If the medical community hopes to meet the nation’s need for comprehensive preventive health care, more physicians must change the way they do business—literally.

Despite rapid growth of public interest in holistic health care and many other aspects of healthy living, and greater openness to integrative approaches within medical circles, many Americans are hard-pressed to find holistically-minded physicians who can guide them in the prevention or non-pharmaceutical treatment of common chronic diseases.

In the “trenches” of health care, implementation of holistic/integrative medicine has been far slower than one would expect. In large part, this is because American medicine is dominated by insurance, and most of what falls under the holistic/integrative rubric is not covered.

Some insurers will pay for things like acupuncture or chiropractic, but only for specific indications, and for limited numbers of sessions. Nutrition counseling may be billable under Evaluation & Management codes, but it is often time-intensive and reimbursement is far lower than for procedure-based services. Despite much lip-service about prevention and patient- centered care, insurers and federal payers have not embraced holistic approaches.

According to a recent survey by the market research firm of Jackson & Coker, few physicians expect that to change. Sixty-two percent of those surveyed said they believed increased coverage of integrative services is unlikely, though the public wants it and more doctors are using integrative therapies themselves.

Holistically-minded physicians have been forced by necessity to find or develop new practice models, often outside the insurance framework. Fee-for-service and concierge care are particularly appealing because they eliminate third-party involvement in the physician-patient encounter. But these practice structures also present significant challenges.

Total Fee-for-Service

Since most holistic approaches are not covered by insurance anyway, fee-for-service (FFS) has always appealed to MDs, DOs and DCs wishing to practice holistic medicine full-time. For naturopaths, it is seldom a choice: in most states, insurance-based practice is not an option for NDs and NMDs.

FFS markedly reduces practice overhead. It simplifies many aspects of practice administration, and more or less eliminates the need for billing staff, CPT coding, claims adjudication, and much else that is oppressive about insurance-based practice. For many, FFS might just as well stand for “Freedom From Slavery.”

But without insurance plans to feed them patients, FFS doctors must learn how to market their practices, a skill set seldom acquired in medical school.

Established physicians who switch from insurance to FFS risk losing some existing patients who cannot afford to pay out of pocket. Some fear an FFS move amounts to abandonment of people with limited income. This is a legitimate concern, but FFS medicine need not be overly expensive.

Brian Forrest, MD, runs an FFS-based conventional family medicine practice in Apex, a small working class town in the mountains of Central North Carolina. Apex is definitely not Beverly Hills, and his patient base is not rich. With an FFS model, Dr. Forrest has been able to strip out hundreds of thousands of dollars in overhead, enabling him to charge just $45 per office visit. In most cases, patients get 50 minutes of Dr. Forrest’s time for that fee. He contends that care at his clinic is well within reach of most working people.

FFS permits him to provide much more attentive care than is possible in an insurance practice, with its constant pressure to see more patients in less time. That, he says, has real value to patients—value for which they’re willing to pay.

Over the last decade, several networks have emerged to help doctors transition into FFS. The best known is Simple Care, started by Vern Cherewatenko, MD, a Renton, WA, family physician who became fed up with working himself into bankruptcy and exhaustion in insurance-based medicine. Ten years after its founding, SimpleCare (www.simplecare.com) now represents 1,500 FFS doctors serving roughly 38,000 patients across the country.

Concierge Practice

The concierge care model, popularized by a Florida company called MDVIP is taking hold in many regions, particularly in Florida, New York, Pennsylvania, and Arizona. Other concierge groups include MD2 (pronounced, “MD-squared”), Signature MD, ModernMed, Total Access Medical, and Concierge Choice.

Essentially, concierge medicine is a membership plan: patients pay an annual fee, variable from region to region and plan to plan, to be a member of their doctor’s practice. That fee buys them more or less unlimited access to their doctor for a broad set of basic healthcare and preventive services.

As in FFS, concierge physicians can reduce their overhead by eliminating most if not all billing and administrative staff. In exchange for a cut of the patients’ annual fees, the concierge companies provide doctors with logistical and management support, including extensive marketing services.

Concierge plans offer patients short waits, long visits, close personal attention and direct 24-hour cell phone access to their doctors; they offer physicians lower overhead, predictable income, more control over their time, and opportunities to develop deeper therapeutic relationships with fewer patients—concierge doctors typically have in the range of 300–400 patient members. That, plus the “wellness” orientation of many of the concierge groups (MDVIP’s name stands for “Value in Prevention”), holds great appeal for holistic doctors.

