My name is David Santander, I operate a concierge naturopathic and acupuncture clinic in Hawaii. In 2021 we began building the first integrated concierge and naturopathic medicine practice [that I’ve heard of, might not be the first but, it also might be] - Oahu Holistic Medicine in Kailua, HI. 

I believe you’ll be seeing many more doctors and practitioners going the route of concierge medicine in the coming years. 

If you’re a patient wondering what concierge medicine is and if it’s something for you to pursue in your own life, I’ll do my best to shed some light on those topics for you, as efficiently as possible. I know time and focus is at a premium these days, so I’ll do my best to be concise. 

First, allow me to furnish some definitions and background so we’re all on the same page about the words and what we’re actually talking about at any given moment in this writing. 

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What is Concierge Medicine and Do I Need It?

What is concierge medicine: Concierge medicine is a format in administering medicine, aimed at offering superior care through more facetime with doctors and individually tailored care. 

Here’s Wikipedia definition of concierge medicine: 

“Concierge medicine, also known as retainer medicine, is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges. In exchange for the retainer, doctors agree to provide enhanced care, including principally a commitment to limit patient loads to ensure adequate time and availability for each patient]” (PBS/Wikipedia)

Doctors: When we mention “doctors” as it relates to concierge medicine, most literature talks about MDs, and not doctors of other medical sciences. 

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It’s a challenging time to be a patient in the USA. People are tired of going to their doctors and not getting enough facetime, not getting explanations and their questions answered. Many patients confess to us frustrations around not being listened to - leading to misdiagnosis and mis-treatment, often with great consequence. 

We’ve all heard way too many horror stories about patients being misheard, put on medications for life, given life altering surgeries without 2nd, 3rd, 4th, 5th opinions.

Rant: 

If you take nothing else from this, ask yourself this - how many loaves of bread to you comparison shop for till you find the brand you want to settle on? How many kinds of pasta do you try out before you find the one you like? We look at 3, 4, 5 or even 6 or more different kinds of the same thing at the supermarket before we decide what works best for us, how come we only take one or 2 doctor’s opinions? Did you settle on the first dentist you went to? first cardiologist you went to? First GP/MD you went to? First acupuncturist you went to? First ND you went to? Did you let your experience with one determine what that whole field is about? No judgment, it’s human, we all judge, but we have to look at these things. Rant over. 

Why are we used to not getting enough facetime with doctors, and not getting our questions answered in a mega-rich, first world country (USA) with advanced medicine and more access to information than we know that to do with?

2 reasons I can think of off the top of my head. 

1). Doctors are pushed by multi-million dollar health conglomerates to see as many patients as possible, and compensated based on the number of patients they see (Gorke 2019). 

2). Doctors have massive investments $200,000+ in student loans (not including living expenses)

(Hanson, 2022). 

How many reasons can you think of?

This is probably why your PC/GP doctor wants to spend no more than just a few minutes with you. 

According to Stanford Medical School: 

“We need other practical solutions for this […] especially given that the average patient visit in the U.S. is only 20 minutes, and expectations for what should be accomplished in those visits grows each year.”

Concierge approach is one answer to that problem.

Here’s some icing on the cake from that article:

“During four years of medical school, most students spend fewer than 20 hours on nutrition.” (MINOR, 2019)

So patients need more time with their doctors to ensure beneficial treatment, and allay the risk and probability of mistreatment, and, oftentimes a lifetime of living with the consequences. 

So is concierge medicine a solution to our broken primary care paradigm?

Dr. Michael Stillman defines Concierge medicine as: 

“[...]medical practices, which advertise expanded access to care and individualized attention, collect charges both from insurance companies and directly from their patients.”

He then goes on to say:  

“Some bill hundreds of dollars for one-time "executive" physicals, whereas others have patients pay annual retainer fees. Yet, virtually no data are available about these "luxury" practices. It is not known how many physicians have "turned concierge," whether they have altered their testing and prescribing patterns, or whether their clinical outcomes are superior to those of their colleagues in traditional practices.”

I agree that more research is needed, and we should continue to build systems that develop superior care, for less money. 

The tone of that definition is dismissive, as if to say, that there is no reason to charge more for a physical, and there is no more that needs to be done in a physical, there’s nothing wrong with the paradigm, and this is probably a ripoff and a waste of time. Sounds like that, no? I’m sure there’s a ton of misrepresenting advertising in the world (every pharmaceutical commercial ever made).

He then says:

“Although some have voiced concern that concierge physicians create a 2-tiered system and may contribute to the difficulty that many patients have with access to care, the medical community has largely remained silent on the matter.”

Ok. 

1). I think anyone in the  medical community with their eyes open, knows that we already have a 2 tiered system that has been created by predatory business practices, and an aggressive profit-before-people mentality. There are those who can afford medical care and preventative medicine, and those who cannot. 

Would the system be different if the people who decided what medicine should cost, what should be included, marketers, business executives, underwriters were all doctors? If they were interfacing with patients on a weekly basis? Maybe. 

