The New Wave of Concierge Medicine

What is Concierge Medicine and What’s Been Changing?

Paying cash for a better healthcare experience has been a core part of medicine through the ages. It’s a concept even older than the presidential candidates.

Outside of the US, what you get paying cash is a bit more straightforward. You can pay extra cash to get better amenities at hospitals (room, food, a cold one?, etc.) and better doctors charge much higher rates. 

But as per usual in the US, we want to take the faux egalitarian stance that says everyone should have equal access to the same healthcare services while also creating regulatory and reimbursement structures that create a tiered system anyway. It’s just now there are added levels of confusion in the form of paperwork and “asking a doctor friend for a favor”.

And so instead, “Concierge Medicine” exists as a strange escape hatch. Concierge Medicine is basically people paying some form of cash retainer for a clinic, and in exchange you get a certain set of services, amenities, and access. Some concierge medicine clinics bill your insurance on top of the retainer fee. 

There are many different forms of concierge medicine. Traditionally, there have been concierge programs which are basically private practices that “one-foot-in-retirement” docs or famous docs (e.g. the orthopedist for the Yankees) set up for wealthy patients who want extra time or fast access. 

Executive Health Plans are another form of concierge medicine that typically takes place at large health systems. Programs like Mayo Clinic’s Medallion Program, Cedars-Sinai Executive Health, and Ochsner Health’s Concierge program. And it’s for all executives, even all the “partners” at venture firms.

More practically, for the price of $2-20K per year these programs will include:

• Running a battery of tests (labs, EKG, imaging, etc.)
• Extended visits with a primary care physicians to go over everything concerning you
• On-site coordinators that will take care of your stay and be your point of communication
• Unlimited text/telemedicine follow ups
• No wait times if you want to schedule another appointment
• And other things that plebeians expected at their regular primary care visit

While I think having a 60 minute visit where a doctor listens to all your concerns definitely is appealing, the implicit bargain you get from these programs is cutting months long wait times to get near instant access to the best specialists when you need them. You just can’t say that out loud because all patients are equal, it’s just that some are more equal than others.

An excerpt from a New York Times article in 2017 on concierge care highlights this more clearly.

“When John Battelle’s teenage son broke his leg at a suburban soccer game, naturally the first call his parents made was to 911. The second was to Dr. Jordan Shlain, the concierge doctor here who treats Mr. Battelle and his family.

“They’re taking him to a local hospital,” Mr. Battelle’s wife, Michelle, told Dr. Shlain as the boy rode in an ambulance to a nearby emergency room in Marin County. “No, they’re not,” Dr. Shlain instructed them. “You don’t want that leg set by an E.R. doc at a local medical center. You want it set by the head of orthopedics at a hospital in the city.” - New York Times

So while your peasant ass technically might have that orthopedics doctor in-network, you won’t be able to see them for months and you’re going to be fighting your insurance the whole time before they’ll even do the visit. What money buys you in this case is time.

Concierge medicine isn’t new; here’s a JAMA paper that looked at ~30 of these programs at top medical centers. But lately I’ve seen a shift in the value-prop of these retainer-based programs, which I’m dubbing the “new” concierge models. 

**I want to make it super clear before we go into this that this isn’t me endorsing any of these models. I’m just explaining trends I see, don’t tase me bro.

Concierge Unbundled

If you look at the list of things the Concierge programs sell, there’s actually a lot in there. Not everyone is willing to pay $5K+/year for all of those services, but they would pay less for a subset of those services.

For example, direct primary care is all cash primary care that charges a monthly subscription fee that’s generally <$100/month and most don’t take insurance. They offer low wait times, direct lines to the doctor, the same doctor(s) each time, prescription refills quickly, and a community of other DPCs that will tear you limb from limb if you explain the concept of direct primary care incorrectly. But DPCs generally lack the specialist piece (consults, fast tracking a referral or interpretation, etc.) and don’t have the brand name hospital behind them. 

One Medical offers a slightly more “democratized” version of concierge - where you pay a smaller retainer fee of $199/year to access the One Medical services and clinic visits are charged to your insurance. The clinics are a bit nicer, the wait times are lower, the doctors are a bit less dead in their eyes, and the telemedicine/tech is a bit better. But it isn’t to the level of the other concierge programs and it’s focused on primary care. They have integrations with some health systems to make referrals easier, but in my experience, it doesn’t seem like I’m getting in any faster. 

Another version of this is JUST the virtual pieces of the traditional concierge model. Carte Clinics, for example, staff vetted specialists to review your results, triage your issues for the kinds of experts (physician or non-physician) that should be involved, and speak doctor-to-doctor with the specialists they help you find. But they don’t have their own physical clinic, don’t run the battery of tests themselves, etc.

