Gordon M, Clements-Cortes A. Music at the end of life: bringing comfort and saying goodbye through song and story. Annals of Long-Term Care: Clinical Care and Aging. 2013;21(11):24-29.
Affiliations: 1Medical Program Director, Palliative Care, Baycrest Geriatric Healthcare System,Toronto, Ontario, Canada; 2Professor of Medicine, University of Toronto, Toronto, Ontario, Canada3Senior Music Therapist/Practice Advisor, Baycrest Geriatric Healthcare System, Toronto, Ontario, Canada; 4Assistant Professor, University of Toronto, Toronto, Ontario, Canada
Abstract: Music has been an important part of the human existence across all continents and cultures since the beginning of recorded time. It is used, for example, in the celebration of happy events, for religious rituals, and to acknowledge the death of loved ones, often as part of spiritual and symbolic rituals. Although the formal and structured use of music as a component of care for individuals in end-of-life palliative care and hospice systems is relatively new in the world of contemporary medicine, its use is growing rapidly and is appreciated by both those providing the music and those receiving the benefits of the music, including patients and their families. This article provides a brief review of some of the current uses of music therapy, including its use in end-of-life care, and illuminates the benefits and potential uses of music through a case example.
Key words: Hospice care, end-of-life care, palliative care, quality of life, alternative and complementary medicine, Alzheimer’s disease and dementia, music therapy.
Music is not tangible. You can’t eat it, drink it, or mate with it. It doesn’t protect against the rain, wind, or cold. It doesn’t vanquish predators or mend broken bones. And yet humans have always prized music—or well beyond prized, loved it.
—Robert J. Zatorre, PhD, and Valorie N. Salimpoor, PhD
The American Music Therapy Association defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”1 Music has long been recognized to have a major beneficial impact on individuals in need of comfort, and music as a treatment modality in palliative care and hospice programs is not new, but it is starting to gain more traction. For those at the end of life, music can provide comfort and alleviate the distressing symptoms that arise during the latter stages of a terminal illness. During this time, it is crucial that each patient’s experiences are as physically and emotionally suited to him or her as possible, and music can often help to achieve this goal due to its personal impact.
Our organization, the Baycrest Geriatric Healthcare System, has a robust music therapy program to assist and provide succor and inspiration to those who come to us for the final stage of their lives, which can last anywhere from mere days to weeks or even months. Beyond managing our patients’ clinical symptoms, we try to find ways to affirm their life and its meaning, and sometimes that happens through music. In this article, we present a case example that details how one of our former patients benefitted from music therapy. Following the case example, we outline some of the benefits that music therapy can provide to patients at the end of life and take a brief look at how neuroscience is enhancing our understanding of music therapy and its benefits. Finally, we review how institutions with limited resources can provide music experiences to their patients and discuss factors that they need to carefully consider as they do so.
Chaim, a 91-year-old man, was admitted to Baycrest’s palliative care unit with an estimated prognosis of 3 to 6 months to live due to lung cancer and other illnesses. He had worked as a lawyer until the age of 85 and kept himself actively engaged in professional activities after retirement by reading about and discussing politics and current events with others.
Chaim grew up in Montreal with his parents and brother, and he attended college in Toronto, where he opened a private legal practice after completing his degree. Chaim married and had three children with his first wife, Rebecca. After Rebecca passed away, he met and married his second wife, Sarah, who accompanied him during his final weeks of life. Music had played a significant role in Chaim’s life since his childhood. Although he took piano lessons for only 1 year because he disliked practicing, his brother continued to take lessons and performed for the family on Sunday evenings, which brought Chaim considerable enjoyment and provided him with many fond memories. Chaim continued to be engaged with music, using it to study and relax as a young adult, and he introduced music lessons to his children at an early age.
Five years prior to his admission to Baycrest’s palliative care unit, Chaim received a lung cancer diagnosis and underwent radiation and chemotherapy treatments, which resulted in a period of remission. When Chaim’s cancer returned 3 years after the initial diagnosis, he underwent another course of chemotherapy and radiation, but the treatments were not successful. Chaim also developed other health problems during this time, including pneumonia, arteriosclerosis, and a myocardial infarction, all of which resulted in recurrent acute hospital admissions. When it became too difficult for Sarah to care for him at home, Chaim and his family pursued end-of-life care at Baycrest.
