

Wayne Gretzky

What’s Your Next Move?

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My Second Concierge Practice

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Concierge Medicine – Do I Have Potential?

Clinical experience of 15+ years

Experience managing a practice

Entrepreneurial minded

Loyal patient panel

Patient centered mindset

Top 5-10% for Quality and Patient Satisfaction

Genuine interest in concierge medicine

Patience – 3 to 5 years to grow practice

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How Concierge Medicine Started at Penn Medicine

Small group of well established physicians approached a national concierge group to learn and explore potential

Physicians approached Penn about transitioning to concierge practices

• Physicians did not want to leave Penn for private practice

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Why Convert to a Concierge Medicine Practice? Why Change? In prime of career for transition to concierge

The EMR – extra time demands & increasing burden of documentation

High volume of patients per day and late running schedule

Medical Bureaucracy – prior authorizations, peer-to-peer appeals, etc

Looking to still work hard, but at a less hectic pace

Worsening work/life balance

More time to spend with patients at visits

Increase income

Ease of taking care of 500-600 patients versus 2500-3000 patients

Why not, we were already doing it

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Why Stay at Penn?

Private Practice

More autonomy

More control on expenses

Less university constraints

(pharma & speaking revenue)

Long established access with other specialists

“My” Brand

Staying with Penn

Less “running the business”

Better insurance reimbursement

Allegiance to partners

Even more access to Penn specialists

The Penn EMR

The “Penn” Brand

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Dealing With Emotions and Ethics

Knowing you will end many patient relationships – like with retiring

Worrying what other physicians and colleagues will think

Changing to something unknown and untested at Penn

Global primary care access issues

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American College of Physicians Position Statements & Recommendations

Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians; Doherty, Robert; Ann Int Med, 15 December 2015, www.annals.org

1. The ACP supports physician and patient choice of practice and delivery models that are accessible, ethical, and viable and that strengthen the patient–physician relationship.

2. Physicians in all types of practices must honor their professional obligation to provide nondiscriminatory care, serve all classes of patients who are in need of medical care, and seek specific opportunities to observe their professional obligation to care for the poor.

3. Policymakers should recognize and address pressures on physicians and patients that are undermining traditional medical practices, contributing to physician burn-out, and fueling physician interest in DPCPs.

4. Physicians in all types of practice arrangements must be transparent with patients and offer details of financial obligations, services available at the practice, and the typical fees charged for services.

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American College of Physicians Position Statements & Recommendations 5. Physicians in practices that choose to downsize their patient panel for any reason

should consider the effect these changes have on the local community, including patients' access to care from other sources in the community, and help patients who do not stay in the practice find other physicians.

6. Physicians who are in or are considering a practice that charges a retainer fee should consider the effect that such a fee would have on their patients and local community, particularly on lower-income and other vulnerable patients, and ways to reduce barriers to care for lower-income patients that may result from the retainer fee.

7. Physicians participating, or considering participation, in practices that do not accept health insurance should be aware of the potential that not accepting health insurance may create a barrier to care for lower-income and other vulnerable patients. Accordingly, physicians in such practices should consider ways to reduce barriers to care for lower-income patients that may result from not accepting insurance.

8. Physicians should consider the patient-centered medical home as a practice model that has been shown to improve physician and patient satisfaction with care, outcomes, and accessibility; lower costs; and reduce health care disparities when supported by appropriate and adequate payment by payers.

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ACP Position Statements & Recommendations Calling for Independent Research on DPCPs

# of DPCP physicians

Where located

Growth projections

# of patients in DPCPs

the effect of DPCPs on health care workforce

impact and structure of DPCP models that may affect their ability to provide access to underserved populations

factors that may undermine the patient–physician relationship, contribute to professional burnout, and make practices unsustainable and their effect on physicians choosing to provide care through DPCPs

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ACP Position Statements & Recommendations Calling for Independent Research on DPCPs

Patients' out-of-pocket costs and overall health system costs

Patients' experience with the care provided, quality of care, and outcomes

Effect of physicians not participating in insurance and therefore not participating in national quality programs, interoperability with other electronic health record systems, and the associated effect on quality and outcomes

