Physician Services
Concierge Care Characteristics and Considerations for Medicare Gao ID: GAO-05-929 August 12, 2005Concierge care is an approach to medical practice in which physicians charge their patients a membership fee in return for enhanced services or amenities. The recent emergence of concierge care has prompted federal concern about how the approach might affect beneficiaries of Medicare, the federal health insurance program for the aged and some disabled individuals. Concerns include the potential that membership fees may constitute additional charges for services that Medicare already pays physicians for and that concierge care may affect Medicare beneficiaries' access to physician services. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 directed GAO to study concierge care and its relationship to Medicare. Using a variety of methods, including a nationwide literature search and telephone interviews, GAO identified 146 concierge physicians and surveyed concierge physicians in fall 2004. GAO analyzed responses from 112 concierge physicians. GAO also reviewed relevant laws, policies, and available data on access to physician services and interviewed officials at the Department of Health and Human Services (HHS) and representatives of Medicare beneficiary advocacy groups.
Concierge care is practiced by a small number of physicians located mainly on the East and West Coasts. Nearly all of the 112 concierge physicians responding to GAO's survey reported practicing primary care. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500 to $1,999. The most often reported features included same- or next-day appointments for nonurgent care, 24-hour telephone access, and periodic preventive care examinations. About three-fourths of respondents reported billing patient health insurance for covered services and, among those, almost all reported billing Medicare for covered services. Two principal aspects of concierge care are of interest to the Medicare program and its beneficiaries: compliance with Medicare requirements and its effect on beneficiary access to physician services. HHS has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements; for example, the membership fee must not result in additional charges for items or services that Medicare already reimburses. Some concierge physicians reported to GAO that they would like more HHS guidance. The small number of concierge physicians makes it unlikely that the approach has contributed to widespread access problems. GAO's review of available information on beneficiaries' overall access to physician services suggests that concierge care does not present a systemic access problem among Medicare beneficiaries at this time. In comments on a draft version of this report, HHS agreed with GAO's finding on concierge care's impact on beneficiary access to physician services and indicated it will continue to follow developments in this area.
GAO-05-929, Physician Services: Concierge Care Characteristics and Considerations for Medicare
This is the accessible text file for GAO report number GAO-05-929
entitled 'Physician Services: Concierge Care Characteristics and
Considerations for Medicare' which was released on August 12, 2005.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Committees:
August 2005:
Physician Services:
Concierge Care Characteristics and Considerations for Medicare:
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-929]:
GAO Highlights:
Highlights of GAO-05-929, a report to congressional committees:
Why GAO Did This Study:
Concierge care is an approach to medical practice in which physicians
charge their patients a membership fee in return for enhanced services
or amenities. The recent emergence of concierge care has prompted
federal concern about how the approach might affect beneficiaries of
Medicare, the federal health insurance program for the aged and some
disabled individuals. Concerns include the potential that membership
fees may constitute additional charges for services that Medicare
already pays physicians for and that concierge care may affect Medicare
beneficiaries‘ access to physician services. The Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 directed GAO to study
concierge care and its relationship to Medicare.
Using a variety of methods, including a nationwide literature search
and telephone interviews, GAO identified 146 concierge physicians and
surveyed concierge physicians in fall 2004. GAO analyzed responses from
112 concierge physicians. GAO also reviewed relevant laws, policies,
and available data on access to physician services and interviewed
officials at the Department of Health and Human Services (HHS) and
representatives of Medicare beneficiary advocacy groups.
What GAO Found:
Concierge care is practiced by a small number of physicians located
mainly on the East and West Coasts. Nearly all of the 112 concierge
physicians responding to GAO‘s survey reported practicing primary care.
Annual patient membership fees ranged from $60 to $15,000 a year, with
about half of respondents reporting fees of $1,500 to $1,999. The most
often reported features included same- or next-day appointments for
nonurgent care, 24-hour telephone access, and periodic preventive care
examinations. About three-fourths of respondents reported billing
patient health insurance for covered services and, among those, almost
all reported billing Medicare for covered services.
Two principal aspects of concierge care are of interest to the Medicare
program and its beneficiaries: compliance with Medicare requirements
and its effect on beneficiary access to physician services. HHS has
determined that concierge care arrangements are allowed as long as they
do not violate any Medicare requirements; for example, the membership
fee must not result in additional charges for items or services that
Medicare already reimburses. Some concierge physicians reported to GAO
that they would like more HHS guidance. The small number of concierge
physicians makes it unlikely that the approach has contributed to
widespread access problems. GAO‘s review of available information on
beneficiaries‘ overall access to physician services suggests that
concierge care does not present a systemic access problem among
Medicare beneficiaries at this time. In comments on a draft version of
this report, HHS agreed with GAO‘s finding on concierge care‘s impact
on beneficiary access to physician services and indicated it will
continue to follow developments in this area.
Location of Concierge Physicians Identified by GAO:
[See PDF for image]
Note: We did not identify any concierge physicians in Alaska or Hawaii.
[End of figure]
www.gao.gov/cgi-bin/getrpt?GAO-05-929.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact A. Bruce Steinwald at
(202) 512-7119 or steinwalda@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Characteristics of Concierge Care:
Aspects of Concierge Care of Interest to Medicare and Its
Beneficiaries:
Concluding Observations:
Agency and Other Comments:
Appendixes:
Appendix I: Scope and Methodology:
Appendix II: Summary of Physician Responses to GAO Concierge Care
Survey:
Appendix III: Comments from the Department of Health and Human
Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Limits on Physician Charges for Medicare-Covered Services:
Table 2: Features Offered by Concierge Physicians, October 2004:
Table 3: Concierge Physicians' Views on HHS Information about How
Medicare Requirements Might Affect the Practice of Concierge Care,
October 2004:
Table 4: Patients from Physicians' Conventional Practices Who Joined
Physicians' Concierge Practices:
Table 5: Characteristics of Concierge Physicians and Their Practices,
October 2004:
Table 6: Estimated Number of Patients in Individual Practice, October
2004:
Table 7: Actions Concierge Physicians Reported They Took to Help
Medicare Patients Who Did Not Join the Concierge Practice Find New
Physicians:
Table 8: Concierge Physicians' Views on the Information Available from
HHS about How Medicare Requirements Affect Concierge Care, October
2004:
Table 9: Concierge Physicians' Views on Remaining in Medical Practice
and Treating Medicare Beneficiaries if Physicians Were Unable to
Practice Concierge Care:
Figures:
Figure 1: Location of Concierge Physicians Identified by GAO, 2004:
Figure 2: Yearly Growth in Number of Concierge Physicians:
Figure 3: Annual Membership Fee for Individuals, October 2004:
Figure 4: Number of Concierge Patients under the Care of Individual
Concierge Physicians, October 2004:
Figure 5: Medicare Participation Status of Concierge Physicians
Surveyed by GAO, October 2004:
Figure 6: Medicare Beneficiary Patients of Concierge Physicians,
October 2004:
Figure 7: Physicians' Goals for Total Number of Concierge Patients,
October 2004:
Figure 8: Annual Membership Fees Charged by Physicians Who Did and Did
Not Bill Patient Insurance, October 2004:
Abbreviations:
AMA: American Medical Association:
CMS: Centers for Medicare & Medicaid Services:
HHS: Department of Health and Human Services:
MSA: metropolitan statistical area:
OIG: Office of Inspector General:
PMSA: primary metropolitan statistical area:
Letter August 12, 2005:
The Honorable Charles E. Grassley:
Chairman:
The Honorable Max Baucus:
Ranking Minority Member:
Committee on Finance:
United States Senate:
The Honorable Joe Barton:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable William M. Thomas:
Chairman:
The Honorable Charles B. Rangel:
Ranking Minority Member:
Committee on Ways and Means:
House of Representatives:
Concierge care is an approach to medical practice in which physicians
charge their patients membership fees in exchange for enhanced services
or amenities. Concierge physicians typically care for fewer patients
than do doctors in conventional practice, and they are more readily
available to member patients, for example, by cell phone or same-day
appointments. The approach has attracted media attention in recent
years. Critics contend that concierge care makes health care more
lucrative for a few physicians and more convenient for some patients,
but less accessible to patients who cannot or choose not to pay a
membership fee. Proponents, in contrast, describe concierge care as
both a rational response to patient demand for more personal care and a
way for physicians to regain control of their medical practices and
their lives. They say the approach allows concierge physicians to spend
more time with their families, enhance their incomes, and spend more
time on research and other professional activities. Because concierge
care has gained attention only recently, little is known about how many
concierge physicians there are or about how the approach could affect
access to physician services.
Concierge care has also generated attention within Congress, the
Department of Health and Human Services (HHS), and state governments.
Federal attention has centered on how membership fees might affect
beneficiaries of Medicare, the federal health insurance program for
individuals aged 65 and older and certain persons with disabilities. Of
particular concern is the potential that membership fees may constitute
additional charges for services that Medicare already pays physicians
for and that concierge care may affect Medicare beneficiaries' access
to physician services. Members of Congress introduced bills that, if
enacted, would have prohibited physicians from imposing membership fees
on Medicare beneficiaries as a condition for the provision of a
Medicare-covered item or service.[Footnote 1] A few states are
monitoring concierge care to ensure compliance with state insurance
laws.[Footnote 2]
Given the concerns about how concierge care might affect Medicare
beneficiaries, the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 required us to study and report on the
practice.[Footnote 3] As discussed with the committees of jurisdiction,
this report addresses the following questions:
1. What are the characteristics of concierge care?
2. What aspects of concierge care are of interest to the Medicare
program and its beneficiaries?
