Concierge Medicine: Better Care, or Just More Care?

0:00You can't see your doctor when you need to. Rushed visits, an overwhelmed medical system. Concierge medicine promised an escape, paying a few thousand dollars a year, you could buy the one thing that matters more time with an excellent doctor and easier access. Sounds good, sign me up, but now a lot of other doctors and even non-doctors are setting up concierge practices. And the corporations are stepping in. Are you paying for great medical care or just a high-price VIP club in a white coat? Let's find out. Hi, I'm Dr. Bobby DeBoys and welcome to Live Long and Well, a podcast about what the evidence can and can't tell us about living healthier lives. As a physician, scientist, Iron Man Triathlete, an author of several hundred scientific papers. I read the studies so you don't have to. Helping you cut through the hype, focus on what actually works make better choices for your health.

1:04Welcome my dear listeners. Today's episode is titled Concierge Medicine. Better care or just more care. Plans here I didn't episode called, do you like your doctor? And in and I talked about concierge doctors. You pay a yearly fee and you get more access to your doctor since they have a far smaller number of patients. And I explored as an option for those of you who find that it's really hard to get an appointment. When you see the doctor, you have very little time and often you end up with the nurse practitioner or a physician's assistant. When the beginning, concierge was really experienced doctors, typically internal medicine doctors who decided that you know after decades of practice, 20 minutes of patient was not the style they want. And so they chose a new approach more time, the retainer monthly or yearly to make the practice work. Here's the problem. Over the last decade, there's been a lot of changes in what

2:08concierge practice looks like. From 2018 and 2023, a study showed that the number of concierge practices grew 83 and the growth in corporations owning those practices grew over 500. So so many concierge practices are now part of large corporations, not individual doctors seeing you as your patient. So this is what I'm seeing today. Yes, those good internist concierge doctors are still there. The problem is there's a whole lot of other stuff that's there. Slick marketing, for-profit stuff, clinics that used to be hormone clinics or longevity clinics or functional medicine clinics are being rebranded as we're a concierge with lots of testing and supplements and protocols. And increasingly, these are non doctors, non internists, at least the family physicians,

3:08nurse practitioners, it's really a different breed of providers. Now, the concept of concierge medicine is amazing. It helps patients who can't find a doctor or find one that spends time with them to get improved care, but it's been diluted and it's been co-opted. And this is a big issue and it's going to become a really bigger issue because it's estimated over the next decade. We're going to have a shortage of 86,000 primary care doctors. All right, so this is my review of some of the literature. This is my assessment, but my assessment may or may not be right. So today I am excited to share that we have two esteemed doctors that are going to join me and either sent me straight or corroborate that where I'm going makes some sense. So one of the physicians that you will meet has been a concierge physician for many years and the other one, not a new physician, but he's about to become a new concierge physician, spoiler alert for full transparency. The first doctor I'm about

4:15to introduce is my brother's doctor, Dr. Spiro Smith. And the second doctor is my doctor for many years, Dr. Hyyan Yaku. So let me introduce their bios and then we'll get them on here and the real dialogue will get started. So Dr. Spiro Smith is board certified in internal medicine. He worked in the hospital environment for about 20 years and he started a concierge practice about six, eight years ago in Connecticut. Not a little known fact, certainly a little known fact to my audience is he travels to Switzerland in Greece a few times a year and actually has concierge patients there, not just in the US. Of course, he hikes and has other fun things to do while he's there. And he's been recognized widely for his work both locally and nationally. And Dr. Hyyan Yaku is also a board certified internal medicine physician in Austin, Texas. And he spent over a decade at Austin Regional Clinic where he ran one of the largest and busiest internal medicine practices

5:18in a 400 provider network. So he was quite renowned in that environment. And now he's decided to leave that large environment and start his own concierge practice with a special interest in evidence-based longevity medicine. He also completed a full Ironman triathlon in November of 25 at age 53. And I might have had something to do with encouraging him to do that. So welcome, Spiros and Hyyan. Great to have you. Thank you. Thank you for having us. Any opening words about kind of how you're thinking about concierge practice? We're going to dive in in great depth. But any opening comments you'd like to share? Well, I mean, the reason I jumped into it was after 20 years in hospital medicine. I always had a passion for preventative medicine. I practiced in a traditional practice, insurance-based, etc. as a medical director coming when I came out of the hospital. The paperwork was immense. We had 10 minutes per patient. But to see them to