2). The medical community remaining silent on the matter, shows me, that there’s something here that can upset the balance of the system, what’s known as “industry disruptive” 

Dr. Stillman continues: 

“The mere existence of concierge medicine may reflect our need as physicians to do better by our patients.” Yet our responsibility as a professional community is to engage in--not run from--that monumental challenge.” (Stillman)

This is an unfortunate understatement. 

Potential PROS of concierge medicine include:

• Increased access to physicians - primary care and/or specialists: With a smaller patient base, concierge physicians are able to see patients more quickly and spend more time with them during appointments.

• Get in quick, get out quick, get results quick: You likely won’t have to 3-6 months to see the doctor if you are paying a retainer. Get your appointment fast, get your tests, treatments and prescriptions fast (herbs, supplements, diet, exercises, referrals and medications), then get your re-tests and follow-up appointments fast. I can’t speak for other practices, but we’ve been able to show that with a concierge model, we can do 6 months of work in 6 months. A simple but not at all small part of that comes from more time to educate patients on what we’re doing and why, and not having to wait on opening in a completely saturated schedule to get your labs read to you. 

• Greater continuity of care: Because patients are able to see the same physician regularly. Same physician - now that’s not terribly uncommon, most medical groups have you seeing the same doctors unless you’re in the hospital for something or at a VA hospital. Regularly - In our practice, we’ve been able to see patients week over week, treat with acupuncture, monitor with subjective and objective measurements, refill herbs and supplements as needed, and fill in the knowledge gaps every week, not every quarter, every 6 months or every year.

• Greater convenience: Some concierge practices may offer extended office hours, telemedicine appointments, housecalls or other features that make it easier for patients to access care.

Potential CONS of concierge medicine:

• Cost: The annual or monthly fees associated with concierge medicine can be expensive, and may not be covered by insurance, and therefore may be cost prohibitive. 

• Limited access to specialists: Because concierge practices typically focus on primary care, or another specialized modality, patients may need to seek care elsewhere if they require specialized treatment. (GPT and Oahu Holistic Medicine LLC 2023)

While it is true that patients may need to seek care at another physician or specialist’s practice, that is true of any practice, office, hospital, medical discipline etc. All physicians and medical disciplines have their limitations. 

Speciality by its very nature, has its limitations. 

For example, in our practice (this is not meant to be a sales pitch), we combine Naturopathic Medicine and as many facets of Traditional East Asian Medicine that we can. We can’t see 100 patients in a day, as a 2 person team, and we can;t perform xrays, scope exams, emergency medicine etc. That’s a conversation for another time, but all medicine is specialized, and has its blindspots. 

How to choose a concierge practice: 

Background question: What kind of medical practice/discipline is this, and does this give me what I need?

The following points are meant to give you questions to ask your doctor(s) when interviewing and qualifying practitioners. Concierge medicine is a growing trend, and may not even exist in your area yet. You can use these questions with any practitioner, just adapt them to fit your unique circumstances.

1). Get VERY clear about what’s included and what isn’t: I'm learning, in business and relationships, life, never assume you both know what you’re talking about, and you both have the same definition for words. Go through all the inclusions - the services, supplements, fees, office visits, procedures, and have the practitioner or sales person break it all down for you, and explain it to you like you're 5 years old. It is SO helpful to clear up these assumptions when entering into contracts and arrangements, it’s a good idea not to assume anything, and weed out as many of those assumptions as early as possible. . 

2). Ger very clear about what's your responsibility and what’s your practitioner/doctor’s responsibility: You may have to visit a lab for blood tests, change your diet temporarily, take some different herbs and supplements, show up at the office frequently, track down paperwork, talk to your insurance company. Find out what needs to get done and whose responsibility it is, so there’s absolute clarity going forward. 

3). Find out how many treatments are included, and which are not included: There should be a list of features, inclusions and exclusions, again, no assumptions. They’re probably not going to wave a magic wand and everything in your life is going to get better (good marketing can actually set doctors and patients up for disappointments, and mismanage expectations, but that's a rant for another time). Again, expectations and transparency - are you seeing a theme?

4). What’s the out? If it doesn’t do what it says on the label, how do you get out? If you get 6 weeks down the road and decide it’s not working for you, what’s the out? Is there a way to break the contract? Is there a probationary period where you can leave? Are you expected to tough it out for 6 mo to a year if you don’t like it? Again, no assumptions. 

5). Get an itinerary: what’s going to  be happening when? How soon/how often will there be testing and retesting? 

6). What is the deliverable: What is the thing they are saying they’ll do for you? Are they promising good health? Are they promising x amount of good treatments? Are they promising peace of mind, knowing that you’re looking under the hood with a competent professional, and setting a lifetime of good habits, routines and protocols in motion?

7). Prescribing schedule: How often does the practitioner cycle herbs, supplements, medications. Does the doctor prescribe medications with no out date? In our practice, we almost never prescribe a patient something indefinitely. Everything we put in our bodies comes with long term consequences. There’s very few diseases in which someone needs to be on a drug for the rest of their life, and hypertension and high cholesterol usually isn't it. 

Concierge medicine can be expensive. The reality is that all medicine is expensive. I used to believe that medicine should be free for all, but the reality is that medicine and health cost an arm and a leg. Massive sacrifice is made by the patient, massive sacrifice is made by the doctor, and both parties have everything at stake, and everything to lose - So if it’s going to be expensive, let’s make sure it’s worth it, and it’s actually going to do the thing. 

