How much would you pay to see your doctor?

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.

References

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

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13 Comments

  1. Yagotta B. Kidding

     /  May 1, 2011

    Tough call.

    Most of us don’t remember the early days of HMOs, but back then at least some of them were genuinely focused on improving patient care by moving medical resources from treatment to prevention. My then-girlfriend went to work for Arizona Health Plan (later acquired by Cigna) and I got to know some of the founding doctors — they were quite serious about making primary care more readily accessible so that people wouldn’t let problems progress before intervening.

    I suspect that there are quite a few dissertations somewhere on how that turned into what we have today.

    As far as concierge medicine is concerned, I suspect that we’re more likely to see a proliferation of NP- or PA-based clinics with this model taking more of the first-line contact role. A couple of years ago $EMPLOYER opened contract NP clinics in our plants with zero copay, same-day visit walking distance from our desks. IMHO great for things like routine blood draws and screening; the coworkers love the convenience and the management tells us that they save bucketfulls on lost time.

    Since I’m on pretty good terms with my PCP, I asked him how that worked for his business. He’s cautiously positive, in that with the in-plant clinics there’s still good continuity of care and he’s still in the loop; much of what I see the NP for isn’t stuff people would be likely to bring to him anyway. Then again, he doubles as an anaesthesiologist (long story) so he tends to see things differently anyway.

  2. AndrewD

     /  May 1, 2011

    When consulting my primary care Doctor, there should be no charge, all costs should be met from general taxation.
    (I am, however, a British Citizen in the UK)

  3. Have friends that work at places where they have NP’s staffed clinics on site. They love it for when the have a cold or need a flu shot, but they still regularly see a PCP for physicals and major issues. But if you have sinus infection and just need some antibiotics, its nice not to have to leave work provided you can get an appointment.

    But then again, this model only really works for big employers.

    • D. C. Sessions

       /  May 1, 2011

      But then again, this model only really works for big employers.

      That’s currently the model, but it could very easily be extended to (for instance) large office buildings where the landlord adds value for the tenants by partly subsidizing an on-site clinic which the tenants can contract with for their employees.

      • We are sort of getting to that in the burbs. My parents have a PCP office at the front of their mega-subdivision and homey will even come out and do a house call if you live in the neighborhood. But there is no club-based model yet for them.

  4. To me, insurance is something that helps you out in the event of an accident. That’s not a good way to look at healthcare. There’s just a fundamental cultural problem in the US; I feel like healthcare is seen as something that you hope you won’t need, not something you inevitably will need.

    • Natalie Sera

       /  May 3, 2011

      I think you have the right idea, and that’s exactly why all those countries who have lower costs and better care have single-payer systems. Health care should be just like police protection, fire fighting and education — everyone pays in, and everyone can draw out in case of need. No employment or wealth-based discrimination.

  5. BB

     /  May 2, 2011

    Dh and my internist wanted to go this route a few years back. We sent him a letter saying we’d fine a new internist rather go the concierge route. It just felt wrong to us to have to pay more to see him for an emerging problem. He dropped it, and added more office hours instead.

  6. I would pay more for just for email contact information.

    I don’t abuse my pediatrician’s inbox, but the few times I have contacted her via email have been very helpful in determining whether or not a child needs to be seen. It also helps with sharing information and coordinating care among providers. When we have gone to specialists, she sends me quick updates to make sure I understood and am in the loop. I pay for this extra service in homemade cookies….

    • Genomic Repairman

       /  May 2, 2011

      I’ve heard of docs that have some IM office hours to consult with patients.

    • BB

       /  May 3, 2011

      When my kiddies were little, their pediatrician took phone calls from 8:30 to 9 Mon – Fri (before office hours) for questions ranging from why doesn’t new baby eat to should I bring my kidlet in for eval. That was a great service.

  7. Jim

     /  May 3, 2011

    There’s a definite disconnect. What we should be looking for is how to provide universal healthcare. What we’re getting instead is universal health insurance, which just isn’t going to work.

  8. 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.

    Well, duh. The insurance companies are designing these little experiments, so of course they take care of themselves and their CEOs first (you never hear of, say, a claims examiner making extra coin off these things).

    I don’t know what it will take for Americans to realize how badly off we are in the current business* model and actually do something about it without fear of turning into Lenin and Marx.

    (*”Business” being a key term; I don’t like my health to be tied to someone’s profits because it generally means they don’t want me to have care which negatively affects my health.)

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