Doctors Charging "Membership" Fees

[Cruise]

Um, is that a typo, or did this doctor really practice into her hundreds?

Well, a couple of things. First, we're not talking about any size practice, we're talking about individual physicians (back somewhere in this thread, at least one poster pointed out that one of the three doctors where they go went this route, not the whole practice) - so the charge appears to be per physician, not per practice. After all, if you're paying for a concierge doctor, you expect THAT doctor, not just someone in the practice.

So then I did a little research. Now, granted, I'm fully aware that these rates are outdated and it's entirely possible there've been astronomical increases in the last three years, but effective 2008: in not one location (DC included) could I find anywhere that malpractice insurance for an individual internist was over $100,000. In only a handful of states did surgeons and OB/GYNs not have at least one under-$100,000 option. And it appears that from 2007-2008, insurance rates decreased.
http://mymedicalmalpracticeinsurance.com/medical-malpractice-insurance-rates.php

Again, I'm well aware those figures aren't up-to-date. I started researching after I got home really early this morning and didn't care to delve too deeply.

Right... but, for an individual doctor, insurance isn't the only cost. For their office, there's rent, utilities, cleaning service, instruments, lab equipment, etc. Then they need to pay at least one nurse or physician's assistant. There's the receptionist, the transcription service, the secure file service, the medical billing,..... it goes on and on.

Hey, maybe I could become a concierge teacher? I would give the parents who paid the membership my cell phone number and personal email and spend more time teaching their child above and beyond what the "normal" students would get. Instead of them having to come to school for a conference, I would come to their house and meet with them twice a year, and there would not be a 15 minute limit on the conference. They would get priority placement in the class of their choice for the next year as well. If I charged $25/month for that service, and half the students were "members", maybe I could do without the second job I have to work to make ends meet on a North Carolina teacher's salary.

I think you just described a private tutor. In some places, a certified teacher makes upwards of about $75/hour as a tutor.

 

[vicki_c]

Right... but, for an individual doctor, insurance isn't the only cost. For their office, there's rent, utilities, cleaning service, instruments, lab equipment, etc. Then they need to pay at least one nurse or physician's assistant. There's the receptionist, the transcription service, the secure file service, the medical billing,..... it goes on and on.

That's what I was thinking - it would actually cost more for 1 doctor in practice alone than multiple doctors, because you have less to spread it out over - basic economies of scale.

 

[fkj2]

In only a handful of states did surgeons and OB/GYNs not have at least one under-$100,000 option. And it appears that from 2007-2008, insurance rates decreased.
http://mymedicalmalpracticeinsurance.com/medical-malpractice-insurance-rates.php

Again, I'm well aware those figures aren't up-to-date. I started researching after I got home really early this morning and didn't care to delve too deeply.

My gynecologist quit his obstetric practice about 10 years ago. He told his wife, the office manager, to call the patients who were pregnant the morning they got the malpractice premium of $400,000. He was probably the best OB/Gyn in the area--the one many of the nurses and resident's wives saw. That insurance premium denied many women of quality obstetrical care. How'd THAT work out?

The residents locally probably make in the low-mid- $40'sK. And really, a yearly salary of $150,000 divided by the number of hours a primary care physician puts in weekly isn't all that much. Consider the hours of office, hospital rounds for those who still make them, on-call availability, and non-billable documentation = way more than a 40-hour workweek.

Oh but wait...they know what they're getting into. Is that really a legitimate justification? Do people not realize how the population has changed over 20 or 30 years? Huh. When I began working as a nurse, cataract patients stayed in the hospital for a week and slept on the opposite side of their surgery. If people had told me then that I'd see what's going on now, I'd never have believed them.

 

[kaytieeldr]

Right... but, for an individual doctor, insurance isn't the only cost. For their office, there's rent, utilities, cleaning service, instruments, lab equipment, etc. Then they need to pay at least one nurse or physician's assistant. There's the receptionist, the transcription service, the secure file service, the medical billing,..... it goes on and on.

I absolutely understand that - but the person to whom I was responding claimed $600,000 per year wouldn't even cover a small practice's malpractice insurance. I was simply pointing out that, even forgetting we're not discussing practices of any size but merely individual physicians, that claim is hyperbole.