On admission to the palliative care unit, Chaim spoke with the social worker about his love of music and drama, and also about an urgent need he had to complete his memoirs, a project he had been working on for the previous 2 years. The social worker referred him to our music therapy program because she thought he would enjoy participating in a music-centered intervention and that it would enhance his quality of life.
Reflections on Music Therapy With Chaim: As Narrated by Coauthor Amy Clements-Cortes
Keeping the ultimate goal of writing his memoirs in mind, Chaim decided that I could help him use his life stories to create a play. When I proposed the idea of adding music to the play, Chaim agreed that it would enhance the stories. He decided to turn his memoirs into an opera, which he named Heroes as a way to honor Rebecca and Sarah—the two most important relationships of his life.
To fulfill his goal, we began our music therapy process together by writing the dialogue, or what is known as the libretto in opera. By engaging in this practice, the important stories and relationships that were central to Chaim’s life surfaced. He also thoughtfully reflected on the most appropriate songs to accompany the stories in his play, and he had a prominent role in writing the music with me. The idea was that writing the libretto, analyzing the lyrics, and selecting and writing the songs to accompany his stories would enable him to express any issues that he had with the individuals in the stories, which in turn would allow him to complete his relationships with them.
The concept of relationship completion refers to five sentiments that must be expressed in the lifetime of a relationship: “I love you,” “Thank you,” “Forgive me,” “I forgive you,” and “Goodbye.”2 According to Dileo and Parker,3 “Songs can convey these messages more powerfully and completely than words alone.” Further, Dileo and Magill4 assert that various clinical methods can be used to facilitate the expression of these sentiments, including song choice, song improvisation, song discussion, song dedication, song narrative, creation of song legacies, and songwriting. During our sessions, we discussed the meanings expressed in the songs we shared, the relationships described in the songs, the emotions that arose from those ruminations, the work needed for relationship completion, and the feelings associated with relationship completion.
For example, writing the song for Rebecca, titled Come Now Friends, expressed the love he felt for her and captured the feelings he experienced before her death when he struggled with how he would live without her. This expression of love for Rebecca helped Chaim to honor her and say a final goodbye to her, which in turn enabled him to close that chapter of his life and complete his relationship with her.
His opera also included two songs dedicated to Sarah. The song titled The Love I Feel for You Sarah focused on the love he felt for his second wife on their first anniversary. What follows are the lyrics to the song:
Tell me Sarah, say it’s love,
Why dost thou do me favour?
I am unworthy of thy grace.
The gracious smile upon thy face,
My very soul doth savour.
I watch thee bathed in morning sun;
I seek the night’s sweet holding.
Yes, thou has saved this solemn soul,
And caused me to perform a role,
That keeps our world unfolding.
So, at this first anniversary
I celebrate my love for thee,
I say to thee on bended knee,
It is a lasting certainty.
I will love you always!
Listen to the song here>>
The second song he wrote for Sarah was titled Gratitude, and it enabled Chaim to express his appreciation to her for many things, including being his wife, being his friend, and giving him a reason to engage in life again after Rebecca’s death. Writing this song also facilitated Chaim’s awareness of the importance of discussing his impending death with Sarah and articulating his wishes for her once he died. By expressing “I love you” and “thank you” to Sarah in both of the songs he wrote for her, he was working toward completing his relationship with her. The final thing for Chaim to do before his death was to say “goodbye” to her. To give him this opportunity, we invited Sarah to join our sessions, which enabled Chaim to verbally express his love to her, both through the songs and in the discussions that ensued. By Chaim reading the story of their anniversary and me singing The Love I Feel for You Sarah, he was able to speak to Sarah about his impending death and his desire for her to continue to engage in life after his death.
Another significant person who weighed heavily on Chaim’s grieving process was Joseph, his grandson who had recently passed away after a short illness. He wrote a song for him, and reading the story of Joseph’s death from the opera and singing The Rose, a song performed at Joseph’s funeral, facilitated a discussion of grieving and the importance of seeking grief support. These were important things for Chaim to discuss with Sarah to help him reduce his anxiety over his own death and Sarah’s grieving process. It assisted Chaim in communicating to Sarah his desire for her to obtain support and help when he passed away, as well as his wishes for her to find new things to put her energy towards.
