Simply put, concierge medicine is a new type of business model where instead of fee for service care paid for by insurance the patient pays a flat annual fee (usually a few thousand/yr) in return for a host of “premium” benefits like shorter wait times, much longer and more detailed face time with the physician, same day appointments, 24/7 direct access to the MD, etc. etc. etc.

There is as of yet no hard data on the growth of concierge medicine (it may be as few as only 500 physicians since 1997) other than to say that it attracts a lot of media attention where ever a new one of these practices opens. One of the biggest players in this new practice model is MDVIP out of Florida which helps manage about 100 concierge practices. MDVIP claims to have preliminary data showing better outcomes for their patients, at least as far as hospitalizations go.

Data from MDVIP show its patients’ hospital admissions are 65% lower than the national average for Medicare members and 26% lower than a top-ranked HMO’s average. The average hospital length of stay was 17% lower for commercially insured patients and 5% lower for Medicare patients. Total hospital charges, too, were reduced: 14% for commercial patients and 13% for Medicare patients. Company executives say they achieved these results despite higher severity ratings for MDVIP-admitted patients.

But obviously not every patient can afford $1,500 or more to “retain” a VIP doctor so medical ethicist have been have been grumbling about the possibility of a “two-tiered” system where those who can will be able to pay for a higher level of better medical care. However, the ethicists are in a no win situation here.

When more data comes out on concierge medicine there will be two general possible conclusions. If there is little or no proof that concierge medicine makes a difference in major medical end points (mortality, morbidity, life span, hospitalizations, quality of life, etc.) then the ethicists can relax, lean back, and laugh at all those foolish rich suckers who are paying thousands of dollars just to have access to their doctor’s cell phone number!

But this then raises the question, what is so unethical about providing better service to the patient even if this does not lead to better medical care? It’s called capitalism. Remember that? It’s about providing better service even if the end product is the same. It’s not about getting from point A to point B but in how we do it and if someone wants to pay more to do it in more comfort and style then so be it. In our country most people fly coach, some fly 1st class, and a few fly in private jets but hordes of egalitarian fanatics do not descend from their ivory towers insisting that we all be forced to fly “cattle-car” because not everyone can afford their own LearJet!

However, what is to happen if there is data that shows significant improvements in medical end points for patients in concierge practices? Of course the ethicists will rant and rave from every possible media outlet about this unethical practice of concierge medicine! But if they do this then they paint themselves into a corner. In the face of evidence that longer and more detailed physician visits and more personalized attention improves health care they will effectively advocate directly against such better care on the grounds that not everyone can afford it!

If concierge medicine does make for better medical care then why can’t Medicare simply raise reimbursement rates for professional fees? I mean, Congress just gave the pharmaceutical companies a blank check worth hundreds of BILLIONS of dollars in the form of Medicare part D! But things don’t work like that. In a more realistic scenario, CMS and private insurance companies would try and calculate how much money they could save by increasing professional fees up to a point of diminishing returns for money spent. As usual your life would be reduced to a cost-benefit analysis. So much for personalized care.

But even without any proof that concierge medicine improves health care we have to face the fact that MDs are taking a serious look at this model not as a way to get stinking rich but as a way to improve their job satisfaction. Trust me. Seeing patients every few minutes in “meat grinder mode” is a miserable and exhausting way to practice medicine. You don’t have time to think (ironically). You don’t have time to rest. You don’t even have time to get to know your patients! Every additional complaint becomes a major crisis since you don’t have time to address everything but you can’t afford to blow off something that may come back to haunt you in the form of a lawsuit.

On those occasional slow days when I have fewer patients I can actually take the time to cover every aspect of the patient care from addressing acute problems to covering the bases of preventative care to answering every question the patient has. On these days I find myself to be much more satisfied and relaxed. But these days are few and far between and getting rarer. At this point I would love to change to a concierge medicine model and I would do it for as low as $300-500 per year.

BUT! I practice in an “underserved area” which means that there are far fewer physicians serving the local population than the national average which means that it’s an economically depressed area and most of the patients have Medicare and Medicaid which means that doctors practice elsewhere where there is more private insurance coverage which means that there is no way in hell that any significant number of my patients are going to be willing to fork over a few hundred no matter how much they love me (many complain about not being able to afford $20 copays).

What DB didn’t (yet) delve into is what I see as a coming crisis in health care should this trend continue. But don’t get me wrong! The crisis will stem from worsening insurance reimbursements combined with worsening working conditions and increasing paperwork demands. Greater numbers of physicians leaving traditional insurance for retainer arrangements will be a SYMPTOM of this crisis and not the cause. Already in California where managed care and HMOs reign, physician incomes have shrank over the last 10 years (name another industry where incomes have decreased during the longest peacetime economic expansion in history) and it is becoming more and more difficult just to get an appointment.

As physicians switch to retainer systems, those that remain in the insurance system will be hit with increasing numbers of patients and a dangerous downward spiral will start. A serious rift in the quality of health care between the few who can afford a retainer system and the rest of the insured population will develop (by “quality” of health care I mean patient satisfaction with prompt attention by and easy access to their retained physician. As of yet, there are no studies that show that this type of concierge medicine is any better than the traditional shorter office visits but it very well may be). It probably won’t be until mass dissatisfaction with the current system hits the middle class that attention will start to be paid. The insured patient population will begin to realize the difference in care that their insurance affords them compared to the privileged few who can afford to retain a physician. Initially the physicians themselves will be blamed for being greedy and self serving. Then it will be realized that managed care and insurances drove the system to where it is. If you live in a country where a lawyer gets paid hundreds of dollars an hour to sue McDonalds because their idiot client poured hot coffee into her groin but doctors get paid $39 for a 20 min office visit then you will eventually get into a situation where you get what you paid for.