To obtain information on the characteristics of concierge care, we
surveyed concierge physicians about their practices and the types of
services and financial arrangements they offer. Because no
comprehensive directory of concierge physicians was available, we
identified concierge physicians through a variety of methods, including
a nationwide literature search, telephone interviews, and referrals
from other concierge physicians. We identified as concierge physicians
those who (1) had established a direct financial relationship with
patients in the form of a membership or retainer fee and (2) provided
enhanced services or amenities, such as same-day appointments or
preventive services not covered by patient health insurance. We located
a total of 146 concierge physicians practicing in the United States. We
received survey responses from 112 physicians who practiced concierge
care in October 2004. Because these 112 respondents were not selected
at random from a larger population of known concierge physicians, the
information they provided cannot be projected to any other concierge
physicians. We did not attempt to verify the accuracy of their
responses.[Footnote 4]
To review the aspects of concierge care that are of interest to the
Medicare program and its beneficiaries, we reviewed documents and
interviewed officials from two HHS entities responsible for
administration and oversight of the Medicare program: the Centers for
Medicare & Medicaid Services (CMS) and the Office of Inspector General
(OIG). We also reviewed relevant sections of Medicare law and
regulations; interviewed concierge physicians and their
representatives; and in our survey, asked concierge physicians for
their views on the guidance available from HHS on concierge care. To
assess what is known about how concierge care may affect Medicare
beneficiary access to physician services, we reviewed nationwide
sources of information on Medicare beneficiaries' overall access to
physician services, for example, reports by the Medicare Payment
Advisory Commission. While we did not contact Medicare beneficiaries
who were patients of physicians who converted to concierge practices,
we contacted organizations that Medicare beneficiaries were likely to
call with concerns or questions about concierge care, such as the 1-
800-MEDICARE call line. We conducted our work in accordance with
generally accepted government auditing standards from May 2004 through
July 2005.
Results in Brief:
Concierge care is practiced by a small number of physicians located
mainly on the East and West Coasts. Nearly all of the 112 concierge
physicians who responded to our survey reported practicing primary
care. They differed, however, on the characteristics of their concierge
practices, such as the membership fee charged, features offered, and
whether they billed patient health insurance. For example, the amount
of the concierge care membership fee ranged from $60 to $15,000 a year
for an individual, with about half of respondents charging individual
annual membership fees of $1,500 to $1,999. The most frequently
reported features offered by concierge physicians responding to our
survey included same-or next-day appointments for nonurgent care, 24-
hour telephone access, and periodic preventive-care physical
examinations. In addition, about three-fourths of the respondents
reported billing patient health insurance for covered services and,
among those physicians, almost all reported billing Medicare for
covered services.
Two principal aspects of concierge care are of interest to the Medicare
program and its beneficiaries: compliance with Medicare requirements
and its effect on beneficiary access to physician services. HHS has
determined that concierge care agreements are permitted as long as the
arrangements do not violate any Medicare requirements; for example, the
membership fee must not result in additional charges for items or
services that are already reimbursed by Medicare. Various strategies
for concierge care practice design have been developed to help
concierge physicians avoid potential Medicare compliance problems, but
most of our survey respondents expressed a need for more information
from HHS to guide them. Although no national data directly address the
impact of concierge care on beneficiaries' access to physicians, the
information available as of 2004 on overall beneficiary access to
services indicates that access has been good. The small number of
concierge physicians makes it unlikely that the approach has
contributed to widespread access problems. In addition, information
from beneficiary advocacy organizations and on physician supply in
communities where more concierge physicians practiced does not indicate
that concierge care was contributing to any systemic access problems.
In commenting on a draft of this report, HHS agreed with our finding
about the effect of concierge care on Medicare beneficiary access to
physician services, and also noted that it remains interested in
concierge care and will continue to follow developments in the area.
Background:
Physician practices that charge membership or retainer fees and provide
enhanced services or amenities are referred to as concierge care or
retainer-based medicine.[Footnote 5] The origins of this practice
approach are often traced to a medical practice founded in Seattle,
Washington, in 1996. Physicians in this practice provide comprehensive
primary care to no more than 100 patients each and currently charge
annual retainer fees of $13,000 for individuals. These physicians do
not bill any form of patient health insurance. As more physicians have
begun concierge practices, concierge care has become more diverse,
comprising physicians who bill patient insurance, charge lower
membership fees, and see more patients than the original Seattle
practice.
The American Medical Association (AMA) has described concierge care as
one of many options that patients and physicians are free to pursue.
AMA in 2003 adopted ethics guidelines for physicians who have concierge
care contracts--which AMA calls retainer contracts--with their
patients.[Footnote 6] These guidelines specify, for example, that
physicians should facilitate the transition to new physicians for
patients who choose not to join their concierge practices and that they
must observe relevant laws, rules, and contracts.
The Medicare program was established by title XVIII of the Social
Security Act, which governs how physicians bill for services that the
program covers. Limits on what physicians may charge their Medicare
patients depend on (1) the relationship between the physician and the
Medicare program and (2) the type of service provided.
Physicians who provide services to Medicare beneficiaries may choose
one of three ways to relate to the program: participating,
nonparticipating, or opted out.
* Participating: Participating physicians agree to accept Medicare's
fee schedule amount as payment in full for all covered services they
provide to beneficiaries.[Footnote 7] In accordance with the Medicare
participation agreement, these physicians receive reimbursement
directly from the Medicare program and agree to charge beneficiaries
only for any applicable deductible or coinsurance. More than 90 percent
of the physicians and others who billed Medicare agreed to participate
in Medicare in 2004.[Footnote 8]
* Nonparticipating: Nonparticipating physicians do not agree to accept
the Medicare fee schedule amount paid to participating physicians as
payment in full for all covered services they provide to beneficiaries.
They are still subject to limits on what they may charge, however, and
those limits depend on whether they seek reimbursement directly from
Medicare. When a nonparticipating physician files a claim to be
reimbursed directly from Medicare, he or she must accept the Medicare
fee schedule amount for nonparticipating physicians, which is 95
percent of the fee schedule amount for participating physicians, as
payment in full and may charge the beneficiary only for any applicable
Medicare coinsurance or deductible.[Footnote 9] When a nonparticipating
physician does not request reimbursement directly from Medicare, he or
she may charge the Medicare beneficiary up to 115 percent of the fee
schedule amount for nonparticipating physicians.[Footnote 10]
* Opted-out: Physicians who opt out of Medicare are not subject to any
limits on what they may charge their Medicare beneficiary patients,
even for services that Medicare would otherwise cover.[Footnote 11]
Physicians who opt out of Medicare must agree not to submit for 2 years
any claims for reimbursement for any of the services they provide to
Medicare beneficiaries.[Footnote 12] Contracts between opted-out
physicians and their beneficiary patients allow them to make their own
financial arrangements for services that would otherwise be covered by
Medicare, effectively taking those services outside the program. These
contracts must be in writing and they must clearly state that the
beneficiary also agrees not to submit claims to Medicare and assumes
financial responsibility for all services provided by that physician.
In addition to a physician's Medicare participation status, the type of
service provided also determines whether limits apply to physician
charges. Physicians and beneficiaries are free to make private
financial arrangements for the provision of services that Medicare does
not cover.
* General standard for Medicare coverage: Medicare law states that, to
be covered, services must be reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the functioning of a
malformed body member.[Footnote 13] The scope of coverage and the exact
type of service that may be reimbursed depend on the circumstances of
each case. This medical necessity standard can result in situations
where the same service--for example, a comprehensive office visit--is
considered medically necessary and reimbursable by Medicare in some
circumstances but not others.
* Specific inclusion in Medicare coverage: Medicare law also
establishes coverage for certain specific services. For example,
Medicare covers an initial preventive physical examination for
beneficiaries who become eligible for Medicare on or after January 1,
2005. Other examples of specific preventive benefits established by
statute include immunizations against pneumonia, hepatitis B, and
influenza and periodic screening tests for early detection of certain
cancers.
* Specific exclusion from Medicare coverage: Medicare law specifically
excludes certain items or services--for example, personal comfort
items, purely cosmetic surgery, hearing aids, and routine physical
checkups except for the initial preventive examination for newly
eligible beneficiaries.
Table 1 summarizes the limits on physician charges depending on their
Medicare participation status and the type of service provided.
Table 1: Limits on Physician Charges for Medicare-Covered Services:
Physician status: Participating;
Medicare-covered services: Medically necessary items or services and
specific preventive or other benefits;
Limits on physician charges: Medicare fee schedule amount for
participating physicians. The beneficiary may be charged applicable
deductible and coinsurance only.
Physician status: Nonparticipating;
Medicare-covered services: Medically necessary items or services and
specific preventive or other benefits;
Limits on physician charges: Reimbursement claimed directly from
Medicare: Medicare fee schedule amount for nonparticipating physicians,
which is 95 percent of the amount for participating physicians. The
beneficiary may be charged applicable deductible and coinsurance only;
Reimbursement not claimed directly from Medicare: No more than 115
percent of the Medicare fee schedule amount for nonparticipating
physicians. The beneficiary may be charged this entire amount and may
be reimbursed 80 percent of the fee schedule amount for
nonparticipating physicians.
Physician status: Opted-out;
Medicare-covered services: None, except when emergency or urgent care
is provided to a beneficiary with whom the physician does not have a
contract.[A];
Limits on physician charges: No statutory limits apply. The amount of
payment is determined by contracts between physicians and patients.
