Physician Services: Concierge Care Characteristics and		 
Considerations for Medicare (12-AUG-05, GAO-05-929).		 
                                                                 
Concierge care is an approach to medical practice in which	 
physicians charge their patients a membership fee in return for  
enhanced services or amenities. The recent emergence of concierge
care has prompted federal concern about how the approach might	 
affect beneficiaries of Medicare, the federal health insurance	 
program for the aged and some disabled individuals. Concerns	 
include the potential that membership fees may constitute	 
additional charges for services that Medicare already pays	 
physicians for and that concierge care may affect Medicare	 
beneficiaries' access to physician services. The Medicare	 
Prescription Drug, Improvement, and Modernization Act of 2003	 
directed GAO to study concierge care and its relationship to	 
Medicare. Using a variety of methods, including a nationwide	 
literature search and telephone interviews, GAO identified 146	 
concierge physicians and surveyed concierge physicians in fall	 
2004. GAO analyzed responses from 112 concierge physicians. GAO  
also reviewed relevant laws, policies, and available data on	 
access to physician services and interviewed officials at the	 
Department of Health and Human Services (HHS) and representatives
of Medicare beneficiary advocacy groups.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-929 					        
    ACCNO:   A32877						        
  TITLE:     Physician Services: Concierge Care Characteristics and   
Considerations for Medicare					 
     DATE:   08/12/2005 
  SUBJECT:   Data collection					 
	     Health care programs				 
	     Health surveys					 
	     Medical fees					 
	     Medicare						 
	     Patient care services				 
	     Physicians 					 
	     Policy evaluation					 
	     User fees						 

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GAO-05-929

                 United States Government Accountability Office

GAO

                       Report to Congressional Committees

August 2005

PHYSICIAN SERVICES

         Concierge Care Characteristics and Considerations for Medicare

                                       a

GAO-05-929

Contents

    Letter                                                                  1 
                                  Results in Brief                          3 
                                     Background                             4 
                          Characteristics of Concierge Care                 9 
              Aspects of Concierge Care of Interest to Medicare and Its  
                                    Beneficiaries                          17 
                               Concluding Observations                     26 
                              Agency and Other Comments                    26 

Appendixes                                                              
                Appendix I:             Scope and Methodology              28 
                                Summary of Physician Responses to GAO      
               Appendix II:                 Concierge Care                 
                                                Survey                     32 
                              Comments from the Department of Health and   
              Appendix III:                     Human                      
                                               Services                    42 
              Appendix IV:      GAO Contact and Staff Acknowledgments      44 

Tables	Table 1: Table 2: Table 3:

Table 4: Table 5: Table 6: Table 7:

Table 8:

Limits on Physician Charges for Medicare-Covered
Services 8
Features Offered by Concierge Physicians, October
2004 15
Concierge Physicians' Views on HHS Information about
How Medicare Requirements Might Affect the Practice of
Concierge Care, October 2004 20
Patients from Physicians' Conventional Practices Who
Joined Physicians' Concierge Practices 23
Characteristics of Concierge Physicians and Their
Practices, October 2004 32
Estimated Number of Patients in Individual Practice,
October 2004 36
Actions Concierge Physicians Reported They Took to Help
Medicare Patients Who Did Not Join the Concierge
Practice Find New Physicians 39
Concierge Physicians' Views on the Information Available
from HHS about How Medicare Requirements Affect
Concierge Care, October 2004 40

                                    Contents

Table 9:	Concierge Physicians' Views on Remaining in Medical Practice and
Treating Medicare Beneficiaries if Physicians Were Unable to Practice
Concierge Care 41

Figures Figure 1:

Figure 2: Figure 3: Figure 4:

Figure 5:

Figure 6:

Figure 7:

Figure 8:

Location of Concierge Physicians Identified by GAO,
2004 10
Yearly Growth in Number of Concierge Physicians 11
Annual Membership Fee for Individuals, October 2004 13
Number of Concierge Patients under the Care of
Individual Concierge Physicians, October 2004 14
Medicare Participation Status of Concierge Physicians
Surveyed by GAO, October 2004 17
Medicare Beneficiary Patients of Concierge Physicians,
October 2004 22
Physicians' Goals for Total Number of Concierge
Patients, October 2004 37
Annual Membership Fees Charged by Physicians Who
Did and Did Not Bill Patient Insurance, October 2004 38

Abbreviations

AMA American Medical Association
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services
MSA metropolitan statistical area
OIG Office of Inspector General
PMSA primary metropolitan statistical area

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
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separately.

A

United States Government Accountability Office Washington, D.C. 20548

August 12, 2005

The Honorable Charles E. Grassley
Chairman
The Honorable Max Baucus
Ranking Minority Member
Committee on Finance
United States Senate

The Honorable Joe Barton
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives

The Honorable William M. Thomas
Chairman
The Honorable Charles B. Rangel
Ranking Minority Member
Committee on Ways and Means
House of Representatives

Concierge care is an approach to medical practice in which physicians
charge their patients membership fees in exchange for enhanced services
or amenities. Concierge physicians typically care for fewer patients than
do
doctors in conventional practice, and they are more readily available to
member patients, for example, by cell phone or same-day appointments.
The approach has attracted media attention in recent years. Critics
contend
that concierge care makes health care more lucrative for a few physicians
and more convenient for some patients, but less accessible to patients who
cannot or choose not to pay a membership fee. Proponents, in contrast,
describe concierge care as both a rational response to patient demand for
more personal care and a way for physicians to regain control of their
medical practices and their lives. They say the approach allows concierge
physicians to spend more time with their families, enhance their incomes,
and spend more time on research and other professional activities.
Because concierge care has gained attention only recently, little is known
about how many concierge physicians there are or about how the approach
could affect access to physician services.

Concierge care has also generated attention within Congress, the
Department of Health and Human Services (HHS), and state governments.
Federal attention has centered on how membership fees might affect
beneficiaries of Medicare, the federal health insurance program for
individuals aged 65 and older and certain persons with disabilities. Of
particular concern is the potential that membership fees may constitute
additional charges for services that Medicare already pays physicians for
and that concierge care may affect Medicare beneficiaries' access to
physician services. Members of Congress introduced bills that, if enacted,
would have prohibited physicians from imposing membership fees on Medicare
beneficiaries as a condition for the provision of a Medicarecovered item
or service.1 A few states are monitoring concierge care to ensure
compliance with state insurance laws.2

Given the concerns about how concierge care might affect Medicare
beneficiaries, the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 required us to study and report on the
practice.3 As discussed with the committees of jurisdiction, this report
addresses the following questions:

1. What are the characteristics of concierge care?

2.	What aspects of concierge care are of interest to the Medicare program
and its beneficiaries?

To obtain information on the characteristics of concierge care, we
surveyed concierge physicians about their practices and the types of
services and financial arrangements they offer. Because no comprehensive
directory of concierge physicians was available, we identified concierge
physicians through a variety of methods, including a nationwide literature
search,

1See for example, the Medicare Equal Access to Care Act of 2003, H.R.
2423, 108th Cong., and the Equal Access to Medicare Act of 2003, S. 345,
108th Cong.

2In Washington, for example, the Office of the Insurance Commissioner is
monitoring concierge care and has considered requiring that physicians who
charge a set fee in exchange for comprehensive primary care meet all the
requirements that apply to health maintenance organizations. The basis for
this requirement is that an agreement to provide unlimited health services
in exchange for a fixed fee results in the assumption of insurance risk.

