Imagine a practice in which you can name all of your patients off the top of your head and are as familiar with their medical histories as you are, say, with your close friends’ or relatives’—all while receiving the same income as you would in a busy full-time practice.  For some physicians, this situation has become a reality through the practice of concierge medicine. 

Facing tightening budget constraints, a small but growing number of primary care physicians across the United States are turning to a non-traditional business strategy by which a smaller number of patients are served but at a much greater rate of return.  Operating under a variety of names, from “concierge medicine” or “boutique practice” to “direct medicine” or “retainer practice,” the framework charges patients a substantial fee − anywhere from a few hundred dollars a month to $15,000 or $20,000 annually for an entire family − in exchange for a more personal patient-physician relationship and a more focused level of care.  These high fees in return allow practices to drastically reduce patient enrollment numbers while providing a superior level of care, according to adherents of concierge medicine. 

With ethical and practical concerns from a host of observers, concierge practices are far from revolutionizing primary care medicine, though the trend towards more intimate medicine is gaining mainstream popularity.

The origins of concierge medicine

Concierge medicine dates back to 1996 when a former NBA physician directed his frustration at the overwhelming number of patients his practice required him to see each day towards establishing a new system for primary care.  Dr. Howard Maron appreciated the high level of care he had once been able to provide to Seattle Supersonics basketball players and teamed up with his current partner, Dr. Scott Hall, to structure their new practice, MD2, around a more feasible schedule.  Instead of the 2,000 to 4,000 patients a typical practice would see in a year, MD2 only serves about 100 patients at a price of approximately $13,000 per individual per year.

MD2 initially began as an alternative to dealing with insurance companies, as the large fee was levied to cover all costs associated with private practice.  Other practices mimicked MD2's model, charging for extraordinary services like home visits, same- or next-day appointments, regular communication with patients on the telephone, 24-hour access to non-ER medical care, and hour-long visits with physicians.  Some practices include numerous perks as part of the overall compensation plan while others charge for individual services as they are used. 

Scope of services

Practices often offer concierge treatment in addition to care covered by standard health insurance.  Pricing varies greatly depending on the practice, and a large number of practices offer concierge-level care for as little as $1,300 on top of existing insurance costs.  The Society for Innovative Medical Practice Design (SIMPD), a group of physicians who practice concierge medicine, suggests that at $100 to $200 per month plus the cost of a high deductible health plan to cover serious emergencies, concierge medicine is actually cheaper than a traditional insurance scheme.

With its status as a relative newcomer to the health care scene, comprehensive data on concierge medicine remains largely nonexistent, and the exact number of concierge physicians varies depending on whom you ask.  In a 2004 report to Congressional Committees, the U.S. Government Accountability Office identified 152 physicians domestically practicing concierge medicine, yet MDVIP, one of the largest concierge medicine groups, has over 215 physician members, while SIMPD has over 100 members.  Edward E. Goldman, co-founder and CEO of MDVIP, estimates that there may be as many as 2,000 primary care physicians who could be characterized as concierge physicians, though this number is significantly larger than other estimations.

For patients and physicians, concierge medicine can have great benefits.  With a more personalized level of care, patients can ultimately receive better treatment.  Thanks to the increased amount of time spent with patients, physicians are able to consider all of the facts in a medical case including family history, reaction to previous treatments, and overall health and wellness.  Additionally, increased patient-physician interaction leads to a more preventative style of medicine where more diseases and conditions can be caught at the earliest stages.  Beyond care-level incentives, patients are better able to coordinate their busy schedules with doctor's visits, including same-day appointments and more regular follow-ups.  Evening home visits can be used for minor emergencies.  For physicians, the reduced patient load can allow more time to be spent on individual cases, providing a much more rewarding experience for a doctor concerned with the medical impact of their work.

Ethical considerations

Though the benefits are numerous, the cost may be prohibitive for many ordinary Americans, particularly those on Medicare and Medicaid.  This is a major cause of concern for the American Medical Association, which emphasizes that while concierge medicine is ethically sound, doctors still have an obligation to provide the same level of care to all patients regardless of their economic status.  For practices that see both Medicare patients and concierge-level patients, preferential treatment of higher-paying individuals can result in loss of a medical license.  Additionally, when practices switch over to a concierge model, their physicians are legally obligated to notify all of their patients with sufficient time to find alternative means of primary care if they decide not to pay for concierge treatment.  If patients cannot find alternate arrangements, the physicians are ethically obligated to continue to treat these patients with the highest standards.

Others are disgusted at the idea of a two-tiered system where individuals who can afford the large fees receive "better" treatment.  This not only prevents poorer patients from receiving a high level of care but puts unnecessary pressure on physicians in already overworked practices, who are forced to pick up the "unwanted" patients that are unable to afford preferential treatment or are sitting on a waiting list for a concierge practice (concierge practices have patient retention rates of just under 95 percent).  Critics agree, furthermore, that this problem will only be magnified in rural areas where there are already too few primary care physicians.

Physicians currently practicing concierge medicine remain largely unconcerned with these arguments and instead blame the current state of health care as the enemy to universal and equal treatment.  Medicine is about treating patients, they respond, and under the existing system, the sheer number of patients prevents doctors from being able to perform high-quality work.  Concierge medicine represents the opportunity to work very closely with a handful of patients instead of superficially brushing over thousands.  Charging an annual fee of $5,000 is the only way to achieve this level of service.  This sentiment is particularly strong in older doctors who are tired of being overworked and seek new professional arrangements.  The majority of MDVIP physicians have over 15 years’ experience in primary care.

A Canadian perspective

Though retainer practices like MDVIP are primarily intended to solve the problems of a competitive, free-market health care system like that in the United States, it should not be surprising that concierge facilities are beginning to develop in countries where health care is socialized, such as Canada.  Not satisfied with the standard level of care or methods of receiving treatment, a small number of Canadian patients have expressed interest in a form of premium care that is still in accordance with the Canada Health Act.  The Copeman Private Healthcare Centre, with locations in Vancouver, Toronto, and Calgary, offers an "Elite Program" where individuals enjoy concierge-level services for an annual membership fee of C$3,500 (about $3,400 in American dollars).  The Canada Health Act prevents doctors from charging for any service that is considered medically necessary, but membership fees to groups like Copeman are legally acceptable provided that they complement − not replace − the existing socialized health care framework.  As many advocates of socialized medicine in America look to Canada for inspiration, the existence of concierge practices like Copeman's raises interesting questions.

Whether concierge medicine in the United States thrives in the future depends upon a number of variables.  Substantial reforms of the existing health care system would provide physicians more incentive to stay at traditional practices, and ethical and legal regulations may hamper boutique practices if the AMA and other official organizations take a firmer stance as the field develops.  With such a limited number of examples currently in place, it remains to be seen whether a substantial market for concierge medicine even exists.  Nevertheless, concierge medicine continues to raise questions about the direction of health care in this country.

Further Reading:

GAO: Concierge Care Characteristics and Considerations for Medicare, http://www.gao.gov/new.items/d05929.pdf.

American Medical Association: Code of Medical Ethics.

Society for Innovative Medical Practice Design, http://www.simpd.org/.

MD2, http://www.md2.com/home.php.

MDVIP, http://www.mdvip.com/NewCorpWebSite/index.aspx.

Copeman Private Healthcare Centre, http://www.copemanhealthcare.com/index.htm.