The Back Page: Is Specialty Medicine Applicable to a Concierge Practice Model?

	Ronald Riner, MD and Rafael Otero, MHA

While no recent studies have been conducted to identify the number and type of physicians going into “concierge,” or “retainer,” medicine, from most published accounts there has been an increase in the number of internists exploring or converting to this type of practice. In addition, the concierge medicine practice model is likely to pique the interest of certain specialists such as cardiologists and nephrologists, who tend to establish long-term relationships with their patients.

Concierge medicine is traditionally used to describe a relationship with a primary care physician, where an annual retainer is paid in addition to any normal charges. In exchange for the retainer, doctors provide enhanced care, usually exclusively outpatient focused, or services that may not be offered (or no longer available) in a traditional primary care office. Physicians practicing concierge medicine charge patients a retainer fee from $500 to as high as $20,000 year. The average fee for a concierge patient is reported to be $1,500 per year (JAOA 2005;105:515-520).

The number of physicians converting their practices, in total or partial, to a concierge practice is believed to be small. However, the factors influencing this trend are significant, and include: decreasing reimbursement; time-consuming unreimbursed paperwork that is no longer proportionate to time spent on patient care; loss of autonomy credited to the onslaught of managed care plans and payor impediments; and an increasingly fragile legal climate. All this has left physicians scrambling to find alternative income sources and a different way to practice medicine.

Older physicians remember a “Golden Age of Medicine” when services were reimbursed on a fee-for-service basis, and treatment plans and drug prescriptions were not dependant on the approval of a formulary or a third-party “case manager.” Younger physicians do not want to be burdened with excessive call and administrative busy work that negatively impact their quality of life. New physicians are not necessarily interested in putting medicine ahead of family and/or personal time. Many residents are gravitating toward nonsurgical specialties without the call burden. These factors have resulted in fewer people entering primary care, as well as more rigorous and demanding specialties, such as cardiology.

We have generally seen concierge medicine make the most sense for primary care physicians. However, specialists most often considering concierge medicine include oncologists, cardiologists, pediatricians and nephrologists. These specialties often provide ongoing relationships with defined groups of patients. In some practices, they may hire internists to handle the “primary care” component and rely heavily on the specialists to provide the specialty care. Other specialists are using their backgrounds as internists to meet the primary care needs of the patient while also providing the specialty care.

Yet, some legal and ethical issues arise, including the risk of patient abandonment, exacerbation of existing healthcare inequities based on ability to pay and a possible decrease in physicians’ provision of charity care. Some who are opposed to the concept of concierge medicine have predicted that the model will result in resource over-utilization and inappropriateness of care. In 2003, the American Medical Association Council on Ethical and Judicial Affairs outlined several guidelines for “retainer contracts” to help limit some of the potential abuses articulated by opponents.

In early 2008, it was reported that one health insurer was dropping physicians who charged an annual fee from its provider networks. However, other payors do not oppose concierge medicine as long as patients are clearly informed that the fees will not be reimbursed by their health plan.

The practice of concierge medicine is an evolving phenomenon. While opponents of the practice believe it creates an elite tier of healthcare delivery for the affluent, proponents believe it is a model that helps physicians and patients experience medical care as it was intended—personal and attentive.

Mr. Otero is a consultant and Dr. Riner is president and CEO of The Riner Group, Naples, Fla.