Recently, I received an e-mail from a friend. His wife’s physician is changing his practice to a plan where she would pay him $1,500 a year in addition to insurance payments. The physician will limit his practice to only 600 patients and will give her his cell phone number for instant, round-the-clock, access.  My friend’s question was, “Should she do this?”  I sent him by cell phone number and told him to send me $1,500.

I already knew the answer I would give but because my friend was the valedictorian of our high school class and one of the smartest people I know, I wanted to give him a substantive answer.  I Goggled “concierge medicine” and got an education.

MDVIP, MD2, Signature, Excel MD, PinnacleCare, ABC (Above and Beyond), Concierge Choice Physicians – are only a few of the names associated with the “concierge” movement.  My searched resulted in over 150,000 references.  One website, announcing a conference on this form of medicine, states:

“’Concierge medicine,’ now known as direct medicine, is emerging as the only solution for physicians to escape the failing health care system. Over 1,000,000 patients across the country are in a direct practice and according to the Physicians Foundation study 17,000 primary care doctors intend to transition to a direct practice in the next 5 years. Direct practice is a way to get back to practicing medicine without all of the interference of insurance companies and other third parties. Physicians simply can no longer increase volume and push patients through an assembly line to survive, and yet practice quality care, while enjoying being a physician healer.” 

This ad, like others, included motivations like “fear of the future of medicine,” “promised increase in income: “control of your future”, “escape from intrusive governmental regulation” and more.  Interestingly, the better websites promised:

• Same day appointments
• Longer appointments
• Screening care
• Preventive care
• Personalized wellness plan
• After-hours access
• Attention from your personal physicians
• The provider’s personal cell phone number

Many of these benefits sounded strangely familiar, as they are similar to some of the principles of patient-centered medical home (PC-MH), only PC-MH does not require the payment of a significant “franchise fee” to the provider. While the movement also touts the restoration of the physician/patient relationship – not unlike PC-MH – they fail to mention that some of these franchises are owned by corporations with non-physician stock holders who expect to profit from their investment.  The plans also promise that the routine care of the patient will continue to be paid by their insurance company.  This latter proposition is not certain.

CMS and Concierge Medicine

In a 2004 study mandated by the government, the General Accounting Office argued that “concierge medicine” did not limit access to care because only a few physicians (1233 at the time as opposed to tens of thousands today) were involved. The study concluded that as long as the model did not duplicate charges for services CMS paid for, there is no problem with continuing to be a CMS provider while charging a “membership fee” for a practice.  As the movement grows and as they continue to tout that if you join their “concierge practice,” you will receive preventive healthcare, which, of course, you should have been receiving already, it appears on the surface that this model is duplicating charges for services already paid for by CMS.  The GAO study notwithstanding, every physician who moves to the new form of practice, functionally removes one provider from the pool available to the general population.  And, each provider also dismisses 80+% of patients from the practice.  It will be argued here that physicians have the right to make this choice for themselves.  However, as the country grapples with healthcare access, this model should not be promoted by our finest healthcare institutions in the land. 

State Medical Societies and Concierge Medicine

The Texas Medical Board (TMB) has not taken a position on “concierge medicine” at this time but I suspect will have to as the popularity of the model grows. Proctor & Gamble’s “take over” of MDVIP is the subject of the first article on the TMB’s list of articles. It notes that P&G expects to net $300,000 a year from each of its practices participating in MDVIP.  An indirect cost of $25,000 a month cost added to the overhead of a primary care practice is not an inconsequential sum for non-medical support.  If that fee is calculated on membership and/or productivity, it may be found to violate the TMB’s requirement for physicians only to own medical practices. 

Hospital Staff Privileges and Concierge Medicine

If the “concierge” physician is going to follow his/her patients in the hospital, then he/she will have to have hospital privileges.  This means that he/she will have to “take call” for unassigned. and/or uninsured patients, who present to the emergency department for care and which require admission to the hospital.  If the physician refuses to follow the patient after discharge from the hospital, he/she will have to say to his/her colleagues, “I want you to assume my community health responsibility and follow-up this patient in your clinic, as my patients cannot be bothered with this type of patient and I will not be bothered by them either.”  If that is not a violation of the patient-care oath every physician embraces; it should be.  If being a physician is simply a way to “make a living,” and a very good one at that, “concierge medicine” which identifies the physician exclusively as an entrepreneur, is acceptable; if being a physician is a “calling,” which makes it a “profession,’ then it “concierge medicine” is not acceptable.

