The greatest deception of concierge medicine is the pretense of being patient-centric.  The problem is they are patient-centric for less than 25% of their patients, which is only for the patients left after they impose a tax on being a part of the concierge practice and after abandoning patients unable or unwilling to pay the tax,  many of whom they have cared-for for years. 

Remember our contrasting of concierge medicine and medical home in last week’s article.  That contrast indicates why NCQA, AAAHC, URAC and the Joint commission should not allow concierge practices to apply for PC-MH recognition or certification.  If these organizations allow concierge practices to receive approval as medical homes, they will have abandoned any moral imperative they have as accrediting bodies.  There is nothing in the mission of medical home, in the Triple Aim, or in ACOs which allows for the exclusion of people who cannot afford a financial premium upon their care.  Furthermore there is nothing in the medical home design for the exclusion of those who have complex, chronic health conditions but who cannot afford to pay a franchise fee for the mdVIP program.  In addition if the Agency for Healthcare Quality and Research tacitly embraces concierge medicine, as they currently do by listing one of the concierge-practice articles as “an article of interest,” they will do a disservice to the advancement of quality medicine.

Apparently, mdVIP and other concierge practices created the International Journal of Person Centered Medicine to promote concierge medicine.  Of this journal, the inaugural editor says:

““Person-centered Medicine is dedicated to the promotion of health as a state of physical, mental, social and spiritual well-being as well as to the reduction of disease. It is founded on the articulation of science and humanism to enhance personalized understanding of illness and positive health, clinical communication, and respect for the dignity and responsibility of every person, at individual and community levels.  The Journal Editorial Board is drawn from all major medical specialties and health disciplines and is constituted by the world’s most distinguished thinkers in the field. “

Regional Editors are being appointed for North America, Latin America, Europe, Africa, Asia, and Oceania. Professor Andrew Miles said: ‘The Int J Pers Cent Med, creating as it does an international forum for the exchange of ideas and the promotion of scholarly debate, is an extremely important contribution to the advancement and operationalisation of humanistic medicine in our times.  I am honored to be invited to be the inaugural Editor-in-Chief at this exciting time of paradigmatic change within medicine.  I recommend the journal as essential reading for all clinicians and trainees and to all those academic disciplines with an interest in or responsibility for the promotion of person and people-centered medicine’”

How “humanistic” is a program which increases the convenience of access to care but only for the well-to-do and those who can pay a premium for that access?  There is no problem with healthcare providers making a profit in the practice of medicine.  Nevertheless, the design of practice should be principally for the benefit of patients.  The design of practice should be for the benefit of all patents and not just those able to pay an annual fee.  “Humanistic” medicine would be characterized by the decreasing of the cost of access to care rather than the increasing of that cost.

The methodology of articles published by the Int Journal of Person Centered Medicine, violates fundamental principles of science.  The concierge journal contrasts outcomes in practices which randomly accept all patients and with panels of patients pre-selected panels of patients based on financial considerations.  Under the guise of science, mdVIP pretends that the increase in the percentages of performance of preventive services, due to eliminating thousands of patients from their patient pool, represents an improved method of care.  This is a flagrant, quasi-scientific fraud.  It implies that a non-randomized, small group of patients, selected for pecuniary reasons by a group of physicians apparently intent on decreasing their responsibilities and increasing their income, is a valid sample for scientific study, contrasted against a randomly selected larger population of patients. 

After violating sound scientific principles, concierge medicine then boasts that its excellent numbers for preventive care in a fraction of their former patient population is evidence of the superiority of the concierge model.  If SETMA selected 500 patients for study based on their ability to pay for their care and excluded from consideration the other tens of thousands of patients we care for, everyone would cry foul; why would this same principle not also apply to mdVIP.

SETMA’s data is based on all patients no matter whether they are insured or not, well educated or not, have adequate resources for their healthcare or not.  When SETMA decided to become a Patient-Centered Medical Home in 2009, we did not exclude our sick patients. We did not exclude our patients who had inadequate money.  We included everyone and determined to improve the health of all of our patients. 

Rather than charge patients a premium to be a part of SETMA and to dismiss from the practice those who could not afford that premium, the partners of SETMA established The SETMA Foundation.  Annually, SETMA partners give $500,000 of their money to the Foundation.  That money cannot profit SETMA but is used to pay for the care of our patients who cannot afford their care.  We pay for our patients’ medications, transportation, surgeries, co-pays for surgery, dental care, etc, as well as treat them at  no charge at SETMA. 

The following is a link to a description of  SETMA's Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change.   As an anecdotal rejection of the claims of concierge medicine and of mdVIP, on April 23, 2013, SETMA received a plaque which  read:  “Texas Physician Practice Award presented to Southeast Texas Medical Associates, LLP for Providing Exceptional Preventive Health Care Services using Health Information Technology.”  This was awarded by The Texas Physician Practice Quality Improvement Award Committee, which is made up of the TMF Health Quality Institute (Texas’ CMS Quality Improvement Organization), the Texas Medical Association and the Texas Osteopathic Medical Association. 

Because our Nurse Practitioners are also included in the award, SETMA has recommended expanding the sponsoring organizations to include the Texas Nurses Association.  The Committee commented further, ‘Congratulations on this significant accomplishment, which illustrates your commitment to delivering quality care to all patients.  (emphasis added)  Your award demonstrates that SETMA has an exceptional team.”  Quality care to all patients  is one of the major goals of healthcare reform and one of the foundational principles of medical home.  This award is also an affirmation of SETMA’s decision in the year 2000 to begin tracking quality metrics performance and our 2009 decision to begin public reporting of performance by provider name.  The results are now posted on SETMA’s website www.jameslhollymd.com under Pubic Reporting for 2009-2013.”

Concierge articles note the following conclusion, “€¦the results from this retrospective chart review support our belief that the MDVIP primary care model providess (sic) more of the recommended preventive care services when compared to national health plans and delivers possibly better clinical outcomes.  Further research is necessary to demonstrate that this personalized, preventive care model and increased physician contact time results in better health outcomes and ultimately lower healthcare costs.”   The only thing the mdVIP journal’s data proves is that it is possible to select a subset of your patients for evaluation and prove that that subset has better preventive care than the whole. 

It is SETMA’s hope that concierge medicine will be recognized for what it is, an aberration and that it will be rejected by academia, by quality standards organizations, by NCQA, AAAHC, URAC and Joint Commission and by mainstream medicine.  Do physicians have the right to adopt a concierge model of practice legally?  Yes, they do.  But, morally concierge medicine and mdVIP are highly questionable as a professional model of care which fulfills our responsibility to our communities and to our patients.