Primary care as affordable luxury

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A concierge physician makes a home visit to an elderly woman.

When I first arrived in California several years ago, I selected my primary care doctor based on the recommendation of a colleague from residency.  Several months ago, when my doctor announced his departure to join a concierge practice, I assumed I'd find my next physician the same way — through a trusted colleague.

While it may be true that doctors make the worst patients, they generally pick good doctors — or at least the doctors they perceive as good, since it's not at all clear there's any correlation between perception of quality and actual quality.

At the very least, as a physician, you're generally able to steer clear of the conspicuously bad providers ("gome docs"), and equally importantly, you're usually able to get into see even the busy docs whose practices might be closed - an increasingly common situation in primary care.

Armed with a promising recommendation, I called up the offices of the suggested doctor (whose practice, as expected, was closed to new patients), spoke to helpful staff member, and was told I'd hear back from them about my request, one way or another, by the end of the day.

No reply.

I called back the next day, spoke to a different staff member who had no record of my first call, but was helpful and told me I'd hear back by the end of the day.

Again, no reply.  The pattern repeated the following day as well.

By the end of the third day, I gave up, and decided to take my chances with an emerging health care company called OneMedical — it's been profiled in Forbes here and here.

OneMedical seems to be positioning itself as "concierge medicine for the masses" — an "affordable luxury," as Howard Schultz of Starbucks might put it.  For a yearly membership fee of $150 (in places like SF) or $200 (if you're in DC, for example) — about the cost of a weekly latte at Starbucks — you have access to a relatively high touch primary care practice. (In contrast, true concierge practices that I looked at seemed to have yearly fees on the order of $1500.)

The theory is that the membership fee provides the physicians with an adequate cushion, enabling them to take time with patients, and resist what seems like the increasingly common practice of upselling patients on a revenue-enhancing adjacency, such as bogus nutritional supplements, wrinkle creams, or tattoo removal.

Remarkably — following payment of the membership fee — I was able to make a same-day appointment, online, with a provider I selected, a doctor I chose based on location and  biosketch (and who [disclosure] I subsequently learned was the mother of a child in my daughter's pre-school class).

The website interface was especially well-designed, and in advance of my first visit, I was able to provide key aspects of my medical history in a way that seemed focused but not onerous.  I was also able to link my Withings devices to the practice, so that when I showed up for my appointment, they already had a series of baseline weight and blood pressure measurements.  (I will discuss health and wellness gadgets in a future post.)

I was pleased with my visit, and equally pleased by the prompt, e-mail follow up, including lab results attached as a PDF.  To be sure, I would have preferred a mechanism to access my lab results directly and immediately, and download them to a spreadsheet or health-tracking app; hopefully such an optiona will be available in the future.

About a week after my initial phone call, I heard back from the first doctor's office that I had contacted, letting me know that the physician I had requested had kindly agreed to open up a spot for me.  By that time, however, I already had found — and been seen by — another doctor, and had bought in (both literally and figuratively) to another style of practice.

A few thoughts about this experience:

Basics Are Now Luxuries

Similar to airlines and other industries, medicine seems to have reached the point where you now must pay extra for features once viewed as basic and foundational.  It's sad to think that timely appointments and personalized follow-up represent small luxuries, rather than standard medical practice available to all.  On the other hand, it's at least encouraging to know that there's enough incentive in the system to drive meaningful improvements in customer service - unlike cable TV, say, where a near-monopoly (at least here in the Bay area) seems to have left customers unavoidably stuck with premium pricing and bad service.  Hopefully, innovative practices that are introduced by organizations like OneMedical will rapidly diffuse, and come to represent the new baseline.

Technology Is An Essential Tool — But Not An End In Itself

Successful companies in the health care space — Retrofit is another example I've previously discussed — will intelligently embrace technology, while avoid becoming defined by it.  Enter the OneMedical office, for instance, and you feel like you're in a high-end waiting room — comfortable couches, current magazines — but there's nothing techy about it.  The tech features are almost all on the back end, in service of the doctor/patient relationship.

Continuous Care Brings Challenges As Well As Opportunities

Health care, driven by the emerging technologies of digital health, is undergoing a transition "from an episodic, symptom-driven practice to a more holistic vision focused on presymptomatic care and a more continuous assessment of health," as Denny Ausiello and I recently wrote in the Boston Globe.  This evolution is motivating providers to redefine and reimagine our profession, a key goal of many digital health initiatives, including the MGH/MIT Center for Assessment Technology and Continuous Health (CATCH) I co-founded.  As ultimately beneficial as this shift in perspective is likely to be, however, we must not underestimate the profound new challenges these shifts will create for already burdened providers (nor the opportunity it will generate for imaginative entrepreneurs).  For example, if patient data - such as my blood pressure measurements - are continuous ported to the physician's office, are doctors obliged in some way to monitor them?  Even if not, will patients assume their doctors are watching these numbers?  And — to be crass — who will pay for providers monitoring patient data, a non-trivial concern given the amount of effectively uncompensated worked most physicians already do.  I suspect the answers here might be very different in fee for service and accountable care models.

Perception Of Quality Isn't The Same Thing As Quality

Finally, there's the issue of quality.  As pleasant and convenient as OneMedical is, I've no idea about the quality of care they're actually providing.  Moreover, their business model doesn't seem to depend on the quality of care delivered, nor on the savings that might be generated through good care, as in the case of ACO models, where providers own the risk.  Rather, OneMedical presumably makes money by attracting a lot of customers, and keeping them happy.  Yet, patient satisfaction, like physician ratings, hospital ratings (as Zeke Emanuel and Andrew Steinmetz eloquently highlight in this recent WSJ commentary), and medical worker certification, for that matter - isn't necessarily correlated with quality.   The distinction between perception of quality and the documented delivery of quality is one that many reputation-based rating approaches — and the customers (i.e. patients) who use them — would do well to keep in mind.

 

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About the Author

 

David
Shaywitz
  • Dr. Shaywitz trained in internal medicine and endocrinology at MGH, and conducted his post-doctoral research in the Melton lab at Harvard. He gained experience in early clinical drug development in the Department of Experimental Medicine at Merck, then joined the Boston Consulting Group’s Healthcare and Corporate Development practices, where he focused on strategy and organizational design. He is currently Director of Strategic and Commercial Planning at Theravance, a publicly-held drug development company in South San Francisco. He recently wrote Tech Tonics: Can Passionate Entreprenuers Heal Healthcare With Technology? 

  • Email: davidshaywitz.aei@gmail.com

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