Source: GAO analysis.
[A] Items or services provided by opted-out physicians to their
beneficiary patients under private contracts are not covered by
Medicare.
[End of table]
Physicians who impose charges on beneficiaries beyond the Medicare
limits may be subject to civil monetary penalties.[Footnote 14] The
Secretary of HHS has delegated enforcement of Medicare limits to two
different entities within HHS. CMS, which administers the Medicare
program, has enforcement authority over the limits that apply to
nonparticipating physicians. HHS OIG has enforcement authority over
participating physicians' compliance with the terms of the
participation agreement.
The Medicare law's limits on physician charges protect beneficiaries
from additional charges for services they are entitled to receive under
Medicare. The law does not, however, provide that a beneficiary has the
right to receive services from any particular physician. Physicians are
free to choose how they will interact with the Medicare program. They
may decide to close their practices to new Medicare patients or decline
to treat any Medicare beneficiaries at all.
Characteristics of Concierge Care:
Concierge care is practiced by a small number of physicians, located
primarily in urban areas on the East and West Coasts. Although nearly
all of the concierge physicians who responded to our survey reported
practicing primary care, they differed in many of the characteristics
of practice design, including the annual membership fee charged, number
of patients treated, features offered, whether they billed health
insurance, and their relationship to the Medicare program.
Concierge Physician Location and Specialty:
Concierge physicians are few in number and located primarily in urban
areas on the East and West Coasts. Since the first Seattle practice was
founded in the mid-1990s, the number of concierge physicians has been
rising but remains small. We were able to locate 146 concierge
physicians in the United States as of 2004--a small number compared
with the more than 470,000 physicians who regularly submitted claims to
Medicare in 2003.[Footnote 15] The 146 concierge physicians we
identified practiced in 25 states, with the greatest numbers in
metropolitan areas on the East and West Coasts.[Footnote 16] California
had the highest number, with 26 concierge physicians, followed by
Florida with 22, Washington with 21, and Massachusetts with 17. We
identified 1 to 8 concierge physicians in 21 other states, though most
of these other states had 5 or fewer. All but 2 of the concierge
physicians we located practiced in metropolitan areas. We found the
highest numbers of concierge physicians in the metropolitan statistical
areas (MSA)[Footnote 17] of Seattle (19); Boston (17); and West Palm
Beach-Boca Raton, Florida (13). Figure 1 presents the locations of 144
concierge physicians we identified who practiced in MSAs throughout the
nation.[Footnote 18]
Figure 1: Location of Concierge Physicians Identified by GAO, 2004:
[See PDF for image]
Notes: This figure presents the practice locations of the 144 concierge
physicians we identified who were located in MSAs. It does not include
the 2 physicians located outside MSAs. We did not identify any
concierge physicians in Alaska or Hawaii.
[End of figure]
The number of physicians practicing concierge care has increased in
recent years. Among the 112 concierge physicians who responded to our
survey, the cumulative total number practicing concierge care has
increased by:
more than 10 times in the past 5 years (see fig. 2).[Footnote 19] About
two-thirds of the responding physicians reported that they began to
practice concierge care in 2003 or later. The number of responding
physicians starting to practice concierge care rose each year after
2000, except in 2004, although we did not include physicians who began
practicing concierge care after October 2004.[Footnote 20]
Figure 2: Yearly Growth in Number of Concierge Physicians:
[See PDF for image]
Notes: n = 112 concierge physicians practicing as of October 2004. Data
for 2004 do not include physicians who began practicing concierge care
after October. The earliest year in which a physician in our survey
reported beginning to practice concierge care was 1997.
[End of figure]
Nearly all of the physicians who responded to our survey reported
practicing primary care and most were not new to medical practice.
Physicians reported practicing the primary care disciplines of internal
medicine (about three-fourths of respondents) and family practice
(about one-fourth of respondents). Survey respondents reported being in
various stages in their medical careers, from relatively new to
practice to decades of experience. More than two-thirds reported having
been in medical practice for 15 years or more. The average length of
time in medical practice was 19 years, and about one-fourth of the
respondents reported being in practice for 25 years or more. See
appendix II for additional information provided by survey respondents.
Characteristics of Practice Design among Surveyed Concierge Physicians:
Concierge physicians responding to our survey reported a variety of
practice characteristics. These included the amount charged to be a
concierge patient, practice size, features offered, whether they billed
patient health insurance, and their relationship to the Medicare
program.[Footnote 21]
Amount of Annual Membership Fee:
The annual membership fee for an individual to join a concierge
practice ranged from $60 to $15,000 among the physicians responding to
our survey. As shown in figure 3, more than 80 percent of respondents
reported annual fees from $500 to $3,999; the most frequently reported
annual fee was $1,500. Three-fourths of our respondents reported that
they waived the membership fee for some of their concierge
patients.[Footnote 22] About one in eight of these physicians reported
waiving the fees for 20 percent or more of their concierge patients.
Figure 3: Annual Membership Fee for Individuals, October 2004:
[See PDF for image]
Notes: n = 111 concierge physicians practicing as of October 2004; 1
respondent did not provide this information. The maximum reported
annual individual membership fee charged was $15,000.
[End of figure]
Practice Size:
Concierge physicians responding to our survey reported, on average, 491
patients under their care as of October 2004--significantly fewer than
the average of 2,716 patients they reported for the year before
beginning to practice concierge care. Of the total patients they
reported in October 2004, an average of 326 were concierge patients--
that is, patients who either paid the membership fee or had the fee
waived, and were offered the enhanced services or amenities associated
with membership.
Nearly two-thirds of responding physicians reported having fewer than
400 concierge patients (see fig. 4). Concierge physicians also reported
seeing fewer patients per day: the average number of patients
physicians reported seeing on a typical day fell to 10 in October 2004
from 26 in the year before they began practicing concierge
care.[Footnote 23]
Figure 4: Number of Concierge Patients under the Care of Individual
Concierge Physicians, October 2004:
[See PDF for image]
Notes: n = 109 concierge physicians practicing as of October 2004; 3
respondents did not provide this information. The maximum reported
number of concierge patients was 980.
[End of figure]
Many respondents reported that they were still establishing their
concierge practices and had set targets for the number of concierge
patients in their care. Respondents reported target numbers for
concierge patients ranging from 10 to 1,300; the two most frequently
reported goals were 300 and 600 concierge patients (reported by 23 and
30 respondents, respectively). About 80 percent of respondents reported
that they had not yet reached their target number of concierge patients
as of October 2004. About 1 in 2 of the respondents who began concierge
care in 2001 or earlier reported having met their goal for the number
of concierge patients in their practices, compared with about 1 in 7 of
those who reported starting their concierge practices on or after
January 1, 2002.
Concierge physicians may continue, for various reasons, to treat some
nonconcierge patients. Thirty-six, about one-third of survey
respondents, reported that their individual practices included some
nonconcierge patients, while about two-thirds had practices consisting
entirely of concierge patients. Physicians who continued to see
nonconcierge patients reported doing so for various reasons: to ensure
continuity of care for patients who did not join the concierge
practice, to maintain a combined concierge and conventional practice,
or to see patients as part of a subspecialty practice.[Footnote 24]
Less frequently reported situations in which respondents reported
seeing nonconcierge patients included seeing family members of their
concierge patients occasionally as a courtesy or when urgent needs
arose, and covering for other doctors who were out of town.
Features Offered:
The concierge physicians responding to our survey reported offering a
variety of features, some of which were offered by nearly all the
respondents, others by relatively few (see table 2). The most
frequently reported features were same-or next-day appointments for
nonurgent care, 24-hour telephone access, and periodic preventive-care
physical examinations.
Table 2: Features Offered by Concierge Physicians, October 2004:
Feature: Same-or next-day appointments for nonurgent care;
Percentage of respondents offering feature: 99.
Feature: 24-hour telephone access;
Percentage of respondents offering feature: 99.
Feature: Periodic preventive-care physical examination;
Percentage of respondents offering feature: 99.
Feature: Extended office visits;
Percentage of respondents offering feature: 96.
Feature: Access to physician via e-mail;
Percentage of respondents offering feature: 94.
Feature: Access to physician via cell phone or pager;
Percentage of respondents offering feature: 93.
Feature: Wellness planning;
Percentage of respondents offering feature: 93.
Feature: Nutrition planning;
Percentage of respondents offering feature: 82.
Feature: Coordination of medical needs during travel;
Percentage of respondents offering feature: 82.
Feature: Patient home or workplace consultations;
Percentage of respondents offering feature: 78.
Feature: Smoking cessation support;
Percentage of respondents offering feature: 77.
Feature: Preventive screening procedures;
Percentage of respondents offering feature: 72.
Feature: Newsletter;
Percentage of respondents offering feature: 71.
Feature: Stress reduction counseling;
Percentage of respondents offering feature: 67.
Feature: Private waiting room;
Percentage of respondents offering feature: 63.
Feature: Mental health counseling;
Percentage of respondents offering feature: 60.
Feature: Online or other electronic access to personal medical records;
Percentage of respondents offering feature: 42.
Feature: Accompaniment to specialist appointments or medical
procedures;
Percentage of respondents offering feature: 38.
Feature: Home delivery of medication by physician or office staff;
Percentage of respondents offering feature: 31.
Feature: Priority for diagnostic tests in affiliated medical
facilities;
Percentage of respondents offering feature: 27.
