Originally Published in August 2020
If you’ve ever been frustrated by short, impersonal visits to your primary care doctor, you’re not alone. Turns out, that conveyer-belt approach is a symptom of how most practices work: The physician is forced to increase patient volume as much as possible to keep the practice profitable.
James S. Hahn, MD, is one of the many physicians who have moved away from this high-volume model to the “concierge” approach. In this arrangement, patients pay a retainer for immediate, round-the-clock access to their own doctor, receiving much more personal attention and care.
Dr. Hahn, based in Central Austin, spoke to us about his own decision to become a concierge doctor, the benefits of this model to patients and doctors alike, and how the COVID-19 pandemic may encourage even more physicians to make a similar move.
Let’s start with a bit of background on you. What was your education like?
I went to the University of Texas for undergrad, then did medical school at the University of Texas Health Science Center in San Antonio. I then did my residency here in Austin at Brackenridge Hospital from ’90 to ’93 and started my private practice in late ’93. I changed over to this concierge model about five years ago.
Before we get into the concierge model, can you explain the typical private practice business model?
The model of a family practice doctor or primary care doctor is a lot like that of any other business: You establish a location, people come see you, and you try to see enough people to make a profit. If a family practice doctor sees about 15 patients a day, that generally pays for overhead. If you see an additional 10 or 15 patients a day, that’s where you start to make money to take home. In that sense, the doctoring business is no different than any other business when it comes to generating revenue. Unfortunately, doctors don’t get much training in the business side of things.
Were there difficulties in that model that drove you to seek something else?
I ran my practice that way for 20 years. In that model, the doctor’s revenue is based on billing each patient visit to an insurance company or Medicare or Medicaid. In the early 1990s, when I started, the insurance companies were paying better. They would pay not only for the patient’s visit but also for the doctor’s professional expertise in running and interpreting things like X-rays, EKGs, labs, and so on.
But eventually the insurance companies started paying less and less. They stopped paying for phone calls to the patient. They stopped paying for the primary care doctor to do the X-ray, EKG, or labs. All those got farmed out to other places. Now that the primary care doctor was paid just for the visit, doctors were pushed to see more and more patients.
On top of that, insurers started setting up more stringent guidelines for what they would pay for, and everything had to be coded just right. There was a lot more use of “prior authorizations,” where the insurer must approve medications, procedures, and specialists visits. These prior authorizations take a lot of time—time that we physicians don’t really have, and time that takes away from patients.
When did the concierge model of medicine start to get popular?
It started over 20 years ago in Seattle. These doctors saw payments from insurance getting smaller and smaller and the process getting more difficult. So they began charging a retainer directly to patients for more intensive, personalized care. That allowed them to give better care and diminished their reliance on payments from insurers.
I personally started looking at the concierge option about 10 years ago, like a lot of doctors. At first, it went against an assumption of most doctors, which is that the more patients you see, the better of a doctor you are, and that you are obligated to see every patient. The idea of a doctor limiting the number of patients in their practice went against the grain. It took me a while to come to grips with the idea of not trying to see as many patients as I could.
But ultimately, I knew that I couldn’t have 4,000 patients—seeing 30 people or more a day—and take really good care of each one of them. It’s impossible. I got to a point where I had answer the question: How well am I taking care of my patients? When I looked more deeply at the concierge model, I saw that if I limited my practice to a few hundred people—versus a few thousand—I could really take care of them better.
What is the full load for you as a concierge doctor?
Currently, I’m with MDVIP, which is a group of about 1,100 physicians around the country. MDVIP believes that no more than 600 patients is ideal. I had nearly 4,000 patients when I switched over; going from 4,000 to 600 was night and day. But a lot of concierge doctors keep their numbers even lower—600 patients is at the top end.
How has the concierge model changed how you treat patients?
The concierge model allows the physician to think of patients as truly their patients—you want to be there for them, take care of them, find out what makes them who they are, and discover the root of their medical problems. That’s possible as a concierge doctor, because the model allows you to spend so much more time with the patient.
One thing included in the patient’s fees is a once-a-year, executive-style physical. The patient comes in and we do bloodwork and a bunch of labs—an EKG, lung function test, body-fat analysis, circulation screen, vision screen, hearing screen. We go over all of that data and spend an hour or two if needed looking closely at it. And possibly more important, we look at the patient’s family history. We see what we can do to improve their health and watch out for potential problems. Then, throughout the year, we follow up to make sure the patient is doing well and getting things done. That’s a level of personalized care that a doctor running a volume-based practice would really struggle to give.