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Evaluating & Converting to Concierge Practice: How We Started Concierge Medicine at Penn Medicine

Analyses of the physician practices occurred to predict success of conversion to attain 230+ patients at the start of the new practices

Patient zip codes, length of patient care by each physician, patient survey of desires to join a concierge practice, and other factors were assayed

After consideration over several months it was decided not to use an outside group but to form concierge practices through resources at Penn

1st practice to start 1/1/2012; 2nd practice to start 8/1/2012; 2 physicians dropped out

Penn needed to work with health insurers

Created selling points to encourage joining the new practice vs helping patients that would not join to remain in Penn Medical practices (using the EMR as a selling point for them for the seamless transfer of their prior records)

Penn designated operational staff to lead the business processes, and a point person to head communication and contact with patients

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Creating Concierge Practices at Penn Medicine

Established a starting point for the membership fee ($2500/year for PPC) while looking at the range of rates in the Philadelphia area ($1500-4000) in 2011

Developed logo, stationery, patient forms, processes for contacting patients and answering their questions

Decided when and how to notify each physician’s patients about the practice change

Decided on the # of personnel needed for each practice based upon at least 230 patients

Posted new job openings

Selected potential office staff from current employees that would be high quality to create and fulfill the “concierge” deliverance of services

Decided on salaries for employees within the salary structures of a large organization

Decided on salary for physicians based on projected revenues and expenses

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Creating Concierge Practices at Penn Medicine

Decided on office space, separate waiting room, number of exam rooms, office décor

Decided on services beyond a regular practice that would be offered to patients

Decided on amenities to offer

Scheduled patient meetings and receptions with each physician and practice administrators to present the concept and answer patient questions

Reception after the formal presentations with proposed office staff present to allow patients to sign paperwork to join the new practice

Staff familiar to the patients was clearly an attraction to the new practice

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Marketing the Concierge Practice

Discussions on how to discretely market the practice after giving current patients the chance to join (not to compete with other Penn practices)

Finding PR opportunities for each physician

Finding speaking opportunities on health subjects to groups of people or businesses

Word of mouth to physician colleagues, especially specialists, who have patients expressing interest in concierge medicine or recognizing patients with need for more care and with more communication needs

Declining to use expensive marketing tools

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Conversion Phase

Contacting all patients by announcement letter

Communicating with patients during office visits

Contacting patients by phone

Not using impersonal mail or email for initial contact beyond the announcement letter

Conducting “Information Sessions”

Scheduled in person, one-on-one meetings with:

• Marketing professional

• Operations Leader

• Physician

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What Type of Patient Wants to Enroll?

Patients wanting an experienced, high quality physician

Executives & others wanting ease of access, help with scheduling

People wanting a Quarterback for health care

People wanting internet communication

Patients of sub-specialists that want to change to a primary care physician in the Penn System

Referrals from other patients or other physicians

Referrals from Penn Signature Services

Patients that did not enroll initially and are frustrated with more traditional service

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What Were the Expenses in the Conversions?

Remuneration to the point person

Letters, forms, stationery, pamphlets, postage, business and appointment cards

Recruitment of staff

New phone, fax lines, computers and computer ports

Staff time helping with evening meetings with patients

Parking vouchers for evening meetings

Healthy refreshments for evening meetings

Office reconstruction for private waiting room, private reception desk, and other upgrades in 3 of the 4 practices

Health-related gift items given at each Annual Physical

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What Has Been Offered? What Has Been Delivered?