Feature: Other (e.g., visits to homebound patients, lecture series on
wellness and nutrition, assistance for patients' family members, or an
on-site assistant to help patients with insurance);
Percentage of respondents offering feature: 31.
Source: GAO survey of concierge physicians.
Note: n = 112 concierge physicians practicing as of October 2004.
[End of table]
When asked to list the most important features of concierge care that
were not routinely available to their nonconcierge patients,
respondents most frequently cited features related to increased time
spent with patients, direct patient access to the physician at any
time, same-or next-day appointments, and comprehensive preventive and
wellness care.
Interaction with Patient Health Insurance and Medicare:
Concierge physicians responding to our survey reported different ways
of interacting with patient health insurance and the Medicare program.
Eighty-five, approximately three-fourths, of respondents reported that
they billed patient health insurance for covered services. Of these 85
physicians, 79 reported they billed Medicare and 6 reported they did
not. About one-fourth of the concierge physicians responding to our
survey reported that they did not submit any claims to patient health
insurance, including Medicare.
About three-fourths of our survey respondents reported that they were
Medicare participating physicians, and about one-fifth had opted out of
Medicare as of October 2004 (see fig. 5). Nationwide, relatively few
physicians--approximately 3,000 in 2004--have opted out of the Medicare
program.
Figure 5: Medicare Participation Status of Concierge Physicians
Surveyed by GAO, October 2004:
[See PDF for image]
Notes: n = 111 concierge physicians as of October 2004; 1 respondent
did not provide this information. Percentages do not add to 100 due to
rounding.
[End of figure]
Aspects of Concierge Care of Interest to Medicare and Its
Beneficiaries:
Two principal aspects of concierge care are of interest to the Medicare
program and its beneficiaries: its compliance with Medicare
requirements and its effect on beneficiary access to physician
services. HHS has established general policy on concierge care and
alerted physicians to areas of potential noncompliance. Although
concierge physicians have followed various strategies to ensure
compliance with Medicare requirements, most physicians responding to
our survey indicated more HHS guidance would be helpful. Available
measures of access to care as of 2004, while not directly addressing
concierge care, indicate that Medicare beneficiary access to physician
services has been good. The small number of concierge physicians makes
it unlikely that the approach has contributed to widespread access
problems.
Compliance with Medicare Requirements:
HHS has established general policy on concierge care and has alerted
physicians to areas of potential noncompliance. Concierge physicians
have expressed the need for additional guidance and have taken various
steps--such as structuring their practices in an attempt to avoid
associating their membership fees with Medicare-covered services or
opting out of Medicare--to avoid compliance problems.
CMS outlined its position on concierge care in a March 2002 memorandum
to CMS regional offices that CMS officials told us remains current as
of June 2005. The memorandum states that physicians may enter into
retainer agreements with their patients as long as these agreements do
not violate any Medicare requirements.[Footnote 25] For example,
concierge care membership fees may constitute prohibited additional
charges if they are for Medicare-covered items or services. If so, a
physician who has not opted out of Medicare would be in violation of
the limits on what she or he may charge patients who are Medicare
beneficiaries.[Footnote 26]
HHS OIG has addressed the consequences of noncompliance with Medicare
billing requirements. In March 2004, HHS OIG issued an alert "to remind
Medicare participating physicians of the potential liabilities posed by
billing Medicare patients for services that are already covered by
Medicare."[Footnote 27] The alert stated that "charging extra fees for
already covered services abuses the trust of Medicare patients by
making them pay again for services already paid for by Medicare."As an
example, the alert referred to a Minnesota physician who paid a
settlement and agreed to stop offering personal health care contracts
to patients for annual fees of $600. According to HHS OIG, these
contracts included at least some services that were already covered and
reimbursable by Medicare. The alert advised participating physicians
that they could be subject to civil monetary penalties if they
requested payment from Medicare beneficiaries for those services in
addition to the relevant deductibles and coinsurance charged for these
services. In addition, the alert noted that nonparticipating physicians
may also be subject to penalties for overcharging beneficiaries for
covered services.
Unless a concierge physician opts out of Medicare, the question of
Medicare coverage is central to whether a concierge care agreement
complies with the program's limits on patient charges. HHS OIG's March
2004 alert provided three examples of services offered by the physician
in Minnesota: coordination of care with providers, a comprehensive
assessment and plan for optimum health, and extra time spent on patient
care. HHS OIG did not indicate which, if any, of those three services
were already covered by Medicare. The resulting uncertainty, about
which features of the Minnesota physician's concierge agreement formed
the basis for HHS OIG's allegation that he violated the Medicare
program's prohibition against charging beneficiaries more than the
applicable deductible and coinsurance, generated concern among some
concierge physicians.
According to HHS OIG officials, HHS OIG has not issued more detailed
guidance on concierge care because its role in this area is to carry
out specific delegated enforcement authorities, not to make policy. HHS
OIG addresses each situation in its specific context. Physicians with
questions about their own concierge care agreements may obtain guidance
specific to them from HHS by requesting an advisory opinion. HHS OIG's
Industry Guidance Branch issues advisory opinions on matters that fall
within its enforcement authority. It covers provisions of Medicare law
that prohibit knowingly presenting a beneficiary with a request for
payment in violation of a physician's participation agreement.[Footnote
28] Consequently, any participating physician who operates or is
considering starting a concierge practice could request an advisory
opinion. Advisory opinions are legally binding on HHS and the
requesting party as long as the arrangement is consistent with the
facts provided. The process involves a written request that meets
certain requirements, plus a fee. Advisory opinions are not available
for hypothetical situations, "model" situations, or general questions
of interpretation. Officials with HHS OIG reported that as of May 2005,
the Industry Guidance Branch had received very few inquiries regarding
advisory opinions about concierge care agreements, and no opinions have
been issued on this subject.
Most of the physicians who responded to our survey indicated that more
guidance from HHS on how Medicare requirements might affect concierge
care is needed. Although about one-fourth of respondents said that the
information available from HHS was clear and sufficient, more than half
reported that it was not. Of those who reported that the guidance was
not clear and sufficient, about one-third stated that information was
available from other sources, including private attorneys, the Society
for Innovative Medical Practice Design, and concierge care consultants
(see table 3).
Table 3: Concierge Physicians' Views on HHS Information about How
Medicare Requirements Might Affect the Practice of Concierge Care,
October 2004:
View: The information available from HHS is clear and sufficient;
Percentage of physicians: 26.
View: The information available from HHS is not clear and sufficient,
but clear and sufficient information is available from other sources;
Percentage of physicians: 18.
View: The information available from HHS is not clear and sufficient,
and clear and sufficient information is not available from other
sources;
Percentage of physicians: 34.
View: Don't know/no opinion;
Percentage of physicians: 22.
Source: GAO survey of concierge physicians.
Note: n = 111 concierge physicians as of October 2004; 1 respondent did
not provide this information.
[End of table]
Medicare compliance is an important consideration in how concierge
physicians set up their practices. For example, concierge physicians
should avoid including services covered by Medicare in their concierge
agreements to ensure that no additional charges are associated with
those services. Different strategies have been undertaken to accomplish
this. One such strategy emphasizes the convenience and availability of
concierge physicians as the primary benefit of membership. Another
strategy is to focus on preventive care, linking the membership payment
only to screening that Medicare does not cover. Some concierge
physicians opt out of Medicare, thus avoiding potential compliance
problems; opting out requires physicians to forgo all Medicare
reimbursement for 2 years.
Information on Medicare Beneficiary Access to Physician Services:
Most of the concierge physicians responding to our survey reported
having patients who were Medicare beneficiaries; however, the numbers
of beneficiary patients they reported as part of their concierge and
previous nonconcierge practices are very small compared to the more
than 40 million Medicare beneficiaries. Surveys and national sources of
information on beneficiary access to care do not address the impact of
concierge care directly. In the absence of direct measures of the
impact of concierge care on Medicare beneficiaries' access to physician
services, we reviewed available nationwide data and other indicators
about beneficiaries' experiences overall. These sources showed that
overall access to physician services has not changed substantially in
recent years.
Medicare Beneficiary Patients of Surveyed Concierge Physicians:
Estimates provided by 105 of the respondents indicated that about two-
thirds of the estimated 19,400 Medicare beneficiaries who were patients
of these physicians in October 2004 were considered concierge
patients.[Footnote 29] The rest were nonconcierge patients who were
neither charged a fee nor offered enhanced services. Physicians who
continued to see nonconcierge patients reported doing so for various
reasons, including to ensure continuity of care for individuals who had
not yet found a new physician and to maintain a practice consisting of
both concierge and nonconcierge patients.
On average, Medicare beneficiaries represented about 35 percent of the
total number of patients--concierge and nonconcierge--that responding
concierge physicians reported having in their care as of October 2004.
Eight of the 105 physicians who provided this information reported
having no Medicare beneficiaries in their practices at all; 36 reported
treating some, but fewer than 100 Medicare beneficiaries among their
patients; and 12 reported having 400 or more Medicare beneficiaries
under their care (see fig. 6).
Figure 6: Medicare Beneficiary Patients of Concierge Physicians,
October 2004:
[See PDF for image]
Notes: n = 105 concierge physicians as of October 2004; 7 respondents
did not provide this information. Includes Medicare beneficiaries who
were nonconcierge patients of concierge physicians. The highest number
of Medicare beneficiary patients reported was 2,825.
[End of figure]
Concierge physicians who responded to our survey reported that, on
average, Medicare beneficiaries in their previous nonconcierge
practices joined their concierge practices in about the same proportion
as their patients overall. When physicians begin practicing concierge
care, existing patients may choose not to become concierge patients.
