A Boutique System of Primary care for Medicare

Copyright (C) 2009 Robert S. Rosson. All rights reserved.

The shortage of primary care physicians has been well-documented in these pages and elsewhere.  It is particularly acute with respect to Medicare patients.  Not only are physician reimbursements low, but these patients often have complicated illnesses requiring more time than the physician has to give. Many primary care internists have closed their practices to new Medicare patients.  Graduating medical students are opting for more lucrative fields such as cosmetic dermatology or plastic surgery. 

Many internists have turned to a boutique or concierge system of medical practice in order to provide better care, increase income and improve physician life style.  This system involves a limited panel of patients and a pre-paid retainer fee.  In return the patient is guaranteed 24/7 access, adequate time for visits, and home care.

I have suggested a boutique system for Medicare patients, associated with an incentive to attract medical students into primary care.  James Ocampo, a fourth-year medical student at the University of Connecticut, is currently working on this idea as a selective project.  Such a plan might work as follows:  Medicare would support the formation of groups to provide boutique care exclusively to Medicare patients.  Groups would consist of four to ten internists complemented by nurse practitioners and physician assistants. The groups would provide ready access to care 24/7 with same day access, easy communication by telephone or e-mail, home visits, and adequate time for office visits. The optimal panel size per physician and the amount of the annual retainer per patient remain to be determined.  Hospital care and prescription drug coverage are not included in this proposal.

Medicare would pay the retainer per patient plus a reasonable overhead sum to the groups. Patients would pay the usual Medicare monthly fee plus deductible, with adjustments for income level.  An additional surcharge may be added for the boutique program.  Patient satisfaction with access and quality of care would be measured by annual questionnaires.

As an incentive for medical students to choose internal medicine residencies and residents to join Medicare boutique groups, a program of debt forgiveness would be initiated by Medicare.  Reimbursement for student debt could vary from 25 percent per year for four years to 10 percent per year for 10 years of service.

I am confident that Mr. Ocampo’s research will indicate whether this plan could provide improved access and quality of primary care for seniors at reasonable cost, and attract medical students into primary care.  If such a plan appears reasonable, a grant for a pilot project funded by the government or other funding agency could be sought.

Published originally in YJHM February 1, 2009