Thursday, December 20, 2012

Is Concierge Medicine For You?

With the Affordable Care Act now a reality, many physicians are looking for ways to improve their bottom line. Providers are concerned that shrinking reimbursements and more complicated insurance requirements are going to whittle away at their profit margins. The public sees doctors as a part of the elite upper class, but doctors face money worries as well. Hundreds of thousands in student loans, overhead for a practice, malpractice insurance and their own bills all weigh heavily on physicians. The reality of being paid less to see more people is frightening and has many providers looking for an alternative. For up to 5,000 of those doctors in the United States, concierge medicine has been the answer.

Concierge medicine goes by many names:  direct care, retainer medicine, boutique practices, and private doctors. The patient pays an annual fee in return for patient-centered care with lots of perks. These perks range from having the doctor’s private contact information, round-the-clock care, extended appointments, and little-to-no wait time. In a world where time is money for many people, having a doctor who can see them any time of the day is a huge improvement on waiting for hours. For doctors, it is an attractive option because the annual fees are straight profit. Also, there is less pressure to see as many patients as possible in a day. Most boutique providers only have between 100 and 500 patients on their roster, so there is more time for each patient and less time spent coding and billing.

There are several things that must be considered when changing from a traditional practice to one that is focused on concierge medicine. The most basic decision is whether all insurance contracts will be severed. The alternative is to have what is called a “mixed practice.” A portion of patients pay the retainer for concierge services, while the remainders are traditional patients who either pay an out-of-pocket fee for services or have insurance.  This may feel like a safer option since you can count on reimbursements from insurance, but it can actually be more complicated when it comes to billing and insurance regulations. Consulting with your attorney at this step of the process is imperative so the limitations of this type of practice are fully understood.

The cornerstone to practicing concierge medicine is the fee arrangement between patient and doctor.  The key aspects of the contract include laying out what the annual retainer fee covers, what will be charged for additional services, and how fees will be structured. The average annual cost per patient is between $1500 and $1800 and normally includes basic well care, as well as “luxuries” like the physician’s email and cell phone number, same day or next day appointments, and after-hours appointment times. Items that are often not included in the basic fee are additional tests and sick visits. Different models include paying for “levels of service” in addition to the retainer, and some use a “pay-as-you-go” system. The contract that patients sign should be in very clear and concise language. It is also imperative that the provider has a delegate to help guide patients through the enrollment process so all questions can be answered and concerns addressed.  In a “mixed practice” it must be very clear what will and will not be filed with insurance. Once the provider changes the practice into a boutique practice, the AMA Code of Medical Ethics states that any patients who do not choose to pay the retainer must be transferred to another physician. 

A survey of 501 doctors in 2011 by the Deloitte Center for Health Solutions showed that 64% believe a concierge medical practice that does not take insurance has the greatest chance of financial success with the new healthcare reforms. With this sentiment rising, the number of private doctors will likely grow in the next several years. If this is something that you are thinking about for your own career, it is vital to meet with an attorney to discuss the best ways to transition your practice. Careful structuring up front will create a smooth conversion for the practice and its patients.


DuBois, James M. et al. (September 3, 2012). Will Concierge Medicine’s Image Improve as it Evolves? American Medical News. Retrieved December 11,2012.

Harris, Steven H. (October 8, 2012). What to Consider before Switching to Concierge Medicine. American Medical News. Retrieved December 11,2012.

Monday, December 17, 2012

Physicians and Pharmaceuticals: What are the Rules?

The relationship between pharmaceutical companies and medical providers has been a long and complicated one. Not so long ago, physicians were being treated to lavish trips, tickets to expensive concerts, and fancy meals in the name of education. Representatives from drug companies were given seemingly endless money to convince doctors that their drug was the best on the market. The idea was that the more gifts and freebies, the more prescriptions were written. While it seemed to be a mutually beneficial relationship, concern began to grow that one part of the equation was losing out: the patient.  Public perception was that when it came to choosing medicines, doctors were not doing what was best for their patients; they were doing what was best for their pockets. Public opinions of big pharmaceutical companies soured. In an effort to right the problems in the industry and restore the public’s faith, in 2009 The Pharmaceutical Research and Manufacturers of America (PhRMA) updated its code of ethics to include banning all kickbacks.

Many physicians deny that gifts and meals influence their prescription writing. Studies show differently. In 2000, the Journal of the American Medical Association showed a direct correlation between receiving gifts and writing prescriptions. This applies even to small gifts like pens and stethoscopes. Doctors are more apt to write scripts for meds that come from companies that give them things, even though it is subconscious. It is part of the human nature to want to reciprocate when a gift is given.

The focus of the pharmaceutical industry has shifted its focus to pure education. All interactions with doctors and healthcare workers must be of educational or scientific value. Companies can provide “modest” meals for medical offices, as long as there is an educational component. The rep must use the time to teach about their product. Gone are the days that lunch could be dropped off with a stack of brochures and a bunch of pens. Also, all “lunch and learn” sessions must be held in-office. The code has banned any meals provided outside the office.  

It is important for any items provided to the office be 100% educational. There can be no personal use or possible personal use of any gift. For example, a heart diagram poster for the exam room is acceptable, because it provides useful information and can assist with patient education. A small DVD player that shows an educational video about the heart is not, because the provider could use it outside of the office for personal use.  Even small items such as pens, notepads, and clipboards are no longer deemed acceptable gifts, despite the fact that they are of little value. Any educational gifts that are provided should be sporadic and have a value of no more than $100.

