Applying the Concierge Medicine Model to Neurology: Will It Work?

[vc_row][vc_column][/vc_column][/vc_row][vc_row][vc_column width=”1/4″][vc_column_text][/vc_column_text][vc_column_text]Maria Todd is an award-winning and internationally respected healthcare business consultant. She is frequently hired to present continuing education workshops, seminars, and keynote addresses for international, national, state, and regional healthcare organizations, investment firms, pharmaceutical and device manufacturers, and medical staff meetings.

The author of numerous books on managed care, physician integration and alignment, medical tourism, physician employment contracting, and other topics in healthcare, her work is easily found all over the Internet.

Maria strives to be accessible to individual practitioners. She maintains a popular website that attracts more than 1000 visitors a day and provides training through her website and private workshops and webinars. She blogs regularly at http://mercuryadvisorygroup.com, and works one-on-one with clinicians across the country and throughout the world.  Through her consulting firm, Mercury Advisory Group, she has been instrumental in building practices throughout the USA and in more than 50 countries.[/vc_column_text][vc_column_text]

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Concierge Medicine as a business model has piqued the curiosity of an increasing number of medical specialists in recent months. On average, we receive about 12 calls each week from physicians who take us up on our offer for a no-obligation 15-minute consultation. Lately, the mix of calls has shifted from primary care only to a mixture of specialists and primary care. The interesting common denominator is that the specialists all treat chronic diseases that require a higher level of personalized attention than the traditional managed care setting permits.

What has changed

More volumes

As of January 2014, many patients with chronic neurological problems who were previously uninsured became eligible to purchase coverage from managed care plans sold on an exchange. At the same time, many States expanded Medicaid managed care programs to cover additional patient populations. In many parts of the country, managed care organizations (MCOs) responded by aggressively seeking to contract with specialists, because these patients have pent up medical needs to manage chronic neurological problems which are better treated by a neurologist. The MCOs are duty bound by their accreditation standards and state regulations to ensure and demonstrate adequate provider networks are available to serve newly insured patients. Unfortunately, what one MCO calls adequate, most neurologists describe as overwhelm. As a result, while not unsympathetic, many want off the “hamster-wheel”.

Incompetent ACO contracting

Despite the demonstrated value of services furnished by health centers, many MCO agreements create significant legal, financial, clinical and operational exposure for specialists. It is not uncommon to find provisions that transfer downside financial risk from the MCO to an ACO that contracts with neurologists while at the same time fail to offer opportunities for upside gain for delivering cost-effective neurological care. Moreover, standard provisions in MCO contracts are easily overlooked and critical provisions related to quality of care are frequently neglected in the review process by inexperienced ACO contracting committees and negotiators. Sometimes, the contract analysts inadvertently overlook terms and conditions that can ultimately prohibit the operation of a concierge practice by a participating physician on a MCO panel through an ACO subcontract.

Legacy contracts

Many of the physicians we chat with hire us to visit their practice for a day, so that we can offer personalized, in-depth guidance about the possibility of converting to concierge medicine. They love our affordable, flat fee, single-day site visit. Even the travel cost is included. Physicians benefit from this one-day consult because of the excellent value they receive. We do a high-level assessment of the community, review the competition, perform a site visit of the practice, talk about current patient panels, demographics, socio-economic status, and specialty interests of the physician. We also brainstorm the vision and strategy for the concierge practice they’d like to have within 5 years. As a part of that, we spend time taking a quick peek at their managed care contracts, to determine if there are any unanticipated landmines mired in the muddy language of what they signed years ago, long before concierge medicine was a twinkle in their eye.

Part of the preparation for a neurologist that wants to transition to concierge medicine may be a staging the implementation of their transition strategy to include a timeline to review and re-evaluate managed care participation, preferred contracts, and even renegotiation to clear a path to operate a concierge practice. While that may be the preferred approach we take, sometimes the MCOs won’t cooperate. In that instance, there are alternative strategies to consider. To learn more about the issues involved in managed care contracting, you may wish to read the Managed Care Contracting Handbook, 2nd edition.