I’ve gotten to know my patients in ways I never did before the concierge model. Every patient has my cell phone number. They can call me for questions, ask me advice anytime. That closeness really speaks to how we can take better care of patients.
You said that billing was a big problem before you moved to the concierge model. Now I assume it’s a standard monthly fee charged to the patient?
Yes. My model is about $150 a month, and it’s a year-to-year contract. So the yearly membership fee is about $1,800. When we do the big physical, it’s worth about that much if you were to break it down. Of course, you also get all-hours direct access to your personal physician. When we see people for other visits, in the office or via telehealth, we do bill insurance or Medicare. But the model gives us the flexibility to know that billing insurance is not an important part of our model—it’s just a little bit of revenue.
You still refer people out to specialists as needed, and ensure that the specialists are in-network, right?
Yes. In fact, the additional time granted by the concierge model allows me to have stronger relationships with specialists. I can make better referrals, and each specialist knows what I’m doing. It’s not the usual “Here, here’s a list of three specialists; call them up and see if you can get in.” I can call up the specialist and say, “Hey, I’m sending over Mr. or Mrs. So-and-So, and this is the reason.” The specialists are welcoming of that. It creates a special bond.
How has the COVID-19 pandemic affected your practice?
It’s been interesting. When this began, we limited people coming into the office to only very necessary visits. Being on the concierge model, that wasn’t a problem, since my practice doesn’t rely on the volume of visits. Still, I’ve been going into the office every day. There are always people who need refills or have questions or do need to come in for necessary visits.
This period has given me a lot more time to research COVID-19, understand what’s actually going on, and reach out to my patients with guidance. I’ve been able to call people, see how they’re doing, and give them up-to-date information, more than what they’d hear on the news or from a friend. I can give them prevention guidelines, tell them what kind of testing is available, and so on.
We have done COVID testing in my practice, but when they first started testing, there were only the invasive, uncomfortable nasal swab tests. It took anywhere from 2 to 10 days to get results back from those, with only a 70 percent accuracy rate. Those are big limitations. Now we also have antibody tests, which look for antibodies that indicate you’ve been exposed and might have some level of immunity. But these are not definite results. In fact, if you got a positive result from a $40 fingerprick antibody test, you sometimes didn’t know if you had COVID-19 antibodies or antibodies from a different coronavirus that caused a cold a few months back. In these situations, it’s best to have a doctor who can find out which labs are good on this. I’ve been able to do that for my patients.
Do you think COVID-19 has put even more strain on primary care doctors who are trying to run their own practice?
In the future, I think we’ll have very few private doctors who see patients on a volume basis. A lot of that is because of the pressures I mentioned earlier, but COVID is certainly making things even more difficult. The American Academy of Family Physicians recently predicted that 60,000 primary care physicians in the US would make staff cutbacks or stop practicing due to the effects of COVID-19. A lot of physicians will either quit or join another big group. I think there’s also going to be a rise in the number of concierge practices once people see the benefits to doctors and patients.
Is this concierge concept happening mainly in primary care, or are there other areas that are moving to this model as well?
A lot of the surgical specialties wouldn’t work on this model, because it’s a one-and-done relationship. But there are a few specialties where the doctor has a lasting relationship with the patient where it could work—things like cardiology, endocrinology, OBGYN. Pediatrics, too, though that’s not a specialty. Those are areas outside of family practice and internal medicine where I can see concierge models working.
If one of our readers is considering a concierge physician, what would you tell them?
For people who are able to, having your own personal physician makes all the sense in the world. I think there are a few reasons CEOs especially might make the move to a concierge doctor.
First is the time you save. My patients can call me up anytime, including after hours, if they need something. And if they need to come into the office, we can get something scheduled very quickly and without interfering in your workday.
A second reason is the knowledge of new medical technology. A concierge physician is going to be able to tell you about the latest, most up-to-date technology, whether it’s COVID-19 tests or a new preventative-health tool.
Third is that annual physical, which is not your standard 20-minute physical at a typical doctor’s office. We really get into who you are and what preventative steps we can take to keep you healthy. For CEOs, who might at times be under a good deal of stress, prevention is particularly important.
And finally there is the connection the patient has with a concierge physician. I get to know my patients as individuals and I don’t mind if they call me outside of office hours because we have that connection. It’s a different ball game when you have a physician who you can call your own.