My gynecologist quit his obstetric practice about 10 years ago. He told his wife, the office manager, to call the patients who were pregnant the morning they got the malpractice premium of $400,000. He was probably the best OB/Gyn in the area--the one many of the nurses and resident's wives saw. That insurance premium denied many women of quality obstetrical care. How'd THAT work out?

You know I don't doubt you at all, right? There must have been other contributing factors, or that site may be incomplete - but the most expensive OB/GYN insurance in 2000 was in Dade & Broward counties in Florida, from Clarendon National Insurance, at $158,157 (seemingly for one physician), and there were other companies in that state that year offering lower rates to the same doctors. In 2002, that company's rates in those counties jumped 32% to $208,949 - again, with other insurance companies offering lower rates to the same pool. The highest rate was in 2005 and 2006 from FPIC in Dade County - $299,420; again, with lower rates from other companies.

Too, there are many, many, many more internists than OB/GYNs and in the nine years covered by that chart, there is no internist malpractice premium over $100,000 - most are much, much lower, with some being even under $10,000 per year. And how many OB/GYNs are moving to the concierge model? Really, this seems to be a trend among general practitioners/internists/family practitioners - much less likely OB/GYNs (most women who want home births tend toward midwives - and even fewer surgeons, another group with higher insurance premiums.

So no, I don't think "$600,000 wouldn't even cover malpractice insurance for a small practice" validates charging a 'membership' or concierge fee to see a single physician, because that fee doesn't - or shouldn't - by definition or policy encompass any size practice, but merely the single physician. And that physician's malpractice insurance isn't anywhere near the $600,000 income that 400 patients at $125 per month would generate.

 

[torinsmom]

Well, when I went into teaching, teachers were getting raises every year and were not expected to go back to school for a Masters degree if they wanted to be considered highly qualified. Now there have been no raises for at least 3 years and you could lose your job if you are not highly qualified. Even if you are HQ, your job is not secure with budget cuts. And FTR, I don't like in a union state and average starting salary is $30,000.

The students were not nearly as needy and demanding when I first started out as they are now. Class sizes were smaller and staff-student ratios were lower. We are also being encouraged to buy insurance that would protect us in the case of a student or parent taking us to court over anything.

So, no, doctors may not have been able to foresee the changes, but neither can people from other professions. I am about to graduate from a Masters program and I have to pay back $30,000 in loans between my second degree in teaching and my Masters.

 

[ssawka]

Not all patients are enrolled in manage care programs. The important thing to remember is the payment is the same whether patients require a lot of care or a little. The natural tendency is to accept only the healthiest patients because the profit margins will be greater and refuse the others.

Well, there in lies my dilemma with the whole thing. DW and I need to see the doctor a few times a year. We are in an HMO and now we are being asked to pay $600 a year on top of the capitation the doctor is already receiving. So if you think we each visit the doctor 3 times a year, we would pay $600 doctor fee, plus $120 in co-pays, plus about $2000 (it's actually $3000, but minus $1000 for DD) a year in health care premiums. So our of our pocket expense is almost $3000 for 6 office visits. That's about $500 per visit! That seems quite steep to me given we are pretty healthy individuals. I know the doctor's office doesn't see all that money, but they would be getting $720 of it plus any capitation, so let's say $850. That still means the doctor would be getting $141 a visit for a 5 to 10 minute consultation. Even without the co-pays and capitation, it's still $100 for 5 to 10 minutes. What other profession makes that kind of revenue?

 

[Cruise]

I absolutely understand that - but the person to whom I was responding claimed $600,000 per year wouldn't even cover a small practice's malpractice insurance. I was simply pointing out that, even forgetting we're not discussing practices of any size but merely individual physicians, that claim is hyperbole.

Actually, the person you quoted said "overhead/malpractice." I was considering the office, office staff, services, etc. to be the "overhead" part. Maybe I misread what she was implying.

 

[fkj2]

So our of our pocket expense is almost $3000 for 6 office visits.

Okay, so just my premium is a few bucks less than $3600 a year and it covers me alone.

