Opinion | Will Electronic Messaging Push Us Toward Concierge Medicine?

Electronic messaging, via email and patient portals, has become an increasingly common method patients use to contact their physicians. Providers are often inundated with messages, frequently unable to keep up with the volume. These real-world frustrations have been voiced repeatedly by physicians.

A controversial question regarding electronic messaging has emerged in recent months: Should health systems or providers bill for responses to patient messages? Cleveland Clinic announced in November that it would begin billing for messaging consultation, headlining a list of health systems engaging in similar practices over the last year.

Though early billing practices have largely resembled fee-for-service models, some have proposed billing solutions involving charging patients a flat, capitated fee to cover all messaging. As some have suggested, this could be baked into the total cost of all healthcare provided — such as in a concierge medicine model — or could be a separate, narrower fee/subscription to cover more specific messaging needs between visits. Insurers may also develop compensation mechanisms (e.g., direct contracting) for messaging, particularly as messaging may be a sufficient and cheaper alternative for patients to consult their doctors while avoiding the overhead of in-person visits.

As the potential to charge for patient messaging looms, one question is clear in my mind: Will the proliferation of electronic messaging accelerate the trend toward concierge medicine?

Towards Concierge

Concierge physician practices, just like patient messaging, have become increasingly common. Most prevalent in primary care, concierge practices represent a model of care in which a suite of agreed-upon services are offered to patients under a subscription-based model. Patients pay a fixed-fee upfront to their physicians in order to cover all services rendered, typically over a year.

Physicians participating in concierge models often have smaller patient panels, a consequence of the guaranteed “subscription” revenue. As this physician notes, concierge medicine allowed him to earn more (while seeing fewer patients) and enjoy more meaningful relationships with his patients.

In theory, the concierge model offers patients greater access to their physicians, unconfined by traditional appointment scheduling and waitlists. Having fewer patients adds flexibility, allowing patients with acute needs to be seen more readily. Messaging and phone calls are often included as a benefit as physicians aren’t constrained by fee-for-service office-based compensation structures. Messaging may be the preferred means of interaction in many situations as responses can be delayed and asynchronous in the same way one responds to their texts and emails throughout the day.

In an environment where healthcare worker burnout is rampant, uncompensated messaging with patients is unsustainable. Just like all healthcare, compensation will take the form of fee-for-service or bundled under a value-based or capitated model.

My prediction is that the trend toward concierge models, specifically in primary care, will be accelerated as a result of patient messaging becoming more prevalent. There will be an exodus of physicians from traditional practices who opt for concierge setups out of a desire to be less overburdened and better compensated. Primary care is most suited for concierge models given the first-line care and consultation they provide, though I also expect providers from specialties like pediatrics, psychiatry, cardiology, and endocrinology to experiment with concierge models in greater numbers.

Lingering Questions

Health system competition

As the trend toward private concierge models accelerates, health systems, with their extensive networks of outpatient practices, will be forced to find a way to compete financially. They will need to create a system for their providers to be compensated for messaging, whether that involves direct billing or not.

The likely solution is that there will need to be blocked-off, dedicated time in physician schedules to allow for time to respond to messages. Restructuring physician salaries would be necessary so that time spent responding to messages is accounted for in the baseline salary or in relative value units (RVUs). Given the current American insurer and payer apparatus, it won’t be possible for the largest health systems to transition to a full concierge model; fee-for-service or other capitated arrangements would need to be made with payers to cover messaging compensation. More providers would also likely need to be hired (no easy task) to account for the lost clinical hours.

Patient equity

The expansion of concierge models will have consequences for health equity. While the wealthiest patients are already able to participate in concierge models, a significant increase in the market share of concierge practices will promote further inequity.

The premise of the concierge model is that physicians see fewer patients so they have time to field patient calls and messages. Primary care physicians are already limited in supply, so any attempts to decrease the census of a physician will only exacerbate the effects of shortages across the system. Over time, patients will be sorted and priced into concierge tiers based on their ability to pay, resulting in even more patients being funneled into already crowded practices that are more financially accessible to patients.

In Short

Responding to patient messages is an added responsibility for providers and is not presently sustainable. Though some systems are beginning to bill for messaging, physicians will want to be compensated for the digital care provided. Concierge practices represent an attractive model that can bake messaging into the compensation structure. Without sustainable solutions that balance the need for patient messaging with the time required for response, physicians will seek out concierge-like practice models, presenting unique challenges to the healthcare system.

Logan Cho is a medical student at the Icahn School of Medicine and an advisory board member of MedPage Today’s “The Lab.”