Eyeworld

EW NEWS & OPINION 22 September 2014 F un with Dick and Jane? If a Baby Boomer can read, he might thank that ubiquitous primer featuring those two winsome characters. Today, Dick and Jane are Medicare patients. Their kids are 40 and will impact healthcare more than any bill Congress might pass. Recently, I ran into Jane's daughter and son-in-law. Jessica and Michael (all names are fi ctional) are in their late 30s, highly educat- ed, have demanding careers, live downtown, and make good money. They are expecting their fi rst child. Internet savvy, they frequently use the web to procure medical informa- tion. They "adore" their family doc- tor and regret leaving her practice. Why abandon their beloved GP? The usual suspects: hard to get an appointment, disengaged staff, time wasted in bleak waiting rooms, calls not returned, a doctor too harried to project interest and compassion. Jessica explained, "It was anarchy. We wanted someone to manage our healthcare like our fi nancial advisor manages money." Hearing a friend's enthusiastic testimonial, they inves- tigated concierge medicine. They called Dr. Sarah. Medical journals have debated "boutique medicine" for years. It grew out of diffi culties integral to primary care medicine. There are not enough clinical hours to provide quality, evidence-based medicine while meeting government and insurance company mandates. For a GP, concierge medicine can be an attractive gig. Jessica and Michael explained how it worked. Due diligence comes fi rst. Concierge medicine is pro- moted as a wellness partnership; you and the doctor must trust each other. Secondly, the patient makes application. The practice rigorously limits its subscribed base. Most panels are capped at 600 lives. New patients aren't accepted unless attrition creates an opening. It's in the contract. Annual fees range from $2,500 to $5,000 per "covered life." This buys access, such as same-day by J.C. Noreika, MD, MBA Healthcare for Dick and Jane's kids appointments with the doctor per- sonally and comprehensive coordi- nation of care. Instructing patients to call her cell phone in the middle of the night as she might miss an email alert, Dr. Sarah is available 24/7. Michael and Jessica will never be directed by a recorded message to the nearest emergency room. If necessary, Dr. Sarah goes to the ER with them. It's in the contract. They visited Dr. Sarah's offi ce, received a tour, and met the prac- tice's clerical associate and clinical technician. They interviewed Dr. Sarah for more than 90 minutes, confi ding concerns and expecta- tions. They set goals. They learned that once their daughter was born, Dr. Sarah would make a house call during the baby's fi rst week home. She would monitor their health status and oversee medications. Nutritional and lifestyle experts would offer advice and answer ques- tions the same day. For convenience, Jessica and Michael elected text messaging. After each appointment, an emailed report would summarize key aspects of the visit such as clini- cal fi ndings and medication instruc- tions. Sophisticated lab tests might be recommended to delimit genetic risks discovered during the initial comprehensive exam. An annual physical performed by Dr. Sarah is not optional; it takes approximately 2 hours. The couple maintains their health insurance. Although Dr. Sarah does not participate in in- surance plans, they might require referral to a specialist, radiology or clinical laboratory, use a prescription drug plan or be unexpectedly hospi- talized. Dr. Sarah's annual fee is paid upfront; no additional paperwork, deductible, or coinsurance, just a friendly farewell at the front desk. When traveling, itineraries are re- viewed and vaccines recommended; a national organization to which Dr. Sarah belongs ensures comparable care and service away from home. Conventional practice man- agement strategies promote "cost effi ciency," "RVU maximization," and "patient throughput." Consul- tants celebrate the practitioner who "sees" 80 patients a day. But Dr. Sarah promises that specialists to whom she refers will meet her and her patients' expectations. Each will be evaluated by post-visit survey. Drive-by consultations won't cut it. Concierge medicine is growing rapidly. A multi-tiered healthcare system is all but guaranteed by the Affordable Care Act or its eventual successor. The 2% of economically advantaged Americans, about 6.6 million people, are early propo- nents. For ophthalmologists, these are premium patients who pay for femtosecond lasers, toric and multifocal lenses, Botox injections, and designer sunglasses. They often direct Mom and Dad's healthcare decisions. The other 98%? As a vexed Dane once ruminated, "Ay, there's the rub." Managed care organizations and ACOs (accountable care organi- zations, for Medicare patients in fee- for-service) are judged and rewarded for value, outcomes, and patient sat- isfaction. Because their primary care panels can exceed 5,000 patients, a "medical team" concept is em- ployed. In 2008, Bodenheimer wrote that "physicians perform many tasks that do not require a medical degree and could thus be delegated to other team members." A physician assis- tant may suggest referral to an eye doctor. What criteria will they use in the choosing? Sound like the HMO-driven gatekeeper model of the 1990s? There is an important distinction. Dissemination and democratization of medical information over the in- ternet and instantaneous satisfaction ratings of physicians on social media have changed the game and raised the stakes. What of today's high- volume ophthalmologist putting up big numbers? Dr. Sarah may decide Jane's kids wouldn't be a good fi t. It's not personal; it's in the contract. EW Reference Bodenheimer T. The future of primary care: transforming practice. N Engl J Med 2008 Nov 13;359(20):2086, 2089. Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com Insights J.C. Noreika, MD, MBA

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