3Pub. L. No. 108-173, S: 650, 117 Stat. 2066, 2331. The conference report
for the Consolidated Appropriations Act, 2004, Pub. L. No. 108-199, 118
Stat. 3, also directed GAO to study concierge care. H.R. Conf. Rep. No.
108-401, at 806 (2003).

telephone interviews, and referrals from other concierge physicians. We
identified as concierge physicians those who (1) had established a direct
financial relationship with patients in the form of a membership or
retainer fee and (2) provided enhanced services or amenities, such as
same-day appointments or preventive services not covered by patient health
insurance. We located a total of 146 concierge physicians practicing in
the United States. We received survey responses from 112 physicians who
practiced concierge care in October 2004. Because these 112 respondents
were not selected at random from a larger population of known concierge
physicians, the information they provided cannot be projected to any other
concierge physicians. We did not attempt to verify the accuracy of their
responses.4

To review the aspects of concierge care that are of interest to the
Medicare program and its beneficiaries, we reviewed documents and
interviewed officials from two HHS entities responsible for administration
and oversight of the Medicare program: the Centers for Medicare & Medicaid
Services (CMS) and the Office of Inspector General (OIG). We also reviewed
relevant sections of Medicare law and regulations; interviewed concierge
physicians and their representatives; and in our survey, asked concierge
physicians for their views on the guidance available from HHS on concierge
care. To assess what is known about how concierge care may affect Medicare
beneficiary access to physician services, we reviewed nationwide sources
of information on Medicare beneficiaries' overall access to physician
services, for example, reports by the Medicare Payment Advisory
Commission. While we did not contact Medicare beneficiaries who were
patients of physicians who converted to concierge practices, we contacted
organizations that Medicare beneficiaries were likely to call with
concerns or questions about concierge care, such as the 1-800-MEDICARE
call line. We conducted our work in accordance with generally accepted
government auditing standards from May 2004 through July 2005.

Results in Brief	Concierge care is practiced by a small number of
physicians located mainly on the East and West Coasts. Nearly all of the
112 concierge physicians who responded to our survey reported practicing
primary care. They differed, however, on the characteristics of their
concierge practices, such as the membership fee charged, features offered,
and whether they billed

4See app. I for details on our scope and methodology.

patient health insurance. For example, the amount of the concierge care
membership fee ranged from $60 to $15,000 a year for an individual, with
about half of respondents charging individual annual membership fees of
$1,500 to $1,999. The most frequently reported features offered by
concierge physicians responding to our survey included same-or next-day
appointments for nonurgent care, 24-hour telephone access, and periodic
preventive-care physical examinations. In addition, about three-fourths of
the respondents reported billing patient health insurance for covered
services and, among those physicians, almost all reported billing Medicare
for covered services.

Two principal aspects of concierge care are of interest to the Medicare
program and its beneficiaries: compliance with Medicare requirements and
its effect on beneficiary access to physician services. HHS has determined
that concierge care agreements are permitted as long as the arrangements
do not violate any Medicare requirements; for example, the membership fee
must not result in additional charges for items or services that are
already reimbursed by Medicare. Various strategies for concierge care
practice design have been developed to help concierge physicians avoid
potential Medicare compliance problems, but most of our survey respondents
expressed a need for more information from HHS to guide them. Although no
national data directly address the impact of concierge care on
beneficiaries' access to physicians, the information available as of 2004
on overall beneficiary access to services indicates that access has been
good. The small number of concierge physicians makes it unlikely that the
approach has contributed to widespread access problems. In addition,
information from beneficiary advocacy organizations and on physician
supply in communities where more concierge physicians practiced does not
indicate that concierge care was contributing to any systemic access
problems. In commenting on a draft of this report, HHS agreed with our
finding about the effect of concierge care on Medicare beneficiary access
to physician services, and also noted that it remains interested in
concierge care and will continue to follow developments in the area.

Background	Physician practices that charge membership or retainer fees and
provide enhanced services or amenities are referred to as concierge care
or

retainer-based medicine.5 The origins of this practice approach are often
traced to a medical practice founded in Seattle, Washington, in 1996.
Physicians in this practice provide comprehensive primary care to no more
than 100 patients each and currently charge annual retainer fees of
$13,000 for individuals. These physicians do not bill any form of patient
health insurance. As more physicians have begun concierge practices,
concierge care has become more diverse, comprising physicians who bill
patient insurance, charge lower membership fees, and see more patients
than the original Seattle practice.

The American Medical Association (AMA) has described concierge care as one
of many options that patients and physicians are free to pursue. AMA in
2003 adopted ethics guidelines for physicians who have concierge care
contracts-which AMA calls retainer contracts-with their patients.6 These
guidelines specify, for example, that physicians should facilitate the
transition to new physicians for patients who choose not to join their
concierge practices and that they must observe relevant laws, rules, and
contracts.

The Medicare program was established by title XVIII of the Social Security
Act, which governs how physicians bill for services that the program
covers. Limits on what physicians may charge their Medicare patients
depend on (1) the relationship between the physician and the Medicare
program and (2) the type of service provided.

Physicians who provide services to Medicare beneficiaries may choose one
of three ways to relate to the program: participating, nonparticipating,
or opted out.

o 	Participating: Participating physicians agree to accept Medicare's fee
schedule amount as payment in full for all covered services they provide
to beneficiaries.7 In accordance with the Medicare participation
agreement, these physicians receive reimbursement directly from the

5We use the term concierge care because the statutory provision that
mandated our work used this term.

6AMA Web site at
http://www.ama-assn.org/ama/pub/category/print/11967.html, downloaded on
March 16, 2005.

7Medicare's payment amount for physician services generally is determined
by a fee schedule and includes 80 percent payment from the program and 20
percent beneficiary coinsurance, once the beneficiary's annual deductible
has been met.

Medicare program and agree to charge beneficiaries only for any applicable
deductible or coinsurance. More than 90 percent of the physicians and
others who billed Medicare agreed to participate in Medicare in 2004.8

o 	Nonparticipating: Nonparticipating physicians do not agree to accept
the Medicare fee schedule amount paid to participating physicians as
payment in full for all covered services they provide to beneficiaries.
They are still subject to limits on what they may charge, however, and
those limits depend on whether they seek reimbursement directly from
Medicare. When a nonparticipating physician files a claim to be reimbursed
directly from Medicare, he or she must accept the Medicare fee schedule
amount for nonparticipating physicians, which is 95 percent of the fee
schedule amount for participating physicians, as payment in full and may
charge the beneficiary only for any applicable Medicare coinsurance or
deductible.9 When a nonparticipating physician does not request
reimbursement directly from Medicare, he or she may charge the Medicare
beneficiary up to 115 percent of the fee schedule amount for
nonparticipating physicians.10

o 	Opted-out: Physicians who opt out of Medicare are not subject to any
limits on what they may charge their Medicare beneficiary patients, even
for services that Medicare would otherwise cover.11 Physicians who opt out
of Medicare must agree not to submit for 2 years any claims for
reimbursement for any of the services they provide to Medicare
beneficiaries.12 Contracts between opted-out physicians and their
beneficiary patients allow them to make their own financial

8Medicare Payment Advisory Commission, Report to the Congress: Medicare
Payment Policy (Washington, D.C.: March 2005).

942 U.S.C. S: 1395w-4(g)(2)(C) (2000).

10A beneficiary may be reimbursed no more than 80 percent of the fee
schedule amount for nonparticipating physicians, regardless of how his or
her nonparticipating physician chooses to bill.

11This option became available through the Balanced Budget Act of 1997,
which amended the Social Security Act to specify that physicians may enter
into private contracts with Medicare beneficiaries. Pub. L. No. 105-33, S:
4507, 111 Stat. 251, 439 (codified at 42 U.S.C. S: 1395a(b) (2000).

12Reimbursement may be made in cases where opted-out physicians provide
emergency or urgent care to beneficiaries with whom they do not have
private contracts.

arrangements for services that would otherwise be covered by Medicare,
effectively taking those services outside the program. These contracts
must be in writing and they must clearly state that the beneficiary also
agrees not to submit claims to Medicare and assumes financial
responsibility for all services provided by that physician.

In addition to a physician's Medicare participation status, the type of
service provided also determines whether limits apply to physician
charges. Physicians and beneficiaries are free to make private financial
arrangements for the provision of services that Medicare does not cover.

o 	General standard for Medicare coverage: Medicare law states that, to be
covered, services must be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a
malformed body member.13 The scope of coverage and the exact type of
service that may be reimbursed depend on the circumstances of each case.
This medical necessity standard can result in situations where the same
service-for example, a comprehensive office visit-is considered medically
necessary and reimbursable by Medicare in some circumstances but not
others.

o 	Specific inclusion in Medicare coverage: Medicare law also establishes
coverage for certain specific services. For example, Medicare covers an
initial preventive physical examination for beneficiaries who become
eligible for Medicare on or after January 1, 2005. Other examples of
specific preventive benefits established by statute include immunizations
against pneumonia, hepatitis B, and influenza and periodic screening tests
for early detection of certain cancers.

o 	Specific exclusion from Medicare coverage: Medicare law specifically
excludes certain items or services-for example, personal comfort items,
purely cosmetic surgery, hearing aids, and routine physical checkups
except for the initial preventive examination for newly eligible
beneficiaries.

