Can Better Access to Health Care Really Lower Costs?

Concierge medicine versus patient-centered medical homes: debating the benefits of enhanced access to care

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Health care access — as measured by the ease and timeliness with which people obtain medical services — is a key indicator of quality of care. Some people have high-quality care, with round-the-clock access to doctors. Others don’t, waiting months for an appointment, resorting to Google for medical advice and the ER for primary care. In other words, having an insurance card or even a doctor doesn’t mean you have good access to health care.

The elusive question for many people is how to get better access. There are no websites or apps that let patients find out how long it takes to get appointments with specific doctors. And efforts to determine waiting times through secret-shopper studies — really the only way to get good info on waiting times — have been thwarted. What’s more, there is no way to know how responsive a doctor will be off-hours, or whether she will return your phone calls promptly.

The good news is that there are two health-care models that promise better access: concierge medicine and the patient-centered medical home. The former has been around for years, but the medical-home model is just catching on, spurred by provisions of the Obama administration’s Affordable Care Act. Figuring out the differences between the way these models work — and whether either is really worth the trouble — is very confusing, even to people who work in the health-care field.

First, let’s start by explaining concierge medicine: for a flat yearly fee — ranging from hundreds to thousands of dollars, depending on the services offered — patients get enhanced access to care. Concierge doctors usually guarantee same-day appointments, give patients their cell phone numbers, and promise to arrange consults quickly with really good specialists and to arrange MRIs on the weekends. Some concierge doctors will even go to the hospital with their patients and monitor their care. They not only explain what is happening, but also scrutinize each medical decision made by hospital staff, and step in if the “right” care is not delivered.

Concierge docs claim to have averted impending medical catastrophes this way, but their critics have several complaints, chiefly that concierge medicine creates a two-tiered system in which the rich get prioritized and the poor have to wait their turn. Many patients who would benefit from having someone help them navigate the health-care system can’t afford concierge care. Further, when primary care physicians practice concierge medicine, they take on fewer patients because they get paid more for and spend more time with each patient. This effectively reduces the already scarce primary care workforce.

Concierge medicine can also potentially lead to increases in unnecessary medical care, particularly if physicians respond to their patients’ every ache and pain by ordering a test or prescribing medication. Such patients may feel compelled to use more health care as well, since they’re already paying a premium for it (interestingly, the same thing happens when you lower people’s co-payments), similar to the way people scramble to spend their pre-paid health savings accounts by the end of the year.

If concierge medicine sounds elitist, consider a different model that uses some of the same methods, but focuses on children, poor patients and those with chronic diseases: the patient-centered medical home. In the medical home, each patient has a personal physician who provides “first contact” care and then coordinates care across multiple settings, from specialist to specialist. The medical home pays attention to the “whole person,” which means that it considers not only the patient’s medical issues, but also social ones that may contribute to health. Importantly, it also promises enhanced access to care through open scheduling, expanded doctors’ hours and increased communication with care providers. In medical homes, patients don’t have to wait months for appointments; often, they can see their doctor the same day they feel sick.

So, what are the similarities and differences between these two models? First and most importantly, they’re both expensive. Enhanced access and better coordination of care represent a higher level of service, so they cost more. The reason doctors don’t offer greater access as a matter of course (e.g. giving patients their cell phone numbers) is precisely because they don’t get paid to do so — the traditional payment model requires a face-to-face encounter and doesn’t pay extra for coordination of care. Yet it takes a doctor time and energy to make sure that her patient’s multiple specialists are working in sync, or that information about what happened during a hospital stay (such as outstanding tests or unanswered questions) don’t get ignored after the patient is discharged.

So, who pays for these enhanced services? In the case of concierge medicine, it is clearly the patient. In the case of the medical home, it’s less clear who will pays; most likely, the increased costs will fall on insurers, who may the indirectly pass the higher costs back to the patient. The resources necessary to transform traditional practices into medical homes may also come from other sources, such as foundations and government entities.

In either case, if the patient ends up using less health care resources as a result, and is ultimately healthier (i.e. health problems are prevented before they happen), there are two winners: the insurer (or taxpayer) who ends up paying less in costs, and the patient who ends up healthier.

Another major difference between the two models lies in who actually delivers the care. In the concierge model, it is usually the doctor. In the medical home, non-doctors (nurses and other professionals) deliver many of the services. This may end up being cheaper in the end because it allows the doctor to focus on doctoring, while letting others coordinate follow-up appointments, deliver diet counseling, and make sure that screening tests and vaccinations are up-to-date.

Perhaps the most important difference, however, is that while concierge medicine is accessible mostly to the wealthy, medical homes are available for both the rich and the poor — at least in theory. There are currently projects testing the medical home model in practices that serve patients on Medicaid, the government-sponsored insurance for the poor. To our knowledge, there are no state-subsidized concierge medicine practices. But it could be argued that at the low-end ($100 per month), concierge fees may actually be affordable to the middle class, particularly for people who already spend a lot on health care.

Ultimately, the key question is whether enhanced access and coordination of care is really worth it. In at least one respect it is: people don’t like waiting for medical care; studies on the benefits of enhanced access show that it increases patient satisfaction and experience. But the jury is still out on whether any of these models really make anyone healthier. No large, well-designed studies have looked at mortality rates in concierge medicine or medical homes. Similarly, while enhanced access would presumably keep patients healthy enough to avoid hospitalizations and ER visits, there are no studies showing that it actually saves money in the long run.

What is clear, however, is that both models offer a greater focus on prevention and care coordination, which is potentially especially helpful for people with chronic medical problems like diabetes and heart failure, for whom close personalized management can reduce hospitalization rates.

In the coming years, as studies are increasingly conducted to explore these issues, it will hopefully become clearer which care-delivery model is better, more effective and sustainable in the long run. But until then, it will be up to patients to weigh the personal costs and benefits, if they’re deciding whether to pay for concierge medicine or to seek out a medical home.

Pines is the director of the Center for Health Care Quality and an associate professor of emergency medicine at George Washington University. Follow him on Twitter at @DrJessePines.

Meisel is a practicing emergency physician and an assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania. Follow him on Twitter at @zacharymeisel.

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