Employment Agreements

Many specialists have tried some unconventional approaches to stabilize their income and not have to deal with the business side of practice management. As a result they’ve become employed in larger medical groups and taken jobs in hospital-owned practices. The specialty of neurology is in short supply. Nationwide, the vacancies for this specialty have increased by 80.52 percent nationwide, with an average growth of 13.42 percent per year.  Moving some of the neurologists to concierge medicine would exacerbate the shortage, but that’s another issue for another article.  When we analyze these clients’ current employment arrangements, we find that many are no longer in private practice, but instead, are currently employed by a larger medical group, a multi-specialty clinic, a hospital, or some other organization. Often, we find that they have an employment contract in place with terms and provisions that were acceptable prior to contemplation of returning to private practice, but that could thwart a transition to concierge medicine and private practice.

If the neurologist’s employment agreement has a non-circumvention or non-compete provision, the strategy to transition to concierge medicine may require some adjustment. Under no circumstances will we aid and abet a physician that wants to convert to concierge medicine if their employment agreement restricts access to patient contact information and other PHI for the purpose of leaving the practice. But, there are other options we can consider that allow for a legitimate and compliant transition without breaching any provision of the employment contract.  What is interesting to me is how many employed physicians tell me that other consultants never raised the issue about their employment agreement restrictions. I guess as the author of the Physician Employment Contract Handbook, 2nd edition, it is a little higher on my radar.

The Market Assessment

Currently, there are more neurologists licensed in New York, California, Florida, Texas, Illinois, Pennsylvania, and Ohio. Crowded markets can make for some of the most lucrative places to set up a concierge practice for neurology. Interestingly, we get many calls from these markets, but we haven’t received calls from some of the states with the lowest number of neurologists, per capita, including: the Virgin Islands, Wyoming, South Dakota, Alaska, North Dakota, Mississippi, Hawaii.  Recently, we received one call from Wyoming, but it was from an orthopedist who wanted to transition his practice.  We also get calls from neurologists considering a relocation to a new city, and we receive many calls from a disproportionate number of female neurologists that have just completed residency and want to launch a concierge practice as their initial business model. In some of these cases, the neurologist wants to go back home after residency or fellowship and startup in their hometown. In other instances, the move may be predicated on following a spouse or significant other for the other’s job requirements. These approaches are more difficult in some cases, but present opportunities for us as consultants to draw from our creative and innovative side to come up with viable solutions. A lot depends on where the new practice will be located and what the concierge “product” will be.  The market has to find it valuable enough to want to pay money for the concierge medicine product in addition to the money for medical service.

In 1995, Douglas Goldstein wrote a book titled Alliances: Strategies for Building Integrated Delivery Systems, (1995, Jones and Bartlett) the author discussed the various approaches to building integrated health delivery systems. He recommended matching the model to the market, (MMM) as a late-stage approach towards successful integrated health delivery system strategies. This is also relevant to the strategy for building a concierge medical practice as well. If you build a concierge medical practice design strategy that doesn’t fit the market in which you will establish the practice, it matters not how many years you have in practice. The practice strategy will ultimately fail. It is far easier to change your strategy a bit than it is to change or “disrupt” the market.

What’s your biggest fear?

Most neurologists articulate fears and frustrations that are similar, regardless of their situation. They fear that they don’t have the skills to run this business model, they are bewildered about how social media marketing and selling memberships works and who is going to do it. They are busy and wonder if they have the time to devote to learning the new skills and overcoming the inertia of day-to-day chaos that frustrates them. They also fear how much the transition might cost.  For those in practice, their frustration is centered on a few things, namely: managed care, Medicare and Medicaid, and infringement on their clinical autonomy, the drive-through nature of their current practice, with inadequate time to care for patients the way they believe is necessary, and their income keeps dropping while their workload seems to be increasing. It’s amazing how many of them use the word quicksand to describe their impression of what’s happening.