Honestly, even telemedicine + pharmacy companies feel like an unbundled version of concierge medicine. You’re still paying a regular retainer fee for the value proposition of faster visits, ability to text a doctor/care team, and drugs shipped to your door. But instead of it being the same doctor each time, it’s a somewhat faceless void or totally async chat and the care is more protocolized than personalized. And that has its own place in healthcare too.

The “Outside Of Evidence” care

For something to go from being found useful via research to being implemented as a part of regular care can take years, sometimes decades. But now thanks to the internet, patients and doctors are finding treatments or care plans they think would improve health but aren’t yet part of normal care. 

Now we're seeing concierge clinics that dabble in care that's outside of normal guidelines. Some examples of this:

• Full body MRIs of healthy people to catch diseases earlier (Prenuvo, Ezra)
• Clinics focused on controlled use of recreational drugs for disease areas (e.g. Mindbloom, Joyous)
• Cancer screening blood testing (Galleri, etc)
• Coronary Calcium Screens and regular ApoB testing (many local clinics)
• Functional and Integrative Medicine (Index Health, Parsley Health, Acupuncture/Eastern Medicine clinics)
• Cold plunging to feel something, anything
• Longevity focused clinics (Modern Age, Biograph, Elitra Health)

Because the evidence for these being clinically beneficial is ambiguous, they typically require pretty progressive doctors to do the prescribing, etc. It’s also worth noting that some of these can potentially be net harmful, as I talked about in the post about why we typically don’t do screening in all healthy people. 

These clinics also tend to be cash pay, at least for a portion of the services. IMO the reason is because the insurance reimbursement for these types of care are either very low or it’s a constant battle for approval with insurance companies. Like me, insurance hates paying for anything. But they especially won’t pay for things that fall outside of what’s considered clinically appropriate. That’s in tandem with a high willingness to pay from a wealthier customer persona that finds value in the services like spending extra time to go over results. 

There are lots of treatments that seem to help people before they become a part of clinical practice and have evidence behind them. Diabetes drugs were being prescribed for weight loss way before they were approved for that, for example. These concierge clinics enable people to get early access and try things where evidence is more scant. For money.

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As per usual, email nikhil@outofpocket.health to chat about group discounts and bundles. Back to your regularly scheduled programming.

Everyday Optimization

Recently, Equinox launched a new membership focused on longevity - it’s $3,000/month + the Equinox membership fee (~$400/month) which totals to around $40K a year.

“Officially dubbed “Optimize by Equinox,” the longevity membership begins with a biomarker test from Function Health, which examines 100 biomarkers to reveal health information about major organs, metabolic, and immune systems. Equinox also runs a series of tests that assess VO2 max, strength, and movement range. An Equinox concierge then gathers the test results to develop a personalized program.”

• Access to Function Health - which does these lab test panels of 100 biomarkers
• Equinox also runs a series of tests that assess VO2 max, strength, and movement range
• An Oura ring
• Three weekly 60-minute training sessions with a personal trainer
• Two 30-minute consultations per month each with a nutritionist and a sleep coach
• One massage therapy appointment per month
• Access to their exclusive gym E by Equinox - which looks like if John Wick designed a gym, but it was filled with the worst people you know
• The assessment happens twice a year and then you’re given a personalized training regimen.

Your reaction to this is a litmus test to how you feel about the traditional healthcare system. Or marginal tax rates. Or eucalyptus towels. 

There are a lot of people that know they’re supposed to be doing healthy activities, but want more specific advice to them than “eat well, sleep well, stretch, reduce stress”. They want to feel like their healthcare and everyday healthy activities are integrated instead of siloed today. And they want to buy “more health”, but the traditional healthcare system doesn’t really give them a way to do that.

Getting some form of regular testing makes it feel like that gap is being bridged. It makes it feel there are some tighter feedback loops between “healthy activity” and “better health” vs. the amorphous “avoiding a chronic disease in 20 years”. I’m not saying whether or not there’s any added clinical value to the regular testing here, but there’s a lot of perceived value from consumers which might be the thing that keeps them doing healthy activities. Plus, an out-of-pocket cash payment is a type of commitment, which is an important part of healthcare.

This is also part of the appeal for Andrew Huberman’s protocols, Peter Attia’s programs, and Bryan Johnson’s Blueprint program. They give you tips you can be doing everyday, supplements you can be taking to improve your health, tests you can consider getting, etc. to feel like you have some agency over your health. 

Maybe the real personalized medicine people want isn’t personalized to them as a patient. They want it personalized to an online persona, who they want to emulate. Which is why I’m here today to talk to you about Nikhil’s Nootropics.