Patient counts provided by responding physicians indicate that, on
average, Medicare and non-Medicare patients who were under their care
before they began concierge care chose to join as concierge patients in
roughly similar proportions.
Table 4 shows the average numbers of Medicare and non-Medicare patients
responding physicians reported were in their practices before and after
their conversion to concierge care. The numbers of beneficiaries that
responding concierge physicians reported in their practices are
relatively small--for example, the total number of Medicare
beneficiaries that 88 responding physicians reported treating before
conversion to concierge care was fewer than 100,000--compared to the
nation's more than 40 million Medicare beneficiaries.
Table 4: Patients from Physicians' Conventional Practices Who Joined
Physicians' Concierge Practices:
Status of practice: Before conversion to concierge care;
Average number of patients: Total: 2,716 (n = 97);
Average number of patients: Medicare: 1,069 (n = 88);
Average number of patients: Non-Medicare: 1,632 (n = 88).
Status of practice: After conversion to concierge care;
Average number of patients: Total: 301 (n = 94);
Average number of patients: Medicare: 138 (n = 85);
Average number of patients: Non-Medicare: 157 (n = 85).
Source: GAO survey of concierge physicians.
Notes: Although there were 112 unique respondents who practiced
concierge care in October 2004, not all respondents answered each
question. This table presents information about the patients who became
members of the physicians' concierge practices. It does not count
individuals who may have remained under the care of their physicians as
nonconcierge patients.
[End of table]
Respondents reported engaging in a variety of activities to help
Medicare beneficiaries choosing not to join the physician's concierge
practice find new physicians. These activities included designating a
staff person to help with transition questions, referring patients to
other physicians within a group practice, calling new physicians to
discuss a patient's medical history, and remaining available to treat
all patients until they had found a new primary care physician.
Additional activities reported include bringing a new physician into
the practice to take on the concierge physician's previous patients and
speaking individually with each patient. We did not contact Medicare
beneficiary patients of the concierge physicians in our survey to
determine how many of them had sought or found new physicians. See
appendix II for additional details on actions physicians reported
taking to help Medicare patients who did not join their concierge
practices to find new physicians.
Nationwide and Community Indicators of Beneficiaries' Access:
The number of concierge physicians, and the number of Medicare
beneficiaries the physicians reported in their previous nonconcierge
practices, are relatively small, and therefore national surveys of
samples of Medicare beneficiaries are not likely to include many
beneficiaries who come into contact with concierge care. In the absence
of data to directly assess the impact of concierge care on Medicare
beneficiaries' access, however, national surveys can provide general
information about the availability of physicians and beneficiary access
to care. Overall, national surveys showed that Medicare beneficiary
access to physician services has been good, in some cases better than
access for individuals with private health insurance.
Surveys targeting both Medicare beneficiaries and physicians revealed
that overall access to physician services has not changed substantially
in recent years. Most beneficiaries surveyed reported that they have
not had a problem finding a primary care physician. Of those who did
report a problem, only a small percentage attributed their difficulty
to physicians' refusing to take new Medicare patients. Most
beneficiaries attributed problems to transportation barriers or their
difficulty finding a physician they liked, not to a shortage of primary
care physicians who accepted Medicare. Of physicians surveyed, most
reported accepting at least some new Medicare patients.[Footnote 30]
Analysis done by the Medicare Payment Advisory Commission of Medicare
claims data also revealed that the number of physicians who treated
Medicare patients grew at a more rapid pace than the Medicare
beneficiary population from 1999 to 2003.[Footnote 31] Results from our
review of Medicare claims data from April 2000 and April 2002 indicated
increases throughout the country in both the percentage of
beneficiaries who received physician services and the number of
services provided to beneficiaries who were treated.[Footnote 32]
Physician supply data from the Seattle, Boston, and Southeast Florida
metropolitan areas, where we found concierge care is relatively
prominent, suggested that physicians there were relatively plentiful.
The ratio of physicians to overall population in each of these
metropolitan areas exceeded the nationwide average for all metropolitan
areas in 2001. Because concierge physicians treat fewer patients than
do physicians in conventional practices, a community needs other
available physicians to take on Medicare beneficiaries who choose not
to join a concierge practice. Even in communities where the concierge
physician population was largest, however, the number of concierge
physicians we identified was small compared with the physician
population as a whole.
Information about Experiences of Individual Beneficiaries:
CMS officials informed us that CMS has not established a special
tracking system for beneficiary complaints about concierge care because
the practice is not sufficiently widespread to raise concerns about
access to care. Similarly, officials with call centers for 1-800-
MEDICARE and CMS contractors handling beneficiary inquiries and
complaints reported that they have received a small number of calls
from beneficiaries about concierge care. Because of the low volume of
calls on this subject, the majority of these call centers do not have
tracking codes for responses to calls about concierge care.[Footnote
33] Of the 15 CMS contractors who process claims for physician services
and responded to our inquiry, only 1 reported establishing a code to
track concierge care inquiries.[Footnote 34] This contractor
established the tracking code in response to our inquiry about
concierge care in February 2005.[Footnote 35] As of April 2005, none of
this contractor's call centers reported receiving any beneficiary calls
about concierge care.
Because of the relatively high number of concierge physicians in the
Seattle metropolitan area, CMS's Seattle regional office has been
following concierge care, but so far it has not identified an impact in
Medicare beneficiaries' access to care. The Seattle office's efforts
are part of an agencywide effort to monitor beneficiary access to care
through reports in the media and from the CMS divisions that interact
with beneficiaries. According to CMS officials in the agency's Seattle
regional office, that office has received a small number of calls about
concierge care from physicians and beneficiaries, mainly asking whether
concierge care is permitted under Medicare law. Seattle regional office
officials said they respond in accordance with CMS guidelines: they do
not review specific concierge care agreements but help beneficiaries by
providing a list of local physicians who participate in Medicare. The
CMS Seattle regional office has not found indications that
beneficiaries who choose not to pay their physician's membership fees
have had problems locating new primary care physicians.
We did not contact Medicare beneficiaries who were patients of
physicians who converted to concierge care to determine how many of
them had sought or found new physicians. We did, however, contact
organizations that Medicare beneficiaries might call with problems or
concerns,
including AARP and the Medicare Rights Center.[Footnote 36] Like CMS,
officials with these organizations reported receiving a few calls from
beneficiaries about concierge care, and none reported complaints from
beneficiaries about finding a physician or about access to services
because of concierge care. Officials with these groups also reported
that they have not developed a formal system to track the issue.
According to officials from these organizations, calls from
beneficiaries about concierge care are usually requests for help
interpreting the letters from their physicians explaining the
physicians' conversion to concierge care.
Concluding Observations:
Although the number of physicians practicing concierge care has grown
in recent years, the total number remains very small. Available
measures of Medicare beneficiaries' overall access to care, while not
directly addressing concierge care, indicate widespread availability of
physicians to treat them. The small number of concierge physicians at
the time of our review, along with information from available measures
of access to services, suggests that concierge care does not present a
systemic access problem for Medicare beneficiaries at this time.
Agency and Other Comments:
We provided a draft of this report for comment to HHS. In its comments,
HHS agreed that concierge care has had a minimal impact on beneficiary
access to physician services at this time. HHS noted, however, that the
agency is interested in developments in concierge care and will
continue to follow this area and to evaluate whether any further steps
are indicated. See appendix III for HHS's written comments. HHS also
provided technical comments, which we incorporated where appropriate.
We also provided a draft to the Society for Innovative Medical Practice
Design, formerly the American Society of Concierge Physicians, which
had no comments.
We are sending copies of this report to the Secretary of HHS, the
Inspector General of HHS, the Administrator of CMS, and appropriate
congressional committees. We will also provide copies to others upon
request. In addition, the report is available at no charge on the GAO
Web site at [Hyperlink, http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7119 or [Hyperlink, steinwalda@gao.gov].
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who
made major contributions to this report are listed in appendix IV.
Signed by:
A. Bruce Steinwald:
Director, Health Care:
[End of section]
Appendixes:
Appendix I: Scope and Methodology:
To obtain information on the characteristics of concierge care, we
surveyed concierge physicians about their practices and the types of
services and financial arrangements they offer. Because no
comprehensive directory of concierge physicians was available, we
compiled our own list of concierge physicians to survey. We focused our
survey on physicians who, as of October 2004, (1) had established a
direct financial relationship with patients in the form of a membership
or retainer fee and (2) provided enhanced services or amenities, such
as same-day appointments or preventive services not covered by patient
health insurance.[Footnote 37]
We identified concierge physicians through a variety of methods,
including a nationwide literature search, telephone interviews, and
referrals from other concierge physicians. With the assistance of a
contractor, we compiled an initial list of potential survey
participants, contacted them to confirm that they met the criteria for
inclusion in our survey, and requested referrals to additional
concierge physicians. We used a variety of sources to establish our
initial list of potential survey participants, including a nationwide
Internet search of articles in newspapers, business journals, and
medical publications; attendance at the first annual meeting of the
American Society of Concierge Physicians (now known as the Society for
Innovative Medical Practice Design); and a list of physicians
affiliated with a consulting firm that helps physicians establish and
maintain concierge practices. This process yielded a final mailing list
of 187 individuals.
We mailed the questionnaires in November 2004, after pretesting it with
concierge physicians and incorporating suggestions from several
reviewers familiar with concierge care; we followed up with
nonrespondents during December 2004 and January 2005. Two
questionnaires were returned as undeliverable; we removed those names
from our total count of potential concierge physicians. The total we
used to calculate the response rate for our survey was therefore 185.
