Diane Garbini was dissatisfied with all the hassle involved in getting in to see the primary care doctor for her husband, Dennis, 75. He has complex medical needs for which he sees specialists, but she often also needs to contact his primary doctor quickly, such as when he’s sick, has a medical question, needs medication or has another urgent issue.
Garbini turned to concierge medicine, an extra service that guarantees quick access to their doctor, among other benefits, for an additional fee.
“I decided to try it because with all of Dennis’s issues, something always happens at an odd time of day, and this offers services 24 hours a day, seven days a week,” says Garbini, who lives in Denville, New Jersey. “I can either call or text the doctor, and Dennis will be seen in a couple of hours, or medication will be refilled.”
The Garbinis have Medicare and supplemental insurance plans that cover their medical needs, but it was well worth the out-of-pocket yearly fee to join the concierge service their primary care doctor was offering.
“If he has a cold or cough, we see the primary first and then seek a specialist if necessary. Because of his complex issues, our primary is copied on everything,” Garbini says.
Due to the extra fee and less need for constant access, Garbini herself doesn’t participate in her doctor’s concierge service.
“The cost is $1,800 a year — it only covers Dennis, not me, even though we have the same doctor,” she explains. “I have to go through all the hoops to get an appointment.”
Garbini’s experience is all too familiar for those who need to see the doctor frequently, such as older people and those with chronic conditions.
But how the extra costs of concierge medicine fit in with Medicare and private insurance is complex and may depend on the practice.
“There are some cash-only concierge practices that truly don’t accept any insurance coverage, so patients must pay the membership fee and the full cost of their care; other practices accept insurance and bill patients’ insurers for the services they provide,” says Hannah Neprash, an associate professor in the division of health policy and management at the University of Minnesota School of Public Health.
We looked into some ways those scenarios might play out.
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How Concierge Medicine Works
Concierge medicine is a growing trend in health care in which patients pay a set monthly or yearly fee to have better access to their doctor. Services and benefits in this fee may include:
— 24/7 phone, text and/or email access
— Same- or next-day appointments
— Little to no waiting in the waiting room
— Longer visits with more personalized care
— More in-depth labs and screenings
— Preventive planning for health and fitness goals
— Coordinating with specialists if necessary
“Appointments start on time and last as long as they need,” says Dr. Louis Minsky, a family physician in Baton Rouge, Louisiana, who is part of the MDVIP network of concierge doctors.
With this additional yearly fee, doctors can take on fewer patients and devote more time to the ones they have.
“Practices at MDVIP are capped at 600 patients, as opposed to 2,000 to 4,000 in higher-volume, traditional primary care practices, where they often see 25 to 30 patients in one day for very little time during appointments, 15 minutes on average, and almost no time to address anything beyond the problem of the day,” says Minsky, who is also on MDVIP’s Medical Advisory Board.
[Read: What to Do If Your Doctor Stops Accepting Medicare]
Medicare and Insurance With Concierge Practices
Medicare is a federally funded insurance plan for those over 65, or under 65 with certain medical conditions.
Because employer-sponsored health coverage often ends at retirement age (65), this social safety net helps people afford health care as they age and are likely to need it more often.
Given the exclusive nature of concierge medicine, do these practices take Medicare and insurance?
“There are two parts to this question: the fee for having concierge service — not covered — and the charges for actual medical treatment, which could be covered by the health insurance payer, but not guaranteed,” says Michael Seavers, an assistant professor of healthcare informatics at Harrisburg University of Science and Technology in Pennsylvania.
Whether the concierge practice takes Medicare or not, the annual fee, or retainer fee, which usually costs around $2,000 per year or more, is entirely out of pocket.
If the concierge practice does take Medicare, or is in-network with private insurances, the medical charges that are separate from the yearly fee are billed similarly to traditional practices.
“CMS (Centers for Medicare & Medicaid Services) and commercial health plans could cover specific diagnoses and/or procedure codes from a concierge provider,” Seavers says. “For example, an insurance plan could cover treatment for a broken foot.”
[Read: How to Choose the Best Medicare Advantage Plan]
Complicated Coverage in Concierge Medicine
Coverage and potential costs is where it gets a little more complicated. Some aspects of well and preventive care might be included in the retainer fee, so those wouldn’t go through insurance.