Chaim was able to finish writing the opera before he died, and I, per his wishes, completed the project by recording the songs for his family after his death. Listening to this legacy gift played an important role in their grieving process.
While Chaim’s case is quite unique in that writing an opera is an ambitious goal that relatively few individuals at the end of life would be able to achieve due to the energy required to complete such a task, there are many examples of powerful and transformational music therapy work in palliative care. For example, many patients are able to compose original—even if relatively simple—music, and this can often be completed within one to three sessions, depending on the length of the song and the patient’s energy levels. Although persons with advanced dementia might have serious limitations, those with mild cognitive impairment can participate successfully in songwriting projects with great personal satisfaction when structure is provided by a music therapist. The sessions can even involve the participation of a family member or a significant other. As demonstrated by Chaim’s case, the involvement of a family member in the music therapy sessions can add another therapeutic dimension, helping that individual cope with his or her grief and find closure.
Music has been universally enjoyed and treasured by people throughout human history, in all cultures and in all parts of the world. While the formal practice of music therapy in palliative care originated nearly 40 years ago, Forinash5 described a rich history on the use of music in the context of death and dying that predates its formal use in palliative care. According to West,6 music has been associated with medicine since the Paleolithic era, and Riedweg7 stated that Pythagoreanism, a religious movement founded by the ancient Greek philosopher Pythagoras, is associated with connecting music and healing. In addition, the sixth-century philosopher and theologian Boethius maintained that harmony provided a balancing effect for different parts of the body and the soul.8
Over the past few decades, there have been many initiatives in North America to formalize and improve the philosophy of end-of-life palliative and hospice care, whether that care is provided in dedicated units, long-term care facilities, or even general hospitals, where many patients spend the early days of this last phase of their lives. Music therapy has been one such initiative. In fact, one of the pioneers in palliative care in North America, Balfour Mount, described how music therapy has made a significant contribution to a wide variety of palliative care problems.9 The use of music across care settings has been well received by patients and their families, including at our institution. It is often able to provide comfort when words are inadequate or inappropriate, and it may even provide a means of positive interaction and facilitate the expression of feelings. In fact, a wide variety of social, emotional, physical, and spiritual benefits have been reported in the literature.
Benefits of Music Therapy in End-of-Life Care
There has been growing literature on the importance and benefits of music in end-of-life care. Music therapy can offer support to the patient and help palliate symptoms that are common at the end of life (eg, pain, fatigue, sleep disturbances, nausea, existential and spiritual concerns, anxiety, fear).10 It can help individuals achieve an awareness of their own limitations and losses11 and can assist with one’s life review and relationship completion. It has also been found to be a valuable intervention to achieve common palliative care goals.12,13 Hilliard14,15 reported that music therapy is a creative and innovative way to meet the multidimensional needs of terminally ill patients and their loved ones, and can address their spiritual and existential concerns. Music therapy has been used successfully in the treatment of a variety of physical, emotional, and spiritual issues within palliative care, including decreasing social isolation and loneliness and lessening emotional distress (eg, depression, anxiety, anger, fear).12,16-18 Music therapy is also used in palliative care to improve pain management and relaxation, which are important goals for many palliative care patients.19-22 Some other general goals of music therapy include improving quality of life; enhancing learning; enabling self-expression, communication, and self-development; and facilitating self-awareness.14 In their 2006 study, Gallagher and colleagues22 found that music therapy had a significant effect on several symptoms in patients with chronic and/or terminal illness, including shortness of breath, body movement, facial expression, and verbalizations.
Similar to music therapy, music thanatology is another specialty that has been used during the dying process. Developed in the 1970s by Therese Schroeder-Sheker, music thanatology provides live harp and vocal music at the bedside of the dying patient.23 Music thanatologists are formally trained to adjust their harp and vocal music to respond to specific organic changes that are occurring in their listeners, such as changes in breathing rates or circulation. The goal is to support the patient in his or her own process by offering music in a prescriptive manner to create an environment that can enable the patient to experience what he or she needs to experience in the most supportive way possible. Prescriptive music is not specifically outcome-based, meaning that the music thanatologist does not try to control what the patient is experiencing but instead works to support the patient in whatever he or she is experiencing. For example, creating a supportive musical field may be helpful to a patient who is anxious by making it easier for him or her to calm down or to become more at peace.
