Long wait for a rushed doctor’s visit? Maybe you’ll get more with a ‘membership’ fee

Michele Andrews had been seeing her internist in Northampton, Massachusetts for about 10 years. She was happy with the care, although she did start to notice it was harder to get an appointment.

“You’d call and you’re talking about weeks to a month,” said Andrews.

That’s not surprising, as most workplace surveys show the supply of primary care doctors has fallen well below the demand. But Andrews still wasn’t prepared for the letter that arrived last summer from her doctor, Christine Baker, at Pioneer Valley Internal Medicine.

“We are writing to inform you of an exciting change we will be making in our Internal Medicine Practice,” the letter read. “As of September 1st, 2024, we will be switching to Concierge Membership Practice.”

Concierge medicine is a business model in which a doctor charges patients a monthly or annual membership fee – even as the patients continue paying insurance premiums, copays and deductibles.

In exchange for the membership fee, the doctor limits their overall number of patients, so it’s easier for each patient to be seen quickly, and spend more time talking to the doctor, if needed.

Andrews was floored when she got the letter. “The second paragraph tells me the yearly fee for joining, um, will be $1,000 per year for existing patients. It’ll be $1,500 for new patients,” she said.

More physicians are converting their practices to the concierge model, particularly in primary care. One trade magazine, Concierge Medicine Today, estimated there are about 12,000 concierge practices in the U.S., and medical practices are converting at an increasing rate. Membership fees can range from $1,000 to as high as $50,000 a year.

Many doctors who made the change have said it resolves, at least on an individual level, some of the pressures they face in primary care, such as too many patients to see in too short a time.

But critics counter that concierge medicine only helps patients who have the extra money, while at the same time shrinking the overall supply of primary care practitioners in a community. It can particularly impact rural communities already experiencing a shortage of primary care options.

Andrews and her husband had three months to either join and pay the fee, or leave the practice. They left.

“I’m insulted and I’m offended,” Andrews said. “I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”

In an interview, Dr. Baker said fewer than half her patients opted to stay, shrinking her patient load from 1,700 to around 800 — which she considers much more manageable. She said she had been feeling so stressed that she had considered retiring.

“I knew some people would be very unhappy. I knew some would like it,” she said. “And a lot of people who didn’t sign up said, ‘I get why you’re doing it.'”

Another patient at Baker’s practice, Patty Healy, said she didn’t even consider leaving.

“I didn’t question it,” Healy said. “I knew I had to pay.”

As a retired nurse, Healy knew about the shortages in primary care, and she was convinced that if she left, she’d have a very difficult time finding a new doctor.

Healy was also open to the idea that she might like the concierge model.

“It might be to my benefit, because maybe I’ll get earlier appointments and maybe I’ll be able to spend a longer period of time talking about my concerns,” she said.

This is the conundrum of concierge medicine, according to Michael Dill of the Association of American Medical Colleges.

The quality of care may go up for those who can and do pay the fees, Dill said. “But that means fewer people have access,” he said. “So each time any physician makes that switch, it exacerbates the shortage.”

The Association estimates the US will face a shortage of 21,000 primary care doctors within the next decade, given the growth of the population and its medical needs.

Dill pointed out that the impact of concierge care is worse in rural areas, which often already experience physician shortages. For example, western Massachusetts already has fewer doctors per capita than many other regions in the state.

“If even one or two make that switch, you’re going to feel it,” Dill said.

Dr. Rebecca Starr, an internist who specializes in geriatric care, recently started a concierge practice in Northampton, Massachusetts.

For many years before that, she consulted for a medical group where patients only got 15 minutes with a primary care doctor, “and that was hardly enough time to review medications, much less manage chronic conditions,” she said.

So when Starr decided to open her own medical practice, she decided she wanted to offer longer appointments, including time to talk about nutrition and general well-being — but still bring in enough revenue to make the business work. To her, the concierge model was the only way to accomplish that.

“I did feel a little torn,” Starr said. While it was her dream to offer high-quality care in a small practice, she said, “I have to do it in a way that I have to charge people, in addition to what insurance is paying for.”

Her patient load will be capped at 200, Starr said, much lower than the 1,000 or even 2,000 patients that some doctors have.

But within the first year of starting her practice, she still hasn’t hit her limit.

“Certainly there’s some people that would love to join and can’t join because they have limited income,” Starr said. Starr declined to disclose the amount of her membership fee.

Joanne Rome, of Florence, Mass, told NPR that when she contacted Starr’s practice on behalf of her mother, she was quoted a fee of $3,600 a year.

But for many doctors making the switch, the concierge membership model is the only way to have the kind of personal relationships with patients that attracted them to the profession in the first place.

“It’s a way to practice self-preservation in this field that is punishing patients and doctors alike,” said Dr. Shayne Taylor, who recently opened a practice offering “direct primary care” in Northampton.

Direct primary care is similar to concierge care in that it charges a recurring fee to patients – but direct care bypasses insurance companies altogether.

Taylor’s patients – who pay her $225 a month – still must have health insurance to cover things like X-rays or medications. But Taylor doesn’t accept insurance for any of her services.

This means patients must pay their bill out of pocket, and seek reimbursement from their insurance company afterwards. The reimbursement may not cover the full cost of the bill, especially since doctors like Taylor do not belong to insurer’s approved provider networks.

“We get a lot of pushback because people are saying, ‘Oh, this is elitist, and this is only going to be accessible to people that have money,'” Taylor said. “But ultimately, the numbers don’t work. We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company.”

While much of the pushback on the membership model comes from patients, advocates, and health policy experts, some of it comes from other physicians.

Dr. Paul Carlan, who runs Valley Medical Group in western Massachusetts, said his practice is more stretched than ever. One reason is that the group’s clinics are absorbing some of the patients who have lost their doctor to concierge medicine.

“We all contribute through our tax dollars, which fund these training programs,” Carlan said, referring to the fact that the federal government pays the salaries of doctors during their residency training after medical school.

“And so, to some degree, the folks who practice health care in our country are a public good,” Carlan said. “We should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public.”

Michelle Andrews, the patient who did not follow her doctor into concierge care, eventually found a new doctor. But she’s still angry at the system — and at concierge doctors.

“You’re not fighting the system,” she said of the doctors who are converting their practices. “This is a work-around.”

But Dr. Shayne Taylor said it’s not fair to demand that individual doctors take on the task of fixing a dysfunctional healthcare system, in which insurance companies determine what doctors should be paid for certain services, and how long they spend with patients.

“It’s either we do something like this,” Taylor said, “or we quit.”

In other words, she said, serving only 300 patients is still better than serving zero.

This story comes from NPR’s health reporting partnership with New England Public Media and KFF Health News.