Pediatricians experiment with concierge house call practices

When Edward Kulich, MD, a pediatrician in New York City, New Jersey and Connecticut, treats patients, they are usually at home in bed.

Dr. Kulich, who founded KidsHousecalls a few years ago, is one of a small but growing number of physicians to establish a concierge pediatric house call practice. He is available 24 hours a day, seven days a week. He has no office and accepts no insurance. Although his practice is financially viable, he has learned that working this way is not for the faint of heart.

"I wasn't sure it was going to work, but I wanted to at least try it," he said.

Most concierge practices focus on providing additional services and physician access for adults. House calls are sometimes part of the package, but most care is office-based.

"This is probably something that could be very appealing," said Bernard Kaminetsky, MD, medical director of MDVIP, a network of hundreds of concierge physicians. "I can see where there would be a need."

These new practices are usually marketed as a convenient choice for middle-class and wealthier families. Another selling point is that house calls are a healthier option than seeing children in a medical setting where they could be exposed to various pathogens.

These practices -- usually the only one of their kind in their market -- benefit special needs children who have a hard time leaving the house. The practices are listed in the directory of the American Academy of Concierge Pediatricians, which Dr. Kulich established.

The practices have different structures. Some provide urgent and well-child care, and some are urgent care only. Others charge an annual membership fee or provide services 24/7. Still others are more limited.

Most charge and collect a fee for the service at the time it is provided and give parents paperwork to file for out-of-network reimbursement from a private insurer or a health savings account.

"The feedback from people with good insurance is that they are generally reimbursed 50% to 75%," said Michael Milobsky, MD, who runs Chicken Soup, which provides urgent pediatric care house calls after 5 p.m., seven days a week, in the Denver area. "I set my price points so that they are fairly close to what people with insurance are paying out of pocket."

Most pediatric house call concierge practices were launched in the past year or two. But experts say this niche is unlikely to make concierge medicine -- a relative rarity in most areas -- significantly more common.

"The cost of joining a concierge practice can be considerable," said Russell Libby, MD, a pediatrician in Fairfax, Va. "Young families can't really spend money on this, but there are some families that would pay for it."

Dr. Libby, who is working to establish a hybrid concierge practice, is a member of the board of the American Academy of Home Care Physicians.

Tips on making it work

Physicians who work this way have made it viable by investing a lot of time and hard work. For example, Dr. Kulich expanded his coverage area from Manhattan to Connecticut and New Jersey and spends a lot of time on the road. Dr. Milobsky's practice is profitable, but he also works full time as a pediatric hospitalist.

Marc Tanenbaum, MD, who recently launched Priority Pediatrics in Atlanta, has about 25 regular patients but is looking for a few hundred more. He supplements his income by working part time at an after-hours clinic.

"The hardest thing is becoming known," Dr. Tanenbaum said. "But I'm very satisfied with what I'm doing. I look forward to future growth as people find out that I'm available."

Marketing can be difficult because this type of practice is so different from others that care for children. Dr. Kulich offered a coupon on a daily deal website but got no takers.

"Advertising didn't really enhance my growth," Dr. Milobsky said. "The practice grows by referral. And if patients go on Facebook and they talk about it, a thousand other people can know about it."

Dr. Milobsky's practice has a website and a Facebook page, but he does not promote his house call practice at his job.

Collecting at the time of service can be uncomfortable. Most concierge house call practices offer discounts to families who have multiple children or frequently need a pediatrician's services.

Physicians say they usually discuss payment arrangements on the phone before arriving at a family's door. Families rarely balk at paying after the care has been rendered, but it does happen. These bills usually are written off to maintain good will in the community. "I always address how the practice works on the phone and say how much I charge," Dr. Milobsky said. "Sometimes they say, 'I cannot pay now.' It puts me in an awkward position."

Striking a work-life balance can be difficult. Dr. Kulich said he hasn't had a vacation since opening his practice and receives calls at all hours.

"I have no predictability in my life," he said. "It's a lot more of an intrusion in my life than I anticipated, but I enjoy spending time with my patients and knowing them on another level. I truly love what I do."