Office visits are $40 per visit in addition.

Consider the $5000 annual deductible if I were to meet it and $3000 looks like a bargain.

Plus, are you restricted to three office visits each or is that a typical pattern for you and your wife? Or would you be able to see the physician for additional visits and at what cost to you? You can't reasonably determine what a 5 to 10 minute office call generates without knowing the office's expenses. And since I only have my experiences to base this on, my primary care provider isn't out in less than 10 minutes...more like 15.

 

[QuiverofArrows]

Um, is that a typo, or did this doctor really practice into her hundreds?

No, she really did practice in her hundreds. We saw here when she was 102 and I believe she retired at 103. My daughter had been on some of the strongest antibiotics out there and was on SEVEN antibiotics in a row but couldn't get rid of her ear infection. It wasn't until we saw Dr. Denmark that we realized she couldn't have milk and I couldn't have milk or cheese while breastfeeding her. My daughter outgrew that when she was about 5 or 6 but still has to be careful to limit her dairy intake and we use Dr. Block's lymphatic massage instead of antibiotics if we can. Dr. Denmark was around when people got antibiotics in the hospital only and she prescribed them to be taken every 3 hrs for 72 hrs. It was a nightmare because if you were off by so much as 10 minutes then you messed up and would have to start over. She prescribed my daughter amoxicillin and sure enough, it cleared right up. She is one of the 15 oldest living people. Here is her wiki entry.

http://en.wikipedia.org/wiki/Leila_Denmark

 

[ssawka]

Okay, so just my premium is a few bucks less than $3600 a year and it covers me alone.

Office visits are $40 per visit in addition.

Consider the $5000 annual deductible if I were to meet it and $3000 looks like a bargain.

Plus, are you restricted to three office visits each or is that a typical pattern for you and your wife? Or would you be able to see the physician for additional visits and at what cost to you? You can't reasonably determine what a 5 to 10 minute office call generates without knowing the office's expenses. And since I only have my experiences to base this on, my primary care provider isn't out in less than 10 minutes...more like 15.

That is our typical pattern. Yes I understand that the conceiger version of medicine may be a good deal for some, but I'm just trying to determine if it is worth it for DW and I. If it were DD doctor going to this plan, I would do it in a heart beat (pardon the pun), but for DW and I I just don't see how it is worth it.

What I was trying to say is that people are spending a large percentage of their income on medical coverage already. Asking them to spend another $25-$50 a month, IMHO, is quite a large burden. As I said earlier, if you use your doctor quite a bit, it might be worth it.

 

[Maryr1]

Um, is that a typo, or did this doctor really practice into her hundreds?

Well, a couple of things. First, we're not talking about any size practice, we're talking about individual physicians (back somewhere in this thread, at least one poster pointed out that one of the three doctors where they go went this route, not the whole practice) - so the charge appears to be per physician, not per practice. After all, if you're paying for a concierge doctor, you expect THAT doctor, not just someone in the practice.

So then I did a little research. Now, granted, I'm fully aware that these rates are outdated and it's entirely possible there've been astronomical increases in the last three years, but effective 2008: in not one location (DC included) could I find anywhere that malpractice insurance for an individual internist was over $100,000. In only a handful of states did surgeons and OB/GYNs not have at least one under-$100,000 option. And it appears that from 2007-2008, insurance rates decreased.
http://mymedicalmalpracticeinsurance.com/medical-malpractice-insurance-rates.php

Again, I'm well aware those figures aren't up-to-date. I started researching after I got home really early this morning and didn't care to delve too deeply.

If you are going to refrence me, please QUOTE me. I wrote- OVERHEAD and malpractice. I know that malpractice can be as low as $100.000/year, but when you add in salaries for staff,benefits, rent, office expenses, set up, suppleis, utilities, etc. etc. etc. that was what I was including. The beauty of this system is you don't have to participate. It's a choice, just like car insurance-you want full glass, you pay for it. If it was offered to me I would pay it as when I am admitted to the hospital, I want to see my doctor, not one that works for the hospital. That alone is worth the price IMO.

