Clinical Innovators | Interview by Katlyn Nemani, MD

Deeb Salem, MD, FACC, is the chairman of medicine at Tufts University School of Medicine and the physician-in-chief at the Tufts Medical Center, and has had a distinguished career as an academic cardiologist. Dr. Salem has been president of the New England Cardiovascular Society, and was the founding president of the New England Affiliate of the American Heart Association. His academic accomplishments include more than 130 scientific publications, and he is recognized as a national expert in coronary artery disease and congestive heart failure. Dr. Salem has repeatedly been listed in Boston Magazine as one of “Boston’s Best” physicians, most recently in November 2013. In 2004, Dr. Salem co-founded an academic retainer practice at Tufts Medical Center, offering a new model of concierge medicine.

Since the beginning of your career at Boston University Medical School until now at Tufts Medical Center, you have cared for an economically diverse population. How has that influenced your practice?
I was raised in Brooklyn in a very economically diverse neighborhood. My parents were immigrants. My grandmother was in this country for 50 years, and she only knew two words of English. I came to Boston to go to school and cared for a diverse community at Boston Medical Center, which I do here at Tufts as well. At Tufts, we’re right in the middle of Chinatown, and ever since I did my cardiology training here I’ve cared for non-English speaking patients and patients from diverse economic backgrounds.

Tufts is the third oldest hospital in the country. We were founded by Paul Revere. At the time when this hospital was founded, people of means helped support the care of people with no means. There was no such thing as insurance. I thought that this tradition of those more fortunate contributing to the care of the underserved could be an interesting model to carry forward.

How did you come up with the idea of a “mission-driven” concierge practice?
About 15 years ago, there was a company called MDVIP that wanted to talk to me about a concierge service. Initially I told them that we weren’t interested and didn’t think that there was a place for that at an academic medical center. But then I started thinking about one of the key problems in primary care—the underpayment of primary care doctors. In order to survive, they need to see several patients in a day. Many physicians are frustrated with the demands of caring for a lot of patients. That is the reality.

I started my career as an interventional cardiologist. In those days, the “cash cow” for cardiology was doing interventional procedures. I thought it could be interesting to create a “cash cow” for primary care. We could start a practice in which a subset of patients who did not want to be rushed through their visits and wanted a slower pace could pay a fee, and that money could be pooled in with the funds that we use for paying our primary care doctors that do the usual work. Patients in the traditional practice would not be abandoned by their physicians, as their physicians would only work part time in the concierge practice. We started it as an experiment, and it worked. The initial retainer practice started with MDVIP, but over time we were able to run it ourselves.

How are the doctors in the program able to afford the extra time to take care of patients in the concierge practice while retaining the patients in their traditional practice as well?

In the beginning we had three doctors who were splitting their time between the two practices. Each one had a day on the concierge side, and they would cover for each other. They stopped taking new patients in their traditional practice but were able to maintain their old ones. Initially there weren’t many concierge patients, so it wasn’t too difficult. Over time (10–15 years), just by attrition of their traditional patients, those physicians now spend just about all of their time in the concierge practice.

What were some of the barriers you encountered when starting the practice?
Some people took issue with the idea of patients getting treated differently in the concierge practice. But what often goes unsaid in academic medical centers is that if you’re the president of a big company and a big donor to the hospital, you will be treated differently by your primary care doctor. The hospital makes sure of this. We are just totally open about it. And people pay a fee which goes towards improving care for everybody in the practice, including patients in the traditional practice. It’s not a big fee—about $2,000/year—the equivalent of a gym membership. It’s a small number of doctors caring for a small number of patients. There are concierge practices where a doctor keeps a panel of 20 patients, and patients pay $10,000–$20,000/year.

In our practice, a concierge doctor can handle about 300 patients. This is in contrast to a regular primary care who has to take care of about 1,500–2,000 patients to earn a reasonable living. The hours aren’t fewer—they are on call 24/7—but the pace is less crazy. The only reason we decided to do it was to bring a little more income into our primary care pool. I do think the concept is a good one—everybody wins.

How do patients feel about it?
Unlike many other concierge practices, our traditional patients did not lose their primary care physicians—they were not abandoned and were not forced to establish care with another provider. The patients in the concierge practice are comforted by extra time with their doctors. They may not be all that ill, but the social aspect of the visit is as important to them as the medical part. My parents aren’t alive, but if they were, I would want to enroll them in the concierge practice—they always felt that their doctors didn’t spend enough time with them.

A very interesting thing happened early on. We had a couple of patients enroll in our program who were part of another concierge program, and I asked them why they switched. They told me it was because with our practice, they felt that their money wasn’t just helping them but going to another purpose—helping us take care of free care patients, underserved patients in the middle of downtown Boston. It made me feel great to know that some patients share our vision and mission. It may be a minority of the patients, but at least some people have felt that way. I wish we had more of these patients, because if we could have more we’d do better.

Has recruitment been an issue?
Recruitment slowed down when our economy crashed. That was one issue. To give you an idea of the scale, we have over 35,000 primary care patients at Tufts Medical Center in medicine, and the concierge service is about 700 patients. It’s a small percentage of the primary care population, but it still generates some money. If we could get it up to 1,500 patients, it would help a lot.

Our neighborhood in downtown Boston is transforming, which gives us a lot of opportunity to build. When I first came here this was called “the combat zone.” Now Chinatown is becoming extremely developed with baby boomers buying apartments and moving in from the suburbs. We are starting to market our program more now in the hopes that we can get more patients enrolled, because we do have the capacity.

Could this hybrid model be applied to a cardiology practice?
I think the model could be applied to a specialty service, and it already has. If there’s anything outside of primary care that this would work in, it would be cardiology. For one, there are a lot of patients. There would be opportunity for a significant number of patients to enroll depending on the demographics of the area where the hospital is located. I do think that if it’s applied to a cardiology practice, cardiologists would also be doing some primary care for patients. I’ve been approached by several institutions in the past to learn about what we are doing here—I think people recognize that we have a mission-driven model that can improve care for everyone.

Keywords: CardioSource WorldNews, Intervention Studies

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