Concierge Medicine Compared to CSFM

Because half of my goal in opening CSFM is to provide AFFORDABLE medical care, I want to take a moment to answer a question I have received several times: What makes CSFM different from concierge medicine?  Isn’t this just another get-rich-quick scheme?  I have a whole other group asking me, how can you even afford to pay rent with this model?  I find it amusing that my finances concern people so much in both directions, but as my goal is to be community supported, I think it only appropriate that I explain to my community how this works.  Today, I’ll start with explaining how we compare to concierge medicine.  Another day, I’ll explain how I’m able to make ends meet.  I also want to discuss how I define QUALITY medical care, since that is the first half of my goal.

Let’s start by talking similarities.  Obviously, there are enough of them that people are asking.  The one similarity that has caused the questions is the membership option for care.  You’ll recall that you can become a CSFM member for $30 a month ($360 a year) for the first two members of the household and $15 a month ($180 a year) for the rest of the members of the household.  Concierge practices also charge a membership fee.

Concierge practices and I are all interested in providing high-quality, personal care.  You’ll notice that I answer my own phone or it goes to my own voicemail: no receptionists, no nurses.  If you need urgent care, you can page me directly.  In my case, it is a cost-cutting measure to allow me to lower my overhead and pass on the savings to those who may not otherwise be able to afford medical care.  For concierge practices, it’s part of the “value added.”  Nonetheless, it is a similarity.  We also both provide longer appointment times.  That’s because we all enjoy taking the time to get to know our clients/patients and make sure we provide the best care possible.

I did an online search for “concierge medicine denver” and here are the first five practices that came up (they are not all in Denver, but all are along the Front Range).  I copied bits from their websites to illustrate the differences.  Concierge practices typically charge much higher membership fees, and all of those that charge lower membership fees also charge a hefty price per appointment, and a different price for different types of appointments.  They typically will not see you unless you are a member…you must belong to the club, so to speak.

1. Advanced Integrative Medicine.  ”This service is provided for a fixed annual fee of $1,500 per patient, $2,500 per couple and $250 per child (18 years and younger).”  That would be the first big difference.  Price of membership.

2. Dr. Kevin Lutz.  ”For $3,000 a year (just $250 monthly), Dr. Lutz and his staff provide comprehensive and proactive care. Your health insurance still covers prescriptions, hospitalizations, lab and radiology tests, and care from other doctors.”  That price thing again.  The assumption is that your insurance foots the bills for everything else.  As you know, one of the huge benefits in my practice is that I assume you are paying out of pocket so run your labs through my account (at a huge discount) and help you find affordable medications and imaging whenever possible.

3. Flatiron Premier Medicine.   ”Yes.  Your insurance company will be billed directly for office visits with Dr. Erik Mondrows.  If your insurance carrier/plan requires a co-pay, Dr. Erik Mondrow is required to collect it. Office visit charges, with the exception of your Annual Comprehensive Medical examination, are not included in your annual fee.”  Many concierge doctors are charging the fee just for you to belong, and they also charge for visits on top of that.  This doctor does not say how much the appointments themselves are.

4. My Family Doctor.  ”For $350 a year, patients receive: A 1-hour comprehensive annual physical exam with age and sex-appropriate screening tests (e.g. pelvic exam, breast exam, prostate exam, etc.).  Cost of pap smear pathology fees and lab fees are not included.  A discounted rate of 30% on office visits which are charged based on time spent by the physician.  E.g.  a member can expect to pay $110 for a 30 minute visit, whereas a nonmember would pay $165 for a 30 minute visit.”  This office actually lists their prices.  $110 or $165 for a 30 minutes visit are typical costs for any doctor’s office and are charged in addition to the annual fee.

5. Pinnacle Family Medicine.  ”Annual Access Fee   $360/adult $240/minor  Office Visits  •15 minutes   $85  •30 minutes $110 •45 minutes   $150  •60 minutes  $200.”  This is her silver level option.  The membership prices go up from there.  Again, there is that additional charge per visit.