Table 1 summarizes the limits on physician charges depending on their
Medicare participation status and the type of service provided.

1342 U.S.C. S: 1395y(a)(1)(A) (2000).

       Table 1: Limits on Physician Charges for Medicare-Covered Services

Physician status  Medicare-covered services   Limits on physician charges  
                    Medically necessary items or Medicare fee schedule amount 
    Participating   services and                      for participating       
                    specific preventive or other  physicians. The beneficiary 
                             benefits.              may be charged applicable 
                                                  deductible and coinsurance  
                                                            only.             
                    Medically necessary items or 
Nonparticipating services and                 
                    specific preventive or other 
                             benefits.           

Reimbursement claimed directly from Medicare: Medicare fee schedule amount
for nonparticipating physicians, which is 95 percent of the amount for
participating physicians. The beneficiary may be charged applicable
deductible and coinsurance only.

Reimbursement not claimed directly from Medicare: No more than 115 percent
of the Medicare fee schedule amount for nonparticipating physicians. The
beneficiary may be charged this entire amount and may be reimbursed 80
percent of the fee schedule amount for nonparticipating physicians.

Opted-out	None, except when emergency or urgent care is No statutory
limits apply. The amount of payment is provided to a beneficiary with whom
the determined by contracts between physicians and patients. physician
does not have a contract.a

Source: GAO analysis.

aItems or services provided by opted-out physicians to their beneficiary
patients under private contracts are not covered by Medicare.

Physicians who impose charges on beneficiaries beyond the Medicare limits
may be subject to civil monetary penalties.14 The Secretary of HHS has
delegated enforcement of Medicare limits to two different entities within
HHS. CMS, which administers the Medicare program, has enforcement
authority over the limits that apply to nonparticipating physicians. HHS
OIG has enforcement authority over participating physicians' compliance
with the terms of the participation agreement.

The Medicare law's limits on physician charges protect beneficiaries from
additional charges for services they are entitled to receive under
Medicare. The law does not, however, provide that a beneficiary has the
right to receive services from any particular physician. Physicians are
free to choose how they will interact with the Medicare program. They may
decide to close their practices to new Medicare patients or decline to
treat any Medicare beneficiaries at all.

1442 U.S.C. S: 1320a-7a (2000).

Characteristics of 	Concierge care is practiced by a small number of
physicians, located primarily in urban areas on the East and West Coasts.
Although nearly all of

Concierge Care 	the concierge physicians who responded to our survey
reported practicing primary care, they differed in many of the
characteristics of practice design, including the annual membership fee
charged, number of patients treated, features offered, whether they billed
health insurance, and their relationship to the Medicare program.

Concierge Physician Location and Specialty

Concierge physicians are few in number and located primarily in urban
areas on the East and West Coasts. Since the first Seattle practice was
founded in the mid-1990s, the number of concierge physicians has been
rising but remains small. We were able to locate 146 concierge physicians
in the United States as of 2004-a small number compared with the more than
470,000 physicians who regularly submitted claims to Medicare in 2003.15
The 146 concierge physicians we identified practiced in 25 states, with
the greatest numbers in metropolitan areas on the East and West Coasts.16
California had the highest number, with 26 concierge physicians, followed
by Florida with 22, Washington with 21, and Massachusetts with

17. We identified 1 to 8 concierge physicians in 21 other states, though
most of these other states had 5 or fewer. All but 2 of the concierge
physicians we located practiced in metropolitan areas. We found the
highest numbers of concierge physicians in the metropolitan statistical
areas (MSA)17 of Seattle (19); Boston (17); and West Palm Beach-Boca
Raton, Florida (13). Figure 1 presents the locations of 144 concierge
physicians we identified who practiced in MSAs throughout the nation.18

15Medicare Payment Advisory Commission, Report to the Congress: Medicare
Payment Policy (Washington, D.C.: March 2005).

16Other groups which have estimated the number of concierge physicians
include the Society for Innovative Medical Practice Design (formerly the
American Society of Concierge Physicians), which estimated that about 200
concierge physicians practice in the United States. AMA's Institute for
Ethics located 144 concierge physicians, using the same identification
approach that we followed, for its own study in 2003.

17An MSA is a geographic region consisting of a central county or counties
that contains an urban area with a population of at least 50,000 plus any
adjacent counties having a high degree of social and economic integration
with the central county

18Two concierge physicians, both in Washington, were not located in MSAs.

more than 10 times in the past 5 years (see fig. 2).19 About two-thirds of
the responding physicians reported that they began to practice concierge
care in 2003 or later. The number of responding physicians starting to
practice concierge care rose each year after 2000, except in 2004,
although we did not include physicians who began practicing concierge care
after October 2004.20

Figure 2: Yearly Growth in Number of Concierge Physicians Number of
physicians

120

100

80

60

40

20

0 Before 2000 2001 2002 2003 2004 2000

New concierge physicians

Established concierge physicians

Source: GAO survey of concierge physicians.

19Converting a conventional practice to a concierge practice may take
time. Our data on new and established concierge practices included
physicians responding to our survey who charged membership fees and
offered enhanced features to at least some of their patients in October
2004, although some of these physicians may have still been seeking
additional concierge patients and continuing to treat some nonconcierge
patients.

20Because our survey included only physicians who practiced concierge care
during October 2004, it does not account for physicians who may have
started and discontinued concierge practices before that date, or
physicians who started to practice concierge care after October 2004.

Notes: n = 112 concierge physicians practicing as of October 2004. Data
for 2004 do not include physicians who began practicing concierge care
after October. The earliest year in which a physician in our survey
reported beginning to practice concierge care was 1997.

Nearly all of the physicians who responded to our survey reported
practicing primary care and most were not new to medical practice.
Physicians reported practicing the primary care disciplines of internal
medicine (about three-fourths of respondents) and family practice (about
one-fourth of respondents). Survey respondents reported being in various
stages in their medical careers, from relatively new to practice to
decades of experience. More than two-thirds reported having been in
medical practice for 15 years or more. The average length of time in
medical practice was 19 years, and about one-fourth of the respondents
reported being in practice for 25 years or more. See appendix II for
additional information provided by survey respondents.

Characteristics of Practice Design among Surveyed Concierge Physicians

Amount of Annual Membership Fee

Concierge physicians responding to our survey reported a variety of
practice characteristics. These included the amount charged to be a
concierge patient, practice size, features offered, whether they billed
patient health insurance, and their relationship to the Medicare
program.21

The annual membership fee for an individual to join a concierge practice
ranged from $60 to $15,000 among the physicians responding to our survey.
As shown in figure 3, more than 80 percent of respondents reported annual
fees from $500 to $3,999; the most frequently reported annual fee was
$1,500. Three-fourths of our respondents reported that they waived the
membership fee for some of their concierge patients.22 About one in eight
of these physicians reported waiving the fees for 20 percent or more of
their concierge patients.

21About one-third of our respondents were affiliated with a consulting
firm that helps physicians establish and maintain concierge practices.
This firm recommends that concierge physicians offer a program oriented
toward preventive care, limit patients to no more than 600 for each
physician, and submit claims to insurers for covered services.

22Our survey distinguished between concierge patients granted waivers of
the membership fee but still offered the enhanced features of concierge
care, and "nonconcierge" patients who were neither charged a membership
fee nor offered the features associated with concierge care.

         Figure 3: Annual Membership Fee for Individuals, October 2004

                            Number of physicians 60

                                       50

                                       40

                                       30

                                       20

                                       10

                                       0

0-499	500- 1,499

1,500- 1,999

2,000- 3,999

                    4,000+ Amount of annual fee, in dollars

Source: GAO survey of concierge physicians.