We received responses to our survey from 129 physicians, yielding an
overall response rate of 70 percent. Of the respondents, 112 physicians
confirmed that they practiced concierge care--that is, they reported
that they charged a retainer or membership fee for enhanced services or
amenities--as of October 2004. We analyzed only the information
provided by these 112 physicians. Because these 112 respondents were
not randomly sampled from a larger population of known concierge
physicians, the information they provided cannot be projected to any
other concierge physicians. We did not attempt to verify the accuracy
of their responses.
In addition to the 112 physicians practicing concierge care in October
2004 and responding to our survey, we confirmed--through, for example,
telephone interviews conducted by us or our contractor--the concierge
status of an additional 34 physicians who did not return our
questionnaire. This process yielded a total of 146 confirmed concierge
physicians. To analyze the geographic practice locations of these 146
physicians, we assigned the physicians' zip codes to larger geographic
units called metropolitan statistical areas (MSA) or primary
metropolitan statistical areas (PMSA), as defined in 1999 by the Office
of Management and Budget.
To review the aspects of concierge care of interest to the Medicare
program and its beneficiaries, we reviewed relevant provisions of
Medicare law and documents from the Department of Health and Human
Services (HHS), including Centers for Medicare & Medicaid Services
(CMS) policy manuals and internal memorandums, information posted on
the CMS Web site, an alert published by the HHS Office of Inspector
General (OIG), and correspondence between interested parties and HHS
officials regarding concierge care. We also interviewed CMS officials
at CMS headquarters and in the Seattle regional office, officials with
HHS OIG, and concierge physicians and their representatives and, in our
survey, asked concierge physicians for their views on the guidance
available from HHS on concierge care.
To assess what is known about how concierge care might affect Medicare
beneficiary access to physician services, we reviewed national surveys
and reports on overall Medicare beneficiary access. Because so few
physicians and beneficiaries are affected by concierge care, concierge
physicians or their patients are unlikely to be randomly chosen to
participate in surveys on access to physicians by Medicare
beneficiaries. National surveys and analysis on beneficiary access to
physician services are also not sufficiently detailed to address
concierge care, but they can provide information about physician
availability and beneficiary access to care overall. The sources we
consulted targeted beneficiaries, physicians, or both and included the
following:
* Bernard, Shulamit, et al. Medicare Fee-for-Service National
Implementation Subgroup Analysis. Prepared for the Centers for Medicare
& Medicaid Services. Research Triangle Park, N.C.: Research Triangle
Institute, 2003.
* Center for Studying Health System Change. Community Tracking Study
(CTS) Section Map. Washington, D.C.: October 2004. [Hyperlink,
http://www.hschange.org/index.cgi?data=10] (downloaded October 2004).
* Centers for Medicare & Medicaid Services. Medicare Current
Beneficiary Survey. Baltimore, Md.: September 2004. [Hyperlink,
http://www.cms.hhs.gov/MCBS/default.asp] (downloaded October 2004).
* GAO. Medicare Fee-for-Service Beneficiary Access to Physician
Services: Trends in Utilization of Services, 2000 to 2002. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-145R]. Washington, D.C.:
January 12, 2005.
* Lake, Timothy, et al. Results from the 2003 Targeted Beneficiary
Survey on Access to Physician Services among Medicare Beneficiaries.
Prepared for the Centers for Medicare and Medicaid Services. Cambridge,
Mass.: Mathematica Policy Research, Inc., 2004.
* Medicare Payment Advisory Commission. Report to the Congress:
Medicare Payment Policy. Washington, D.C.: 2005.
* Schoenman, Julie, et al. 2002 Survey of Physicians about the Medicare
Program. Prepared for the Medicare Payment Advisory Commission.
Bethesda, Md.: Project HOPE Center for Health Affairs, 2003.
Because concierge physicians generally treat fewer patients than
physicians in conventional practices, we assessed community-level data
on physician supply to see if other physicians might be available to
take on Medicare beneficiaries who choose not to join a concierge
practice. We calculated physician-to-population ratios in communities
where we found the highest numbers of concierge physicians and compared
them to the average ratio for all metropolitan areas in the United
States. To calculate this ratio, we used data from a 2003 HHS Health
Resources and Services Administration database known as the Area
Resource File. This database included county-level data on active,
nonfederal, office-based, patient-care physicians from the 2001
American Medical Association Physician Masterfile database and county-
level resident population data from the U.S. Census Bureau for 2001,
which we aggregated by MSA and PMSA.
We did not contact Medicare beneficiaries who were patients of
physicians who converted to concierge practices. We obtained
information from organizations likely to receive calls from Medicare
beneficiaries to determine whether individual beneficiaries were
reporting concerns about concierge care or difficulty finding new
physicians. We obtained and analyzed information from officials at CMS,
call centers for 1-800-MEDICARE, and 15 of 18 CMS contractors that
process Medicare claims for outpatient physician services. We spoke
with representatives of AARP, the American Bar Association's Commission
on Law and Aging, the Center for Medicare Advocacy, the Health
Assistance Partnership of Families USA, and the Medicare Rights Center.
We conducted our work in accordance with generally accepted government
auditing standards from May 2004 through July 2005.
[End of section]
Appendix II: Summary of Physician Responses to GAO Concierge Care
Survey:
This appendix summarizes the results from questions we asked physicians
who practiced concierge care as of October 2004. We sent surveys to 185
physicians with valid addresses whom we had identified as potential
concierge physicians. We obtained responses from 129 individuals, for
an overall response rate of 70 percent, and analyzed the responses from
112 physicians who practiced concierge care in October 2004.
The following tables and figures present information on reported
characteristics of the 112 concierge physicians who responded to our
survey and their practice settings (table 5), the estimated number of
patients in their individual practices (table 6), goals for the total
number of concierge patients when physicians' practices are fully
established (fig. 7), annual membership fees charged by physicians who
did and did not bill insurance (fig. 8), actions concierge physicians
reported taking to help Medicare beneficiaries who did not join their
concierge practices find new physicians (table 7), concierge
physicians' views on the sufficiency of HHS guidance on concierge care
and Medicare (table 8), and concierge physicians' views on remaining in
medical practice and treating Medicare beneficiaries if concierge care
were not an option (table 9).
Table 5: Characteristics of Concierge Physicians and Their Practices,
October 2004:
Characteristic: Year physician began concierge care:
Category: 1997;
Respondents: 2.
Category: 1998;
Respondents: 0.
Category: 1999;
Respondents: 1.
Category: 2000;
Respondents: 3.
Category: 2001;
Respondents: 11.
Category: 2002;
Respondents: 22.
Category: 2003;
Respondents: 41.
Category: 2004;
Respondents: 32.
Category: Total responses;
Respondents: 112.
Characteristic: Years physician in medical practice:
Category: 1-9;
Respondents: 14.
Category: 10-19;
Respondents: 44.
Category: 20-29;
Respondents: 45.
Category: 30 and above;
Respondents: 9.
Category: Total responses;
Respondents: 112.
Characteristic: Physician specialty:
Category: Internal medicine;
Respondents: 84.
Category: Family practice;
Respondents: 24.
Category: Other (e.g., emergency medicine);
Respondents: 1.
Category: Total responses;
Respondents: 109.
Characteristic: Practice setting:
Category: Solo;
Respondents: 41.
Category: Group;
Respondents: 65.
Category: Other (e.g., partnership, management group, and integrated
delivery system);
Respondents: 6.
Category: Total responses;
Respondents: 112.
Characteristic: Number of physicians in group practice[A]:
Category: 1- 9;
Respondents: 51.
Category: 10-19;
Respondents: 6.
Category: 20-29;
Respondents: 1.
Category: 30-39;
Respondents: 1.
Category: 40-49;
Respondents: 2.
Category: 50 and above;
Respondents: 3.
Category: Total responses;
Respondents: 64.
Characteristic: Number of concierge physicians in group practice[A]:
Category: 1;
Respondents: 10.
Category: 2;
Respondents: 30.
Category: 3;
Respondents: 24.
Category: 4;
Respondents: 4.
Category: 5;
Respondents: 4.
Category: Total responses;
Respondents: 72.
Characteristic: Status of transition to concierge care:
Category: All physicians: Complete;
Respondents: 22.
Category: All physicians: In progress;
Respondents: 90.
Category: Total responses;
Respondents: 112.
Category: Physicians who began concierge care during 2001 or earlier:
Complete;
Respondents: 9.
Category: Physicians who began concierge care during 2001 or earlier:
In progress;
Respondents: 8.
Category: Physicians who began concierge care during 2001 or earlier:
Total responses;
Respondents: 17.
Category: Physicians who began concierge care during 2002 or later:
Complete;
Respondents: 13.
Category: Physicians who began concierge care during 2002 or later: In
progress;
Respondents: 82.
Category: Physicians who began concierge care during 2002 or later:
Total responses;
Respondents: 95.
