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."

Boutique practices, retainer fees, concierge medicine

People often ask me about these so-called boutique practices (AKA: retainer fees, concierge medicine, patient financed medical care, etc.). I usually refer them to the SIMPD. The Society for Innovative Medical Practice Design (SIMPD) is an organization of physicians promoting a direct financial relationship with their patients. Translated = patients who are willing to pay for personalized health care can have more one-on-one time with their physicians by paying cash and bypassing insurance companies.

I think that's fine for patients who have that type of money. If doctors want to offer personalized services and cater to those who can afford it, so be it. However, in today's world, the leading cause of bankruptcy is healthcare bills. As the population ages, fewer can even keep up with the bills. Fewer patients can afford their medications. And, when people reach 65, they can hardly understand the instructions to sign up for all the appropriate Medicare plans. What does this say about our healthcare system?

Working adults (and non-working adults) face different types of struggles. Insurance premiums are escalating, and many have a difficult time keeping up with these rising costs. Consumer directed health plans (CDHP) are starting to get more popular for healthy patients who don't have any serious problems. Fewer physicians are accepting Medicaid, so those who accept Medicaid are getting all the patients in the area. Patients on Medicaid often can't afford medications, so now you have non-compliant patients all going to a single clinician. That clinician will never excel based on pay-for-performance standards since none of his/her patients are being compliant and reaching goal levels. So who gets punished for accepting Medicaid?

The entire system needs a serious overhaul. I wonder what American's health system will look like in a few years. Will these presidential candidates make a dent in the way healthcare is delivered? I guess we'll have to wait and see...