 

[karice2]

I am really blessed that my doctor does a lot of the concierge stuff without that price but I would pay it in a heartbeat. She is phenomonal. She has a really small practice. I can get in and see her whenever I need to. Same day appointments and she faxes my scripts and refills.

I never feel rushed. She listens carefully and doesn't over prescribe just to shut me up and go away.

Of course I am a fairly healthy woman but I still like to go in for check ups and if there is something remotely going on. I am from the school of thought, catch it before it gets worse.

I would pay the $25 per month subscription. It's my health. If I don't have that I don't have anything

 

[fkj2]

What I was trying to say is that people are spending a large percentage of their income on medical coverage already. Asking them to spend another $25-$50 a month, IMHO, is quite a large burden. As I said earlier, if you use your doctor quite a bit, it might be worth it.

On that we agree. I can hardly wait (not) to see what the 2011 premium will be.

The thing is the specialists are probably doing fairly well financially (but I'd still not want to sacrifice my life to be a doctor).

The providers who see patients most frequently, um, probably not so well. As much as $25 to $50 is a burden for us, it's also not fair to expect physicians to be the ones who take the financial hit entirely either. Trust me, caring for the public is no picnic regardless of whether you're a physician, nurse, therapist, dietician, etc.

But I think it's a good thing to have these discussions and get a more rounded outlook on professions. As I said earlier, there's not many vocations that are a panacea; everything's got drawbacks.

 

[Cruise]

On that we agree. I can hardly wait (not) to see what the 2011 premium will be.

The thing is the specialists are probably doing fairly well financially (but I'd still not want to sacrifice my life to be a doctor).

I actually had an interesting conversation today with a cardiologist. I mentioned this thread to him and asked his opinion. I would have thought he was rolling in the money, but no, apparently not. He quoted me a number which I know to be about equal to family doctors in the area.

Apparently the problem with cardiologists in general is that most of the people that need a heart specialist are older patients.... thus, Medicare. He gets barely any reimbursement compared to the costs involved in the treatments. He admitted to me that they've actually had to take out loans to make payroll for office staff and that unless something changes in the next year, they'll have to close the practice.

I'm guessing the only doctors doing really well anymore are plastic surgeons and dermatologists... or any other doctor that provides "elective" or "cosmetic" procedures that aren't covered by insurance and thus are paid in cash.

 

[kaytieeldr]

If you are going to refrence me, please QUOTE me. I wrote- OVERHEAD and malpractice. I know that malpractice can be as low as $100.000/year, but when you add in salaries for staff,benefits, rent, office expenses, set up, suppleis, utilities, etc. etc. etc. that was what I was including. The beauty of this system is you don't have to participate. It's a choice, just like car insurance-you want full glass, you pay for it. If it was offered to me I would pay it as when I am admitted to the hospital, I want to see my doctor, not one that works for the hospital. That alone is worth the price IMO.

I didn't "reference" you. I quoted you, word for word, as requested - originally, without ever editing that post. Look: http://www.disboards.com/showpost.php?p=38702639&postcount=96 What I didn't do, as Cruise pointed out above very politely, was respond to both aspects of the statement I quoted. But I absolutely quoted you.

Even given that, I disagree that a single internist/family practitioner/general practitioner's overhead + malpractice insurance - again, remember, the membership or concierge fee is on a per-physician basis, not a per-practice one - approaches $600,000. I maintain that few OB/GYNs or surgeons (specialties with much higher malpractice rates) would have much success in the concierge route.

 

[Maryr1]

I didn't "reference" you. I quoted you, word for word, as requested - originally, without ever editing that post. Look: http://www.disboards.com/showpost.php?p=38702639&postcount=96 What I didn't do, as Cruise pointed out above very politely, was respond to both aspects of the statement I quoted. But I absolutely quoted you.

Even given that, I disagree that a single internist/family practitioner/general practitioner's overhead + malpractice insurance - again, remember, the membership or concierge fee is on a per-physician basis, not a per-practice one - approaches $600,000. I maintain that few OB/GYNs or surgeons (specialties with much higher malpractice rates) would have much success in the concierge route.

