Appreciating the Differences & Similarities in Concierge Medicine Versus Direct Primary Care
What’s in a Name? Two Docs Speak Up
A recurrent point of discussion with our recent guests on the ROAMD podcast is the nomenclature of concierge medicine vs direct primary care. Like many other parts of the healthcare industry, the jargon is open to interpretation based on where one may be standing, but to dissect the language, Dr. Scott Pope enlists the perspectives of two successful physician leaders: Dr. Mark Niedfelt, owner of Mark Niedfeldt, MD outside of Milwaukee, Wisconsin, and Dr. Jason Littleton, founder and CEO of Littleton Concierge Medicine near Orlando, Florida.
Each of these entrepreneurs shares their path towards their current business model. Dr. Niedfelt opened his solo practice in October 2008, which due to the financial crisis, was “The worst time possible to start a cash-based practice where people have to pay extra.” His career began as an academic, full-time faculty at the Medical College of Wisconsin. When he began his own private practice, it was a traditional concierge practice, with a membership-based fee, as well as working with insurers.
He shares how his path to self-employment originated through working with professional and high-level athletes: “I said to myself, if we’re doing this for these athletes, why can’t I do this for all my patients? Today, 40-50 percent of my panel is musculoskeletal patients, and I do bill insurance for those types of services, and then I have the second piece of it, which is the membership-based practice.” He describes that he has partially transitioned away from insurance because “it didn’t feel right to chase people down for copays and deductibles.” This is an attractive proposition for many doctors considering concierge medicine or direct primary care.
Dr. Littleton’s journey starts back in 2011, in his very first year out of residency: “I was in a local primary care practice in Michigan. That’s where I started to see that something has to change. My first year out, I’m seeing 18, 25, 30 patients a day, I just remember being in my office feeling burnt out. My message as to why I got into medicine wasn’t being communicated.” He describes being frustrated by the “conveyor belt” of 15 and 30-minute visits. It was his business coach who originally told him about DPC, which he began four years later.
“In 2015 I started out with one patient in my new DPC practice. I charged them about $250/month, close to $2500/year. Now I’ve got a large practice in Orlando…I have three tiers now, so things have expanded, but now I’m spending more time with the patient. I only see four patients a day, I leave room for emergencies, it’s quality – it’s why I got into medicine. I enjoy it, they love it, we have a great relationship, I tell my people all the time. You guys are like neighbors to me, we get the opportunity to share stories and go forward. I love what I’m doing. I think this is something that every doctor should consider.”
Messaging versus Meaning
The nuts and bolts of the discussion reveal a telling truth: While good medicine is true north, in healthcare and business, meaning is often in the eye of the beholder. Dr. Niedfeldt shares that his reluctance to embrace the label of concierge medicine instead of direct primary care came from some of the early rhetoric from the American Academy of Family Physicians, who were skeptical of pay-to-play access to medicine.
“My pushback to that: If people are able to keep their panels smaller, then medical students are [more likely to go] into primary care. But, it is an elitist term…You don’t go into the Motel 6 and talk to the concierge, you go to the Ritz Carlton and talk to the concierge….I wanted to make sure that when patients came into my practice they felt like they were getting the things they needed from me, and that I found in traditional practice I couldn’t give those things.”
He explains how, from his early days, he focused on both affordability for certain patients: “When I designed my practice, I designed it so that ten percent of patients in my primary care panel are basically on scholarship, so they don’t pay a membership fee. That was important to me when I started out.”
Dr. Littlefield describes how his use of the term “concierge” is more about catering to his clientele and setting expectations for his patients, but that technically speaking, he is offering direct primary care services: “I use the term concierge medicine because it brings awareness….I don’t think I’ve brought up the term ‘DPC’ with any one of my patients. It’s in the contract, but we say ‘Hey I’m your concierge doctor, how can I help you?’…In a DPC model you’re not using insurance so that’s a key difference between concierge medicine vs direct primary care. In DPC, you’re establishing an agreement with the patient, a contract so to speak, and they are paying cash for your services, however, you deliver it. So, in a DPC model, I call this a qualitative model. In a quantitative model or an insurance-based model, you have to understand that you are part of a group…in order to cushion payments. It’s not necessarily specific to you. In a qualitative model – it’s more tailored care.”