Daphne Goldberg, MD, a board-certified holistic family physician in Bala Cynwyd, PA, joined the Total Access Medical concierge group two years ago. She believes the term “concierge,” with it “luxury” connotation is an inappropriate term for a form of practice that better enables doctors to truly meet their patients’ needs.

Dr. Goldberg’s primary interest is in women’s and family health, and her patients often have a complex of physical, psychosocial and interpersonal issues that cannot be addressed in a 10-minute office visit. In her current practice, she can spend as much time as is needed to attend to multiple health issues, not just the patient’s “chief complaint.” She seldom has more than one patient in the office at a time, creating a calm, unharried work atmosphere that contrasts markedly with insurance-based primary care settings. “It’s just a more humanistic way of practicing medicine,” she told Holistic Primary Care.

As with FFS, doctors who “go concierge” risk losing patients who cannot afford the annual fee. Critics of the model argue that it enables the wealthy and relatively healthy to opt out of standard insurance pools, leaving less money to care for the poor and truly ailing. That argument is somewhat simplistic, since most concierge plans require patients to carry at minimum, a high-deductible major medical insurance policy. Participation in a concierge program is a supplement to insurance, not a substitute.

Dr. Goldberg said she wrestled long and hard with the ethical issues. Throughout her career, she has served patients from low-income communities, most notably as a co-founder of the Covenant House Health Center, a shelter-based clinic for homeless teens. She worried that in joining Total Access, she’d be abandoning her poorer patients.

“The company understood my concerns and they were very accommodating,” she said, noting that she was able to negotiate terms that allow her to set aside special hours during her work week to see low-income patients at her Total Access office free of charge, or at reduced member fees. She is able to give them the same attention she gives her other patients. The big surprise, she said, was the number of patients of modest means who were able to come up with the fees to join the practice.

One potential drawback to concierge care is that physicians are essentially self-capitated, a prospect that scares some who survived managed care’s obsession with primary care capitation in the 1990s. It is theoretically possible that in the future, managed care companies could simply buy up the concierge networks, recreating a new version of an old scenario. There is no indication that this is happening, but it could. The safeguard is that concierge doctors always have the option to not renew their contracts. For now, concierge provides a viable economic framework for holistic practice.

Concierge and FFS are not the only options for holistically minded doctors. Some are building or joining comprehensive integrative care clinics, often acting as clinical quarterbacks for a panoply of interdisciplinary healers. Others are working in medical spa or executive fitness programs such as the innovative programs offered by Canyon Ranch. Still others continue to take insurance but develop out-of-pocket revenue streams from aesthetic procedures, in-office natural products dispensaries, or bookstores, to offset the costs of in-depth holistic care.

Functional Medicine

The rapidly evolving discipline of functional medicine also holds great promise both as a clinical toolset, and as a business model. This approach involves assessment of genetic predispositions to various chronic diseases, and then designing nutritional and lifestyle protocols to minimize risk and optimize health. Functional medicine is not so much about “getting rid” of symptoms, as about improving organ system function, which will ultimately lead to symptom resolution. It’s an “upstream” approach. Rooted firmly in biochemistry and physiology, it is intellectually challenging and has strong appeal for those with a taste for hard science.

From a business perspective, functional medicine involves extensive and repeated blood, saliva, urine and fecal testing for which physicians can bill. A few insurance plans cover some of these tests. But by and large, functional medicine is outside mainstream insurance. Some practitioners dispense nutritional products in their offices, creating a strong revenue stream, though others believe this is ethically questionable.

There is no one “ideal” business model for holistic practice. Each has advantages and disadvantages. As the integrative/holistic field continues to evolve, new practice models and settings will likely emerge. But the evolution will not be spurred by insurers who suddenly see the light and recognize the value of holistic/preventive health services. It will be led by physicians who sincerely want to serve their patients in the best, most healthful way possible.

New models for holistic primary care, including fee-for-service and concierge care, are among the keystone topics of Holistic Primary Care’s upcoming “Heal Thy Practice: Transforming Primary Care,” conference at the Westin La Paloma, Tucson, AZ, from Oct. 31–Nov. 2. Dr. Brian Forrest and Dr. Daphne Goldberg, interviewed for this article, are among the featured speakers. For more information visit www.holisticprimarycare.net.