24/7 coverage of patient care by primary care concierge physician (phone, e-mail, secure MyPennMedicine EMR portal)

Limited coverage (when on vacation, etc) by another designated physician; now by a designated concierge physician

Premium customer service experience

• Phone answered by concierge office staff during business hours, not an automated phone tree of choices

• Private waiting room

• Refreshments and light snacks at time of visit

• Parking voucher for free parking

In 2 out of 4 practices, in-patient coverage of patients by concierge physician

Longer patient visit times – how this has changed as we learned more about same day access

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What Has Been Offered? What Has Been Delivered? Ease of obtaining same day appointments with their concierge

physician

THE ANNUAL PHYSICAL:

• Extended history and physical

• Basic labs, EKG, vision screen, hearing screen, screening spirometry, InBody impedence body composition analysis

• Preventive medicine review (immunizations, cancer screens, diet, exercise)

Physicians and staff facilitating appointments for consultations in a much more timely manner than letting the patient call by themselves

Physicians and staff facilitating appointments for radiologic and other diagnostic studies

With fewer patients – looking at the patient a little more and the computer a little less

With fewer patients, more timely responses to phone calls, e-mails, patient portal notes, texts, prescription refills

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What Has Been Offered? What Has Been Delivered? Evening programs by invitation on preventive health topics (diet,

exercise, cooking class, mindful meditation, intro to yoga)

One practice – Wednesday Walks with your Doctor

One practice – Travel with your Doc

Gift item at the time of annual physical

Annual abbreviated physical for care of “dependent” children without concierge fee

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Top 10 Services Loved by Patients

10 – Refreshments

9 – Fancier gowns and facilities

8 – Private waiting room

7 – Parking vouchers

6 – The annual physical, including the body composition analysis that is very popular

5 - Special evening programs on health related topics

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Top 10 Services Loved by Patients

4 – The coordination of care with other physicians, outside hospitals, PT, and in our own hospitals

3 – The promptness of responses in any media

2 – The office staff

• they are less rushed

• they are devoted to “my” care

• have time to arrange appointments

consults or scans

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Top 10 Services Loved by Patients

#1 My Physician Physician seems more relaxed and

less rushed

Physician has more time to spend with me

Physician is on time or rarely runs behind

The 24/7 availability puts patients at ease

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Re-Enrollment – What Are You Doing to Bring Value to Your Practice?

Revenue is driven by annual or monthly fees, concierge practices must ensure that current concierge patients are deriving value from their membership to ensure re-enrollment

Industry standard 15% attrition

Typical Penn Medicine concierge practice based on patient panel of 500: • Start-Up – target for 10% of patient panel (280 patients) + new patients

• 1st year 85% renew/15% attrition

• 2nd year 90% renew/10% attrition

• 3rd year 92% renew/8% attrition

• 4th year 95% renew/8% attrition

• 5th year 98% renew/2% attrition

Example Penn Personalized Care now starting year 3 (with initial Patient Panel CAP at 350):

Startup - 238 patients enrolled of established 2800 patient panel

End of Year 1 – 329 enrolled

End of Year 2 – 385 enrolled

Year 3 – ?

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Managing New Patient Requests

Set your target for panel size

Develop patient panel until you reach goal

Increase panel size as you find balance in practice, financial and life goals

Increase panel when you reach target but not reached balance in practice

Add an additional doctor when you close your panel and need to add work/life balance

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Managing the Wait List

If you have reached your balance, it may be time for a wait list

• Know when you can’t say No

• Offer other physician

• Offer waitlist

– Provide an estimate of when you will have availability

– Review waitlist monthly

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What Have the Concierge Physicians Gained?

Higher physician satisfaction with the practice of medicine, less burnout; improved work/life balance

Higher staff satisfaction – positive feedback from the patients on staff role in their care. The physician must give them positive feedback for their role in OUR practice

Significantly higher patient satisfaction scores (Press Ganey average of 98.6%)

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What Has Penn Medicine Gained?

Highest practice revenue per primary care physician

High patient satisfaction ratings, which are increasingly important

More personalized, high-touch care for high-end patients of the Health System, high-end patients in town, and cultivating potential donors

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Lessons Learned

Billing Challenges

Insurances

Blue Cross/Blue Shield of PA – out of network to them

Annual retainer fee

• letters and calls to renew

• payment processing and tracking

• payment plans

• follow-up for past due memberships

• action on non-payments

What Has Been More Difficult to Deliver

Quarterly newsletter on health topics

Letter to patient after annual physical

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Do We Have What it Takes?

“Hockey's a funny game. You have to prove yourself every shift, every game. It's not up to anybody else. You have to take pride in yourself.” Paul Coffey

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Thank You

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Questions?