Friday, March 12, 2010

Blog War: Concierge Medicine

Readers, today begins an occasional series in which Senior Editor/Blog Mistress Sara Michael and Editorial Director Bob Keaveney will take opposing views on some hot topic affecting physicians, then invite you all to join the fray.

The subject of our inuagural Blog War: Concierge Medicine: The Savior of Private Practice Medicine, or Evil Unethical Trend?

From Bob:
I’ve written about concierge medicine in the past. For background, a typical concierge (sometime called retainer or boutique) practice charges an annual or monthly "membership fee" directly to patients, who in return get a different level of access to the physician — usually longer and more frequent visits. They can usually get the doctor on the phone pretty quickly, and many offer e-mail communication, too. A concierge physician might have a few hundred patients rather than a few thousand. Concierge practices — the good ones, anyway — run the way primary practices are supposed to run: With doctors getting to know their patients, becoming truly part of their lives, and spending enough time with them to talk and listen.Read more

That's not possible to do within the confines of the ordinary modern practice. The economics don’t work because primary healthcare today is about volume. Doctors have too many patients to spend more than 10 minutes or so with any one of them. Even when you do see 30 patients a day, in primary care you're way behind your specialist colleagues when it comes to income. That's why so few med students are opting for careers in primary care anymore.

So, for me, concierge medicine is a response to a dysfunctional economic climate that allows primary care doctors to do their jobs in the way they always dreamed — and in a way that's best for patients. Sara, what's your beef with that?

From Sara:
The trend of concierge medicine troubles me. I am not insensitive to the struggles many primary-care physicians face, but concierge medicine is far from being a solution to declining reimbursements and not enough time with patients. Instead, it’s a harbinger of what’s wrong with the system as a whole. The model flies in the face of any commitment to community and public health, which I think should be at the foundation of medical care.
Read more

Concierge medicine further divides our population into those can afford quality care, and those who can’t. What happens to the hundreds of other patients who decide they can’t afford the $1,500 to $3,000 (or more) annual fee? What about those who have had the same physician for years, and who may have trouble finding another primary-care physician? I think basic quality primary care should be afforded to every American and concierge medicine in many ways exacerbates the problem.


  1. Sara, let’s talk for a moment about how the price of something affects its availability.

    A $1,500 fee works out to $125 a month. When a retainer physician sets her membership fee, she’s saying “This is how much my service is worth on the open market.” If ALL primary-care physicians were paid their actual market value (or even something close to it), our primary care physician shortage would, in time, largely evaporate. Suddenly primary care medicine becomes attractive again as a career choice to the young medical students who are currently avoiding it in droves. Properly valuing a commodity or service increases its availability to society at large — even, paradoxically, to the poor, because whenever there is MORE of something good (like primary care physicians), everyone wins.

    Which brings me to another point. How many of the people who “can’t afford it” pay close to, or more than, $125 a month on their cell phone bill? Or cable? Or dates, booze, movies and other forms of entertainment? (My DirecTV bill pushes $100 a month and I don’t even get HBO.) Which of these consumer choices is more important than access to quality care? How much of this discussion is about what people can actually afford — and how much is it about what they have come to expect to receive “for free,” and what they prefer to spend their money on?

    As for “commitment to community and public health” … since when does such a commitment obligate doctors to give away their services at below-market prices to ALL PATIENTS, not just those poor enough to need help? Almost every doctor I have ever met believes in giving back to community. It’s one reason they went to medical school in the first place. That’s why so many volunteer at community clinics and offer free and reduced-price care in their practices to uninsured patients with a genuine need.

    But the regular primary-care system essentially requires doctors to provide their services at below-market prices to all comers, notwithstanding any patient’s ability to pay. That’s not fair. If we agree as a society that “basic quality primary care should be afforded to every American,” then great. I’m with you. But that’s a societal objective, and, by God, SOCIETY should underwrite it collectively, not demand that doctors alone do so.

  2. Bob, I certainly agree that primary-care physicians should be paid their fair market value. What I am not convinced of is that it should come at the expense of (a few) patients.

    And if we're talking $1,500 a year (which I understand is low for this fee), that's on top of what someone pays for health insurance. If you don't have employer-based insurance, that can cost easily $275 a month (far more of you are not a healthy 30-something). That's a lot of money. That is way beyond a night out at the bar.

    We agree the system is broken. But having some wealthier patients pay for care, while cutting out those can't afford it isn't the answer.