Pharmaceutical companies are permitted to sponsor CME courses. There are several criteria that must be followed closely. The class should not be in support of a single medicine and the company may not have any part in planning the course. Also, any financial aid is to be given to the organizer to disburse among all participants. If a company pays for a particular physician, that is considered a cash gift. Also permissible is financial support for a conference of a meeting. These follow the same rules as CME. Donations to defray cost to the physicians must be disbursed evenly and education must be the main focus of the gathering.

One way the pharmaceutical companies have continued trying to focus attention on the top producers is to make them a paid speaker. Reps target the top 20% of their doctors because studies show that this group writes as many prescriptions as the rest of the 80%. The best way they can court the top tier is to make them what the industry calls “thought leaders.” The doctors are paid for their time and knowledge and are educated on a certain drug and then sent out to speak to other doctors. The code indicates that training must take place in an appropriate venue and specifically names resorts and vacation spots as inappropriate. The 2009 ethics code allows for speakers as they are seen as a “valuable part of the industry.”  It permits that they be paid for their time, lodging, travel, and meals. It is imperative that in turn the doctor provides a “valuable service to the company” as well as makes it clear that they are being paid for their endorsement. Physicians who do take on this role have the responsibility to ensure that is more than just being a “token consultant” and that actual appropriate education is being provided. 

Understanding what is and is not appropriate in the pharmaceutical rep /doctor relationship is important for both medical offices and patients. Physicians’ number one concern should always by the patient. Maintaining a professional and ethical relationship with their reps ensures that they are always putting their patients’ needs above anything else.

Wazana, Ashley. (January 19, 2000). Physicians and the Pharmaceutical Industry: Is a Gift ever just a Gift? The Journal of the American Medical Association. Retrieved December 6, 2012 from

Spiegel, Alix. (October 21, 2010). How to Win Doctors and Influence Prescriptions. NPR. org Retrieved December 6, 2012 from

Code on Interactions with Healthcare Professionals. (July 2008). Retrieved December 6,2012 from

Thursday, December 6, 2012

Holiday Party Etiquette

It is the time of year again when companies everywhere are planning their holiday celebrations. While it is a great time to unwind and enjoy coworkers and management alike, it is an easy time to make a misstep that can affect your job. Follow these simple rules for a disaster-free office party. 

Planning Rules:

Respect the Diversity of the Office. If your office has a diverse religious population, be sensitive with theme, decorations, entertainment, and games. It is important to make everyone feel welcomed and included in the holiday celebration.

Pick an Appropriate Venue. The attitude and culture of the office should be considered when choosing where to host the party. A bar may be not be appropriate for a conservative workplace. A buttoned-up fancy restaurant may not be the proper location for a more progressive workplace. Make sure the employees will be comfortable wherever you choose.

Determine Who is Invited. Decide early in the planning process who will be included in the festivities. Budget constraints are causing lots of businesses to scale back, so often the budget will determine if families or “plus ones” will be included.

Think about Time of Day.
When is the best time for your employees to celebrate, and what works best within the party budget? It is often a huge treat in itself to close the office for an extended lunch. Middle of the day celebrations also tend to be less expensive. If the majority of employees are parents or have many outside obligations, it may also make more sense to plan a lunch. For other businesses, it is impossible to do something during office hours. Also, employees may look forward to a chance to enjoy a night out at a holiday party.

Make the Invite Clear. Don’t leave any of the details to chance. Be specific about whether guests are included, what the dress is, and if there will be a cash bar. Being clear will help avoid any uncomfortable situations.

Employee Rules:

Don’t Drink too Much. Often there is a bar at the company party. Be very careful with the amount you and your date drink. Embarrassing situations can quickly arise when coworkers are intoxicated. It will be difficult to show your face at work on Monday if you make a fool out of yourself in front of the boss.

Dress to Impress. Determine ahead of time acceptable party attire. It never feels good to show up in the wrong thing. It is uncomfortable to show up in a cocktail dress when the boss is in jeans. Avoid the mortification of wearing a tacky Christmas vest if you are supposed to be wearing a tux. It is also wise to err on the side of conservative when choosing for the work party. Too much cleavage and too tight clothing are as inappropriate at the office holiday party as they are at the office.

Make an Effort. Your demeanor at the Christmas work party is important. Having a holiday celebration is a gift from your employer. Being unappreciative reflects poorly on your character and makes you look bad to other coworkers and ultimately your boss. It is important to smile, make appropriate small talk, and enjoy yourself.  Participate in whatever is being offered, whether it is karaoke, dancing, games, or singing carols. Anything less will be noticed.

Attendance is Important. How often do you find yourself enjoying hors d ’Oeuvres and a beer with your boss? The holiday party is one of the only times of the year most employees have to chat with the higher-ups in a relaxed atmosphere. Also, it does not look good to simply “make an appearance.” Others will note that you did not stay through the owner’s boring speech or the gift exchange.

Don’t do Anything that can Affect Your Job. Drinks and dancing may lead coworkers to do things that would never happen in the light of the day. Remember that office gossip can be fierce, and mistakes at the Christmas party can decimate your reputation. Any inappropriate behavior on office property is a lapse in judgment that can lead to dismissal.

Enjoy the Food in Moderation. Don’t be the coworker that stands at the buffet heaping food on your plate while everyone else nibbles a few appetizers. You should enjoy the food provided, but don’t take more than your share. Remember that you need to able to chat with coworkers and management, and that is hard when you are busy eating.

Office parties are a fun way to celebrate the holidays. They provide a chance to unwind and enjoy coworkers with no deadlines, projects or customers.  Just remember, following the proper rules of etiquette when planning and attending the office Christmas is imperative. Anything less and you may show up at the office with a lot of embarrassment and possibly a pink slip.
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