The Neuroscience of Music
The growing literature on music and end-of-life palliative and hospice care is supported by recent scientific studies that more formally document and demonstrate the neurobiological basis for the enjoyment and satisfaction that comes from hearing music, which, according to the end-of-life literature, presumably can occur even during the terminal phase of one’s existence. The recent review by Zatorre and Salimpoor24 provided scientific-based explanations for what most music lovers understand as the special sensual qualities of music. In the following passage from a recent article that appeared in The New York Times, Zatorre and Salimpoor25 explain the already-established neuroscience that elucidates the way in which music works in humans, which is based on their aforementioned review:
More than a decade ago, our research team used brain imaging to show that music that people described as highly emotional engaged the reward system deep in their brains—activating subcortical nuclei known to be important in reward, motivation and emotion. Subsequently we found that listening to what might be called “peak emotional moments” in music—that moment when you feel a “chill” of pleasure to a
musical passage—causes the release of the neurotransmitter dopamine, an essential signaling molecule in the brain.
After a detailed explanation of the processes by which music affects the brain, the authors conclude, “In the cross talk between our cortical systems, which analyze patterns and yield expectations, and our ancient reward and motivational systems, may lie the answer to the question: does a particular piece of music move us? When that answer is yes, there is little—in those moments of listening, at least—that we value more.”25
These experiences, for which there is now a good scientific basis, can occur even during the waning months, weeks, days, and hours of life. This fact allows us to use music to provide whatever semblance of joy can exist in what remains of the life of those we love and care for.
Music Therapy Considerations for Allied Healthcare Professionals
Once an individual is deemed a suitable candidate for music therapy, a music therapist conducts a formal assessment that takes into consideration patient preferences and abilities and establishes a baseline with goals and objectives. The types of interventions vary widely and may include, for example, songwriting, singing, moving to music, lyric discussion, and/or listening to music. Because music therapy offers a variety of active and passive activities, musical ability is not required for a patient to participate in or benefit from this intervention.
To ensure optimal support, the music therapist needs to take the patients’ musical preferences into careful consideration. After all, patients in hospice programs can vary in age and have different tastes; thus, it is impossible to select music that would appeal to this entire population. In addition, Hogan26 maintains that there are multiple benefits of using familiar and preferred familiar music with terminally ill patients, including providing them with a sense of achievement, enabling greater control over their environment, providing them with a physically and mentally stimulating experience, heightening their awareness, and encouraging exploration of their emotional needs. Familiar and preferred music can also enhance purpose and self-worth by stimulating creative participation, and creating recordings of familiar music may provide comfort to the patient in times of fear and loneliness while leaving behind a legacy gift for family members in the bereavement process, as demonstrated in the case example.26 Mitchell and MacDonald27 found that preferred music was distracting, had a positive affective impact on the experience of pain, and increased tolerance time of painful stimuli and perceived control over pain in both male and female patients.
Although not every long-term care facility, palliative care program, or hospice unit may have the benefit of—or in some cases, the luxury of—professional music therapy staff to assist in providing musical interventions, there are many resources that can help healthcare professionals and social service providers in these settings bring music to those who might benefit from it. Attempts can be made, for example, through a volunteer department to explore who, among the volunteers, might have a significant musical background and interest in learning about and providing music to patients and their families. Although these musical interventions may not be as sophisticated as professional music therapy programs, they still have the potential to achieve the goal of providing meaningful musical support during the end-of-life experience.
When implementing such resources, healthcare professionals need to keep in mind that music has a very personal and intimate meaning for each individual, a fact that demands a great deal of respect. Therefore, it is important to stress the need for a careful assessment of each individual patient before introducing musical interventions. An example of an appropriate approach might be for a healthcare provider to suggest that a patient use music if he or she is having difficulty falling asleep and recommend one of several CDs that have been created for this purpose. Another example is playing background music during a painful procedure or routine care.