Characteristic: Treated some nonconcierge patients:
Category: Yes;
Respondents: 36;
Category: No;
Respondents: 76;
Category: Total responses;
Respondents: 112;
Characteristic: Reasons for seeing nonconcierge patients[B]:
Category: To ensure continuity of care for patients who did not join
concierge practice;
Respondents: 14;
Category: As part of a combined concierge and conventional practice;
Respondents: 11;
Category: As part of a subspecialty practice (e.g., pulmonology,
nephrology, endocrinology, cardiology, and sleep medicine);
Respondents: 11;
Category: Other (e.g., occasionally as a favor for family members of
concierge patients, to treat indigent and Medicaid patients, and to
cover for other physicians);
Respondents: 13;
Characteristic: Practice accepting new concierge patients; Category:
Yes;
Respondents: 101;
Category: No;
Respondents: 11;
Category: Total responses;
Respondents: 112;
Characteristic: Practice open to new Medicare concierge patients:
Category: Yes, only those who pay the membership fee;
Respondents: 62;
Category: Yes, and would consider waiving the membership fee;
Respondents: 33;
Category: No;
Respondents: 3;
Category: Total responses;
Respondents: 98;
Characteristic: Billed patient health insurance for covered services:
Category: Yes;
Respondents: 85;
Category: No;
Respondents: 26;
Category: Total responses;
Respondents: 111;
Characteristic: Of those who billed patient health insurance, billed
Medicare for covered services:
Category: Yes;
Respondents: 79;
Category: No;
Respondents: 6;
Category: Total responses;
Respondents: 85;
Characteristic: Relationship to Medicare:
Category: Participating;
Respondents: 84;
Category: Nonparticipating;
Respondents: 4;
Category: Opted-out;
Respondents: 23;
Category: Total responses;
Respondents: 111;
Characteristic: Age ranges of concierge patients:
Category: Percentage of patients aged 20 or younger:
Category: 0;
Respondents: 26;
Category: 1-24%;
Respondents: 76;
Category: 25-49%;
Respondents: 3;
Category: 50-74%;
Respondents: 1;
Category: 75% and above;
Respondents: 0;
Category: Total responses;
Respondents: 106;
Category: Percentage of patients aged 21 through 64:
Category: 0;
Respondents: 0;
Category: 1-24%;
Respondents: 4;
Category: 25-49%;
Respondents: 36;
Category: 50-74%;
Respondents: 42;
Category: 75% and above;
Respondents: 24;
Category: Total responses;
Respondents: 106;
Category: Percentage of patients aged 65 or older:
Category: 0;
Respondents: 3;
Category: 1-24%;
Respondents: 28;
Category: 25-49%;
Respondents: 34;
Category: 50-74%;
Respondents: 37;
Category: 75% and above;
Respondents: 4;
Category: Total responses;
Respondents: 106;
Source: GAO survey of concierge physicians.
Notes: Although there were 112 unique respondents, not all respondents
answered each question. The total number of responses expected for each
question varied; for example, only physicians who stated that they were
accepting new patients were asked whether they were accepting new
Medicare patients.
[A] Totals include the responding physicians. The responses for group
practice include some physicians who responded to the "other" category
for practice setting and nonetheless provided information about
multiphysician practice settings.
[B] Physicians could select more than one response to this question.
[End of table]
Table 6: Estimated Number of Patients in Individual Practice, October
2004:
Patients: Concierge patients;
Total number of patients: Minimum: 3;
Number who were Medicare beneficiaries: Minimum: 0.
Total number of patients: Maximum: 980;
Number who were Medicare beneficiaries: Maximum: 590.
Total number of patients: Mean: 326;
Number who were Medicare beneficiaries: Mean: 129.
Total number of patients: Mode: 600;
Number who were Medicare beneficiaries: Mode: 0.
Total number of patients: Total responses: 109;
Number who were Medicare beneficiaries: Total responses: 105.
Patients: Nonconcierge patients;
Total number of patients: Minimum: 0;
Number who were Medicare beneficiaries: Minimum: 0.
Total number of patients: Maximum: 4,000;
Number who were Medicare beneficiaries: Maximum: 2,800.
Total number of patients: Mean: 166;
Number who were Medicare beneficiaries: Mean: 57.
Total number of patients: Mode: 0;
Number who were Medicare beneficiaries: Mode: 0.
Total number of patients: Total responses: 109;
Number who were Medicare beneficiaries: Total responses: 105.
Patients: Total patients;
Total number of patients: Minimum: 20;
Number who were Medicare beneficiaries: Minimum: 0.
Total number of patients: Maximum: 4,035;
Number who were Medicare beneficiaries: Maximum: 2,825.
Total number of patients: Mean: 491;
Number who were Medicare beneficiaries: Mean: 185.
Total number of patients: Mode: 200 and 600 (multiple modes exist);
Number who were Medicare beneficiaries: Mode: 0.
Total number of patients: Total responses: 109;
Number who were Medicare beneficiaries: Total responses: 105.
Source: GAO survey of concierge physicians.
Notes: Although there were 112 unique respondents, not all respondents
answered each question. Physicians were asked to provide their best
estimates if specific patient counts were not available.
[End of table]
Figure 7: Physicians' Goals for Total Number of Concierge Patients,
October 2004:
[See PDF for image]
Notes: n = 111 concierge physicians practicing as of October 2004; 1
respondent did not provide this information. Physicians were asked
their individual goals for the number of concierge patients in their
care. The largest reported goal for number of concierge patients was
1,300.
[End of figure]
Figure 8: Annual Membership Fees Charged by Physicians Who Did and Did
Not Bill Patient Insurance, October 2004:
[See PDF for image]
Notes: n = 110 concierge physicians as of October 2004; 2 respondents
did not provide this information. Fees represent those charged for an
annual individual adult membership.
[End of figure]
Table 7: Actions Concierge Physicians Reported They Took to Help
Medicare Patients Who Did Not Join the Concierge Practice Find New
Physicians:
Action: Designated a staff person to help patients in transition (n =
81);
Percentage of physicians who reported each action, for approximately
how many patients: None: 15;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 3;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 5;
Percentage of physicians who reported each action, for approximately
how many patients: All: 78.
Action: Forwarded patient medical records to new physicians (n = 83);
Percentage of physicians who reported each action, for approximately
how many patients: None: 6;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 13;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 11;
Percentage of physicians who reported each action, for approximately
how many patients: All: 70.
Action: Remained available to treat all patients until they had found a
new physician (n = 84);
Percentage of physicians who reported each action, for approximately
how many patients: None: 7;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 11;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 15;
Percentage of physicians who reported each action, for approximately
how many patients: All: 67.
Action: Referred patients to physicians within group practice (n = 81);
Percentage of physicians who reported each action, for approximately
how many patients: None: 19;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 16;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 25;
Percentage of physicians who reported each action, for approximately
how many patients: All: 41.
Action: Provided patients with a list of area physicians who accept new
Medicare patients (n = 80);
Percentage of physicians who reported each action, for approximately
how many patients: None: 28;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 26;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 8;
Percentage of physicians who reported each action, for approximately
how many patients: All: 39.
Action: Referred patients to physicians outside the practice who accept
new Medicare patients (n = 83);
Percentage of physicians who reported each action, for approximately
how many patients: None: 13;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 51;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 8;
Percentage of physicians who reported each action, for approximately
how many patients: All: 28.
Action: Coordinated with patients' insurance companies to verify that
all patients chose new physicians (n = 77);
Percentage of physicians who reported each action, for approximately
how many patients: None: 66;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 17;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 7;
Percentage of physicians who reported each action, for approximately
how many patients: All: 10.
Action: Referred patients to their insurance or managed care
organizations for physician lists (n = 77);
Percentage of physicians who reported each action, for approximately
how many patients: None: 61;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 30;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 3;
Percentage of physicians who reported each action, for approximately
how many patients: All: 7.
Action: Called new physicians to discuss patient history (n = 81);
Percentage of physicians who reported each action, for approximately
how many patients: None: 12;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 80;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 3;
Percentage of physicians who reported each action, for approximately
how many patients: All: 5.
Action: Wrote individual letters on behalf of patients to new
physicians (n = 76);
Percentage of physicians who reported each action, for approximately
how many patients: None: 46;
Percentage of physicians who reported each action, for approximately
how many patients: Some: 49;
Percentage of physicians who reported each action, for approximately
how many patients: Most: 3;
Percentage of physicians who reported each action, for approximately
how many patients: All: 3.
Source: GAO survey of concierge physicians.
Notes: Percentages do not necessarily add to 100 because of rounding.
Although there were 112 unique respondents, not all respondents
answered each question.
[End of table]
Table 8: Concierge Physicians' Views on the Information Available from
HHS about How Medicare Requirements Affect Concierge Care, October
2004:
Subject: The information available from HHS is clear and sufficient;
Responses: Yes;
Number of physicians: 29.
Responses: No, but clear and sufficient information is available from
other sources;
Number of physicians: 20.
Responses: No, and clear and sufficient information is not available
from other sources;
Number of physicians: 38.
Responses: Don't know/no opinion;
Number of physicians: 24.
Responses: Total responses;
Number of physicians: 111.
Subject: More official guidance is needed from HHS on how Medicare
requirements might affect concierge care;
Responses: Yes;
Number of physicians: 67.
Responses: No;
Number of physicians: 20.
Responses: Don't know/no opinion;
Number of physicians: 24.
Responses: Total responses;
Number of physicians: 111.
Source: GAO survey of concierge physicians.
Note: Although there were 112 unique respondents, not all respondents
answered each question.
[End of table]
Table 9: Concierge Physicians' Views on Remaining in Medical Practice
and Treating Medicare Beneficiaries if Physicians Were Unable to
Practice Concierge Care:
Subject: If not able to practice concierge care, would have continued
in the clinical practice of medicine;
Responses: Definitely yes;
Number of physicians: 11.
Responses: Probably yes;
Number of physicians: 34.
Responses: Don't know/no opinion;
Number of physicians: 16.