Notes: n = 111 concierge physicians practicing as of October 2004; 1
respondent did not provide this information. The maximum reported annual
individual membership fee charged was $15,000.

Practice Size	Concierge physicians responding to our survey reported, on
average, 491 patients under their care as of October 2004-significantly
fewer than the average of 2,716 patients they reported for the year before
beginning to practice concierge care. Of the total patients they reported
in October 2004, an average of 326 were concierge patients-that is,
patients who either paid the membership fee or had the fee waived, and
were offered the enhanced services or amenities associated with
membership.

Nearly two-thirds of responding physicians reported having fewer than 400
concierge patients (see fig. 4). Concierge physicians also reported seeing
fewer patients per day: the average number of patients physicians reported
seeing on a typical day fell to 10 in October 2004 from 26 in the year
before they began practicing concierge care.23

23Information on the number of patients seen per day was provided by 101
of the 103 physicians who reported that they established their concierge
practices in the same community in which they had practiced before
converting to concierge care.

Figure 4: Number of Concierge Patients under the Care of Individual
Concierge

Physicians, October 2004 Number of physicians

40

35

30

25

20

15

10

5

0 1-199 200-399 400-599 600-799 800 +

Number of concierge patients

Source: GAO survey of concierge physicians.

Notes: n = 109 concierge physicians practicing as of October 2004; 3
respondents did not provide this information. The maximum reported number
of concierge patients was 980.

Many respondents reported that they were still establishing their
concierge practices and had set targets for the number of concierge
patients in their care. Respondents reported target numbers for concierge
patients ranging from 10 to 1,300; the two most frequently reported goals
were 300 and 600 concierge patients (reported by 23 and 30 respondents,
respectively). About 80 percent of respondents reported that they had not
yet reached their target number of concierge patients as of October 2004.
About 1 in 2 of the respondents who began concierge care in 2001 or
earlier reported having met their goal for the number of concierge
patients in their practices, compared with about 1 in 7 of those who
reported starting their concierge practices on or after January 1, 2002.

Concierge physicians may continue, for various reasons, to treat some
nonconcierge patients. Thirty-six, about one-third of survey respondents,
reported that their individual practices included some nonconcierge
patients, while about two-thirds had practices consisting entirely of
concierge patients. Physicians who continued to see nonconcierge patients
reported doing so for various reasons: to ensure continuity of care for
patients who did not join the concierge practice, to maintain a combined

concierge and conventional practice, or to see patients as part of a
subspecialty practice.24 Less frequently reported situations in which
respondents reported seeing nonconcierge patients included seeing family
members of their concierge patients occasionally as a courtesy or when
urgent needs arose, and covering for other doctors who were out of town.

Features Offered	The concierge physicians responding to our survey
reported offering a variety of features, some of which were offered by
nearly all the respondents, others by relatively few (see table 2). The
most frequently reported features were same- or next-day appointments for
nonurgent care, 24-hour telephone access, and periodic preventive-care
physical examinations.

Table 2: Features Offered by Concierge Physicians, October 2004

                                                                Percentage of
                                                         respondents offering
                                                              Feature feature

               Same- or next-day appointments for nonurgent care

24-hour telephone access

                 Periodic preventive-care physical examination

Extended office visits

Access to physician via e-mail

                  Access to physician via cell phone or pager

Wellness planning

Nutrition planning

                  Coordination of medical needs during travel

                    Patient home or workplace consultations

Smoking cessation support

Preventive screening procedures

Newsletter

Stress reduction counseling 67

Private waiting room 63

Mental health counseling 60

Online or other electronic access to personal medical records 42

24Subspecialties for which concierge physicians reported seeing
nonconcierge patients included pulmonary medicine, endocrinology, and
nephrology.

                         (Continued From Previous Page)

                                                                Percentage of
                                                         respondents offering
                                                              Feature feature

Accompaniment to specialist appointments or medical procedures

Home delivery of medication by physician or office staff

Priority for diagnostic tests in affiliated medical facilities

Other (e.g., visits to homebound patients, lecture series on wellness and
nutrition, assistance for patients' family members, or an on-site
assistant to help patients with insurance)

Source: GAO survey of concierge physicians.

Note: n = 112 concierge physicians practicing as of October 2004.

When asked to list the most important features of concierge care that were
not routinely available to their nonconcierge patients, respondents most
frequently cited features related to increased time spent with patients,
direct patient access to the physician at any time, same- or next-day
appointments, and comprehensive preventive and wellness care.

Interaction with Patient Health Concierge physicians responding to our
survey reported different ways of

Insurance and Medicare	interacting with patient health insurance and the
Medicare program. Eighty-five, approximately three-fourths, of respondents
reported that they billed patient health insurance for covered services.
Of these 85 physicians, 79 reported they billed Medicare and 6 reported
they did not. About onefourth of the concierge physicians responding to
our survey reported that they did not submit any claims to patient health
insurance, including Medicare.

About three-fourths of our survey respondents reported that they were
Medicare participating physicians, and about one-fifth had opted out of
Medicare as of October 2004 (see fig. 5). Nationwide, relatively few
physicians-approximately 3,000 in 2004-have opted out of the Medicare
program.

Figure 5: Medicare Participation Status of Concierge Physicians Surveyed
by GAO, October 2004

Nonparticipating

Opted out

Participating

                  Source: GAO survey of concierge physicians.

Notes: n = 111 concierge physicians as of October 2004; 1 respondent did
not provide this information. Percentages do not add to 100 due to
rounding.

Aspects of Concierge Care of Interest to Medicare and Its Beneficiaries

Two principal aspects of concierge care are of interest to the Medicare
program and its beneficiaries: its compliance with Medicare requirements
and its effect on beneficiary access to physician services. HHS has
established general policy on concierge care and alerted physicians to
areas of potential noncompliance. Although concierge physicians have
followed various strategies to ensure compliance with Medicare
requirements, most physicians responding to our survey indicated more HHS
guidance would be helpful. Available measures of access to care as of
2004, while not directly addressing concierge care, indicate that Medicare
beneficiary access to physician services has been good. The small number
of concierge physicians makes it unlikely that the approach has
contributed to widespread access problems.

Compliance with Medicare HHS has established general policy on concierge
care and has alerted

Requirements	physicians to areas of potential noncompliance. Concierge
physicians have expressed the need for additional guidance and have taken
various steps- such as structuring their practices in an attempt to avoid
associating their membership fees with Medicare-covered services or opting
out of Medicare-to avoid compliance problems.

CMS outlined its position on concierge care in a March 2002 memorandum to
CMS regional offices that CMS officials told us remains current as of June
2005. The memorandum states that physicians may enter into retainer
agreements with their patients as long as these agreements do not violate
any Medicare requirements.25 For example, concierge care membership fees
may constitute prohibited additional charges if they are for
Medicarecovered items or services. If so, a physician who has not opted
out of Medicare would be in violation of the limits on what she or he may
charge patients who are Medicare beneficiaries.26

HHS OIG has addressed the consequences of noncompliance with Medicare
billing requirements. In March 2004, HHS OIG issued an alert "to remind
Medicare participating physicians of the potential liabilities posed by
billing Medicare patients for services that are already covered by
Medicare."27 The alert stated that "charging extra fees for already
covered services abuses the trust of Medicare patients by making them pay
again for services already paid for by Medicare." As an example, the alert
referred to a Minnesota physician who paid a settlement and agreed to stop
offering personal health care contracts to patients for annual fees of
$600. According to HHS OIG, these contracts included at least some
services that were already covered and reimbursable by Medicare. The alert
advised participating physicians that they could be subject to civil
monetary penalties if they requested payment from Medicare beneficiaries
for those services in addition to the relevant deductibles and coinsurance
charged for these services. In addition, the alert noted that
nonparticipating physicians may also be subject to penalties for
overcharging beneficiaries for covered services.

Unless a concierge physician opts out of Medicare, the question of
Medicare coverage is central to whether a concierge care agreement
complies with the program's limits on patient charges. HHS OIG's March

25HHS refers to concierge care contracts as "physician-patient retainer
agreements."