I am not criticizing the concierge physicians for their decisions any more than I criticize friends for going into business or retail instead of teaching or social work.  We each have to make decisions according to our own values, and I’m sure these physicians provide excellent care; however, our goals and values are different.

The goal of my “membership” is to allow patients to budget their primary care over the course of the year and then not limit themselves to only coming in if they absolutely have to.  Most uninsured and underinsured people I know won’t see a doctor unless they absolutely must because of the cost of the appointment.  By having appointments without a separate charge for each appointment, I’m hoping everyone will come in when they feel they need to come in, instead of waiting.  I want everyone to get things (concerning skin spots, ongoing cough, blood pressure creeping up, low moods, whatever) taken care of instead of just living with them.  Some studies have shown that even a $10 copay prevents insured people from seeing their doctor.  These are people who are often already paying hundreds of dollars a month for insurance.

I also want the prices to be transparent.  Many of us have had the experience of going into a doctor’s appointment for one concern and coming out with several other issues addressed.  In a typical practice, you would be charged more because the visit was more complicated and took longer.  Me, I expect most people to have more than one concern and I plan accordingly…but don’t penalize you by raising the price for my time.

Ultimately, it comes down the goal of CSFM.  My primary goal is to provide quality, affordable primary care for families and individuals regardless of their ability to acquire insurance. Yeah, I need to pay the bills and feed my family, but I don’t need a big fancy house (I live in a little bungalow a few blocks from the practice), a new car (I’m proud of our one car and its 100K miles), or long vacations (besides, it would be hard to find someone to take care of the chickens for more than a few days).  What I do need is to find meaning in my work.  If I’m going to have to be away from my family during the day, I’d rather spend my time doing this than anything else.

My Take on Vaccinations

Increasing numbers of doctors are refusing to see children whose parents have declined vaccinations. I think this is a silly stance to take…like a pastor refusing to talk with someone about their spiritual well-being until they’ re no longer living-in with their boyfriend/girlfriend. Because of this, I’ve ended up with a higher percentage of unvaccinated or partially vaccinated (on an alternative schedule/plan) children in my practice. That doesn’t mean that I personally am against vaccines…it means that I am against discriminating against a family just because their intense desire to do the right thing for their children leads them to do something different from what I believe is the safest course.

Families who chose to forego some or all vaccines are not doing it because they want their children to suffer. They are doing it because of a deep love for their babies that has led them in the opposite direction of many physicians. What kind of parents would they be if they truly believed that vaccines would do irreparable damage and did no good and then let their children have them? I would rather have parents who disagree with me but are standing their ground for their child.

Parents often ask what I do for my children. I vaccinate. My son didn’t have any reactions to vaccines so got them on a regular schedule until his 1st birthday when he had RSV and pneumonia. He got behind then and we forgot that we had to get him caught up. So I understand getting behind unintentionally too! Forgetting to get your kiddo into the doctor doesn’t make you a terrible parent…just a busy and overwhelmed parent.

My daughter was pretty miserable for over a week after getting her 4 month vaccines so we broke them up and took her in for one vaccine at a time. We prioritized Influenza, DTaP (for the tetanus and whooping cough protection), Prevnar (pneumonia) and Hib (Hemophilus Influenza type B).  I would not recommend doing this if you have a choice!  For the baby, this just stretches out the misery of all those needlesticks.  Their immune systems are strong enough to handle multiple vaccines at once.

I did my daughter’s vaccines in order of my fear: Hib first. Because I have a secret for you…doctors make decisions based on their own emotions and experiences too. We may tell patients to make decisions based on the research…and certainly I want you to do the same and that’s the main reason my children are vaccinated. But the reason I am chomping at the bit to get them vaccinated is because of my experiences. When I first started my training, I saw babies dying of Hib meningitis. Those who survived may have developed deafness or mental retardation because of the infection. I saw the living hell their parents went through, wondering day by day whether they would get to watch their baby grow up. And now with the rousing success of the Hib vaccine…almost no Hib disease.

