Friday, July 3, 2009

Ethics of concierge medicine

Concierge medicine is often referred to as boutique or retainer-based medical practices. We have seen a surge of physicians and medical groups converting to this type of model over the last several years. Why? Because you can get paid more for seeing fewer patients. Sounds almost ironic, doesn't it? In a typical concierge practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. What does this mean? It means that you may be able to call your doctor directly. Forget about answering services. Also, it may mean that you doctor will see you in the middle of the night if you develop chest pain. Forget waiting in the ER if you need to get admitted by your physician.

If political leaders like presidents can have concierge-type medical care, then is it unethical to offer it to other rich and powerful people? If a billionaire hires you to live and work as a personal doctor for his/her family, would it be unethical to do that? I think the bigger issue revolves around the accessibility to care. If you're the only doctor in a 50 mile radius and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. A related topic deals with the acceptance of Medicaid insurance. Many physicians are choosing not to accept Medicaid because the reimbursement is so low. Eventually, a cash-only model may become the prominent model (especially if the government steps in and offers some level of universal health coverage).

Let's evaluate the ethics behind concierge medicine:
  • Autonomy: Probably not an issue.
  • Beneficence: "the act of doing good things." Well, as long as you offer good care to those who are paying you, you're fine there.
  • Non-Maleficence: "do no harm." Well, this is where concierge medicine may have a problem. If you move to a brand new area to set up your concierge medical care, then you may be fine. However, as I mentioned above, if you're the only doctor in a remote area and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. You may be "harming" those who are unable to afford your prices.
  • Informed consent: Don't see any issues here as long as your contract is well-written.
  • Confidentiality: Probably not an issue.
The AMA Principles of Medical Ethics ends with this statement: "A physician shall support access to medical care for all people." Hmm, not sure how this relates to concierge medicine.

However, the AMA Principles of Medical Ethics also has this statement: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."


  1. I am a concierge physician, and was credited with starting the first such practice in the United States 'from scratch. Your commentary on "Ethics of Concierge Medicine" was a good summary of an over-inflated concern. I too used to believe that their could be some general access to care problems if a physician in a remote area converted to a retainer model. However, after 13 years of slow growth, there are still no concierge physicians in rural areas, as far as I know. This is likely because there are additional economical barriers to success, as well as a much larger catchment area for the physician to serve, making it more difficult for him/her to provide the level of service promoted. Thank you for the opportunity to comment on this interesting topic.

    Dr. Michael O'Neal

  2. is it any less "unethical" if the rural doctor can no longer afford to stay in business and folds up his shop and leaves? Because that is precisely what is going on out there. So many "in the city docs" who know precious little about rural practice clearly have time to debate this. If your concerned about ethics, come work in a rural town.