CONCIERGE MEDICINE

Concierge practice has yet to arrive in Alaska. This is primarily due to the “isolation” of our State from the “events” in the lower 48.  Today I am going to discuss a little bit about the growing practice of "concierge" or "boutique" medicine patients are encountering in the Lower 48.  What is concierge medicine?   Basically, in concierge medicine, patients pay an additional fee (usually $1500-$2000 a year), and in return they receive better access and service. It is a promise that if they join the plan, the doctor will answer their phone calls 24-7 and concierge patients have more time available when they come in for an office visit, and they do not have to go through a tedious process to gain access to the appropriate specialists in a timely fashion. In other words, patients are going to get “more” of the doctor for the extra fee paid once a year.

What is fueling this shift towards this practice, particularly in primary care?

Simple, it is the red tape, hassles, bureaucracy, micromanagement, and too much overhead cost that primary care providers are facing in the current healthcare environment combined with inequality in the reimbursement formula that favors procedures over cognitive services. There is just not enough time to see patients, and people feel as though they are on an assembly line. It's understandable that the idea of having patients pay more as a way of getting out of a broken system might come to the fore. A lot of people are doing this. There are probably 6000 primary care physicians alone who have shifted over to a concierge practice. To be honest, concierge medicine for the superrich has always been around. The person who has an addiction who goes off to the Betty Ford Clinic and the executive who takes a jet for an executive physical at the Mayo Clinic or the Virginia Mason Clinic:  These are versions of concierge or boutique medical practice. Now it's expanding into the middle class because of our broken health system.

What is the downside, and what are the ethical worries about this growing type of practice?

First, there aren't enough primary care providers around to begin with. We all know that we have too many specialists, not enough generalists, and not enough primary care providers in the United States. If you take a significant number of them out of the pool available to every patient and make them available only to people who can pay additional fees, it results in a bigger workload for the rest of the providers who are doing primary care. No matter how you look at it, if you allow providers to buy out, you are going to leave other patients with lower-quality care, and you are going to burden the remaining primary care practitioners (who don't take the concierge route) with more work and the patients are going to end up getting lower-quality care because they might see more physician extenders, a trend that is rampant in Anchorage with “Primary Care Clinics” and “Senior Medicare Clinics” mushrooming all over the city. 

There are certainly some great physician extenders who can play a role in team work -- but patients don't understand that they may be seeing someone with a lot less training and may be paying the same money or fees for someone with less qualification.  Current trend in Anchorage is appalling as large group of sub-specialty physicians choose to use mid-level practitioners as their first contact with referred patients.  My patients are not happy as they wasted time seeing a mid-level when I referred them to a sub-specialist as the diagnostic and treatment plan required a higher level of training and expertise. How can we justify wasting valuable health care dollars on sub-standard sub-specialty consultation rendered by a mid-level who has less training and experience than a referring Primary Care Doctor?

At the end of the day, we have a justice issue. Concierge practice is a business solution to what is essentially a broken system. We must find different ways of solving the problems with healthcare, other than having people pay a fee to escape the broken system.

Concierge medicine is fundamentally unjust, however until the wide discrepancy in the primary care reimbursement formula is fixed we will see more and more PCP’s migrating to the “Concierge Practice” to keep their doors open. The result is what we have just started seeing: medical clinics run by nurse practitioners and physician assistants. We have to come up with a better answer. It will probably be something along the lines of payment reform for Primary Care Cognitive services that our AMA and other Medical Societies (primarily representing increasing numbers of sub-specialists) choose not to discuss.  Concierge medicine is more a symptom of a broken system than it is a solution.

Harbir Makin, MD

Internal Medicine, Anchorage Alaska