My reasons for vaccinating are two-fold:

1. The baby I save may be my own. Perhaps this is where my B.A. in history most influences my medical practice. You know the saying that those who forget the past are doomed to repeat it? My mom has told me about being lined up to get the polio vaccine at school to avoid the crippling disease and the “iron lungs” used to save children. Here’s an interesting video interviewing awoman who contracted polio as a child. And here’s a TED talk about eradicating polio. The woman who first brought small pox innoculation to England did so to save children from the horrors of the disease (and if you enjoy history I highly recommend reading her fascinating letters.) More pertinent to our time, please be able to recognize whooping cough! Here’s a video of a baby with whooping cougha slightly older baby with whooping cough and a girl with whooping cough. If you think your child has whooping cough, please get medical attention right away!

I have a couple children in my practice who suffered the severe birth defects resulting from their moms catching vaccine-preventable illnesses while pregnant.  I would never, ever wish the 20 reconstructive surgeries one of my patients had to have on my worst enemy, much less my grandchild because I chose to not have my daughter vaccinated!

2. The baby I save may NOT be my own. The reason why polio and smallpox are mostly eradicated and Hib is rarely seen is a phenomenon called herd immunity. The reason polio has been almost eradicated is because of an amazing vaccination campaign that meant that if someone did develop polio, they couldn’t pass it on to anyone else because people around them are immune.  Herd immunity is important in all the vaccine-preventable illnesses so that large numbers of children do not fall ill if a case does show up in the community.  I actually know a number of parents who don’t vaccinate because they feel they can rely on herd immunity. Besides the fact that this is risky in some conditions and impossible in others (such as tetanus…which is still seen and deadly; I have a patient my age whose childhood best friend died of tetanus), I think it’s only fair that I vaccinate my children to contribute to the herd immunity and help all of society.

Update in 2015: Here is a model of herd immunity that you can play with that is somewhat like what you might experience with measles, which is highly contagious.  Prior to having a vaccine against it, nearly every child contracted measles.  And remember that 1/20 kids who get measles will develop pneumonia, 1/1000 kids who get measles will develop encephalitis (brain swelling) and 1-2/1000 kids who get measles will die.  If a million children developed measles, 50,000 would get pneumonia, 1000 would develop encephalitis, and 1000-2000 would die.  To put that in perspective, there are about 1.25 million children just in Colorado.  Aren’t you glad most of us in the United States are vaccinated against measles?

So do I kick you out if you choose not to vaccinate? Of course not! As I’ve said about a million times, I go home and live my life and you go home and live yours. You make your decisions, I make mine. In pure numbers, parenting choices affect more children than vaccines.

Do I make sure you have the correct information? Definitely.

Here are a few things you should know:

Thimerosal has not been used in pediatric vaccines since 2000 (a few flu vaccines still use thimerosal).  Autism rates have actually increased since thimerosal was removed.

The doctor who published studies linking vaccines with autism was a fraudAutism Speaks has a lot of great information about autism (update: and when I went to their website to grab the link, I found this new study about the “too many too soon” concern about vaccines. On a side note, please watch your child for signs of autism. It is very common and the earlier it is caught, the sooner you can start highly effective interventions. Speaking not just as a physician but as the sister of a person with autism, in addition to all the information on Autism Speaks, here is a good article explaining it.

Many parents are worried about exposing their children to so many different vaccines at once.  In reality, LIFE exposes children to far more antigens.  In the span of time that vaccines expose children to 315 antigens, life (eating, playing, living) exposes them to MILLIONS of pathogens.  The immune system does a great job with everything coming at it.  In fact, only a handful of specific immune cells respond to each pathogen/antigen so there are plenty of others sitting around clipping their toenails waiting for something to do.

Older resources have inaccurate data. Here’s from the article mentioned above: “Even though the routine childhood schedule in 2012 contains several more vaccines than the schedule in the late 1990s…the maximum number of antigens to which a child could be exposed by age 2 years was 315 in 2012, compared with several thousand in the late 1990s.” So any book written a decade ago is going to show a very different set of chemicals in the vaccines than in the modern ones.

