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Red-carpet medical care, for a fee

It's unclear whether keeping a doctor on retainer translates into better health for patients—and the concept raises thorny ethical questions

Consumer Reports magazine: February 2013

Illustration: Shaw Nielsen

One of my patients, a 75-year-old retired life-insurance salesman who spends eight months of the year in Florida, was telling me about the great medical care he gets from his primary-care physician there. Same-day appointments, no waiting in the office, 24/7 availability, even the doctor’s cell-phone number and e-mail address. In return, he ponies up a $1,500 annual retainer, which he pays out-of-pocket. He figures it’s worth it to ensure all that extra responsiveness—the same responsiveness, incidentally, that he gets from me at no extra cost during the four months that he spends in New York.

Health for wealth

My patient was referring to concierge medicine (also known as boutique medicine or retainer medicine), a concept that originated in the 1990s and now includes many of the country’s affluent areas. The idea is relatively simple. A patient pays a fee—usually $1,500 to $5,000 a year, sometimes made in installments—in exchange for the promise of immediate attention from a doctor. To meet those obligations, physicians who offer the service typically have to limit the number of patients they treat, usually to about 600 instead of the 2,500 or so in the average traditional primary-care practice.

Does the extra attention translate into better care? In a Tufts University study published in 2009, researchers found that patients in concierge practices indeed got better service, greater access to care, and faster referrals to specialists than those in conventional medical practices. But the more important question—whether such patients actually have better health outcomes—has yet to be answered, though concierge doctors claim that their patients are hospitalized less frequently than those in non-retainer practices.

Thorny ethical issues

From the start, the concierge-medicine model was criticized as elitist—and rightfully so, since only the wealthy could afford such luxury. The trend toward a medical system of haves and have-nots also raises moral, legal, and ethical questions—for example, whether it’s appropriate that a concierge doctor who treats Medicare recipients essentially gets paid twice: the premium he or she collects from the patient, plus payment from Medicare, which is funded by taxpayers.

As if to counter those charges, some practices now offer certain concierge services for a much smaller fee, sometimes as little as $50 to $200 a year. Under such systems, the number of daily office visits per internist is limited to 16, on average, instead of the usual 25, leaving time for walk-ins and e-mail responses.

Even if a smaller price tag puts concierge-style services within reach of more people, it doesn’t solve the problem of restricted access to health care for a large chunk of the country (and in fact might contribute to it). In 2014 about 14 million people will leave the ranks of the uninsured. The U.S. already faces a shortage of primary-care physicians. The influx of newly insured patients when the Patient Protection and Affordable Care Act kicks in promises to strain an already stressed system, resulting in a projected shortfall of 45,000 primary-care doctors.

Restricting medical practices to 600 patients per doctor is no answer to that problem. Indeed, if concierge medicine continues to expand, people who struggled for years without health insurance might find themselves grappling with a whole new problem: adequate insurance, but no one to accept it.

Marvin Lipman, M.D.

Chief Medical Adviser and Medical Editor
   

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