We pay far too much for health care in this country, spending ridiculous amounts and getting outcomes no better than countries that spend a fraction of what we do. But most efforts at reforming the system have been aimed not toward better, more cost-effective care.
The last twenty years have seen all sorts of experiments arise in how to fund health care in the US. One thing many of these models—such as HMOs—have in common is being loathed by patients and doctors alike. It seems as if each new incarnation of private health insurance is designed solely to maximize insurance company profits rather than to deliver safe, timely, evidence-based care for which doctors are fairly compensated.
One of the experiments of the last ten years is so-called “boutique” or “concierge” medicine. In this model, patients pay their doctor a retainer and in return, the doctor takes on fewer patients and uses the reduced patient load to make herself more available to her patients. In addition to collecting the retainer, the doctor can still charge for individual visits and she or the patient can send the bill on to the insurance company.
Something about this model has always rubbed me wrong, but in truth, there appear to be few ethical problems with this model, at least in theory. However, the model requires a pool of patients willing to put out a retainer for their care. Is the care actually any better? To my knowledge, this hasn’t been well-studied, but I would make an educated guess that patients are in general more satisfied, but that there is no reason to expect better medical outcomes. My diabetic patient with proteinuria should be on an ACE inhibitor whether or not I see five patients a day or twenty.
It certainly can work out well for the physician. It is much more satisfying to care for a fewer number of patients and to make money from the choice (e.g. 250 patients paying a $1500 retainer each, plus insurance reimbursement). But in the present economy, it can be difficult to recruit enough patients willing to shell out the bucks for this sort of care. Some doctors have prosed a hybrid model, in which some patients are part of the concierge patients, others standard fee-for-service or HMO patients.
This model seems fraught with ethical dangers. To have a practice where patients are inherently unequal, where a few bucks insures better treatment for some will inevitably lead to poorer care for both groups. Concierge patients may not have the access they expect (although presumably this is set out in some sort of contract), and more important “regular” patients may end up at the bottom of the to do list, having less access to their doctor, less of their time.
In a free market, a patient unsatisfied with this arrangement can walk away. But in reality, it is not always easy to find a primary care physician, and insurance and geography may place significant restraints on choice.
Given the failing model we currently have, where primary care doctors are reimbursed poorly and are forced to see increasing volumes, hybrid practices and other questionable models will keep popping up, and our already inequitable health care system will continue to divide us into haves and have-nots, with both groups encountering sub-standard outcomes and excessive costs.
Lucier, D., Frisch, N., Cohen, B., Wagner, M., Salem, D., & Fairchild, D. (2010). Academic Retainer Medicine: An Innovative Business Model for Cross-Subsidizing Primary Care Academic Medicine, 85 (6), 959-964 DOI: 10.1097/ACM.0b013e3181dbe19e
Alexander GC, Kurlander J, & Wynia MK (2005). Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics. Journal of general internal medicine, 20 (12), 1079-83 PMID: 16423094