Most people understand the positive impact of music in their lives, but they may not realize that music can have a therapeutic effect for a wide array of clinical conditions, with these effects going well beyond the “enjoyment” factor that music brings in all its various formats and methods of presentation. For individuals in the later stages of life, especially when in need of palliative, long-term, or hospice care, music may offer another important modality of clinical intervention that may provide comfort and emotional satisfaction to those susceptible to its effects. Practitioners working in these care settings generally become adept at manipulating medications to achieve the therapeutic goals of comfort while maintaining the patient’s ability to participate as much as possible in human activities, especially visits with loved ones. For those in whom music is helpful in this endeavor, it is important to note that, as far as is currently known, music has no lingering adverse effects. It can be discontinued quickly if necessary; it can engage other members of the family in a conjoint effort; and, as in the case of Chaim, it can tap into the core humanity of the person who is either the recipient of the music or the participant in the musical project that they have chosen.
2. Byock I. Dying Well: The Prospect for Growth at the End of Life. New York, NY: Riverhead Books; 1997.
3. Dileo C, Parker C. Final moments: the use of song in relationship completion. In: Dileo C, Loewy JV, eds. Music Therapy At the End of Life. Cherry Hill, NJ: Jeffrey Books; 2005:43-56.
4. Dileo C, Magill L. Songwriting with oncology and hospice adult patients from a multicultural perspective. In: Baker F, Wigram T, eds. Songwriting: Methods, Techniques and Clinical Applications for Music Therapy Clinicians, Educators, and Students. London, England: Jessica Kingsley, 2005:180-205.
5. Forinash M. A Phenomenology of Music Therapy With the Terminally Ill [dissertation]. New York, NY: New York University; 1990.
6. West M. Music therapy in antiquity. In: Hordon P, ed. Music as Medicine: The History of Music Therapy Since Antiquity. Brookfield, VT: Ashgate; 2000:51-60.
7. Riedweg C. Pythagoras: His Life, Teaching and Influence. Ithaca, NY: Cornell University Press; 2005.
8. Garber JJ. Harmony in Healing: The Theoretical Basis of Ancient and Medieval Medicine. New Brunswick, NJ: Transaction Publishers; 2008.
9. Mount BM. Music therapy in palliative care. Can Med Assoc J. 1979;120(11):
10. Dileo C, Dneaster D. Introduction: state of the art. In: Dileo C, Loewy JV, eds. Music Therapy at the End of Life. Cherry Hill, NJ: Jeffrey Books; 2005:xix-xxvii.
11. Salmon D. Music and emotion in palliative care. J Palliat Care. 1993;9(4):48-52.
12. Clements-Cortés A. The use of music in facilitating emotional expression in the terminally ill. Am J Hosp Palliat Care. 2004;21(4):255-260.
13. Clements-Cortés A. Episodes of relationship completion through song in palliative care. University of Toronto Research Repository. http://hdl.handle.net/1807/17744. Published September 23, 2009. Accessed June 21, 2013.
14. Hilliard RE. Music therapy in hospice and palliative care: a review of the empirical data. Evid Based Complement Alternat Med. 2005;2(2):173-178.
15. Hilliard RE. The use of music therapy in meeting the multidimensional needs of hospice patients and families. J Palliat Care. 2001;17(3):161-166.
16. O’Callaghan C. Bringing music to life: a study of music therapy and palliative care experiences in a cancer hospital. J Palliat Care. 2001;17(3):155-160.
17. Lee C. Music at the Edge: The Music Therapy Experiences of a Musician With AIDS. London, England: Routledge; 1996.
18. Hogan B. The experience of music therapy for terminally ill patients: a phenomenological research project. In: Pratt R, Grocke D, eds. Music Medicine 3. Music Medicine and Music Therapy: Expanding Horizons. Melbourne, Australia: University of Melbourne; 1999:242-254.
19. Curtis SL. The effect of music on pain relief and relaxation of the terminally ill. J Music Ther. 1986;23(1):10-24.
20. Bailey LM. The effects of live music versus tape-recorded music on hospitalized cancer patients. Music Therapy. 1983;3(1):17-28.
