The Perkins Perspective | Features | Winter 2014
Concierge Medicine: A Bridge From Poverty to Health
By Christopher Jones, MD, FAAP
Maria was an 8-year-old living in La Vallita, a neighborhood in Chicago ranked as one of our nation’s poorest. Her mother was worried about Maria’s bedwetting. I, as her pediatrician, was worried because she smelled of urine.
We discussed bedwetting tips like providing a well-lit path to the bathroom and did tests, which returned the next day and showed a urine infection. Unfortunately, Maria didn’t come to her next appointment, so I wasn’t able to start treatment.
This was the start of nine to 12 months of missed appointments, treatment followed by urine tests that remained positive, letters with prescriptions, medication not taken, and missed appointments for specialists.
I first felt called to medicine during a mission trip to Zaire, Africa, through Seattle Pacific Reachout International, or SPRINT. I had been inspired by the change medicine could make in the life of someone who desperately needed it. But that calling was transferred to the urban poor of American cities when I saw the need there during my medical training. It was reinforced when I realized the problem Art Jones, founding physician of Lawndale Christian Health Center, described when he said, “It is easier to get a physician to go to Africa than to the inner city.”
It was my calling and I loved the mission and work in my community health center, but the overwhelming needs of my patients and the rate at which patients have to be seen in the community health center model often made it difficult to meet the needs of patients like Maria.
During these nine to 12 months, Maria continued to wet the bed and smell of urine. The only time she came to clinic was without appointment, and when she came, I was always several patients behind. My visits with her had to be quick.
Finally, at one appointment when I had time to dig deeper, I learned their apartment did not have electricity except when a neighbor allowed them to borrow it with an extension cord. Maria had no light at night and was scared to walk to the bathroom. Her single mother heated their apartment with a stove, had no phone, and, with six children, often had other priorities that trumped taking Maria to the clinic.
Seeing the Bigger Picture
I wish I had figured all this out months earlier, but I was always interacting with Maria in the minutes between an overbooked schedule requiring me to see five to six patients per hour. I needed time to ask open-ended questions and listen. I needed time, and Maria’s family needed better access to health care.
I was caring for the patients I had been called to serve, but patients like Maria made me question whether I was caring for them in the best way. When my wife and I heard about a group seeking to meet the felt needs of the Rainier Valley, we decided to move to Seattle to help start HopeCentral — a new pediatric and behavioral health primary care practice located in southeast Seattle.
As our group of physicians and community development folks studied the needs of this Seattle neighborhood, we saw that families with Medicaid had access to community health centers similar to the one I had worked with in Chicago ― but among them, large health disparities still existed in asthma, vaccination rates, diabetes, heart disease, and even life expectancy. The community health centers are serving a vital role, but they are not enough.
A New Way: Concierge Medicine
I consider the physicians in community health centers and those with whom I worked in Chicago to be heroes. They struggle with the wave of patients that threatens to drown them every day. With five to six patients scheduled each hour, and patients with too many problems and too few resources, they have no way to meet more than the most urgent needs. In response to this pressure, some colleagues resorted to limiting patients to one problem per visit. Others just ran hours behind with patients leaving in frustration and unseen. Burnout comes quickly. Few physicians last more than a few years in this setting. This all leads to limited access to health care. The group starting HopeCentral wanted to start something different.
Concierge medicine is a model of medical care defined by a high level of service in which the patients have rapid and unlimited access to their physician, longer visit times, and added services catered to meet their needs. Vera Whole Health has shown that this model (renamed direct pay) can decrease hospitalizations by 50 percent and cut urgent care visits by 60 percent. Group Health Cooperative piloted clinics with patient visits of 30 minutes instead of 20 while giving physicians fewer assigned patients to manage. They also gave patients 24/7 access to preventive care.
These pilot clinics showed improved quality measures for patients and fewer ER visits, all with reduced overall costs. They also showed greater patient and physician satisfaction with fewer markers of physician burn out. These trends have led multiple health care companies in the Seattle area such as Qliance, Vera Whole Health, and Paladina to seek to market this model to corporations as a means of offering health insurance to their employees at a lower cost while also improving their employees' health.
As recent New York Times piece reveals that for many the term “concierge” connotes an exclusive form of medicine for the privileged. Unfortunately, this perception mirrors reality, because it remains a model for those who can afford to “buy in” or who have a job at a company that can afford to offer health insurance. But who needs the benefits of concierge medicine more than those in our poorest communities?
Concierge Medicine in Seattle
In Chicago and Seattle, our poorest families live with the consequences of poverty and limited access to health care. These are problems well known to lead to the health disparities plaguing the Rainier Valley. Children in this environment have poorer school performance, leading to reduced graduation and college attendance rates. They have higher rates of admission to the hospital for asthma, and higher rates of depression and suicide.
These are the families and communities that need a high level of access to physicians with services focused on preventive care. They need physicians who can continue to work with compassion and remain in the community long enough to become a part of the community and to know their patients. These are the communities who need concierge medicine.
So we have designed HopeCentral to provide concierge access to children with Medicaid and on a sliding-scale subscription model for those without Medicaid. We plan to do this by keeping costs low and creating a clinic attractive to the entire community but accessible to the underprivileged. We will have pediatricians who can provide primary care or specialty care. We will have integrated behavioral health allowing access to pediatric psychologists for any patient that needs it for treatment or prevention. The disparities created by poverty will not be easily bridged, but we feel that access to concierge medicine can provide the structural changes needed to reduce quantitative and qualitative disparities in health care.
Christopher Jones, MD, FAAP, graduated from Seattle Pacific University in 1994, received his medical degree from the University of Washington, and trained in pediatrics at Loyola University in Chicago. He and his family live in Seattle’s Rainier Valley.
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