6:22even full physicals were 15, 20 minutes, which are hardly enough even to get in the door and start talking with people. And I quickly realized that I wasn't good at exercising that passion I for prevention, let alone do anything complete, and started a partial concierge practice while I was directing that group and went off at the found a formal concierge medicine practice, which I kind of consider I look at as an ultra-concierge practice. I have a very limited number of patients at 150. Most most practices are at 300 to 500, which I think is a little overdone if you truly want to practice and spend time with people and do prevention and look at the longevity models that Bobby was referring to earlier, evidence-based medicine and truly individualized medicine. Yeah, I have. So, Pion, any opening thoughts for you? Sure. You know, I am getting into concierge medicine. And it's one of those things that was always a dream to achieve. Not for any reason,

7:23other than it's the promise that I'll be practicing medicine the way I always loved to what practice it for all of my life as far as being part of a large group. And I always had this time restrained, like you have 15 minutes with every patient. By the time you take care of the acute problems, not much left for prevention, like Sparrow said. I am a person who likes who who is a perfectionist by nature. And I cannot just leave something in front of me that needs to be fixed and touched. So, I found myself always spending way more than the 15 minute. So, in the last 10 years, not a single day I had a lunch break. Every single day I had to stay two hours after finishing my last patient to catch up. So, I tried to do more. Even with that, I still every day felt guilty. I always felt like I left more care that I could have delivered if I had the time. That just it was impossible to do. And the promise for me now, I'll be able to practice medicine

8:24the way I always envisioned it. I can take care of the acute problems and I'll have more time for the preventative. And every day I'll go home thinking I have given every single one I've seen today, everything I have. That's beautiful. Well, let me put some numbers out there because that's the nature of this podcast. So, a typical primary care doctor has 2000 patients. It could be 3000 patients. It's a large number. It's like eight or ten times the number that Spiros has. And the various studies that have been done on average, you spend 15 to 18 minutes of time with your doctor. If you're lucky, it's often less than that. Now, how does that 15 minutes or so break out? Well, typically it's about five minutes for the reason you came in and then a rushed one minute for everything else. So, you might have a minute to talk about prevention, a minute to talk about tests that are needed, a minute to answer other types of questions. And that adds up to your

9:29roughly 15 minutes. It takes about a month to get a routine visit. Yeah, you can get seen by someone more urgently, but it likely won't be your doctor. In contrast, the concierge practice, you know, can have as Spiros said 150 or 200 patients, typically it's more like 300 to 500 patients. The expectation is because there are fewer patients, you can get a same day visit. You can get ready access by text or email or phone. So, Spiros, let's begin with you because you're the granddaddy here in terms of you've been doing this a while. And in the world and the history of concierge, you know, six, eight, ten years is about as long as it's really been around. So, you were one of the pioneers. And you gave us a sense of why you did it that you just didn't have the time you wanted. How is it unfolded for you? What happened that you expected and what's been the unexpected? Well, the unexpected has been the demand. I really, Bobby, so I initially took about

10:3350 patients with me for my old practice into the full concierge world and that 50 became 150 within a year. And I had to stop the flow and say, look, I don't want to do this. I don't want to go above a certain number so I can spend the appropriate amount of time with patients. So, that was the unexpected. The expected was the passion, the better quality of life, even though I'm like Hayan, I'm kind of a perfectionist. I do 24, seven care every day of the year. So, the first phone call always comes to me, whether it's a holiday, whether it's a weekend, whether there's no coverage for the first phone call, text, email, etc. There is coverage, of course, if I'm not physically there for somebody to see my patients. But that allows me to really have a hand in every aspect of care. And that was the expected. That's what I did expect to happen. And it worked more than met my expectation. And when you're in the office, how long do you typically spend with the patient? And how many patients a day do you see? I see several a day. Now, it's tricky to answer that because