The traditional healthcare system is also testing out ways to get into these “optimization” areas. For example, HSS has performance and metabolic programs for athletes. And Mass General has a sports performance center that costs $250 for an assessment and $50-$160 per session. It’s all tech’d out, using cameras to watch your movements, testing reflex times, and simulators to practice things like golf swings. 

“That’s the idea. Mass General Brigham’s Center for Sports Performance and Research is next to Gillette Stadium, where the New England Patriots play football. And the center’s allure of elite training is supported by the staff’s pro team credentials and reinforced by its technology-rich facility, a massive open-plan space devoted to improving athletes’ performance, using a self-pay model for its bespoke services that is reminiscent of concierge medicine.

The center, opened last year, is one of the latest examples of hospitals taking an interest in sports performance, a discipline devoted to helping clients — not patients — after they’ve been cleared medically to pursue whatever sport they’ve chosen at whatever level they aspire to.” - Stat News

The benefit of these programs is you get more touchpoints with patients using non-physician members of the team that can relay the medical information to the more clinical people if they need updates. This again makes the bridge between health and wellness feel more tangible.

Traditional healthcare is now on a collision course with consumer wellness companies on how to build a trusted healthcare brand. The open question is when an Optimize by Equinox member runs into a more serious health issue, will they go to Equinox for advice first or the brand name hospital? I don’t think that answer is so straightforward anymore.

Concierge Emergency Medicine

A few years ago, I did a somersault while drunk on New Years and went to the ER at 12:05 AM. It was a new Guinness World Record for “fastest time to hit a yearly health insurance deductible”. And it actually involved Guinness!

The wait time in that ER was about 2 hours, which was actually shorter than the median in the country. The wait times for emergency services are getting longer and longer.

As a result, you see a new wave of concierge medicine that essentially gives you direct access to an emergency medicine doc and clinic when you need it. While many of these brand name hospitals offer concierge programs that schedule these VIP visits, you still have to walk through their regular emergency department if you have an issue or they might not have an emergency room in your local area. That’s where these concierge emergency services come in.

Many of these centers have CT scanners and the ability to do lab work on site, but can’t do surgery or deal with really acute issues like a gunshot wound. But they can stabilize many patients, and some of them claim they can deal with a majority of cases that usually come to the ER (in a 2018 article they suggested 80% of cases). 

Companies like Sollis offer this service for anywhere from ~$3500-$10K a year depending on which access level you want. Based on the set of services offered on their homepage, it also seems like the emergency services are a wedge to regular primary care services as well.

It’s worth noting that regular emergency rooms have to take any patient regardless of payment under the Emergency Medical Treatment and Labor Act (EMTALA). These concierge emergency medicine businesses don’t take Medicare, so they aren’t bound by EMTALA and can choose the patients they accept (based on payment in this case). They generally seem to be regulated as urgent cares or freestanding emergency departments depending on the state.

Conclusion and Parting Thoughts

IMO the rise of these new concierge clinics is due to a few factors.

1. Patients are dissatisfied with access to care. They think time spent with the doctor is either too long for issues they know the answer to (e.g. I know which drugs I want just give them to me) or too short (e.g. 15 minutes is not enough for my complex issue). They want more right sized care for their issue.
2. Social media is changing things for doctors and patients. Patients see more care options for their issues, many of which are framed as “hacks” or stuff that are outside normal care protocols. And they want access to that. Simultaneously, new clinics see social media as a way to target patients for their program.
3. Doctors themselves are burnt out of regular patient care and many of these programs allow for more time with patients, fewer patients per day, and less dealing with insurance.
4. COVID made the sub-50 year old demographic much more acutely aware of their health. People with disposable income are now willing to spend considerable amounts on their health.
5. Having a “concierge” straddles that line of douchey/cool that you can use to low key flex on your friends. Like using your AmEx concierge - the friend that uses it wants you to know they’re using it. It’s the whiff of insufferability that makes it work.

I’m not here necessarily to ascribe morality to this trend. But it’s worth noting the downside is these concierge clinics are only available to people that can afford it and are attractive enough that they can pluck doctors out of the traditional healthcare system. The model only works if you have intentionally small doctor:patient ratios. What that means is less remaining doctors who then have to treat more and more patients per doctor.

Maybe someone will crack the code to scale these programs and make them accessible to everyone. Or maybe I need to add one of these programs to my wedding registry…

Thinkboi out,

Nikhil aka  “I got money to blow, getting it in, lettin’ these bills fall, so I can get a next day appointment.”

Thanks to Gina Siddiqui for reading drafts of this

Twitter: ​@nikillinit​

IG: ​@outofpockethealth​

Other posts: ​outofpocket.health/posts​

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