Introduction

The medical profession is undergoing a quiet but growing revolution and a new sub-set of health care providers is forming. While millions of uninsured Americans struggle to mitigate the financial and emotional toll health care expenses have on their lives, many physicians are becoming increasingly frustrated and disappointed with the limiting hurdles imposed upon them by the medical insurance industry. Resentful of the financial losses from being forced to accept reduced “negotiated” fees and further stymied by directives from a business person in a corporate office dictating patient care, an increasing number of health care providers are rejecting the medical insurance industry completely and have begun to transform their clinics into nontraditional practices that provide high-end, “luxury” style healthcare. Referred to as “Concierge Care”, “Boutique Medicine”, “VIP Medicine”, and more recently “Direct Practice”, the movement surfaced in Seattle in the 1990’s and was touted as a new business opportunity designed to provide superior quality and greatest availability of healthcare to a limited market niche of “discerning” patients in exchange for annual retainer fees – usually hundreds or thousands of dollars. Under this model, physicians do not accept medical insurance. In exchange, the physician offers services that typically include same-day appointments, more face to face time with their doctor, house calls, physician coordination of specialty-care referrals, and around-the-clock telephone, pager, and e-mail access without fighting the dreaded “phone tree”. In principle, the patient receives more personalized care, and the physician avoids the headaches and high costs of overhead required by administrating insurance in their practices. The emergence of boutique medicine or retainer practice is appealing to the select few who can afford such care, however, for the rest of the population the issue raises important medical, ethical, and legal questions.

New census data taken from the Center on Budget and Policy Priorities, http://www.cbpp.org/8-26-08pov.htm indicates that although the number of “Americans without health insurance fell from 15.8 percent in 2006 to 15.3 percent in 2007, and the number of uninsured declined by 1.3 million to 45.7 million, the improvement occurred because the increased enrollment in public programs — notably Medicare and Medicaid — more than offset a decline in the portion of the population with employer-sponsored coverage.” The percentage of Americans with private health insurance has continued to drop steadily over the past several years and was down to 67.5% as of the 2005 census. The costs of insurance premiums have skyrocketed making coverage out of reach for over one-third of our country’s population, and unaffordable for many small and medium sized businesses as well. Data from the Kaiser Family Foundation http://kff.org show that, “on average, employers are requiring employees to contribute more in cost-sharing (i.e., premiums, deductibles, and/or co-payments) for their health insurance and that fewer small businesses are offering health coverage.” The news is even direr for minorities groups. The census data shows that lack of health insurance is much more common among people with low incomes, and African-Americans and Hispanics were much more likely to be uninsured than white, non-Hispanic people. The elderly and/or the infirm are often unable to afford insurance in the individual market. Coverage is typically only offered to these individuals at very high rates, or they may be denied insurance completely, because of the entrenched practice of medical “underwriting”. This practice denies or greatly limits the amount of insurance offered based on the projection or likelihood that sicker individuals are likely to incur higher health care costs.

In light of these numbers, it is clear that the emergence of the concierge care model of medicine contributes to the widening of the gap between the “haves” and the “have nots” and amplifies class distinctions. Medical resources available to the uninsured and underinsured are undermined in the shift of the best care to a privileged few and raise the murky legal question of discrimination. Yet, Concierge Practice provides an environment of health care that focuses on wellness and prevention rather than on diagnosis and treatment – a focus that is lacking in traditional medicine and is often ignored as an aspect of medical insurance. Proponents of Concierge Care argue that with fewer patients to see and less paperwork, physicians’ attitudes and level of career satisfaction improves and they have more time to engage in altruistic activities beneficial to public health such as volunteering services to community clinics and increasing humanitarian or charity care. One local family practice physician, Dr. Stacey Robinson, is devoting her time and energy to search for an alternative to the traditional family practice model and the concierge care model. Dr. Robinson is attempting to build her clinical practice by combining elements that have heretofore been mutually exclusive – providing high end, quality care emphasizing wellness to all patients regardless of income, while simultaneously rejecting insurance company payments and policies. With a combined patient base of retainer patients and indigent care patients, she believes she can provide all her patients with exemplary care by employing the Robin Hood model – take from the rich to give to the poor…

The Robin Hood Model

Young, bright and deeply caring, Dr. Robinson has long been dogged by the often contrary goals of caring for her patients on the level she feels they deserve and the hurdles she and other physician face by the rules and regulations of the managed care insurance industry. She received her medical degree at Tulane Medical School in 1996 and among other distinctions, served as Medical Director of the Primary Care Clinic at MacDill AFB as an Air Force Major. She prefers Stacey to Dr. Robinson and is as comfortable in her softball clothes as she is in her white coat and is as kind and generous of spirit as she is efficient and practical. Highly active in charitable work, she and her husband, who is an anesthesiologist, spend enormous amounts of their personal time and money working to help the less privileged even as they juggle the demands of their careers and their two young children. Driven by her desire to help those less fortunate and supported by her belief in a more holistic approach to medicine that combines a mind-body-spirit approach to wellness, Stacey embarked on a quest last year to open her own practice. Intrigued by the benefits of the concierge model, yet disturbed by the negative impact on the poor, Stacey is striving to find a balance. Being bound to the insurance industry was not an option, nor did she want to build her practice on the elitist element inherent in the Concierge Medicine model. How could she practice what she loved, survive financially and still give back? Months of reflection brought her to the idea of a self-sustaining family practice that could provide concierge care and indigent care in equal amounts. Looking for a model to build from, her research revealed only one other practice in the country that had attempted to make this model work; St. Luke’s Family Practice in Modesto, California. Inspired and energized, she started her practice several months ago in June of 2008, and as one can see on her website, http://www.robinsonfamilymedicine.com/giving_back, her personal vision is reflected in this message: “The best solution to this health care crisis will come from within our community not from politicians.”

