CMS has, in the past, expressed concern regarding the use of concierge medicine by physicians treating Medicare patients. CMS has prosecuted some concierge care practices for charging concierge fees for “non-covered services” under Medicare. Despite this opposition, patients and physicians have increasingly implemented concierge-like relationships, including amenities that provide unlimited access to physicians via email, phone, or internet portals, house calls, and provide annual physicals for a periodic flat fee.
In response to rising health costs and political pressure from both legislators and the American Medical Association, the Affordable Care Act has forced CMS to begin a shift away from the traditional fee-for-service payment system and begin considering other types of payment, such as bundling and other innovations to reduce costs and measure quality. The Affordable Care Act required CMS to develop pilot programs in order to reduce costs or improve quality and expand successful programs nationwide after January 1, 2016. Some of these programs are beginning to resemble concierge practices.
CMS has already been experimenting with bundled payments projects for two decades. For example, since 2009, Medicare has been using the Acute Care Episode bundled payment program to cover 37 cardiovascular and orthopedic procedures. While the program evaluation is still pending, preliminary data suggest savings of up to 10 percent and improved quality of care. Criticisms of the program includes that it does not cover rehabilitation and other post-discharge services; participation is optional and only a few hospitals are participating.
Recently, CMS established a pilot program for integrated care, using episodic payments centered around hospitalization. This pilot program will be available to entities comprised of providers of services and suppliers including a hospital, a physician group, a skilled nursing facility, and a home health agency. Those payment methods can include bundled payments and bids from entities for episodes of care. Again, the direction of this program is away from Medicare’s traditional fee-for-service reimbursement methodology.
Another way that CMS is responding is by establishing family medical home pilot projects where CMS provides grants or contracts directly with certain states to establish community-based interdisciplinary, interprofessional teams to support primary care practices. These medical teams agree to provide services to eligible individuals with multiple chronic conditions and receive a monthly payment for patient management and providing non-Medicare services. Since these practices are not hospital centric, they require personal physicians to lead all other health providers in caring for their patients. It is assumed that care will be coordinated through all of the providers using integrated healthcare technology, which some argue must be updated to meet the new demands. Interestingly enough, the family homes have a requirement that payments recognize the primary care value and should reflect both physician and non-physician value, including non-face-to-face visits in care management. The payment structures even allows for a $6 per month payment to the doctor for providing non-covered services. These family medical homes begin to resemble concierge care as they provide a primary care doctor who is responsible for overseeing the patients’ care.
Presently, there are estimated to be twenty-six ongoing medical home pilots encompassing 14,000 plus physicians in over 4,500 practices, treating five million patients. With mixed results, some physicians and providers have begun to adapt to the changes in their practice. On the one hand, some patients do not perceive this change to be beneficial. In particular, the use of nurse practitioners and paraprofessionals often are perceived by the patients to be a restriction on their access to care. However, data does suggest that patient outcomes improve in this model and costs become lower with use of the medical home, but it requires substantial investment in technologies and infrastructure to obtain this success.
In summary, although CMS has not fully embraced concierge medicine, the landscape of Medicare billing is quickly changing and the traditional practice models may evolve into medical homes that closely resemble the concierge practices. Perhaps the payment models may evolve in the same direction.