Maybe you’ve though, yeah I need to do more about my health, and I want to assemble a dream team of doctors and resource hubs outside of a particular problem, and I’m going to but it together myself, because I don’t have the money to spend on one comprehensive program, or just don’t feel like spending it that way, and would like to exhaust other options first. 

How does one pay for medicine if they cannot afford out of pocket services?

1. Medicaid: This is a government-funded healthcare program for low-income individuals and families. In many states, Medicaid covers prescription medications as well as other healthcare services.

2. Medicare: This is a federal health insurance program for people who are 65 or older, people with certain disabilities, and people with end-stage renal disease. Medicare Part D covers prescription drugs.

3. Pharmaceutical Assistance Programs (PAPs): Many pharmaceutical companies offer assistance programs to help low-income individuals afford their medications. Eligibility criteria and the type of assistance provided vary by program.

4. Free Clinics: Some free clinics in the US offer free or low-cost prescription medications and medical services to patients who cannot afford them. Sexual health and HIV testing are some of the most common, but not the only types of free clinic. 

5. Government-funded Programs: Some countries have government-funded programs that provide prescription medications at reduced or no cost for certain groups of people, such as veterans, children, or the elderly. (GPT and Oahu Holistic Medicine LLC 2023)

6. Non-profit organizations: There are non-profits all over that help people find the resources and medicine they need. 

7. Religious and/or community groups/organizations: Many community groups and associations have lists of resources, and access to goods and services you may need, specifically for people who cannot afford full price. This may involve some days on the phone, making calls and shaking trees to see what’s out there, but it’s well worth it. 

8. Negotiations with practitioners and clinics: I can already hear practitioners screaming through their computers and phones at me. Many privately owned clinics have flexibility around how they bill, or what they can work out with insurance companies. This isn't a guarantee, but, if you really need help and can’t afford it, it doesn't hurt to ask. Did you know some hospitals have trusts in place to pay for patients who can’t pay? Did you know that “…[n]early a quarter — 24 percent — of community hospitals in the U.S. were classified as for-profit in 2019, while more than 57 percent were nonprofit and nearly 19 percent were controlled by a state, county or city government.Aug 19, 2021”? (staff 2021)

9. Trade skills or services with private practices [This one is my favorite idea and I might kick myself for writing it] - most practices have a need for websites, housekeeping, marketing, testimonials, outreach, bookkeeping, etc. If you have skills or time, you might be able to strike a deal with small and lean clinics. When I was starting out in practice, I would have jumped on an offer to trade for  SEO or website development. It may sound weird, but you never know - we’re thinking outside the box. 

Flexible Spending Accounts through your health insurance (if you have this feature):

“A Flexible Spending Account (FSA) is a type of savings account that is offered through some employer-sponsored benefit plans. The money in an FSA is set aside from an employee's paycheck on a pre-tax basis, and can be used to pay for certain out-of-pocket medical expenses, such as copays, deductibles, and prescription drugs.

FSAs are typically "use it or lose it" accounts, meaning that any money that is not used by the end of the plan year (usually December 31st) is forfeited and cannot be carried over to the next year. Some employer plans may offer a grace period or a limited carryover provision, but it can vary. Some employers offer two types of FSA: 

Health FSA: this account is used to pay for qualified medical expenses.

Dependent Care FSA: this account is used to pay for dependent care expenses, such as daycare for children under age 13 or elderly dependents.

FSAs can be a useful way for employees to save money on taxes and pay for certain out-of-pocket medical expenses. However, it is important to note that FSAs do have some limitations and exclusions and it is always recommended to check the plan's summary plan description or consult with the HR department for more information. (GPT, 2023)

If you’ve actually read this far, may your god, if you have, one bless you thoroughly, and congratulations for not falling asleep. I hope you find this helpful and if you have any corrections, questions, comments, please send them to info@oahuholisticmedicine.com. 

I hope you find this helpful in some way. 

Conflict of interest statement: Most scholarly papers have this. This is not a scholarly paper, but transparency is important. My employer is a for-profit concierge medicine clinic, of which I am the founder, and I have an interest in providing safe, effective and efficient medicine in said format. I do believe in my heart that we need to be creative in figuring out how to make medicine efficient and profitable again, and creative clinics are a part of that conversation - concierge medicine shows promise, and there’s value here not to overlook. 

CITATIONS:
PBS. “Concierge medicine.” Wikipedia, https://en.wikipedia.org/wiki/Concierge_medicine#cite_note-PBSMEWSHOUR07092012-1. Accessed 26 January 2023.

Stillman M. Concierge medicine: a "regular" physician's perspective. Ann Intern Med. 2010 Mar 16;152(6):391-2. doi: 10.7326/0003-4819-152-6-201003160-00009. PMID: 20231570.

Hanson, Melanie. “Average Medical School Debt [2023]: Student Loan Statistics.” Education Data Initiative, 22 November 2022, https://educationdata.org/average-medical-school-debt. Accessed 26 January 2023.