26The memorandum also states that retainer agreements could be problematic
if they attempt to substitute for Medicare supplemental insurance
policies. CMS officials reported encountering problems with physicians
offering unregulated supplemental policies in the mid-1990s. In June 2005,
CMS officials told us that, while such substitutions are not allowed, they
are no longer concerned that retainer arrangements are being used as
substitutes for Medicare supplemental insurance.

27Office of Inspector General, OIG Alerts Physicians about Added Charges
for Covered Services (Washington, D.C.: Department of Health and Human
Services, Mar. 31, 2004).

2004 alert provided three examples of services offered by the physician in
Minnesota: coordination of care with providers, a comprehensive assessment
and plan for optimum health, and extra time spent on patient care. HHS OIG
did not indicate which, if any, of those three services were already
covered by Medicare. The resulting uncertainty, about which features of
the Minnesota physician's concierge agreement formed the basis for HHS
OIG's allegation that he violated the Medicare program's prohibition
against charging beneficiaries more than the applicable deductible and
coinsurance, generated concern among some concierge physicians.

According to HHS OIG officials, HHS OIG has not issued more detailed
guidance on concierge care because its role in this area is to carry out
specific delegated enforcement authorities, not to make policy. HHS OIG
addresses each situation in its specific context. Physicians with
questions about their own concierge care agreements may obtain guidance
specific to them from HHS by requesting an advisory opinion. HHS OIG's
Industry Guidance Branch issues advisory opinions on matters that fall
within its enforcement authority. It covers provisions of Medicare law
that prohibit knowingly presenting a beneficiary with a request for
payment in violation of a physician's participation agreement.28
Consequently, any participating physician who operates or is considering
starting a concierge practice could request an advisory opinion. Advisory
opinions are legally binding on HHS and the requesting party as long as
the arrangement is consistent with the facts provided. The process
involves a written request that meets certain requirements, plus a fee.
Advisory opinions are not available for hypothetical situations, "model"
situations, or general questions of interpretation. Officials with HHS OIG
reported that as of May 2005, the Industry Guidance Branch had received
very few inquiries regarding advisory opinions about concierge care
agreements, and no opinions have been issued on this subject.

Most of the physicians who responded to our survey indicated that more
guidance from HHS on how Medicare requirements might affect concierge care
is needed. Although about one-fourth of respondents said that the
information available from HHS was clear and sufficient, more than half
reported that it was not. Of those who reported that the guidance was not
clear and sufficient, about one-third stated that information was
available

2842 U.S.C S: 1320a-7a(a)(2) (2000).

from other sources, including private attorneys, the Society for
Innovative Medical Practice Design, and concierge care consultants (see
table 3).

Table 3: Concierge Physicians' Views on HHS Information about How Medicare
Requirements Might Affect the Practice of Concierge Care, October 2004

Percentage of View physicians

The information available from HHS is clear and sufficient

The information available from HHS is not clear and sufficient, but clear
and sufficient information is available from other sources

The information available from HHS is not clear and sufficient, and clear
and sufficient information is not available from other sources

Don't know/no opinion

Source: GAO survey of concierge physicians.

Note: n = 111 concierge physicians as of October 2004; 1 respondent did
not provide this information.

Medicare compliance is an important consideration in how concierge
physicians set up their practices. For example, concierge physicans should
avoid including services covered by Medicare in their concierge agreements
to ensure that no additional charges are associated with those services.
Different strategies have been undertaken to accomplish this. One such
strategy emphasizes the convenience and availability of concierge
physicians as the primary benefit of membership. Another strategy is to
focus on preventive care, linking the membership payment only to screening
that Medicare does not cover. Some concierge physicians opt out of
Medicare, thus avoiding potential compliance problems; opting out requires
physicians to forgo all Medicare reimbursement for 2 years.

Information on Medicare Beneficiary Access to Physician Services

Most of the concierge physicians responding to our survey reported having
patients who were Medicare beneficiaries; however, the numbers of
beneficiary patients they reported as part of their concierge and previous
nonconcierge practices are very small compared to the more than 40 million
Medicare beneficiaries. Surveys and national sources of information on
beneficiary access to care do not address the impact of concierge care
directly. In the absence of direct measures of the impact of concierge
care on Medicare beneficiaries' access to physician services, we reviewed
available nationwide data and other indicators about beneficiaries'
experiences overall. These sources showed that overall access to physician
services has not changed substantially in recent years.

Medicare Beneficiary Patients of Surveyed Concierge Physicians

Estimates provided by 105 of the respondents indicated that about
twothirds of the estimated 19,400 Medicare beneficiaries who were patients
of these physicians in October 2004 were considered concierge patients.29
The rest were nonconcierge patients who were neither charged a fee nor
offered enhanced services. Physicians who continued to see nonconcierge
patients reported doing so for various reasons, including to ensure
continuity of care for individuals who had not yet found a new physician
and to maintain a practice consisting of both concierge and nonconcierge
patients.

On average, Medicare beneficiaries represented about 35 percent of the
total number of patients-concierge and nonconcierge-that responding
concierge physicians reported having in their care as of October 2004.
Eight of the 105 physicians who provided this information reported having
no Medicare beneficiaries in their practices at all; 36 reported treating
some, but fewer than 100 Medicare beneficiaries among their patients; and
12 reported having 400 or more Medicare beneficiaries under their care
(see fig. 6).

29The term concierge patients includes all patients who are offered
enhanced services or amenities, including those whose membership fees have
been waived.

Figure 6: Medicare Beneficiary Patients of Concierge Physicians, October
2004

Number of physicians

40

35

30

25

20

15

10

5

0 0 1-99 100-199 200-299 300-399 400 +

Number of Medicare beneficiary patients

Source: GAO survey of concierge physicians.

Notes: n = 105 concierge physicians as of October 2004; 7 respondents did
not provide this information. Includes Medicare beneficiaries who were
nonconcierge patients of concierge physicians. The highest number of
Medicare beneficiary patients reported was 2,825.

Concierge physicians who responded to our survey reported that, on
average, Medicare beneficiaries in their previous nonconcierge practices
joined their concierge practices in about the same proportion as their
patients overall. When physicians begin practicing concierge care,
existing patients may choose not to become concierge patients. Patient
counts provided by responding physicians indicate that, on average,
Medicare and non-Medicare patients who were under their care before they
began concierge care chose to join as concierge patients in roughly
similar proportions.

Table 4 shows the average numbers of Medicare and non-Medicare patients
responding physicians reported were in their practices before and after
their conversion to concierge care. The numbers of beneficiaries that
responding concierge physicians reported in their practices are relatively
small-for example, the total number of Medicare beneficiaries that 88
responding physicians reported treating before conversion to concierge
care was fewer than 100,000-compared to the nation's more than 40 million
Medicare beneficiaries.

Table 4: Patients from Physicians' Conventional Practices Who Joined
Physicians' Concierge Practices

Average number of patients Status of practice Total Medicare Non-Medicare

Before conversion to concierge 2,716 (n = 97) 1,069 (n = 88) 1,632 (n =
88) care

After conversion to concierge 301 (n = 94) 138 (n = 85) 157 (n = 85) care

Source: GAO survey of concierge physicians.

Notes: Although there were 112 unique respondents who practiced concierge
care in October 2004, not all respondents answered each question. This
table presents information about the patients who became members of the
physicians' concierge practices. It does not count individuals who may
have remained under the care of their physicians as nonconcierge patients.

Respondents reported engaging in a variety of activities to help Medicare
beneficiaries choosing not to join the physician's concierge practice find
new physicians. These activities included designating a staff person to
help with transition questions, referring patients to other physicians
within a group practice, calling new physicians to discuss a patient's
medical history, and remaining available to treat all patients until they
had found a new primary care physician. Additional activities reported
include bringing a new physician into the practice to take on the
concierge physician's previous patients and speaking individually with
each patient. We did not contact Medicare beneficiary patients of the
concierge physicians in our survey to determine how many of them had
sought or found new physicians. See appendix II for additional details on
actions physicians reported taking to help Medicare patients who did not
join their concierge practices to find new physicians.