11:36I usually deal with about seven to 10 patients a day, whether it be via phone call, video consultation, but actually physically seeing patients about two to three a day. And those are usually physicals or an add-on for a problem, etc. So, you know, people are maybe thinking, oh, these are just rich people and they're probably healthy. And there's really not much to do other than hold their hand and chat a little bit. How does your practice break down between, you know, people that have multiple conditions? They're really quite sick and they really need a lot of care versus people that want ready access, but they're not particularly ill. I have about 20 to 30% of my patients that have really serious medical problems. Two of them are going to be presented at Yale Grand Rounds for their particular specialties to give you an idea. So, some very complex conditions. And that, I have a patient in the hospital right now, 15 phone calls since yesterday to coordinate his care. So, there is that end of the spectrum and that's where connectivity being known in the community,

12:38being able to pick up a phone and call somebody on their cell phone and say, hey, you're taking care of my patient. Here's the story they give you the story and then you're, you take care of them. That's about 20 to 30%. There's about another 30% or so that are in medium range have an occasional problem that aren't as burdensome. And then there's the younger population and by younger, I mean, 30s to about age 50 that are fairly healthy that are more interested in prevention, cardiovascular risk, their family histories, etc. But we do deep deep dive. So, in answer to your question, my average physical runs about an hour and a half. So, 15, 20 minutes in a regular practice. So, when you see a doctor in a routine care, not a concierge practice, you know, your expectations are, if it's a good doctor, is you won't wait in the waiting room too long, you'll get into the, see the doctor, maybe there'd be an interaction with the nurse taking your blood pressure and such, interact with your doctor. And then you might have some back and forth on a patient internet portal.

13:44Now, I don't think anybody believes that if they end up in the hospital that their regular doctor is going to come and take care of them. That used to be the way it is. It used to be the way, exactly. I don't think they necessarily expect if you're going to the cardiologist that you pick up the phone, a regular doctor, and talk to the cardiologist and say, I heard you just saw Sam, what's going on, what do we need to do with him? There are sound above. Sorry, sorry, sorry, sorry, didn't write there astounded when you do that. It's definitely the exception, not the norm. So, what is, what is the package of things that you routinely offer your patients? How is it different than the traditional model that most people experience? Well, we'll do a breakdown from, their deep family history to their lifestyle to longevity medicine. So, we dive into that part of it. They ask all the aspects of health from meditation, community, exercise, diet, supplements,

14:45what they're taking, what they're not taking, where the evidence-based medicine is for what they're taking. And a lot of my patients will come in. They are affluent and will come in with a myriad of studies lab. Otherwise, whole body MRIs, this that the questions are basically rotate around that. Should I check my neurotransmitters? Which is what, at least in the twice-state area up here, again, we're doing a lot of dopamine level serotonin this that. And you need to sit them down. And if the trust is there and the bond is there, you have to say, look, I get it. As Plato said, a fool will laugh at what he or she can't explain. But on the flip side, if there's a commercial aspect to this where somebody's making money, you need to be very, very careful. So, we have these discussions day in and day out. And that's part of the physical, but it doesn't. It extends way beyond the physical. So, they'll email me. They'll text me, hey, what do you think about peptides? What do you think about growth hormone testosterone? This or that? And we'll have half an hour conversations offline, not during that physical, as a continuation of the physical.

15:50So, let's talk about continuity. You believe the patient needs to see the cardiologist, or the patient, as you mentioned, ended up in the hospital. As a concierge doctor, how do you play quarterback here? And how is that different than what a typical patient might experience? Well, I initiate the phone call to the cardiologist or to the, well, whatever the specialist is, I'll call them. I have a very tight network of people that I work with. And so, I'll initiate the phone call. And then the specialist will call the patient. The specialist office will call the patient and set up that appointment in a much quicker time. And so, within a week or two, that patient's seen, or sooner, even within a few days, if needed, say they're having chest pressure, et cetera. And we often can bypass sending into the ER, because that specialist will see them the same day or the next day. And they'll text me back saying, yes, I've scheduled them for tomorrow. I'm seeing them tomorrow, two o'clock. They'll call me at two o'clock after they see them. And tell me what they find. That never happens anymore. Bobby, when I was training, and I'm sure