However, if the concierge doctor accepts Medicare, they have to adhere to the Medicare-approved cost of covered services and can’t include additional charges for services that Medicare usually covers.
Therefore, they can’t include covered services in the out-of-pocket retainer fee, and patients shouldn’t be charged a larger (or smaller) amount for those services than they would with Medicare.
“As crazy as it sounds, a physician can be equally in trouble for charging less than (Medicare) reimbursement rates as well as more; in other words, they have to follow the very strict rules of engagement and constantly monitor changes in policy,” says Dane DeLozier, president of FreedomDoc, a direct primary care practice, which is an offshoot of concierge medicine.
For example, Minsky’s MDVIP program is compatible with Medicare, so for those patients they charge Medicare-approved costs.
“MDVIP-affiliated physicians comply with their contractual terms for covered services, like sick visits,” he says.
MDVIP practices also take commercial insurance.
“The yearly membership fee pays for an annual wellness program for preventive care services that insurance usually doesn’t cover, such as the advanced diagnostic testing and screenings,” Minsky says.
At a concierge practice, you’ll have the same cost-sharing responsibility you normally would for medical services covered by Medicare or insurance, outside of the annual retainer fee.
“In this case, patients still pay a membership fee and face the typical out-of-pocket charges, such as co-pays and coinsurance, that they experience at a non-concierge practice, plus potentially having to pay the full cost of any services that aren’t covered by their insurance plan,” Neprash says.
The specifics of coverage at individual concierge practices may vary, so your best bet is to contact the practice and go over the costs and insurance coverages before you commit to the yearly fee.
HSA and FSA accounts
Similarly, whether you can use these pre-tax accounts to pay for services also may vary from practice to practice.
“The MDVIP program is often compatible with health savings accounts (HSA) and flexible spending accounts (FSA),” Minsky says.
This usually only applies to medical services, though.
“In general, concierge membership fees cannot be paid from a patient’s HSA account,” Seavers says. “However, if it is determined that medical treatment is required, the medical treatment can be paid from a patient’s HSA account, much like the broken foot example.”
The concierge provider should know when HSA funds can and can’t be used, so again, it’s best to check on the details with the practice before joining.
Concierge practices that don’t take Medicare or insurance
There are some concierge practices that don’t take any insurance, including Medicare.
In some models, such as “direct primary care” (DPC), the practice passes the savings from cutting out the middleman directly to the consumer, so the monthly or yearly fees are cheaper.
“Generally speaking, direct primary care physicians opt completely out of Medicare, Medicaid and insurance contracts,” says DeLozier. “The patients get access, and the physician is freed of the administrative burdens imposed on them.”
For patients on Medicare, however, he says the benefits of joining a DPC practice aren’t usually financial, because Medicare is already low-cost; rather, the pros for these patients are the added access and consistency with the provider.
This is why one category of DPC patients DeLozier commonly sees are older Americans with Medicare who are frustrated with traditional practices and want more personalized care to help improve their quality of life, or even extend their life.
For those with private insurance, the benefits of DPC may also be financial. In DeLozier’s experience, it’s often cheaper to pay the doctor’s negotiated cash pricing on medication, diagnostics and other services to the DPC provider directly, without going through insurance. The reason, he adds, is that inflated insurance pricing, especially with a high-deductible plan and HSA, can actually end up taking more out of your pocket.
It’s still a good idea to have insurance coverage with DCP or concierge medicine, though, especially if you’re older or have medical conditions. You’ll need it for:
— Specialists
— Any other services not performed by your concierge doctor
— Medical services outside of the concierge practice’s annual fee (if they take insurance/Medicare)
Bottom Line: Is Concierge Medicine Worth It?
For some people who can afford it, the advantages of concierge medicine outweigh the disadvantages, and it’s worth the extra cost to pay the yearly fee in addition to Medicare or insurance.
“We make sure to budget our finances to include the cost for this kind of care,” says Stephanie Mitchell, 40, who is a patient of Minsky’s. “Knowing he’s there for me gives me peace of mind.”
For those with chronic problems who frequently need to see their doctor, like Dennis Garbini, concierge medicine is a way to save time and the emotional struggles of dealing with a complicated health system and unavailable doctors.
“I am very happy with the service,” says Diane Garbini. “I like the fact that I know I can get a hold of someone in a very short time to get medical advice if necessary.”
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Does Medicare Cover Concierge Medicine? originally appeared on usnews.com