Nationwide and Community The number of concierge physicians, and the
number of Medicare

Indicators of Beneficiaries' beneficiaries the physicians reported in
their previous nonconcierge

Access	practices, are relatively small, and therefore national surveys of
samples of Medicare beneficiaries are not likely to include many
beneficiaries who come into contact with concierge care. In the absence of
data to directly assess the impact of concierge care on Medicare
beneficiaries' access, however, national surveys can provide general
information about the availability of physicians and beneficiary access to
care. Overall, national surveys showed that Medicare beneficiary access to
physician services has been good, in some cases better than access for
individuals with private health insurance.

Surveys targeting both Medicare beneficiaries and physicians revealed that
overall access to physician services has not changed substantially in
recent years. Most beneficiaries surveyed reported that they have not had
a problem finding a primary care physician. Of those who did report a
problem, only a small percentage attributed their difficulty to
physicians' refusing to take new Medicare patients. Most beneficiaries
attributed problems to transportation barriers or their difficulty finding
a physician they liked, not to a shortage of primary care physicians who
accepted Medicare. Of physicians surveyed, most reported accepting at
least some new Medicare patients.30 Analysis done by the Medicare Payment
Advisory Commission of Medicare claims data also revealed that the number
of physicians who treated Medicare patients grew at a more rapid pace than
the Medicare beneficiary population from 1999 to 2003.31 Results from our
review of Medicare claims data from April 2000 and April 2002 indicated
increases throughout the country in both the percentage of beneficiaries
who received physician services and the number of services provided to
beneficiaries who were treated.32

Physician supply data from the Seattle, Boston, and Southeast Florida
metropolitan areas, where we found concierge care is relatively prominent,
suggested that physicians there were relatively plentiful. The ratio of
physicians to overall population in each of these metropolitan areas
exceeded the nationwide average for all metropolitan areas in 2001.
Because concierge physicians treat fewer patients than do physicians in
conventional practices, a community needs other available physicians to
take on Medicare beneficiaries who choose not to join a concierge
practice. Even in communities where the concierge physician population was
largest, however, the number of concierge physicians we identified was
small compared with the physician population as a whole.

Information about Experiences CMS officials informed us that CMS has not
established a special tracking

of Individual Beneficiaries	system for beneficiary complaints about
concierge care because the practice is not sufficiently widespread to
raise concerns about access to care. Similarly, officials with call
centers for 1-800-MEDICARE and CMS

30See app. I for a list of the sources we reviewed.

31Medical Payment Advisory Commission, Report to Congress, Medicare
Payment Policy (Washington, D.C.: March 2005).

32GAO, Medicare Fee-for-Service Beneficary Access to Physician Services:
Trends in Utilization of Services, 2000 to 2002, GAO-05-145R (Washington,
D.C.: Jan. 12, 2005).

contractors handling beneficiary inquiries and complaints reported that
they have received a small number of calls from beneficiaries about
concierge care. Because of the low volume of calls on this subject, the
majority of these call centers do not have tracking codes for responses to
calls about concierge care.33 Of the 15 CMS contractors who process claims
for physician services and responded to our inquiry, only 1 reported
establishing a code to track concierge care inquiries.34 This contractor
established the tracking code in response to our inquiry about concierge
care in February 2005.35 As of April 2005, none of this contractor's call
centers reported receiving any beneficiary calls about concierge care.

Because of the relatively high number of concierge physicians in the
Seattle metropolitan area, CMS's Seattle regional office has been
following concierge care, but so far it has not identified an impact in
Medicare beneficiaries' access to care. The Seattle office's efforts are
part of an agencywide effort to monitor beneficiary access to care through
reports in the media and from the CMS divisions that interact with
beneficiaries. According to CMS officials in the agency's Seattle regional
office, that office has received a small number of calls about concierge
care from physicians and beneficiaries, mainly asking whether concierge
care is permitted under Medicare law. Seattle regional office officials
said they respond in accordance with CMS guidelines: they do not review
specific concierge care agreements but help beneficiaries by providing a
list of local physicians who participate in Medicare. The CMS Seattle
regional office has not found indications that beneficiaries who choose
not to pay their physician's membership fees have had problems locating
new primary care physicians.

We did not contact Medicare beneficiaries who were patients of physicians
who converted to concierge care to determine how many of them had sought
or found new physicians. We did, however, contact organizations that
Medicare beneficiaries might call with problems or concerns,

33It is possible that some beneficiaries have called Medicare claims
contractors about concierge care and had their inquiries identified more
generally, for example, as "miscellaneous."

34Fifteen contractors responded to our inquiry out of a total of 18
contractors who process Medicare claims for outpatient physician services.

35This contractor processes claims for physician services for California,
Maine, Massachusetts, New Hampshire, and Vermont.

including AARP and the Medicare Rights Center.36 Like CMS, officials with
these organizations reported receiving a few calls from beneficiaries
about concierge care, and none reported complaints from beneficiaries
about finding a physician or about access to services because of concierge
care. Officials with these groups also reported that they have not
developed a formal system to track the issue. According to officials from
these organizations, calls from beneficiaries about concierge care are
usually requests for help interpreting the letters from their physicians
explaining the physicians' conversion to concierge care.

Concluding 	Although the number of physicians practicing concierge care
has grown in recent years, the total number remains very small. Available
measures of

Observations	Medicare beneficiaries' overall access to care, while not
directly addressing concierge care, indicate widespread availability of
physicians to treat them. The small number of concierge physicians at the
time of our review, along with information from available measures of
access to services, suggests that concierge care does not present a
systemic access problem for Medicare beneficiaries at this time.

Agency and Other Comments

We provided a draft of this report for comment to HHS. In its comments,
HHS agreed that concierge care has had a minimal impact on beneficiary
access to physician services at this time. HHS noted, however, that the
agency is interested in developments in concierge care and will continue
to follow this area and to evaluate whether any further steps are
indicated. See appendix III for HHS's written comments. HHS also provided
technical comments, which we incorporated where appropriate.

We also provided a draft to the Society for Innovative Medical Practice
Design, formerly the American Society of Concierge Physicians, which had
no comments.

We are sending copies of this report to the Secretary of HHS, the
Inspector General of HHS, the Administrator of CMS, and appropriate
congressional committees. We will also provide copies to others upon
request. In

36See app. I for a list of the organizations we contacted.

addition, the report is available at no charge on the GAO Web site at
http://www.gao.gov.

If you or your staff members have any questions about this report, please
contact me at (202) 512-7119 or [email protected]. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this report. GAO staff who made major contributions to this
report are listed in appendix IV.

A. Bruce Steinwald Director, Health Care

Appendix I

Scope and Methodology

To obtain information on the characteristics of concierge care, we
surveyed concierge physicians about their practices and the types of
services and financial arrangements they offer. Because no comprehensive
directory of concierge physicians was available, we compiled our own list
of concierge physicians to survey. We focused our survey on physicians
who, as of October 2004, (1) had established a direct financial
relationship with patients in the form of a membership or retainer fee and
(2) provided enhanced services or amenities, such as same-day appointments
or preventive services not covered by patient health insurance.1

We identified concierge physicians through a variety of methods, including
a nationwide literature search, telephone interviews, and referrals from
other concierge physicians. With the assistance of a contractor, we
compiled an initial list of potential survey participants, contacted them
to confirm that they met the criteria for inclusion in our survey, and
requested referrals to additional concierge physicians. We used a variety
of sources to establish our initial list of potential survey participants,
including a nationwide Internet search of articles in newspapers, business
journals, and medical publications; attendance at the first annual meeting
of the American Society of Concierge Physicians (now known as the Society
for Innovative Medical Practice Design); and a list of physicians
affiliated with a consulting firm that helps physicians establish and
maintain concierge practices. This process yielded a final mailing list of
187 individuals.

We mailed the questionnaires in November 2004, after pretesting it with
concierge physicians and incorporating suggestions from several reviewers
familiar with concierge care; we followed up with nonrespondents during
December 2004 and January 2005. Two questionnaires were returned as
undeliverable; we removed those names from our total count of potential
concierge physicians. The total we used to calculate the response rate for
our survey was therefore 185.