21. Krout RE. The effects of single-session music therapy interventions on the observed and self-reported levels of pain control, physical comfort, and relaxation of hospice patients. Am J Hosp Palliat Care. 2001;18(6):383-390.
22. Gallagher LM, Lagman R, Walsh D, David MP, Legrand SB. The clinical effects of music therapy in palliative medicine. Support Care Cancer. 2006;14(8):859-866.
23. Schroeder-Sheker T. Music for the dying: a personal account of the new field of music-thanatology—history, theories, and clinical narratives. J Holist Nurs. 1994;(12)1:83-99.
24. Zatorre RJ, Salimpoor VN. From perception to pleasure: music and its neural substrates. Proc Natl Acad Sci USA. 2013;110(suppl 2):10430-10437.
25. Zatorre RJ, Salimpoor VN. Why music makes our brain sing. New York Times. June 9, 2013:SR12.
26. Hogan B. Music therapy at the end of life: searching for the rite of passage. In: Aldridge D, ed. Music Therapy in Palliative Care: New Voices. London, England: Jessica Kingsley Publishers; 1998.
27. Mitchell LA, MacDonald RA. An experimental investigation of the effects of preferred and relaxing music listening on pain perception. J Music Ther. 2006:43(4):295-316.
Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Michael Gordon, MD, MSc, Baycrest Geriatric Healthcare System, 3560 Bathurst Street, Room 1C24, Toronto, ON, M6A 2E1, Canada; email@example.com
Patients and providers are increasingly turning to concierge medicine—a direct relationship between a patient and a provider—as an alternative care delivery model.
The concept seems simple: patients spend more time with their physician in exchange for an annual fee or retainer. Physicians, likewise, significantly decrease their patient volume to provide these services.
The trend is already on the rise, with companies like MD-Value in Prevention (MDVIP), which claims a network of 900 other primary care doctors in 43 states, offering patients “personalized medicine, patient-centered medicine, and preventive care.” Some medical schools and hospital networks, such as Johns Hopkins Medicine and Massachusetts General Hospital, currently offer concierge medicine for its patients.
“[C]oncierge medicine is clearly filling a market need, both for patients as well as for physicians,” Kevin Grabenstatter, managing director, Healthcare Services at L.E.K. Consulting in San Francisco, said in an interview with First Report Managed Care.
There are a few care delivery models to consider when designing a concierge practice. Some practice owners choose to charge patients directly, while others bill insurance in addition to charging a monthly, quarterly, or annual fee. The range of services offered relative to the cost of an annual membership can vary.
Prices for concierge care can range from a couple hundred dollars per year to tens of thousands of dollars annually, depending on the practice and care delivery model. While concierge medicine is often associated with high annual fees, there are some companies experimenting with lower cost models. Greenfield Health in Oregon charges its members based on their age, with children paying about $12 per month and 70-year-old members paying approximately $70 per month. One Medical, a concierge practice with offices in eight cities, charges $149 per year for its members.
Mr Grabenstatter said while the market is still small and the initial reaction to the model was “abrasive,” the opportunity exists for not only physicians but also payers to consider entering the market. “I think there's an opportunity in the market for forward-thinking payers to think proactively about concierge medicine and perhaps become the payer of choice for these practices,” he said.
However, concierge medicine is not without its critics. Some physicians claim concierge medicine creates a two-tiered system where the patient population is limited to only those who can afford a physician’s annual fee. Other concerns are that physicians may choose only healthy patients to fill out their practice, and that primary care physicians who move to a concierge model are contributing to the shortage of primary care physicians in the United States.
Payers are reacting to the concept of concierge medicine in a variety of ways, Mathew J Levy, Esq, partner and co-chair of corporate transaction and healthcare regulatory practice at Weiss Zarett Brofman Sonnenklar & Levy, P.C., explained to First Report Managed Care in an email interview.
“In situations where patients are paying a standard retainer fee to obtain enhanced services not covered by insurance and providers still maintain their status as in network providers, this arrangement would not have a significant impact on payers as they would still be responsible for providing coverage for covered medical services,” Mr Levy said.
“However, in instances where providers have chosen to terminate their relationship with payers, this may result in higher costs to payers where the beneficiaries have out of network benefits,” he added.
