EDITOR'S PAGE
Concierge Medicine: For Better or for Worse?
Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology*
* Address correspondence to: Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 400, San Diego, California 92122 (Email: ademaria{at}acc.org).
Over the past several months I have encountered a number of papers in the lay press on so-called concierge medicine. Sometimes referred to as retainer or "highly attentive" medicine, concierge medicine offers patients access to a physician who has limited the size of his/her practice in exchange for an annual fee. Practices are nearly all primary care, range in size from 50 families to 600 patients, and cost from $1,500 to $20,000 per year. Benefits include same-day or next-day appointments which are not hurried due to time pressures, house calls, 24-hour-a-day access to cell phone numbers, detailed annual wellness evaluations, and sometimes exquisitely appointed offices and facilities. Although currently amounting to less than 300 practices, concierge medicine has generated considerable controversy with questions directed toward the resource allocations, finances, and ethics of such practices.
One of the major issues raised by concierge medicine involves access to medical care for those who do not participate in such programs. Obviously, concierge physicians displace patients to other providers by limiting the size of their practice. In the process, the problems of excessive demand that the retainer practices seek to eliminate are amplified for those patients and physicians who do not participate. Of course, this problem would be exaggerated if those patients in concierge practices were generally healthier and required less intensive care than those cared for in other settings. The financial implications of such a disparity are also apparent. Finally, the allocation of manpower and resources inherent in retainer medicine must be viewed in the larger context of the approximately 45 million Americans without health care insurance. Far from helping resolve this dilemma, concierge medicine will only serve to compound the problem.
Concierge medicine offers a number of advantages for enrollees. Physicians spend more time with fewer patients in a more relaxed and comfortable environment, and can know the patients more personally and in greater detail. For patients, access to their physician at any time and (often) any place is an obvious benefit. However, retainer care does not provide the same rapid access to specialists, although concierge physicians indicate that they can facilitate such arrangements. In addition, the restricted practices of concierge medicine may expose those physicians to a lesser spectrum of disorders and limit their expertise. Those delivering retainer care counter that they have more time for educational activities. All agree that the service is an expense for patients and financially advantageous to providers.
There is general agreement that concierge medicine provides more convenient health care with more amenities. At the heart of the controversy is whether it provides higher-quality care. Certainly, the opportunity and funding for preventive medicine activities would appear to be greater in retainer medicine. Advocates would argue that the greater time available for evaluations in a less stressed environment enables more accurate diagnosis and more effective therapy. They relate anecdotes of missed diagnoses and treatments resulting in adverse events by physicians working in a setting where patients must be seen in visits of about 10 minutes. Nevertheless, no evidence exists to document a higher quality of care with concierge medicine, and as discussed previously, it is possible that the experience of those physicians might be curtailed. Thus, the quality of concierge medicine relative to standard practice remains unresolved.
In my opinion, the issue of quality of care relative to standard practice is the most critical aspect of concierge medicine. I believe that most physicians and patients would accept the fact that "VIP" medical care with superior amenities and convenience could be purchased by those with sufficient wealth. However, I believe that most Americans would object to the proposition that the quality of health care depends on the amount of money an individual can spend for it. We have come to regard good health as a right rather than a privilege. The thought that an individual might experience more or less morbidity or mortality based on how much money they could devote to medical care would be difficult to accept. Therefore, the ability of concierge care to exist and grow in our system would require that the quality of care provided by such programs be available to every member of society.
It occurs to me that an interesting sidebar to this issue of equal access to care relates to our situation as physicians. I believe that most physicians already have access to concierge medicine for themselves and their families. Our colleagues usually see us promptly when we are ill, and often at convenient locations. Our evaluations are typically allotted a generous amount of time, and laboratory tests are customarily fast tracked. Thus, as physicians we view concierge care with some subjectivity, since we have a level of highly attentive care not available to most patients, and likely will continue to have this regardless of the future of concierge medicine.
To me, the most instructive aspect of concierge medicine is not its attributes, but rather its implications about what is lacking in standard medicine. Clearly, we all seek convenience and a comfortable environment for every service, from hair cuts to legal counsel. Given the stress imposed by an existing or suspected illness, these amenities are probably even more desirable for medical care. Regardless of the service, however, of overriding importance is the sense that the provider is able to focus all of their attention for whatever time is necessary to deliver the best result possible. The desire for this attribute is amplified markedly for health care. I believe that concierge medicine is evidence that patients feel that standard practice often lacks convenience, and often is rushed and delivered by physicians whose attention is being drawn in multiple directions. Such dissatisfaction was responsible for modulating the growth of managed care. Although physicians cautioned loudly of the limitations often present in managed care, it was the dissatisfaction of patients with the system that ultimately brought about change. I see similarities in the growth of concierge medicine. Those patients unhappy with managed care and with sufficient financial resources opt for other health care systems, whereas those not content with standard medicine and of adequate wealth enroll in retainer practices. The major message of concierge medicine, to me, is the importance of providing care that is timely and, of greatest significance, delivered by an unhurried physician whose total attention is focused on the patient.
The initiation of concierge medicine programs has created a fair bit of controversy. Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality. The analogy that comes the closest is airline travel. Passengers in both first class and coach arrive at their destination at the same time, but first class conveys more amenities. However, it would be unacceptable if there were different gradations of health care quality, or if providing concierge service to some compromised the ability to provide adequate care for others. The take-home message should be the importance of providing timely, convenient, and personal care. Rather than taking advantage of the fact that obtaining health care is not optional to ignore patient conveniences, we should provide the kind of service which we usually receive ourselves. When the level of standard medical care is acceptably timely and personal, the attraction for concierge medicine will disappear for all but a few of the most wealthy.
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