16:51the same applies to you, it was common practice to when I send you a patient for you to call me and discuss that patient. Now, on both ends, the specialist is busy, and the primary care physician can't be bothered because they're inundated doing a whole lot of paperwork and seeing 20 patients, 25 patients in the office. So that follow up doesn't happen. Right. That's that's unfortunately the norm these days is opposed to 25 years ago, 30 years ago, when I'm training. So, hi, on let's, let's turn to you. So, Sparrow has been doing this for a while. It's sort of laid out kind of what it looks like for him, what it looks like for the patient. So you are embarking upon this change. So what ultimately prompted you to say, I want something different. What is the different that you really wanted and tell us a little bit about that? You know, it comes down really to time. I want it more time with my patients. Okay. On the same doctor, I have the same knowledge, the same analysis,

17:53I was just, I just had a significant time restrained. I have the connection. It's just like Sparrow said, I didn't have the time to sit and talk to every specialist after they see my patient and come up with a plan. And that was just always on my mind. So when I started this journey, like I want to go to concierge practice, I started to study the market and I looked around and as a matter of fact, a lot of what I saw concern me. There is a version of concierge medicine, which seems to be actually the dominant version in the, at least here in the Austin area. This version is really more about sales operation, slick marketing, hormone packages, supplement lines, panels of hundreds of tests, whether or not they are evidence based. That's not the issue there. The business model is selling you more. What I am building is completely the opposite. What I envisioned myself doing is I'm selling you more time and judgment. My interest is in longevity medicine. But like Sparrow said, it's more like you are

18:59living longer, but still productive. And it's only evidence based longevity exercise, sleep, metabolic health, the screenings we know save lives. It's not that flashy $5,000 biomarker panel that actually works. We know that does not actually work. So after looking at all of that, this I deliberately walked away from that model and I'm building an evidence based internal medicine where basically I'm following the guidelines. I am giving my patients all the time they deserve, whether it is for their acute problem or for prevention, doing collaboration with specialists, arranging for them to see the specialists then sit down and discuss the outcome of their visit with the specialist. If they go to the hospital, I'm coordinating with the hospitalist and then come back and see me to coordinate the after hospital follow up. A lot of this was impossible to do and you have 3,000 patients and you're supposed to see them in 15 minutes each. So you said something,

20:06you probably didn't even realize you said it and it was one word that typifies I think everything you and Spiros have said and that word was my, my patient, not a patient or the patient, my patient. I get chills up and down my spine, maybe I have a neurologic disorder, when you said that because that is what medicine used to be and now it just feels so different. To hear a doctor say, my patient, I mean, how can everyone not want that situation? So thank you, thank you for using that word. Okay, so something probably our listeners don't realize. I think when they've if they've heard about concierge medicine, they're assuming it's a doctor by him or herself in an office and that they've left the big medical establishment to do something with great flexibility

21:13that they are in charge of. But the reality is, many probably most of the new concierge practices are as you said, these for-profit corporate entities where you're just a cog in another wheel. It's a different wheel. Maybe it's a little shinier wheel, but you're not that solo doctor who is offering these types of services. So, when you looked around and these for-profit groups approached you, what were they? What would that practice have been like if you joined them versus doing it on your own? You know, I did not really explore it in depth with them. It's just that it felt like you're like you said you moved from one system to another and if I am at this age deciding to do something different, I want to build it myself. I want to have it my way. I know how to do it now. I've been doing this for most of my life. The thing about practicing medicine, there are so