Dr. Niedfeldt’s anecdote illustrates how this plays out in practice: “One of my patients got prostate cancer…I dove in, I researched things, [and was able to say to him] ‘You need a radical prostatectomy. This is the guy in the midwest who taught everyone how to do this procedure. He’s done 10,000 of these procedures. This is your guy, and by the way, he happens to be here in town.” He shares that he found the best anaesthesiologist in the medical center for the procedure, and how he went and sat with the patient’s wife during the procedure.
Patient Payment as “Skin in the Game”
Regardless of what the model is called, both men concur that the membership fee is a critical part of what makes the model successful whether it’s concierge medicine or direct primary care. “What people have to understand is that it’s an investment,” argues Dr. Littlefield. “I’m unapologetic about the cost of healthcare because I know how much energy I put into it. I want to [offer] the best care…I ask people, ‘What are your top three priorities?’ Their health falls into the top three. What I have found in my practice, I give people three options, a lower, middle-tier option, and a higher-tier option. He describes the value proposition that avoids paperwork, waiting time and a direct relationship with the doctor. I do have patients who are very wealthy, but also the patients who are the opposite. I feel like 100% of my patients are motivated. They put their skin in the game and say, “I’m doing this!”
Dr. Niedfeldt adds: “We’re all trying to provide great care for our patients. What the price point does is it allows us to limit our patients to whatever number we choose. I think that, if I wanted to limit it to 100 patients and charge whatever it took to make it work, whether it’s 100 or 500..we just have to choose that. I don’t think any of us should apologize for that. They’re all in. We’re seeing changes; we’re seeing A1C and cholesterol come down. We see better lifestyle. We see weight loss. We see changes in our patients because they’re engaged with us, and the fact that they wrote us a check is the reason they’re doing it – that’s money well spent.”
The Bottom Line: Happy Doctors & Happy Patients
“The benefit and blessing to owning your own practice,” says Dr. Littlefield, “whether it be a direct primary care or concierge practice, is that the practice is in your own image, and your patients are getting you. They’re not getting someone else’s vision. My patients are getting me: Everything that has- all my experiences that have brought me to this point. All the reading, all the studying, all the experience, all the patients – I’ve rolled it up and I’ve branded it into Littleton Concierge Medicine, and they’re getting me. Yes, there’s a price to that because there was a price to get to that. It’s amazing, I just enjoy taking care of people who want to be well…I’m just grateful to be part of someone’s health journey.”
Dr. Niedfelft echoes this point, adding: “Our name is on the door. When people walk in, that’s what I tell them: ‘This is my practice.’ I take so much pride in that, and I run it exactly the way that I want to run it. I do the things I want to do, and I see patients in the fashion I want to see them; I take the time that I want to take with them, and if somebody needs more, I give it to them. When they walk in and look around, they say ‘This is different.’ When they sit down with me, they say ‘this is different.’
He continues: “I think that’s what people experience with these types of practices…I’m looking you in the eye, I’m listening to what you have to say, and I’m addressing your concerns. We’re giving patients what they need, when they need it. And that’s the beauty of this: I am not restricted by time constraints or by anything else…once people experience this type of care. I’m looking at you thinking, ‘here you are right now, I’m thinking 20 years ahead. What’s going to be the issue in 20 years? What are the things we need to address today to keep you healthy for another 20 years, 30 years, 40 years? And that’s what we’re trying to accomplish.”
For more perspectives on making the transition from traditional concierge medicine or direct primary care medical practice to a membership-based model, make sure to visit us online and check out our other podcast episodes.
Dr. Mark Niedfeldt is a Wisconsin native who lives in Mequon with his wife and three children. He graduated magna cum laude from the University of Wisconsin-Whitewater and earned his M.D. from the Medical College of Wisconsin. Dr. Niedfeldt completed his residency in Family Medicine through the Medical College of Wisconsin’s program at St. Mary’s Hospital, where he was nominated Chief Resident. He completed a fellowship in Primary Care Sports Medicine at MCW.
Dr. Neidfeldt has published articles in medical journals, written reviews, abstracts, and book chapters, and currently teaches medical students at MCW as an associate clinical professor while running his membership medicine primary care clinic in Mequon. He also serves as team physician for the Milwaukee Brewers, the US Snowboarding and Freeskiing Teams, Wisconsin Lutheran College, and Concordia University.
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