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About Concierge Or “Boutique” Medicine

A recent piece in The New York Times wondered if the few patients who can afford to pay for additional attention and access to their primary care doctors in a concierge medicine or boutique medicine practice might be ethical since the extra dollars are used to support the traditional primary care practice that the vast majority of patients currently receive. 

Questions you might ask are:

– What is a concierge medicine or boutique medicine practice?
– Is it worth the money?
– Is the care better quality?
– Is it possible to get similar access and care by doctors not in a concierge or boutique medicine practice?

When you think of a concierge, you think about a fancy hotel staff person who answers questions and speaks various languages, books reservations to restaurants, events, and tours (even sold-out attractions) — right? The hotel concierge is your insider, someone who possesses intimate knowledge of the city and recommends must-see sites like a true local. You are personally cared for and pampered. Imagine, then, your physician providing the same attentive service.

Indeed, a small and growing number of physicians are offering this concierge care, also known as boutique or retainer medicine. Physicians provide services typically not covered by their traditional health insurance, like annual comprehensive physicals and direct access to their doctors 24 hours a day via home phones, cellphones, and pagers. Other benefits include same day appointments with longer physician face time, little to no waiting time in the lobby, and a focus on preventive care. In some practices, the physician will even accompany a patient to specialty doctor appointments and perform house calls. Sound pretty nice? But beware: this kind of service comes at a price. Patients in boutique or concierge care pay a retainer ranging anywhere from a few hundred to a few thousand dollars per year.

The concept of boutique care may have started in 1996, when the Seattle Supersonics former team physician wanted to make available to the general public the same level of medical care and attention provided to professional athletes. MD2, the company he founded, provided a spa-like experience to a select few patients who could afford the $10,000 to $20,000 annual retainer fee (in addition to insurance premiums and costs).

Many physicians are attracted to this new physician-patient relationship as they become more disenchanted with large patient panel sizes, lower reimbursement rates, shorter office visits, increasing overhead, malpractice costs, and paperwork. They want to slow down and spend more time with patients, which is difficult in the current climate of falling insurance reimbursement.

In the July 2002 issue of the Journal of Family Practice, one study noted that 27 percent of physicians anticipated a moderate to definite likelihood of leaving their practices within two years. Leland Kaiser, Ph.D., a healthcare futurist, also notes that lack of physician accessibility and availability is also causing consumer discontent and is a driving force toward concierge medicine.

The high retainer fees these physicians charge frees them financially from health insurance contracts and allow them to care for a much smaller patient panel (typically a third or less than an average physician’s panel of two to three thousand patients). Perhaps not surprisingly, these practices attract patients who are upper middle class, middle-aged entrepreneurs, and wealthy seniors.

Supporters of concierge care claim it’s a lot like private school education. Parents who wish to supplement their children’s education can send them to private school, paying extra for a potentially more personalized education that offers more choices (at a cost). “Like education, luxury primary care is simply a response to a market need [that] serves the interests of both the consumers (patients) and suppliers (physicians).” As long as there are people willing to pay extra for additional personalized care, the more likely the boutique medicine trend will continue.

Understandably, not everyone is happy about this new trend. While the American Medical Association (AMA) has not found concierge practices to be inconsistent with the goal of healthcare delivery, it bears repeating that a physician’s duty is first and foremost to his patients. So, as in the case with physicians who retire or leave a practice, doctors planning on changing to or adopting a new concierge practice need to help their former patients transition to other healthcare providers. If no other physicians in the community are able to care for these patients, the AMA notes that the original physician may be ethically obligated to
continue care.

State and federal healthcare agencies, as well as insurance companies, are watching the new developments carefully to ensure that physicians practicing boutique medicine do not require retainers to provide services already covered by a patient’s health insurance. In July 2003, the government took action and fined a physician over $50,000 after he charged his patients $600 for services partially covered by Medicare.  In 2004, the Health and Human Services Federal Agency reiterated the long-standing policy that physicians are not allowed to charge Medicare patients additional fees for services already covered in the Medicare program. The private health plan Harvard Pilgrim Health Care refused to allow three concierge physicians into its network because it expected that doctors who participated in the network should provide 24-hour access and same-day appointments when appropriate and not charge extra for those services. Many concierge physicians opt to drop all health insurance participation to avoid running afoul of regulators and insurers.

Although concierge patients may feel they are receiving higher quality health care because they have more physician time and attention, there is no scientific evidence at this time to support that assumption.

On the contrary, it is possible that as the doctor spends more time caring for fewer patients, his clinical skills may worsen because of decreased volume and exposure to different patients. If your physician starts to practice concierge medicine, understand that any future contact with your physician may require payment or a
retainer prior to you receiving any additional care or service not covered by insurance. Since most concierge physicians are no longer paid by insurance companies, this cost comes directly to you. And if you choose not to continue care, it is your physician’s responsibility to help you find another doctor.

Should you take part in a concierge practice? It depends. If you can afford it and you enjoy the personal attention and pampering, concierge medical care might be right for you. Your physician is on a retainer and essentially is on your payroll as a paid consultant. Direct access to your doctor, long comprehensive office visits, and same-day appointments can’t be beat.

Or can it? With a bit more time and energy, you can get similar care for less money. Instead of an hour-long consultation with a concierge doctor, you could get the same amount of face time with your regular doctor over a period of three to four separate office visits. The latter would certainly be more inconvenient, however.  The bottom line is that only you can determine how much the extra convenience of concierge care is worth. The lowest retainer for concierge care runs about $600 per person per year. If your current office co-pay costs $20 to $30 per visit, you could see your regular doctor twenty to thirty times for the same amount of money. Also be aware that more and more physicians are working on open-access scheduling. This system focuses on providing patients with same-day appointments, which has improved satisfaction among patients and physicians.  With more physicians adopting this mindset, the same-day access benefit touted by concierge medicine may be less of a deciding factor.

Will concierge medicine be successful? Time will tell.

As much as I understand the attraction to many primary care doctors as well as medical students, I am quite pleased with my own practice and have no intention of joining a concierge boutique either as a doctor or as a patient.  Despite the benefit provided by concierge patients at the Tufts Medical Center to assist other patients, ultimately its existence simply widens the gap between the haves and the have-nots. Whether the have-nots can continue to receive benefits from the philanthropy and willingness of others to pay even more above their health insurance premiums will depend on if healthcare continues to be increasingly unaffordable. Unless the healthcare costs change, no one will be able to afford anything let alone concierge medicine.

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

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