At a time when fear of vaccines is growing, the safety of vaccines is improving.  As cited above, there are FEWER antigens in vaccines now, no thimerosal, etc.  All of us adults are the ones who should have the high rates of whatever you have heard vaccines may cause.

You cannot catch the infection from killed vaccine.  Children with weakened immune systems, such as children with cancer, can have problems from the live attenuated vaccines.  They rely on herd immunity for protection (as do children too young to receive vaccines).  (Added in 2015: Here is an example of this, a little girl with leukemia who was exposed to measles.)

The risks of serious side effects are rare.  Statistics for mild to severe reactions are listed here.  The risks from the diseases are much more common.

There were a total of 1,132 claims for vaccine related deaths over a 29 year period. (Claims do not mean that the vaccine actually caused the death, by the way; whereas death from a disease is definitely from that disease.) That’s about 39 deaths a year possibly related to vaccines.  Vaccine preventable illnesses killed over 5 million A YEAR prior to the vaccines being introduced.  Multiple that by 29 years for comparison purposes and you get 145 million deaths over a 29 year period.  That is an AMAZING success.

Let’s just look at one vaccine preventable illness we’ve seen in our lifetime: prior to the chicken pox vaccine being introduced, over 4 million people caught it every year, over 10,000 were hospitalized, and between 100 and 150 died.  Just that one vaccine saved more hospitalizations and deaths than vaccines potentially cause.

Update in 2015: The best way to protect your baby is to “cocoon” your little ones in a family of people who have been vaccinated.  Here is more about that from a mama doc.

And to quote from another mama-doctor: “Others will claim that vaccine preventable diseases are not that bad. That natural immunity is better. At best they are misinformed and at worst they lie. Many of these diseases kill or maim. That’s why the vaccines were invented in the first place. I have seen people die from influenza (35,000 people die from the flu every year in the U.S.), pertussis, and hepatitis B. I have seen people left seriously impaired from chicken pox (brain inflammation), and fortunately have only seen photos of the devastation that is congenital rubella. There is a reason there is no vaccine against the common cold. It’s a pain in the ass, but that’s all it is.

“And finally, some say all CDC run studies are biased because the CDC has a stake in promoting vaccines. They don’t. The CDC promotes health. The people at the CDC are paid by our tax dollars and are a highly critical group interested in science. They also promote hand washing, HIV testing, breast feeding, using condoms, and maintaining a healthy weight. There is no hidden agenda.”

I have actually seen the devastation of congenital rubella.  I have seen children with permanent brain damage from chicken pox and Hib.  I have patients who have lost children to vaccine-preventable diseases.

So I vaccinate my children and encourage you to do the same.  If you don’t, I’m not going to harangue you, call you names, or try to make you feel like a bad parent.  You love your children dearly, you do everything you can to protect them, and you are making your best decision for them.

If you do want to vaccinate your children, please know that I don’t actually provide vaccines at my practice because they are free at the health department through the Vaccines For Children program for children without insurance or with Medicaid and through insurance for insured children. You can’t beat the price! I do recommend holding your child in your lap for the vaccines if that is their wish (older kids may prefer to sit with you nearby). Many medical professionals will tell you to pin them down to the table, but that just adds fear to an already scary experience. I’ve held both my kids for all their vaccines.

Update 2014: Here’s a great TED talk about empathy with children over shots.  I think it’s a perspective on pain that most of my patients (regardless of your stance on vaccines) would agree with:

Update 2014: I was just given this link from Ron Goodman and I think this is a great perspective.  Especially the end

There is a tiny child in your life whose chubby little face can make the vaccination decision seem overwhelming to the average perfectionist parent. It can be a mentally and emotionally challenging process. Either way, you’ll face potential judgment for your decision – from society, and, if you are so inclined, from yourself. But make your decision and move on – parenthood is full of challenging decisions, and childhood is full of unknowable risks.