Ethical Issues

Whether there are ethical issues with “concierge medicine” remains to be concluded.  The answer may depend upon the community in which physicians were trained.  In Texas, where public support is the principal method of support of medical education, there is no legal but there is, in my judgment, a moral obligation for physicians to “give back” to the community that gave them the right to practice medicine.  This does not make the physician an indentured servant but it does mean the physician has a responsibility to patients other than those who can pay a franchise fee for care.

At a time when the principle issues of public discourse in healthcare delivery is access to care and the cost of care, it seems that physicians who do have a societal responsibility to their profession, should be looking for ways to effectively and excellently expand the scope of their care rather than to take the “cream of the crop” and leave 80% of their former patients to fend for themselves.  This responsibility should have physicians working to design methodologies for providing excellent care to the most vulnerable of our neighbors rather than cutting them off from care.

Entrepreneurism versus Professionalism

“Concierge medicine” may be the ultimate expression of entrepreneurism in medicine as opposed to professionalism.  In this column’s April 15th and April 22, 2010 articles, we discussed “Entrepreneurism versus Professionalism.”  Those articles can be reviewed at below under "Related Articles".  The concept of “concierge medicine” was not addressed there, but it is at the heart and soul of the issue as is clearly indicated by the interest of corporation to have a stake in this form of medicine.

Many of us who argue that basic healthcare, which includes timely access to a healthcare provider, diagnostic and preventive care, are the right of every citizen.  Professionalism in healthcare is at its best supportive of that access to care.  That care should be available regardless of the patient’s economic status, or even their insurance status. 

It is one thing for a physician not to accept responsibility for a patient’s care for a variety of reasons.  It is another for a physician to withdraw that acceptance for an economic reason.  Many of us were surprised when the Mayo Clinic in Arizona announced that all patients with Medicare insurance for whom Mayo had cared for for years would now have to find new healthcare providers.  The problem was the reimbursement rates of Medicare did not fit the Arizona May’s economic model. 

Having studied the life and history of the Mayo brothers who founded the Mayo Clinic, I wonder how they would respond to this act of raw entrepreneurism.  I wonder how they would feel about the Mayo Clinic allowing a “concierge business,” owned by Proctor & Gamble to use the Mayo name in encouraging patients to “buy into” the “concierge” model of care.  And, the website of MDVIP does not claim the right to refer patients to Mayo, but claims an “affiliation” with Mayo.

The ultimate ethical crisis for the “concierge” model of care comes after a patient is accepted into the practice and then becomes unable to pay the “franchise fee.”  Will the patient be dismissed from the practice? If so, then this is a serous ethical dilemma.  If the only bond between a patient and their physician is a franchise fee, we have really come a long and bad way, in healthcare.  If the “concierge practice” will not dismiss a patient who can no longer or who chooses to no longer pay the franchise fee, how many will be so accommodated?  Will one, five, ten, fifty, be kept on as patients or will all be immediately dismissed from the practice?

Medical Home and Concierge Medicine

There are similarities between the vocabulary of patient-centered medical home and “concierge medicine.”  But their differences overshadow the vocabulary. The following table contrasts some of those differences:

Summary

Some have justified allowing their name to be associated with “concierge medicine” because they provide educational materials to any physician.  There is nothing in this critique which argues that physicians do not have the right to do “concierge medicine.”  The argument is whether they ought to do so, or not.  Similarly, there is nothing to prevent a prestigious organization from providing educational materials to a “concierge medicine” company. However, that does not require an organization to allow their name being used to endorse the concept of “concierge medicine.”  And, however it may be explained by the nationally-known organizations, “concierge medicine” claims that they are “affiliated” with these organizations. 

The Centers for Medicare and Medicaid (CMS) goes to great lengths to make certain that those who care for their beneficiaries are providing them quality care.  That effort will expand.  The “concierge medicine” movement exists because of the movement’s rejection of “government control,” “government intrusion” and their assessment of the “impending collapse” of healthcare in the United States.  Yet, they still rely upon public support of their practices by making sure their patients are insured often by Medicare but apparently never by Medicaid.  And, if their patients need attention at one of their prestigious affiliates, they are clear that the patent is responsible for all costs including travel and lodging to visit one of their affiliates.  However, the “concierge practice” will make a phone call or two for the patient.