We received responses to our survey from 129 physicians, yielding an
overall response rate of 70 percent. Of the respondents, 112 physicians
confirmed that they practiced concierge care-that is, they reported that
they charged a retainer or membership fee for enhanced services or

1The scope of our work did not include physicians who imposed additional
charges solely to cover the costs of routine administrative services, such
as filling out forms. In addition, our results do not include the views of
nonconcierge physicians or physicians who may have once practiced
concierge care but no longer do.

Appendix I
Scope and Methodology

amenities-as of October 2004. We analyzed only the information provided by
these 112 physicians. Because these 112 respondents were not randomly
sampled from a larger population of known concierge physicians, the
information they provided cannot be projected to any other concierge
physicians. We did not attempt to verify the accuracy of their responses.

In addition to the 112 physicians practicing concierge care in October
2004 and responding to our survey, we confirmed-through, for example,
telephone interviews conducted by us or our contractor-the concierge
status of an additional 34 physicians who did not return our
questionnaire. This process yielded a total of 146 confirmed concierge
physicians. To analyze the geographic practice locations of these 146
physicians, we assigned the physicians' zip codes to larger geographic
units called metropolitan statistical areas (MSA) or primary metropolitan
statistical areas (PMSA), as defined in 1999 by the Office of Management
and Budget.

To review the aspects of concierge care of interest to the Medicare
program and its beneficiaries, we reviewed relevant provisions of Medicare
law and documents from the Department of Health and Human Services (HHS),
including Centers for Medicare & Medicaid Services (CMS) policy manuals
and internal memorandums, information posted on the CMS Web site, an alert
published by the HHS Office of Inspector General (OIG), and correspondence
between interested parties and HHS officials regarding concierge care. We
also interviewed CMS officials at CMS headquarters and in the Seattle
regional office, officials with HHS OIG, and concierge physicians and
their representatives and, in our survey, asked concierge physicians for
their views on the guidance available from HHS on concierge care.

To assess what is known about how concierge care might affect Medicare
beneficiary access to physician services, we reviewed national surveys and
reports on overall Medicare beneficiary access. Because so few physicians
and beneficiaries are affected by concierge care, concierge physicians or
their patients are unlikely to be randomly chosen to participate in
surveys on access to physicians by Medicare beneficiaries. National
surveys and analysis on beneficiary access to physician services are also
not sufficiently detailed to address concierge care, but they can provide
information about physician availability and beneficiary access to care
overall. The sources we consulted targeted beneficiaries, physicians, or
both and included the following:

Appendix I
Scope and Methodology

o 	Bernard, Shulamit, et al. Medicare Fee-for-Service National
Implementation Subgroup Analysis. Prepared for the Centers for Medicare &
Medicaid Services. Research Triangle Park, N.C.: Research Triangle
Institute, 2003.

o 	Center for Studying Health System Change. Community Tracking Study
(CTS) Section Map. Washington, D.C.: October 2004.
http://www.hschange.org/index.cgi?data=10 (downloaded October 2004).

o 	Centers for Medicare & Medicaid Services. Medicare Current Beneficiary
Survey. Baltimore, Md.: September 2004.
http://www.cms.hhs.gov/MCBS/default.asp (downloaded October 2004).

o GAO. Medicare Fee-for-Service Beneficiary Access to Physician Services:
Trends in Utilization of Services, 2000 to 2002. GAO-05145R. Washington,
D.C.: January 12, 2005.

o 	Lake, Timothy, et al. Results from the 2003 Targeted Beneficiary Survey
on Access to Physician Services among Medicare Beneficiaries. Prepared for
the Centers for Medicare and Medicaid Services. Cambridge, Mass.:
Mathematica Policy Research, Inc., 2004.

o 	Medicare Payment Advisory Commission. Report to the Congress: Medicare
Payment Policy. Washington, D.C.: 2005.

o 	Schoenman, Julie, et al. 2002 Survey of Physicians about the Medicare
Program. Prepared for the Medicare Payment Advisory Commission. Bethesda,
Md.: Project HOPE Center for Health Affairs, 2003.

Because concierge physicians generally treat fewer patients than
physicians in conventional practices, we assessed community-level data on
physician supply to see if other physicians might be available to take on
Medicare beneficiaries who choose not to join a concierge practice. We
calculated physician-to-population ratios in communities where we found
the highest numbers of concierge physicians and compared them to the
average ratio for all metropolitan areas in the United States. To
calculate this ratio, we used data from a 2003 HHS Health Resources and
Services Administration database known as the Area Resource File. This
database included county-level data on active, nonfederal, office-based,
patient-care physicians from the 2001 American Medical Association
Physician

Appendix I
Scope and Methodology

Masterfile database and county-level resident population data from the
U.S. Census Bureau for 2001, which we aggregated by MSA and PMSA.

We did not contact Medicare beneficiaries who were patients of physicians
who converted to concierge practices. We obtained information from
organizations likely to receive calls from Medicare beneficiaries to
determine whether individual beneficiaries were reporting concerns about
concierge care or difficulty finding new physicians. We obtained and
analyzed information from officials at CMS, call centers for
1-800-MEDICARE, and 15 of 18 CMS contractors that process Medicare claims
for outpatient physician services. We spoke with representatives of AARP,
the American Bar Association's Commission on Law and Aging, the Center for
Medicare Advocacy, the Health Assistance Partnership of Families USA, and
the Medicare Rights Center.

We conducted our work in accordance with generally accepted government
auditing standards from May 2004 through July 2005.

Appendix II

Summary of Physician Responses to GAO Concierge Care Survey

This appendix summarizes the results from questions we asked physicians
who practiced concierge care as of October 2004. We sent surveys to 185
physicians with valid addresses whom we had identified as potential
concierge physicians. We obtained responses from 129 individuals, for an
overall response rate of 70 percent, and analyzed the responses from 112
physicians who practiced concierge care in October 2004.

The following tables and figures present information on reported
characteristics of the 112 concierge physicians who responded to our
survey and their practice settings (table 5), the estimated number of
patients in their individual practices (table 6), goals for the total
number of concierge patients when physicians' practices are fully
established (fig. 7), annual membership fees charged by physicians who did
and did not bill insurance (fig. 8), actions concierge physicians reported
taking to help Medicare beneficiaries who did not join their concierge
practices find new physicians (table 7), concierge physicians' views on
the sufficiency of HHS guidance on concierge care and Medicare (table 8),
and concierge physicians' views on remaining in medical practice and
treating Medicare beneficiaries if concierge care were not an option
(table 9).

 Table 5: Characteristics of Concierge Physicians and Their Practices, October
                                      2004

                         Characteristic             Category      Respondents 
                   Year physician began                 1997                2 
                         concierge care                 1998                0 
                                                        1999                1 
                                                        2000                3 
                                                        2001               11 
                                                        2002               22 
                                                        2003               41 
                                                        2004               32 
                                             Total responses              112 
             Years physician in medical                  1-9               14 
                               practice                10-19               44 
                                                       20-29               45 
                                                30 and above                9 
                                             Total responses              112 

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

(Continued From Previous Page)

                      Characteristic Category Respondents

                    Physician specialty Internal medicine 84

Family practice

Other (e.g., emergency medicine)

                              Total responses 109

Practice setting Solo

Group

Other (e.g., partnership, management group, and integrated delivery
system)

                              Total responses 112

             Number of physicians in group 1-9 51 practicea 10-19 6

20-29

30-39

40-49

50 and above

Total responses

          Number of concierge physicians in 1 10 group practicea 2 30

3

44 54

                                               Total responses          72 
        Status of transition to concierge       All physicians    
                      care                         Complete             22 
                                                 In progress            90 
                                               Total responses         112 

Physicians who began concierge care during 2001 or earlier

Complete 9

In progress 8

Total responses 17

Physicians who began concierge care during 2002 or later

Complete 13

In progress 82

Total responses 95

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

(Continued From Previous Page)