As I said, the beauty of this is that you don't have to participate. It's an option. FWIW, locally the OB/GYNs no longer deliver their patients-they provide all the prenatal and post natal care but the patients are delivered by the hospitalists-doctors employed by the hospitals.

 

[ssawka]

I am really blessed that my doctor does a lot of the concierge stuff without that price but I would pay it in a heartbeat. She is phenomonal. She has a really small practice. I can get in and see her whenever I need to. Same day appointments and she faxes my scripts and refills.

I never feel rushed. She listens carefully and doesn't over prescribe just to shut me up and go away.

Of course I am a fairly healthy woman but I still like to go in for check ups and if there is something remotely going on. I am from the school of thought, catch it before it gets worse.

I would pay the $25 per month subscription. It's my health. If I don't have that I don't have anything

See, the problem is not so much the $25 for one person, but for two or three you start talking some real costs. Then in a couple years when DW and I are both 40 it will be $45 for each of us, and if DD doctor's go to this method as well that will probably be another $25. That would be like $115 a month. So basically if all of the primary care doctors do this it will be too expensive for many to afford. Then, it probably won't be long before the specialists get wind of it and start charging as well.

I'm starting to think maybe DW and I should just go to a POS plan and eliminate the PCP all together. I never found this "managed care" idea to be of much benefit. It would be wonderful if your PCP actually worked as a case manager, and maybe that's the whole idea with the concierge form of medicine, but I'm not convince that it is actually going to work out that way and that it is not just an attempt to get more money out of the patient. As I said previously, I like our PCP, but I am not "Wowed!" by her. I think we may just need to check out some other PCPs and decide which direction we should go in.

 

[dvcgirl]

Well, when I went into teaching, teachers were getting raises every year and were not expected to go back to school for a Masters degree if they wanted to be considered highly qualified. Now there have been no raises for at least 3 years and you could lose your job if you are not highly qualified. Even if you are HQ, your job is not secure with budget cuts. And FTR, I don't like in a union state and average starting salary is $30,000..

Not picking on teachers, but this sounds like the real world that the rest of us work in.....

With State and Municipal budgets in crisis, teachers are now only seeing what it's like to work in a competitive world.

 

[LovableGluttons]

I've been an RN for over 20 years. My husband spent 20 years in the military, which meant we relocated every few years. Ove worked with many physicians in many states. Very few were "wealthy". Some worked 6 or 7 days a week to generate their income.

Some were in dire financial situations.

I have Tricare and was horrified to see the "accepted" rate for a procedure be $600 on a procedure that mysurgeon spent 6 hours just in the OR, not to mention the visits to see me before, after, and post op.

If I can make it better for my physician and my family by skipping a restaurant meal once a month, I'm glad to do it. If they stop seeing patients because they can't afford to, my family loses. I can't fix the negotiated rates, and most of the doctors
I see happen to be participating providers.

When DH and I reach Medicare age, the Tricare becomes secondary.

 

[fkj2]

Even given that, I disagree that a single internist/family practitioner/general practitioner's overhead + malpractice insurance - again, remember, the membership or concierge fee is on a per-physician basis, not a per-practice one - approaches $600,000. I maintain that few OB/GYNs or surgeons (specialties with much higher malpractice rates) would have much success in the concierge route.

Well, a friend of mine recently opened a veterinary practice. He's renting about 2400 sq. ft. of office space. I estimate he's paying somewhere around $26,000 a month in rent--and we're not talking a high maintenance area--so that'd be $312,000 just in office RENT. And I think he got about half of the space at a slight discount.

See, that's the thing; I don't think people realize how all this stuff ads up or how much it costs. Just add in salaries, insurance for employees, pension costs, sick time, paid holidays, other PTO, permits, licenses, supplies, equipment (there's a biggie), I think $600,000 would be conservative.

And his hours? Two days a week he's scheduled 11 hours. Two days a week he's scheduled 8 1/2 hours. One days he's scheduled 4, as well as every other Saturday. I stopped on his half day--he was still seeing clients at 3 PM. All his "office work"; callbacks, calls confering with other veterinary specialists, management time...all extra. Just like with our physicians.