22:16many obstacles and challenges you worry about like, will I know how to start a business? Will I know how to get an electronic medical record? So, there are so many obstacles that I had to mentally overcome in my head before I felt, you know what? There are obstacles. It's a hard path, but I am willing to take it and I start talking to people like Sparrows and other doctors who has done it and everybody will be like, you have to do it to yourself. So, let's shift gears a little bit and get some evidence out on the table. So, what you doctors have shared is a wonderful image of a doctor-patient relationship and the way a patient would want to be treated and traverse the healthcare system. Now, the question is, is concierge medicine better? So, there have been some studies out there. There have been no randomized control at draws, so we don't really, really, really know. But from a satisfaction, patient satisfaction standpoint, there was a study that looked at

23:19concierge doctors that went from traditional practice to the new world and on average on a five-point scale. A typical doctor's rating was sort of three to four. The concierge doctor was four to five, so there was an improvement in satisfaction. And given what we've heard from both of you, that would not be a surprise that the patients would feel happier with it. Then there was another study that looked at, well, the cost of all of this. So, they did an interesting study where there were 800 doctors who switched from a traditional practice to a concierge practice. And they had about 28,000 Medicare patients that they could track from one environment to another. What they found was that the care of those patients was 25 to 50 more costly, more testing, and that used more dollars. And at the end of five years, there was no difference in mortality. So, that doesn't mean we have

24:21the answer. So, we do know the satisfaction is better. It appears, and I'm not necessarily saying, it's a bad thing that money, more money was spent because maybe more preventive care happened that otherwise would not have happened. But those are the data points. You know, Bobby, I'm very happy you brought this up because I think me and Sparrows will represent the minority in the concierge world right now, as it is. Absolutely. So, the study included, there was this dilution effect where it included all kind of people claiming to be concierge, whether it is science evidence-based or just testing. So, I try to find that study to try to look into like how, if there was any kind of selection criteria for these concierge, it was more a random selection. So, yes, the cost will go up, and that's probably driven by testing, with

25:27certainly no mortality benefit. This is what happened when the business model is taken over. There will be more testing. Is that better medicine? Certainly not. That is not better medicine. That is more medicine. The other thing about the studies that five years is really not long enough in the primary care world when you look at the mortality. And Hayan, Hayan, what it also didn't look like, so already interject is that, and I agree, we're the minority, and I say that because I think if you look at the, if somebody were to take a look at my practice and see the number of tests compared to an average, internal medicine of patients, and an average practice, you see less tests, and fewer ER visits. So, I actually stopped people from going to the ER, costing the system less. They get fewer CAT scans of abdomen pelvis when they go in for a gastroenoritis, or maybe don't go in at all. So, I would argue that we test less, not more in that. But I think you're right, you hit the nail on the head, both Bob and Hayan, this is a, we're in the minority,

26:30because if you do look at a random sample, you are going to find more testing, you'll find more whole body MRI scans, et cetera. So, let's step back a little bit. So, I wasn't, for time purposes, we're not going to dig in too deeply to the cost of all this. It's, you know, somewhere between two and five, six, seven thousand dollars a year to be in a concierge practice. So, our listeners might be like, well, how can doctors afford to only see 300 patients? Well, you do the math, if you have 300 patients, and they're spending several thousand dollars a year, the doctor is making a decent amount of money without having to do all the other stuff that was part of their prior life. So, that is how the math works. When you pay that amount to the concierge doctor, that doesn't mean for the patient, there's never another payment. Typically, your insurance will pay for the labs and the CAT scans if they're needed and the specialist visits. That's not covered underneath the

27:31few thousand dollars a year, you're paying your concierge doctor. So, there will be some add-ons. Now, if you have good insurance, it picks up most of it. It won't be a big deal. And part of the reason why these practices do lots of tests is they get to build the insurance company for all the tests. So, they're making money at the front end and they're making money in the back end. That's just a just a brief vignette of it. Now, I wanted to get into a thorny issue and Spiros, I think you raised it and Hyanya and I talked about this briefly. Okay, so, you're paying thousands of dollars a year and yes, you're getting time from your doctor and he will answer or she will answer your emails and they'll pick up the cell phone on the weekends. This is great. And with that comes expectations that if I want that antibiotic for a simple cold, I want you to write it. If I want CAT scan or an MRI for my headache, I should get one. How do you deal with patient expectations when there's almost