Better for Patients and Physicians?
Although the origins of concierge medicine can be traced back to when Howard Maron, MD, and Scott Hall, FACP, founded their practice, MD2, in Seattle, Bellevue, WA and Oregon in 1996, the idea is not all that new, James E Dalen, MD, MPH, executive director of the Weil Foundation, said.
“The concierge model is what medicine was like 40 years ago,” Dr Dalen said in an interview with First Report Managed Care. “You could call your doctor and he'd see you next day if he had to.”
That personalized care and close relationship with a patient is what patients are looking for, experts said. Those in favor of a concierge model said the potential benefits for both patients and physicians are many, which can range from benefits such as 24/7 patient care, convenient contact through telemedicine, access to physicians by phone or email, preventative care and wellness plans, same-day or next-day appointments to physicians and referred specialists, and longer appointment times to more luxury care where patients wait in nicer waiting rooms and can “cut the line” and stay in private accommodations for specialty care and acute episodes.
It is not only convenient care, but timely care, he added. Physicians in concierge models can use their network of contacts to help connect patients with the right specialist for their given situation. “That's a huge, huge advantage—your doctor helps you have access to other specialists,” Dr Dalen said.
Another benefit for physicians is seeing fewer patients may lower the risk of burnout. In the Medscape National Physician Burnout & Depression Report 2018, 42% of physicians reported some level of burnout, with 56% naming bureaucracy and 39% citing too many hours at work as reasons why they felt burnt out.
Recent studies indicate that concierge medicine increases rates of screening and provides cost savings for patients and care environments. A study by Nguyen and colleagues in 2017 showed 90.2% of patients in the Center for Executive Medicine concierge primary practice underwent colorectal cancer screening, compared with 63.3% of patients under local IPA Medicare Advantage plans and 57.5% to 66.5% of patients under National Committee for Quality Assurance national plans.
A 2014 study of MDVIP patients who were Medicare Advantage beneficiaries published in the American Journal of Managed Care by Musich and colleagues showed cost savings of $86.68 per member per month after 1 year and $47.03 per member per month in the second year compared with nonmembers. A different study, published in 2012 in The International Journal of Person Centered Medicine, found greater than 93% of MDVIP patients had good hemoglobin A1c control compared with approximately 64% of national HMO and approximately 55% of PPO reported rates. Similarly, approximately 96% of patients under MDVIP underwent cholesterol screenings compared with 89% of national HMO and approximately 84% of PPO plan patients.
In a 2012 study, published in the American Journal of Managed Care, Klemes and colleagues found that, relative to nonmembers, patients under MDVIP were between 42% and 62% less likely to be hospitalized, with lower rates of “elective, non-elective, emergent, urgent, avoidable, and unavoidable” admissions, they said.
“Some payers may also see a significant cost savings in the event high utilizing patients opt to receive services under arrangements where they pay out of pocket and agree to refrain from billing the plan for the services,” Mr Levy said. “Additionally, some payers have found that concierge physicians report less payouts, fewer hospital admissions, and improved care to prevent chronic conditions, like hypertension, high cholesterol, and diabetes, which are costly to treat.”
Ethical and Legal Considerations
When considering a transition to concierge care from a managed care model, said Mr Levy, ethical and legal considerations include "whether collecting a retainer violates state and federal public health laws and constitutes the practice of insurance which would subject the provider’s practice to more stringent regulation.”
For example, practices that want to continue seeing Medicare patients should know Medicare does not allow providers to charge its beneficiaries an additional fee-for-services covered by Medicare, Mr Levy said. In addition, “Practices who choose to not accept Medicare or any third-party insurance need to be sure to follow carefully any and all rules and regulations for opting out of Medicare and/or any other third-party payers,” he added.
If a physician’s provider has any agreements with managed care companies, those agreements should also be reviewed for conflicts or instances of “double billing,” Mr Levy added.
Any practice considering a concierge model should be prepared to enter into an agreement with their patients that specifically outlines what services are being offered in exchange for a fee and how the practice will handle third-party insurance.
“While converting to a concierge practice model may seem like an exciting opportunity for many physicians, it is imperative that all of the risks and benefits be evaluated prior to such transition,” Mr Levy said.