Concierge medicine changes the rules of marketing and customer engagement. The business model places more emphasis on marketing, social media, promotion, building a brand, establishing authority, and finding “the things” that differentiate the practice from all others. This seems to daunt neurologists because it forces them outside their comfort zones. They articulate uncertainty about their ability to develop a marketable product that people of moderate means are willing to pay additional money for. They are correct. If customers won’t buy it, it’s a concept and not a product. It graduates to being a product when people will pay money for it.  They are also apprehensive about selling memberships and the whole sales cycle. They’ve never been trained to do that and they don’t want to sell memberships, they want to focus on patients. There are solutions for that, which is where our value becomes evident.

Many neurologists tend to be more introverted and don’t relish the thought of committing to more engagement in the whole social media complex. They express concern about how to navigate it effectively. We solve that with a combination of training, explanation and some proprietary tools we share that gets them organized so that they can develop and implement an effective social media strategy that is measured in terms of revenue instead of  how many “likes” and “follows” one amasses.

Clients are often amazed how quickly we come up with unique solutions to overcome these and other challenges, and allay their fears. Our recommendations come from experience. We teach them the skills to feel more confident in their ability to thrive in concierge medicine, and we make the learning interesting and fun. We don’t take on the sales function for them, and we don’t take over the management of their practice. Instead, we train their employees to manage the new activities such as membership sales and social media marketing so that the neurologist isn’t forced to also become a sales rep.

Frequently asked questions

The neurologists we have worked with and agreed to take on as clients have many of the same questions as the other primary care and specialists that call. Below are some of the most frequently asked questions I am asked at almost every introductory phone call and initial consultation:

1. Do you think I am ready to convert my practice?
2. How difficult will this be?
3. How long will it take?
4. How much will it cost?
5. Do I have to accept insurance and participate in managed care?
6. Will the managed care plans threaten me with terminations?
7. Do I have to forsake all the patients that won’t pay the membership fee?
8. Can I set a fee and offer unlimited care in my practice each month in exchange for the fee?
9. Do I have to quit Medicare?
10. Do I still have to be compliant with HIPAA? Isn’t there an exemption for a small practice?
11. Will I need an electronic medical records system? Who will help me to convert from paper to EMR?
12. Do I have to learn ICD-10? What if I don’t bill insurance anymore?
13. Do I have to do social media and marketing?
14. How do I re-brand my existing practice? What’s involved and who will help me?
15. Who will help me sell the memberships?
16. Do I have to have my own website or can I keep the listing we have on HealthGrades?
17. How much will it cost to become your client?

Readiness for a switch to concierge medicine has absolutely nothing to do with how many years you’ve been in practice, how many patients you have or don’t have, or the number of patients that visit you each week. Successful transition of a neurology or any other practice to concierge medicine is highly dependent on your goals and objectives, your level of preparation and commitment to learning the skills to be successful, and your commitment to doing what it takes to realize your goals and your vision. The product design, your reputation, and the market you choose are also an integral part of the strategy and how it will be executed in order to realize your goals.

The consulting cost to convert your practice depends on the amount and type of assistance you will need. Every conversion or startup is different. The value we bring is in knowing what needs to be done and in what order it should be carried out to help you execute your chosen strategy. We bring the “must-do”punchlist that comes from experience. The checklist comes with our initial flat-fee, one-day consultation in your office. Even if you choose not to hire us for additional assistance that checklist is invaluable because it prevents oversights and mistakes and saves time and money on trial and error associated with learning curves. We leave it up to you to decide what, if any additional help or coaching you want or need to hire from an a la carte menu of services we can provide through our team.  We take pride in our excellent stewardship of other people’s money. We let you control your costs, and choose what you want help with and when. We don’t take offense if your nephew builds websites for a living or your daughter is a professional graphic artist. We can help them help you if that’s how you want to proceed.

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