28:35this tacit contract that I'm paying you money and I want to get some stuff back from you? Spiros, you've lived through this. How do you deal with it? You select your patients wisely. That's what you do. So, many years ago, there was a billionaire tech guy in New York who called me up and wanted to engage me as his personal physician for his family, which means I wouldn't see anybody other than his family and the execs in his company in New York City. And I said, all right, well, I need to meet you. I know you're going to meet HR first and then my vice president and I said, no, no, no, no, no, no, no, I need to meet you before we engage. I don't want to waste my time and he wasn't willing to do that. So, I said respectfully, thank you for considering me. We had a mutual friend and said, no one walked away. Have you ever had your patient? Yes, I've said, look, we're not seeing things on the same frequency. Okay. Neither here nor there. And it's not about fault or about

29:36an emosity, but we're not on the same page here. One called me from Florida. Should I go on growth hormone and testosterone? Everybody else here at the table is. Why am I not on it? And they're all asking me why my doctor's not prescribing. And I said, well, do you have a half an hour? He says, no, I said, well, when you have a half an hour, give me a call. And we chatted about it. Tyann, how do you think you will approach this? There are a couple of things here that please a factor. A lot of doctors, they basically, when the patient comes in and say, I want this MRI, you'll have six minutes to try to convince the patient that this MRI is not a good idea. So a lot of time they cave in and they order the MRI because they don't have time to go through 30 minutes of explanation why the MRI is not needed, unfortunately. The other thing is the trust factor. I think when people are moving fast through the system, there's really not enough time to build that trust between the physician and the patient. When there is that trust,

30:36it will be much easier when you tell your patient, you know, I don't think this is a good idea because of this, this, this, they're way more likely to be receptive because most people do not want the tests. They want to feel better and they want the right thing. What I would tell my patients, you know, the membership buys you my time, my judgment and my honesty, but it does not buy you a yes. That's beautifully put. Well, I'm sure we could talk for another hour, but I think we're going to start to work towards wrapping up. So there is a huge need for primary care doctors. It's going to get worse and worse. I hear so many people say the doctor doesn't spend any time with me. The doctor left. Now I got to find a new doctor and nobody seems to be the kind of doctor I want. And as I started out, the concierge style has really many positive features. And I think you've heard deep, you know, feelings from both Spiros and Hayan about why they've done what they've done. The problem is

31:40the world of concierge medicine is shifting and much of what we're seeing out there is really not what it was meant to be. So as you look around, as you think about potentially considering a a concierge practice, there's that, you know, Latin phrase caveat, M tour, buyer beware. Make sure you're getting the type of care that what you've heard from Spiros and Hayan because I think that's what will really help you as you work your way through the healthcare system. Any last words Spiros or Hayan? Hayan, you first. You know, as you're speaking, I'm thinking somehow the world concierge medicine does not do justice to the medicine itself. It should be the real medicine. It is called concierge which put emphasis on like white glove service and more hospital, but it's really more than that. It is, if I get a chance to change the name, I'll call it the real medicine. And I am now

32:47imparting on a journey to practice the real medicine. I always dreamt of practicing. Wonderful. Spiros, very, very, very well put Hayan. I couldn't agree with you more. It's about practicing medicine with a passion and the word concierge does give it a bit of a well, am I, is it a concierge and a building, a hotel, etc. So it's about being passionate, listening to your patient, spending the time you need. Well, thank you. Thank you deeply, both of you. For my listeners, you've heard from two of the best practitioners, providers, whether we call them concierge doctors, real medicine doctors or whatever. Think carefully about what your healthcare situation is like. Are you comfortable with your doctor? These are the types of characteristics that we all want for our loved ones and for ourselves when we're sick. I hope that today I've given you a glimpse of a few things and maybe some tools and thoughts about how to approach healthcare moving

33:47forward. As always, I hope you live long and well and till our next get together. Thanks so much for listening to Live Long and Well with Dr. Bobby. If you like this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit the at Dr. Bobby Live Long and Well.com. That's Dr. Asin DR. Bobby Live Long and Well.