A SMALL but growing number of American physicians are abandoning traditional insurance-based practice to offer VIP treatment, including more time with patients, in return for upfront fees. In one common setup, often called concierge or retainer-based medicine, a primary care doctor charges an annual fee ranging from $1 000 to $20 000 just to get in the door. When doctors shift to this model they can cull their patient loads, selecting only those who can foot the bill. The services they provide often include a deluxe annual physical, 24-hour direct cell phone access to a doctor and escorts on visits to specialists. Some doctors still accept insurance and Medicare and bill normally for routine care. Others opt out of that system in order to charge what the market will bear. Some healthcare experts view this as an ominous trend that could exacerbate socio-economic disparity in the healthcare system in light of a looming doctor shortage. They say this development could be especially troublesome once the new healthcare law adds millions of Americans to the health insurance rolls and sends them looking for doctors. The healthcare legislation recently signed by President Barack Obama is aimed at lowering costs and adding insurance coverage for more than 30 million people starting in 2014, including 16 million new Medicaid and Children's Health Insurance Programme members. But it does not account for the projected shortfall of 35 000 to 44 000 new primary care doctors, nurse practitioners and physician assistants that are choosing alternate disciplines because of increasing workloads, low reimbursements, a paperwork burden and a huge gap in pay compared with medical specialists. A 2009 survey of general practitioners by the American Academy of Family Physicians showed that 42 percent were not accepting new Medicaid patients. Sixty-five million Americans are already living in areas the government has deemed short of primary care practitioners. Concierge-style medicine is one way that overloaded doctors have chosen to respond. The American Academy of Private Physicians, the trade group representing the concierge care movement, says more than 1 000 doctors have gone this route. By another measure, 1.2 percent of respondents to AAFP's survey say they practice concierge, boutique or retainer medicine. While fee-for-service or "private" doctors have long existed, primary care doctors began converting to the concierge model about 15 years ago. Companies came along to help doctors set up these practices and handle the administration. The largest, MDVIP, has more than 380 doctors. The American Medical Association says there is nothing inherently wrong with concierge-type of arrangements. However, its ethics manual cautions that they "not be promoted as a promise for more or better diagnostic and therapeutic services." That puts concierge doctors, particularly those who offer traditional service as well, in the awkward position of trying to promise patients that they are getting something for the extra money while telling the rest they are not giving up any medical services. Groups that support concierge physicians say the cost - about $4 per day in most cases - is not prohibitive, and that it comes down to a question of choice in the marketplace.
Adam Graham-Silverman: Kaiser Health News, 20 May 2010