  3. Bob, I understand how going into concierge or cash only or fee-for-service medicine could work well for physicians, both financially and in terms of less volume and more satisfaction about the care they are able to give their patients. And that's great. I certainly want physicians to have successful practices and satisfying careers.
    BUT... Why should only patients who can afford to go to a concierge physician get good healthcare? Do people who work their whole lives in service jobs like social work, teaching our children, building our roads, etc., and still barely make ends meet in our inflated economy not deserve good healthcare? $125 a month (which seems on the low end of the concierge market) multiplied by a family of four IS cost-prohibitive for many folks. People across the country are struggling to buy groceries and pay heating bills. Plus people who go to concierge docs still have to pay for emergency health insurance and sometimes their employer-based insurance, so the costs compound.
    The majority of Americans can't afford to see a concierge physician, so what are their options? The healthcare system is broken. And concierge physicians and their patients are still paying for a broken system through their tax dollars. In my view, it would be better for society and all providers and consumers of healthcare for physicians and patients to take an active role in overhauling the broken system rather than opting out of it.

  4. All the talk in the world is cheap. We moan and complain and point fingers. As a surgeon, I love to give but I prefer to do it on my terms. What have you done today to make health care better for yourself or your neighbor?......that what I thought.

  5. How are these services perceived by the commercial cariers/payors? If the concierge members get faster and better access to the physician than their beneficiaries that do not pay the extra "premium" to the doctor, do they feel it is a violation of the contract they have with a physician?

  6. Concierge Medicine is a smoke screen for physicians that don't want to work as hard, yet make more money. It tends to imply that they provide services that are not being provided in today's primary care practices and that is WRONG! I preach prevention in my practice all the time and spend whatever time is necessary to properly care for my patients. Lastly, we always have and always will provide after hours call coverage. It's elitist medicine, pure and simple.

  7. A hybrid product, part concierge, part traditional practice, would probably work best. It would be like a first class section of the airplane - those in first class get more, but also subsidize those in coach.
    I suspect that those who feel they can provide everything at a high quality to all of their patients don't work in a private practice.
    The reality of the true expenses and revenues, especially in high cost states, makes being the ideal primary care doctor impossible.

  8. As a manager of a small family practice group in OH, the only solution I've come up with regarding the proposed Medicare cut would be to charge our patients a $100/yr "membership" fee to help make up the loss of income. I realize this is not "true" concierge medicine but many patients are willing to pay a little extra to stay with the doc they've seen for years.

  9. I'm curious about the $100 membership fee idea.
    I may be wrong about this, but I'm pretty sure that idea is a Medicare violation. I think you CAN charge extra for genuinely extra services, but NOT simply for being a member of your regular practice. Medicare considers that double-billing -- your charging Medicare to take care of Mrs. Jones and also charging Mrs. Jones a surcharge for the same service.

    Please correct me, anyone, if I have this wrong.

  10. You cannot charge an access fee and be part of Medicare. When you are reimbursed by Medicare part of your fee is for your access. If you charge $100 for access you are double billing. We have looked into this and also had thought we could open our practice to more Medicare patients with such arrangement. Instead we will have to limit our availability to our Medicare population.

  11. People who go to medical school, want to eventually become physicians and make money (medical school bill, family obligations, housing cost, vehicles insurance, malpractice insurance, etc...). Some people feel physicians are suppose to not make money and those that "seem" to make a lot, then some want them to suffer! Quit attacking physicians and start attacking lawyers, pharmaceutical companies, financial institutes and then look yourself in the mirror and ask yourself, what you can do to better your health, so you do not need to be "constantly" under a physician's care!

  12. I really could not concientiously charge a premium for my services to my patients on top of what insurance pays. Many are already so financilly strapped these days. I am considering a type of hybrid practice. I have one nurse practitioner who has added positively to my practice in many ways. I am currently on long term disability and really want to return to work. However, I will probably not ever be able to work as before. This presents a financial dilema. I would lose money going back part time vs continueing with long term disability, so--how can I equalize this financial disparity? What I would like to do is offer concierge medicine without the premium by paradoxically hiring another nurse practioner. I would see our patients for an extended visit (charging as such) every 6 mo to fully cover all of their multiple problems with the nurse practitioners seeing the patients every 3-4 mo, covering 3 or so medical issues or the issues the patient desired, and as needed for acute visits. This would allow easy access to medical care in the practice albiet not to me every time although, I would still see the patients acutely if the problem was complicated or serious. Unfortunately, making ends meet financially in primary care medical practice today ends up forcing us to do volume work. This may be a way to alleviate some of that "volume" pressure on the physician, improving both physician and patient satisfaction. What do you think of this solution?