Interview

Dr. Robinson…Stacey, was gracious enough to give me some of her personal time to answer some of my questions:

1. Stacey, would you explain why you chose this model of healthcare for your practice?

I got tired… tired of being a slave to the insurance industry, tired of seeing patients who were frustrated with a broken system (that I was a part of), and tired of not being able to give patients the care that I knew they deserved. After practicing medicine in an insurance-driven system for the past 10 years, I have come to the conclusion that we need to look outside of the insurance industry to provide quality and personal primary care that every patient deserves. As the cost of health care increases, insurance companies reimburse less money, especially to primary care physicians. Physicians have to see 10 more patients per day than they did 10 years ago to keep their practices afloat. We run faster and faster to keep up while providing less care to our patients. The irony is that the majority of a physician’s office overhead goes toward the process of collecting money from the “middle man”, the insurance company. The direct practice model appealed to me because it eliminates the middle man and allows time to give patients the care they need, time to address things like poor lifestyle choices and chronic stress that are making us sick in the first place. It is estimated that ninety percent of disease is caused by poor lifestyle choices and chronic stress. The average face to face time with a doctor in an insurance driven practice is seven minutes. Physicians do not have time to address the real issues so they resort to ordering tests and writing prescriptions which drives up the cost of healthcare. It is a vicious cycle leading to higher cost of health care and even poorer health of our population. Although I liked the idea of the direct practice model, I didn’t like the idea of caring for only those who could afford it.

2. **How would you define a Robin Hood Practice?**** When I came across the article written by Dr. Forester describing this “Robin Hood model”, I knew this was the model I wanted to follow. The beauty of this model is that it is a non-profit model that is self-sustaining and the first non-profit clinic of its kind. Half of the patients (the benefactors) pay for the personal care of a direct practice and the other half (recipients) get their care for whatever they can afford to donate. The patients who benefit are those who fall through the cracks of our health care system, those who don’t qualify for governmental assistance but who can’t afford to purchase health insurance or whose employer doesn’t offer it. 3. I understand your long-range vision is to build a medical center that will provide a range of wellness services and that it is your dream to have this center materialize almost exclusively from donations and pro bono work from other professionals. In essence, a non-profit medical practice. What kind of feedback have you received when you floated this idea?**** I have had very positive feedback. This model allows physicians and patients to give back to our community and lift up those working poor (and now even the middle class) who are struggling to make a living and raise healthy families. 4. Has the response varied depending on your audience? For example, are other physicians supportive or cynical?**** Everyone who has taken the time to understand the model and the vision has been supportive. 5. What about other kinds of health care providers or social service professionals – what has been there response?**** I have presented the idea to the Midtown Health Counsel, a group of social service professionals. They were all very supportive. The health department director of community clinics thought that this concept fills a huge gap that they can’t fill. There are 140,000 uninsured residents in Pinellas County and only 20,000 qualify for governmental assistance (those whose income is at or below the poverty level). The Pinellas County Health Department is opening eight clinics to serve this population but that leaves 120,000 uninsured, working poor who will still have little access to routine primary care. 6. Do you think you will have to limit the type of patients you are capable of serving? Perhaps relying on a sliding scale for fees?**** I believe that there are enough patients willing to pay for personalized care of a direct practice, especially if it provides free care for someone who is less fortunate. Patients across the country are paying an average of $1800/year for this care. In our model, for each person willing to pay, another person gets the care they desperately need but can’t afford. We considered a sliding scale; however, the problem with a sliding scale is that it would add more overhead expenses for collections and bookkeeping. One of the premises that make this model work is a low practice overhead. The patients (benefactors) who can afford to pay for a direct care model pay an annual fee which eliminates the need to collect money at each visit. The other half are asked for a donation but aren’t billed any specific amount. 7. What do you think will be your greatest obstacle in achieving a self-sustaining practice?**** No obstacle is too big. If it is meant to be, it will happen. 8. You once mentioned that you were looking to make this a not for profit practice and that you were concerned about to make that happen. **** Yes, I don’t know much about this 501(c) 3 business – it is daunting but as I said, no obstacle is too big! 9. How do you intend to get the word out to your intended audience?**** The media and word of mouth. 10. How do you intend to generate community interest? Again, the media and word of mouth. 11. Do you see your model as the seed of an emerging community – a community of physicians supporting the Robin Hood model? **** There**** ****is already a community of direct practice physicians (see www.simpd.org). According to Dr. Forester, physicians from around the country are calling him for advice on starting similar clinics. I would love to see this model spread throughout our communities. I don’t think we should sit around and wait for the government to fix the health care crisis. I believe that it will be more effectively solved at the community level and it won’t be solved without restoring the integrity of the patient-physician relationship. Conclusion**

 Hi Pattie

I think that your narrative is really good. I like the fact that you used statistics to prove your point. My only issue with the paper was all the statistics. I kind of got  lost in the numbers. Maybe as your project continues you can have a version of this narrative that has simple language. I really thought that your narrative was great. As I told others I reviewed I read for content on the first go round not grammar. I enjoyed your narrative.

I'm still working on my recomendations and will upload asap