The Trump administration could make fee-based doctors more affordable for seniors 

  • Concierge medicine and other fee-based primary care practices make up less than 10 percent of physician practices.
  • The Centers for Medicare and Medicaid Services put out a request for information to health-care providers to see how the Trump administration could help fund access to some fee-based practices for Medicare patients.
  • Medicare has been trying to move toward paying doctors for better health outcomes, rather than for the number of procedures they perform.

Tim O’Connor tries to keep himself active in retirement, teaching English as a second language to adults in New York City, and staying fit to ward off health problems.

“I don't have a great cardiac family history in my family,” the retired attorney explained.

When his longtime doctor converted to a concierge medicine practice with a $2,100 annual fee per person, Tim and his wife decided they’d pay to keep their doctor. It was a decision they weighed carefully, now that they’re on a fixed income.

“Is money a consideration? I don't want to say it's not a consideration. But I do believe in preventive medicine,” O’Connor said.

For the O’Connors, the fee provides them with unlimited access for same-day appointments, longer visits and a comprehensive annual physical. For their doctor, converting his practice has meant being able to provide more personalized care to about 500 patients — about a quarter of the size of his old practice.

“If someone has three, four, five (health) conditions, it's impossible to see them in a 10-minute period,” said Dr. Peter Zeale, a cardiologist with the MDVIP concierge medical group. “So, you have the time to … sit down with them, go through each problem and try and direct them in the right direction. And I don't know how you can do that in the traditional model.”

While concierge medicine and other fee-based primary care practices have been around for decades, they make up less than 10 percent of physician practices, nationally according to a number of health industry surveys. Cost is a big deterrent for a lot of patients, especially since they still need to pay for health insurance on top of the concierge fee.

But now the Trump administration could give some fee-based practices a boost. Earlier this year, the Centers for Medicare and Medicaid Services put out a request for information to health-care providers, asking how the administration could help fund access to some fee-based practices for Medicare patients.

A patient is monitored in an examination room inside the Clinical Decision Unit at Kaiser Permanente's Capitol Hill Medical Center in Washington, D.C.
Brooks Kraft LLC | Corbis | Getty Images
A patient is monitored in an examination room inside the Clinical Decision Unit at Kaiser Permanente's Capitol Hill Medical Center in Washington, D.C.

Health and Human Service Secretary Alex Azar has proposed possibly giving some Medicare patients a stipend to help them gain access to fee-based practices that provide more personalized care.

“Arrangements like direct primary care have generated tremendous interest from both patients and providers. They can offer the opportunity for seniors to receive convenient, accessible primary care from a physician they know at a predictable and affordable cost,” Azar said last month during a speech at the World Health Care Congress.

The move comes as Medicare has been trying to move toward paying doctors for better health outcomes, rather than for the number of procedures they perform.

“It would be a significant step, representing the kind of fundamental rethinking of provider compensation that may be necessary to deliver value,” Azar said.

Bret Jorgenson, CEO of MDVIP, the nation's largest concierge medicine business with nearly 150,000 Medicare patients, is watching the proposal closely.

“We save Medicare hundreds of millions of dollars a year by avoiding things like ER visits, hospitalizations, re-admissions to hospitals. So the elements of a more direct-provider contracting model certainly works and works well,” said Jorgenson. “It will have a positive effect on our business.”

Not all the commentary from physician groups has been positive. The way the request for information was worded prompted unfavorable concerns from the Association of American Physicians and Surgeons.

“Many (direct primary care) practices offer patients free, or low cost, access to certain diagnostics and prescription drugs at near wholesale pricing,” wrote Dr. Jane Orient, executive director of AAPS. “The current RFI signals CMS is headed in a direction that would significantly curtail, if not block, the ability of [direct primary care] practices to offer innovative cost saving services to patients, outside of Medicare red tape and overregulation.”

The potential for too much red tape also worries the CEO and founder of ChenMed, a primary care practice for moderate and low income seniors, which contracts directly with Medicare Advantage insurers.

“If you have to go and start hiring third-party people to administer data, that’s going to cost you 3-5 percent of revenues,” said Dr. Christopher Chen, adding that's something a lot of smaller doctors’ offices can't afford to do.

“They need to engage more providers, as opposed to creating a model that’s exclusive to large systems or people with a large balance sheet or capability,” he maintained. “If you engage smaller groups, I think you slow down consolidation that we’re seeing of physician practices.”

It's not clear how the administration would structure a stipend program. For now, it has asked the industry and patients for input, and is reviewing the comments received. CMS will likely outline a pilot program to test the direct primary care model sometime in the months ahead.

If you ask Tim O'Connor, he’s convinced paying for prevention has paid off in better health.

“We have saved more over the years — if we were to sit down and try to figure out the economics of this — by staying under Dr. Zeale and under his care,” O’Connor said.