Responses: Probably no;
Number of physicians: 32.
Responses: Definitely no;
Number of physicians: 18.
Responses: Total responses;
Number of physicians: 111.
Subject: Of those physicians who would have remained in medicine
without concierge care, interaction with Medicare beneficiaries;
Responses: Would have treated Medicare beneficiaries as a participating
physician;
Number of physicians: 25.
Responses: Would have treated Medicare beneficiaries as a
nonparticipating physician;
Number of physicians: 5.
Responses: Would have treated Medicare beneficiaries under private
contracts and opted out of Medicare;
Number of physicians: 7.
Responses: Would not have treated Medicare beneficiaries;
Number of physicians: 1.
Responses: Don't know/no opinion;
Number of physicians: 7.
Responses: Total responses;
Number of physicians: 45.
Source: GAO survey of concierge physicians.
Notes: Although there were 112 unique respondents, not all respondents
answered each question. Only physicians who stated they would have
definitely or probably continued in the clinical practice of medicine
were asked how they would treat Medicare beneficiaries if they were
unable to practice concierge care.
[End of table]
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Office of Inspector General:
JUL 19 2005:
Mr. A. Bruce Steinwald:
Director, Health Care:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Mr. Steinwald:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO's) draft report entitled, "PHYSICIAN
SERVICES: Concierge Care Characteristics and Considerations for
Medicare" (GAO-05-776). The comments represent the tentative position
of the Department and are subject to reevaluation when the final
version of this report is received.
The Department provided several technical comments directly to your
staff.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Signed by:
Daniel R. Levinson:
Inspector General:
Enclosure:
The Office of Inspector General (OIG) is transmitting the Department's
response to this draft report in our capacity as the Department's
designated focal point and coordinator for U.S. Government
Accountability Office reports. OIG has not conducted an independent
assessment of these comments and therefore expresses no opinion on them.
HHS COMMENTS ON THE U.S. GOVERNMENT ACCOUNTABILITY OFFICE'S DRAFT
REPORT ENTITLED, "PHYSICIAN SERVICES: CONCIERGE CARE CHARACTERISTICS
AND CONSIDERATIONS FOR MEDICARE" (GAO-05-776):
The Department of Health and Human Services (HHS) appreciates the
opportunity to comment on the U.S. Government Accountability Office's
(GAO) draft report.
General Comments:
The growth of concierge care has been the subject of some debate in the
past few years. Much of the concern has focused upon the impact
concierge care may have on beneficiary access to physician services.
HHS agrees with the GAO's finding indicating that concierge care has
had a minimal impact at this time. However, we remain interested in
developments in concierge care. Therefore, we will continue to follow
this area and to evaluate whether any further steps are indicated.
[End of section]
Appendix IV GAO Contact and Staff Acknowledgments:
GAO Contact:
A. Bruce Steinwald (202) 512-7119 or [Hyperlink, steinwalda@gao.gov]:
Acknowledgments:
In addition to the person named above, key contributors to this report
were Kim Yamane, Assistant Director; Ellen W. Chu; Jennifer DeYoung;
Linda Y. A. McIver; Perry G. Parsons; Suzanne C. Rubins; Craig Winslow;
and Suzanne Worth.
(290363):
FOOTNOTES
[1] See for example, the Medicare Equal Access to Care Act of 2003,
H.R. 2423, 108TH Cong., and the Equal Access to Medicare Act of 2003,
S. 345, 108TH Cong.
[2] In Washington, for example, the Office of the Insurance
Commissioner is monitoring concierge care and has considered requiring
that physicians who charge a set fee in exchange for comprehensive
primary care meet all the requirements that apply to health maintenance
organizations. The basis for this requirement is that an agreement to
provide unlimited health services in exchange for a fixed fee results
in the assumption of insurance risk.
[3] Pub. L. No. 108-173, § 650, 117 Stat. 2066, 2331. The conference
report for the Consolidated Appropriations Act, 2004, Pub. L. No. 108-
199, 118 Stat. 3, also directed GAO to study concierge care. H.R. Conf.
Rep. No. 108-401, at 806 (2003).
[4] See app. I for details on our scope and methodology.
[5] We use the term concierge care because the statutory provision that
mandated our work used this term.
[6] AMA Web site at http://www.ama-assn.org/ama/pub/category/print/11967.html, downloaded on March 16,
2005.
[7] Medicare's payment amount for physician services generally is
determined by a fee schedule and includes 80 percent payment from the
program and 20 percent beneficiary coinsurance, once the beneficiary's
annual deductible has been met.
[8] Medicare Payment Advisory Commission, Report to the Congress:
Medicare Payment Policy (Washington, D.C.: March 2005).
[9] 42 U.S.C. § 1395w-4(g)(2)(C) (2000).
[10] A beneficiary may be reimbursed no more than 80 percent of the fee
schedule amount for nonparticipating physicians, regardless of how his
or her nonparticipating physician chooses to bill.
[11] This option became available through the Balanced Budget Act of
1997, which amended the Social Security Act to specify that physicians
may enter into private contracts with Medicare beneficiaries. Pub. L.
No. 105-33, § 4507, 111 Stat. 251, 439 (codified at 42 U.S.C. §
1395a(b) (2000).
[12] Reimbursement may be made in cases where opted-out physicians
provide emergency or urgent care to beneficiaries with whom they do not
have private contracts.
[13] 42 U.S.C. § 1395y(a)(1)(A) (2000).
[14] 42 U.S.C. § 1320a-7a (2000).
[15] Medicare Payment Advisory Commission, Report to the Congress:
Medicare Payment Policy (Washington, D.C.: March 2005).
[16] Other groups which have estimated the number of concierge
physicians include the Society for Innovative Medical Practice Design
(formerly the American Society of Concierge Physicians), which
estimated that about 200 concierge physicians practice in the United
States. AMA's Institute for Ethics located 144 concierge physicians,
using the same identification approach that we followed, for its own
study in 2003.
[17] An MSA is a geographic region consisting of a central county or
counties that contains an urban area with a population of at least
50,000 plus any adjacent counties having a high degree of social and
economic integration with the central county
[18] Two concierge physicians, both in Washington, were not located in
MSAs.
[19] Converting a conventional practice to a concierge practice may
take time. Our data on new and established concierge practices included
physicians responding to our survey who charged membership fees and
offered enhanced features to at least some of their patients in October
2004, although some of these physicians may have still been seeking
additional concierge patients and continuing to treat some nonconcierge
patients.
[20] Because our survey included only physicians who practiced
concierge care during October 2004, it does not account for physicians
who may have started and discontinued concierge practices before that
date, or physicians who started to practice concierge care after
October 2004.
[21] About one-third of our respondents were affiliated with a
consulting firm that helps physicians establish and maintain concierge
practices. This firm recommends that concierge physicians offer a
program oriented toward preventive care, limit patients to no more than
600 for each physician, and submit claims to insurers for covered
services.
[22] Our survey distinguished between concierge patients granted
waivers of the membership fee but still offered the enhanced features
of concierge care, and "nonconcierge" patients who were neither charged
a membership fee nor offered the features associated with concierge
care.
[23] Information on the number of patients seen per day was provided by
101 of the 103 physicians who reported that they established their
concierge practices in the same community in which they had practiced
before converting to concierge care.
[24] Subspecialties for which concierge physicians reported seeing
nonconcierge patients included pulmonary medicine, endocrinology, and
nephrology.
[25] HHS refers to concierge care contracts as "physician-patient
retainer agreements."
[26] The memorandum also states that retainer agreements could be
problematic if they attempt to substitute for Medicare supplemental
insurance policies. CMS officials reported encountering problems with
physicians offering unregulated supplemental policies in the mid-1990s.
In June 2005, CMS officials told us that, while such substitutions are
not allowed, they are no longer concerned that retainer arrangements
are being used as substitutes for Medicare supplemental insurance.
[27] Office of Inspector General, OIG Alerts Physicians about Added
Charges for Covered Services (Washington, D.C.: Department of Health
and Human Services, Mar. 31, 2004).
[28] 42 U.S.C § 1320a-7a(a)(2) (2000).
[29] The term concierge patients includes all patients who are offered
enhanced services or amenities, including those whose membership fees
have been waived.
[30] See app. I for a list of the sources we reviewed.
[31] Medical Payment Advisory Commission, Report to Congress, Medicare
Payment Policy (Washington, D.C.: March 2005).
[32] GAO, Medicare Fee-for-Service Beneficiary Access to Physician
Services: Trends in Utilization of Services, 2000 to 2002, GAO-05-145R
(Washington, D.C.: Jan. 12, 2005).
[33] It is possible that some beneficiaries have called Medicare claims
contractors about concierge care and had their inquiries identified
more generally, for example, as "miscellaneous."
[34] Fifteen contractors responded to our inquiry out of a total of 18
contractors who process Medicare claims for outpatient physician
services.
[35] This contractor processes claims for physician services for
California, Maine, Massachusetts, New Hampshire, and Vermont.
[36] See app. I for a list of the organizations we contacted.
[37] The scope of our work did not include physicians who imposed
additional charges solely to cover the costs of routine administrative
services, such as filling out forms. In addition, our results do not
include the views of nonconcierge physicians or physicians who may have
once practiced concierge care but no longer do.
GAO's Mission:
The Government Accountability Office, the investigative arm of
Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order
GAO Products" heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office
441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov
(202) 512-4800
U.S. Government Accountability Office,
441 G Street NW, Room 7149
Washington, D.C. 20548:
