The continued growth of concierge medicine is spurred, in part, by a strong desire for longer, more meaningful visits. This is true for both patients and physicians.

“The typical 15-minute, one-size-fits-all, visit is just not enough time to adequately address the myriad patient concerns, provide preventive care and counseling, and establish a trusting relationship,” says William Martinez, MD, assistant professor of medicine at Vanderbilt University School of Medicine in Nashville, TN.

Jack Ende, MD, president of the American College of Physicians (ACP), notes that universal access to care is one of the organization’s “fundamental, guiding principles. While it is true that not everyone can afford an expensive car or lavish home, those things are not human rights. But medical care is different. It is a human right; in fact, a very basic human right.”

The ethical question is whether this should be an individual clinician’s responsibility, or the entire health system’s.

“As a nation, we should be able to guarantee access to high-quality care for everyone, regardless of economic status. Moreover, as physicians, we need to advocate for same,” says Ende, the Schaeffer professor in medicine at University of Pennsylvania’s Perelman School of Medicine in Philadelphia.

The ACP and other organizations provide opportunities for members to press for universal access to care, regardless of the patient’s ability to pay.

“But when we examine the responsibility of the individual doctor in his or her own practice, it becomes a more difficult question to answer,” says Ende.

There is no consistent definition for concierge medicine, also called “retainer medicine” or “direct primary care.” Typically, practices limit patients to the 200 to 1,000 range, compared to the more than 2,000 seen by most primary care doctors, notes Martinez. The exact number of concierge practices is unknown.

“I have seen estimates of 5,000 to 20,000 physicians in the U.S. practicing some version of retainer medicine or cash-only practices, with growth as high as 5% per year,” says Martinez. “But without any sort of national registry, it is really hard to know.”

Participating patients pay monthly or annual fees, which vary widely depending on the practice. While some practices accept insurance to cover traditional office services like labs and other diagnostics, others are cash-only.

“The negative effects on patients resulting from transitions to retainer medicine don’t affect all patients equally,” notes Martinez. Patients who are unable to pay the retainer fee are disproportionately affected.

“While concierge medicine is far from the only thing that may impact access to care, the medical profession should be looking for ways to improve access — not lessen it,” says Martinez.

Proponents of concierge practices argue that better doctor-patient relationships outweigh the social justice concerns.

“The principal consideration, however, is, can we achieve the purported benefits of retainer practices within a practice model that does not worsen access and particularly disadvantage less affluent patients?” asks Martinez.

Some practices attempt to mitigate social justice concerns by saving some spots for less affluent patients. Others offer reduced or no-fee services to a certain proportion of patients.

“Some retainer practices within academic medical centers use the additional revenue brought in through the retainer fee to subsidize the care of indigent patients,” adds Martinez.

Continuing Appeal

The ACP’s position paper on concierge practices states that physicians should consider the effect of any changes that could make it more difficult for poorer patients to access their practice.1

Ende says, “Whatever happens with the concierge model, the most important consideration is that every member of society has high-quality, affordable care.”

Fewer administrative burdens and appropriate reimbursement would lessen the incentive to move to a concierge model. “Absent that, we may see more doctors retiring, cutting back on patient care, or transitioning into models like concierge,” says Ende.

The persistent appeal of concierge medicine is like “the canary in the coal mine,” says Ende. “It’s a signal that the practice of medicine — which, inherently, should be one of the most rewarding activities anyone can engage in — needs to be fixed.”

REFERENCE

  1. Doherty R. Assessing the patient care implications of “concierge” and other direct patient contracting practices: A policy position paper from the American College of Physicians. Ann Intern Med 2015: 163(12):949-952.

SOURCES

  • Jack Ende, MD, Schaeffer Professor in Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Phone: (215) 614-0928. Fax: (215) 349-8072. Email: jack.ende@uphs.upenn.edu.
  • William Martinez, MD, Assistant Professor of Medicine, Vanderbilt University School of Medicine, Nashville, TN. Phone: (615) 322-5000. Email: william.martinez@vanderbilt.edu.