                      Characteristic Category Respondents

          Treated some nonconcierge                                  Yes   36 
                           patients                                   No   76 
                                                         Total responses  112 
                 Reasons for seeing     To ensure continuity of care for 
             nonconcierge patientsb  patients who did not join concierge 
                                                                practice 

As part of a combined concierge and conventional practice

As part of a subspecialty practice (e.g., pulmonology, nephrology,
endocrinology, cardiology, and sleep medicine)

Other (e.g., occasionally as a favor for family members of concierge
patients, to treat indigent and Medicaid patients, and to cover for other
physicians) Yes, and would consider waiving the membership fee

                   Practice accepting new                           Yes   101 
                       concierge patients                            No 
                                                        Total responses   112 
            Practice open to new Medicare   Yes, only those who pay the 
                       concierge patients                membership fee 

No

Total responses

       Billed patient health insurance for Yes 85 covered services No 26

                              Total responses 111

Of those who billed patient health Yes 79 insurance, billed Medicare for
No 6covered services

Total responses 85

                 Relationship to Medicare            Participating         84 
                                                  Nonparticipating          4 
                                                         Opted-out         23 
                                                   Total responses        111 

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

(Continued From Previous Page)

                      Characteristic Category Respondents

Age ranges of concierge patients	Percentage of patients aged 20 or younger

0

1-24%

25-49%

50-74%

75% and above

                              Total responses 106

Percentage of patients aged 21 through 64

0

1-24%

25-49%

50-74%

75% and above

                              Total responses 106

Percentage of patients aged 65 or older

0

1-24% 28 25-49% 34 50-74% 37 75% and above 4

Total responses 106

Source: GAO survey of concierge physicians.

Notes: Although there were 112 unique respondents, not all respondents
answered each question. The total number of responses expected for each
question varied; for example, only physicians who stated that they were
accepting new patients were asked whether they were accepting new Medicare
patients.

aTotals include the responding physicians. The responses for group
practice include some physicians who responded to the "other" category for
practice setting and nonetheless provided information about multiphysician
practice settings.

bPhysicians could select more than one response to this question.

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

Table 6: Estimated Number of Patients in Individual Practice, October 2004

                                                          Number who were     
                         Patients Total number of      Medicare beneficiaries 
                                  patients             
               Concierge patients           Minimum: 3             Minimum: 0 
                                          Maximum: 980           Maximum: 590 
                                             Mean: 326              Mean: 129 
                                             Mode: 600                Mode: 0 
                                  Total responses: 109 Total responses: 105   

                  Nonconcierge patients Minimum: 0 Minimum: 0

Maximum: 4,000 Maximum: 2,800

Mean: 166 Mean: 57

Mode: 0 Mode: 0

                   Total responses: 109 Total responses: 105

                 Total patients              Minimum: 20           Minimum: 0 
                                          Maximum: 4,035       Maximum: 2,825 
                                               Mean: 491            Mean: 185 
                                       Mode: 200 and 600              Mode: 0 
                                               (multiple 
                                            modes exist) 
                                  Total responses: 109   Total responses: 105 

Source: GAO survey of concierge physicians.

Notes: Although there were 112 unique respondents, not all respondents
answered each question. Physicians were asked to provide their best
estimates if specific patient counts were not available.

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

Figure 7: Physicians' Goals for Total Number of Concierge Patients,
October 2004 Number of physicians 40

35

30

25

20

15

10

5

0 1-199 200-399 400-599 600-799 800-999 1,000 +

Number of concierge patients

Source: GAO survey of concierge physicians.

Notes: n = 111 concierge physicians practicing as of October 2004; 1
respondent did not provide this information. Physicians were asked their
individual goals for the number of concierge patients in their care. The
largest reported goal for number of concierge patients was 1,300.

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

Figure 8: Annual Membership Fees Charged by Physicians Who Did and Did Not
Bill

Patient Insurance, October 2004

Percentage of physicians

70

60

50

40

30

20

10

0 0-499 500-1,499 1,500- 2,000- 4,000 + 1,999 3,999

Amount of annual fee, in dollars

Billed patient insurance

Did not bill patient insurance

Source: GAO survey of concierge physicians.

Notes: n = 110 concierge physicians as of October 2004; 2 respondents did
not provide this information. Fees represent those charged for an annual
individual adult membership.

                                  Appendix II
                     Summary of Physician Responses to GAO
                             Concierge Care Survey

Table 7: Actions Concierge Physicians Reported They Took to Help Medicare
Patients Who Did Not Join the Concierge Practice Find New Physicians

 Percentage of physicians who reported each action, for approximately how many
                                    patients

                           Action None Some Most All

Designated a staff person to help patients in transition (n =  15 3   5 78 
                                81)                                        
    Forwarded patient medical records to new physicians (n = 83)  6  13 11 70 
Remained available to treat all patients until they had found  7  11 15 67 
                      a new physician (n = 84)                             
Referred patients to physicians within group practice (n = 81) 19 16 25 41 
    Provided patients with a list of area physicians who accept   28 26  8 39 
                   new Medicare patients (n = 80)                          
      Referred patients to physicians outside the practice who    13 51  8 28 
               accept new Medicare patients (n = 83)                       
Coordinated with patients' insurance companies to verify that  66 17  7 10 
                 all patients chose new physicians                         
                              (n = 77)                                     
        Referred patients to their insurance or managed care      61 30  3 
             organizations for physician lists (n = 77)                    
     Called new physicians to discuss patient history (n = 81)    12 80  3 
       Wrote individual letters on behalf of patients to new      46 49  3 
                        physicians (n = 76)                                

Source: GAO survey of concierge physicians.

Notes: Percentages do not necessarily add to 100 because of rounding.
Although there were 112 unique respondents, not all respondents answered
each question.

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

Table 8: Concierge Physicians' Views on the Information Available from HHS
about How Medicare Requirements Affect Concierge Care, October 2004

                          Subject               Responses           Number of 
                                                                   physicians 
        The information available                     Yes                  29 
                             from                         
                 HHS is clear and                         
                       sufficient       No, but clear and 
                                  sufficient information  
                                  is                      
                                     available from other 
                                                  sources                  20 

No, and clear and sufficient information is not available from other
sources

Don't know/no opinion

                              Total responses 111

More official guidance is needed Yes 67 from HHS on how Medicare No 20
requirements might affect

concierge care Don't know/no opinion 24

Total responses 111

Source: GAO survey of concierge physicians.

Note: Although there were 112 unique respondents, not all respondents
answered each question.

Appendix II
Summary of Physician Responses to GAO
Concierge Care Survey

Table 9: Concierge Physicians' Views on Remaining in Medical Practice and
Treating Medicare Beneficiaries if Physicians Were Unable to Practice
Concierge Care

                                                                    Number of 
                                     Subject             Responses physicians 
                     If not able to practice        Definitely yes         11 
        concierge care, would have continued          Probably yes         34 
                                      in the                       
                        clinical practice of Don't know/no opinion         16 
                                    medicine           Probably no         32 

Definitely no

Total responses 111

Of those physicians who Would have treated Medicare would have remained in
beneficiaries as a participating medicine without physician 25

concierge care, Would have treated Medicareinteraction with Medicare
beneficiaries as a nonparticipatingbeneficiaries physician 5

Would have treated Medicare beneficiaries under private contracts and
opted out of Medicare

Would not have treated Medicare beneficiaries

Don't know/no opinion

Total responses

Source: GAO survey of concierge physicians.

Notes: Although there were 112 unique respondents, not all respondents
answered each question. Only physicians who stated they would have
definitely or probably continued in the clinical practice of medicine were
asked how they would treat Medicare beneficiaries if they were unable to
practice concierge care.

Appendix III

Comments from the Department of Health and Human Services

Appendix III
Comments from the Department of Health
and Human Services

Appendix IV

                     GAO Contact and Staff Acknowledgments

GAO Contact A. Bruce Steinwald (202) 512-7119 or [email protected]

Acknowledgments	In addition to the person named above, key contributors to
this report were Kim Yamane, Assistant Director; Ellen W. Chu; Jennifer
DeYoung; Linda Y. A. McIver; Perry G. Parsons; Suzanne C. Rubins; Craig
Winslow; and Suzanne Worth.

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