Although there is no arguing that the Affordable Care Act (ACA) has changed the healthcare landscape for Americans who previously could not afford health insurance, it has complicated the physician practice by overloading an already stressed and fragmented healthcare system.

As physicians, we often hear complaints from colleagues about the general ineffectiveness of the ACA or about specific provisions of the law that overly complicate our ability to deliver efficient and personalized healthcare. Yet, it is often forgotten that the healthcare landscape began changing several decades ago.

As reimbursements began to drop in the 1990s, primary care physicians needed to see more and more patients to maintain revenue streams. The outcome has been higher access to care at the high cost of less attentive care. Over the years, patient-physician interactions have become more rushed, limited, and in many cases, geared toward maximizing revenue rather than quality. As a result, both patient and physician satisfaction have suffered greatly. The ACA simply exacerbated the problem by increasing demand while doing little to improve physician access.

Likely recognizing these pitfalls, the majority of medical students have been selecting non-primary care specialties for their future paths. During the last decade, the number of students choosing internal medicine or family medicine has dropped by approximately 80%.1

With relatively low annual incomes in a setting of increasing educational debt, medical liability, and overhead, it is no surprise that medical students have been turning away from primary care medicine as a viable future. In the 1990s, those already in practice began offering more personalized services to their patients for an additional premium or retainer fee. These models have further evolved into what we know today as boutique or luxury medicine and concierge medicine. During the last 10 years, these models have been growing in popularity, and some have argued that they may be the salvation of the otherwise dying primary care specialty.

A typical concierge practice involves patients paying an annual retainer fee, in addition to what their insurance pays for services rendered, in exchange for 24/7 access to their physician, highly personalized attention, and more extensive preventive and wellness services.2 The fee allows physicians to improve income while limiting the size of their practice to allow for more personalized patient services.1 It is no mystery why interest in concierge practices has been growing during the past several years.

Unfortunately, concierge practice models are not ideal for physicians who are trying to establish a new practice because it can be challenging to convince patients to pay an additional annual fee.1 The model is most ideal for physicians with established relationships with patients who are willing to pay the retainer fee to maintain access to that particular physician.1 However, the concierge model offers little to new physicians who are entering private practice.

Yet the most obvious, and probably the most notorious, pitfall of the concierge practice is the fact that physicians must limit their practice to guarantee the accessibility offered by the model in exchange for the retainer. This means that patients who cannot afford to pay the retainer fee will lose access, and therefore the model is a “disruption of care” for them.1 Proponents of concierge medicine argue that grouping it along with boutique or luxury practices unfairly associates the model with the typical ethical, financial, and public health criticisms of boutique medicine that may not necessarily apply.2

In a 2017 evidence review published in Health Services Research Management, Rocco Palumbo, PhD, from the University of Salerno, Italy, argues that the concierge practice could improve access to care by “cross-subsidizing” underserved patients’ access to primary care services.2 The study he cites, however, did not have a typical concierge model. Rather, the Access Assured model used in the study referred patients, who were uninsured and unwilling to pay the monthly membership fee (which was priced according to a sliding scale fee schedule), to safety net practices.3 This was not a test of a typical concierge model but, rather, a test of a sliding scale fee schedule aimed at improving access for uninsured patients by subsidizing lower-income patients with membership payments by higher-income patients without health insurance. Patients with insurance in this pilot program are not charged a membership fee or retainer fee for continued access, and uninsured patients who paid the membership fee had to pay out of pocket for medicines, labs, and imaging tests.3 Although this pilot program improved access, it is not clear how that access improved outcomes for uninsured patients.

The other example given by Dr Palumbo is that of the Academic Retainer Practice (ARP) model at Tufts University in Boston, Massachusetts. Physicians split their time between the ARP “concierge” practice, where patients paid a retainer fee of $1800, and the general medical practice model.4 The retainer fee charged by the ARP model was used to subsidize the general medical practice model and improved access for those patients already enrolled in the practice. Again, as with all concierge models, the improved access and attention came at the cost of limiting access for other potential patients. In this example, the physician panel of patients was restricted to half the typical panel for a general practitioner in an academic medicine practice for both the ARP and general medicine sides of the practice.4

It seems that “improved access” is misconstrued in discussions about concierge medicine. On one hand, there is improved access for enrolled patients who now have access to same-day appointments, a 24/7 on-call physician, and same-day lab services. However, from a population health perspective, there is decreased access because physicians in concierge practices see fewer patients, which will worsen the predicted physician shortage if an increasing number of established physicians downsize to concierge models. That is not to argue that the concierge medicine model is bad for public health. On the contrary, it may offer improved quality of care. However, the increased demand for physicians resulting from more practices moving toward a concierge practice model will throw a wrench into an already struggling healthcare system.

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Access aside, there is also the question of whether or not concierge practice improves quality of care. Proponents argue that physicians in concierge practices have more time to spend with patients, can delve deeper into patient concerns, and can offer more extensive education.1 Although this is a sound argument, there are few data to support these claims other than a series of articles published by authors either affiliated with or who have their research funded by MDVIP, which is a commercial marketing agency for concierge physicians.5,6 The argument is not to refute their findings; however, given the potential benefit of favorable findings to MDVIP, these studies should be approached with some degree of skepticism. There ought to be more emphasis on the concern for bias in addition to other limitations, such as the small sample sizes and poor generalizability of the study population.6 Nonetheless, there may be good reasons to believe that concierge practices can offer better care based solely on the fact that patients have quicker and more thorough access and physicians tend to be less overworked and experience improved satisfaction in their practices.

From a physician point of view, there is certainly an attraction to concierge medicine. Economist Uwe Reinhardt described the concierge model as “quintessentially American” and has set aside concerns about forming a 2-tier system by arguing that we currently have a 3-tier system in which the wealthy and the poor (subsidized by Medicaid) have access to their own tier of medicine, and the middle class struggles for access to care altogether.1 Maybe the ACA offered a temporary solution to the problem of funding, but the issue of access remains untamed. There are not enough physicians to meet the increased demands imposed by the ACA, and it certainly has not offered physicians reason to stay in primary care. Concierge medicine may offer a future solution, but for now it leaves us with more questions than answers about its long-term viability and the role it may play in future healthcare delivery models.

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References

  1. Paul DP, Skiba M. Concierge medicine: a viable business model for (some) physicians of the future? Health Care Manag. 2016;35(1):3-8.
  2. Palumbo R. Keeping the candles lit: the role of concierge medicine in the future of primary care. Health Serv Manag Res. 2017;30(2):121-128.
  3. Saultz JW, Brown D, Stenberg S, et al. Access assured: a pilot program to finance primary care for uninsured patients using a monthly enrollment fee. J Am Board Fam Med. 2010;23(3):393-401.
  4. Lucier DJ, Frisch NB, Cohen BJ, Wagner M, Salem D, Fairchild DG. Academic retainer medicine: an innovative business model for sross-subsidizing primary care. Acad Med. 2010;85(6):959-964.
  5. Klemes A, Seligmann RE, Allen L, Kubica MA, Warth K, Kaminetsky B. Personalized preventive care leads to significant reductions in hospital utilization. Am J Manag Care. 2012;18(12):e453-460.
  6. Musich S, Klemes A, Kubica MA, Wang S, Hawkins K. Personalized preventive care reduces healthcare expenditures among Medicare Advantage beneficiaries. Am J Manag Care. 2014;20(8):613-620

This article originally appeared on Medical Bag