Will concierge medicine’s image improve as it evolves?
■ Are concierge practices more ethical if they use a mixed model?
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Since its introduction in the mid-1990s, concierge medicine has spawned several submodels. Do these models solve earlier ethical concerns with concierge medicine and help physicians give better care to patients?
Reply: A collection of stories by physicians on how financial relationships affect their practice of medicine was recently published in Narrative Inquiry in Bioethics. The picture that emerged was different from typical discussions of conflicts of interest in medicine. Physicians were well-aware that third parties were trying to influence their practice. But instead of focusing on interference from industry, they focused on the bias that can be introduced by medical practice managers, hospital CEOs and even the Food and Drug Administration.
Medical care is rarely ever a simple, dyadic relationship between a patient and physician. Third parties are everywhere, and perhaps no third party influences the practice of medicine so strongly as payers — private and governmental.
Concierge medicine developed in the mid-1990s as an alternative to many of the traditional financial relationships physicians have with insurance companies and Medicaid or Medicare, providing doctors with a higher level of control over the practice of medicine. In exchange for a retainer payment, physicians in those new concierge practices provided a greater level of access to a much-smaller number of patients than in a conventional practice setting.
For many years, the standard view of concierge medicine described an ultra-elite boutique for those wealthy enough to afford it. It was assumed that physicians who chose to go into concierge medicine were making a conscious decision to care for only healthier and wealthier patients. And it was the rare physician who chose to do this.
Things have started to change, however. The Government Accounting Office estimated that the number of physicians practicing retainer-based care increased more than tenfold from 1999 to 2004. An estimated 1,000 to 5,000 doctors practice in these models, depending on which models are included and who is counting. A GAO survey found annual retainer fees ranging from $60 to $15,000, with an average of $1,500 per patient.
Three major models have emerged: “fee for extra services,” such as an annual extended physical and other services not covered by insurance; “fee for care,” where a patient pays a retainer fee for all primary care provided by a doctor who does not generally accept private insurance; and mixed or hybrid models that involve a retainer fee for some concierge benefits and insurance payments for covered services. Hybrid models are typically more affordable but involve compromises for physicians and patients. Doctors see a larger number of patients and reintroduce some level of third-party involvement, and patients lose some of the benefits of being one of a few patients.
These new developments suggest that retainer-based medicine deserves a second look, because some older stereotypes are clearly inaccurate. This article examines briefly three claims that proponents make about retainer-based medicine: It’s a better way to practice medicine, a better way to receive medical care and a remedy for a broken primary health care delivery system.
A lighter patient load
Where an average primary care physician practice serves 2,000 to 4,000 patients, retainer-based practices typically serve 100 to 500 patients. A report by the Medicare Payment Advisory Commission highlights several advantages for the physician, including increased time with patients, decreased stress and burnout, and increased or comparable compensation while working fewer hours and having less administrative and billing responsibility. Direct care and payment means that the constraints imposed by payers are removed, and physicians may recommend the individualized care they believe their patients need.
Concierge physicians regularly provide patients with personal cellphone access, same-day appointments, hour-long annual physicals and 30-minute appointment slots. Studies have shown that patients favor concierge medicine over general medicine practice in terms of care coordination, access to care and time spent with physicians. Some have argued that increased satisfaction leads to a better patient-physician relationship, enhancing trust as well as adherence to medical recommendations.
Additionally, by removing most third parties from the delivery of medical care, conflicts of interest may be reduced. It is unclear, however, whether these conflicts are replaced by a heightened tendency to prescribe (e.g., antibiotics) based on patient requests rather than on needs.
Although concierge medicine may deliver excellent care in a manner that is attractive to physicians, we question whether it has the potential to fix many of the more serious problems that exist in our system for delivering primary care.
First, the affordability of retainer-based medicine is sometimes exaggerated insofar as the patient’s ongoing need for insurance is ignored. In addition to paying a retainer, most patients will want to maintain insurance to cover medications, specialist care, surgical procedures and expensive tests. This can put retainer-based medicine beyond the reach of many (or at least requires a significant change in spending priorities).
Second, reducing the number of patients that concierge-practice physicians see significantly reduces the number of patients served by each primary care physician. Proponents argue that retainer-based medicine will increase the number of physicians who go into primary care by making it more attractive. But this practice model has existed for nearly two decades, and there is no evidence that the number of primary care physicians is increasing. In The Wall Street Journal, columnist John Goodman, president of the National Center for Policy Analysis, recently predicted that “as concierge care grows, the strain on the rest of the system will become greater.”
Finally, to the extent that mixed models reduce costs to patients and increase access by accepting insurance payments, they also are dependent upon the very system that is often vociferously criticized by “concierge” purists.
In conclusion, codes of medical ethics assert that physicians have fiduciary obligations to their patients. The obligations that physicians have to society are less well-specified, requiring the professional to balance social justice concerns (regarding fair distribution of the primary care burden across physicians and access to care for lower-income patients) with professional autonomy concerns.
Given a second look, retainer-based medicine remains attractive to doctors and patients in many regards. But significant questions remain about whether it should be promoted as a model that can meet the needs of most patients in society even with the advent of hybrid models.
James M. DuBois, PhD, DSc, Hubert Mader Professor and director of the Bander Center for Medical Business Ethics at Saint Louis University; Adjunct Professor of Medicine in the Institute for Clinical and Translational Sciences, Washington University, St. Louis
Elena Kraus, coordinator of the Bander Center for Medical Business Ethics and MD/PhD student at Saint Louis University
Erin L. Bakanas, MD, associate professor of internal medicine and associate director of the Bander Center for Medical Business Ethics at Saint Louis University School of Medicine