The ethics of exclusivity: should doctors practice concierge medicine?

Charles Wilson, MD, is a general internist. He is employed by a large clinic that is part of Medibest Health Care (MHC). Wilson has been in practice for seven years. Even before medical school, he was already aware that doctors no longer control much of what happens in doctors' offices and hospitals. However, he pursued his dream of becoming a physician.

He assumed that he would be the final decision maker at least in terms of treating individual patients. Now, he finds that he could practice quality medicine by his own high. standards, but only at the risk of violating several cost-driven Medibest directives composed by people with no clinical training and with minimal if any physician input.

Wilson also assumed he could still enjoy the challenge of caring for his sickest patients, those requiring hospitalization. However, he is expected to turn those patients over to a hospitalist and concentrate on seeing a large volume of plan enrollees in his office every day. Some are suggesting that his job can be done as well by a physician's assistant or nurse practitioner.

Today, Wilson doubts his choice of profession, but his family commitments prevent him from abandoning medical practice and choosing another profession or business.

At the tenth reunion of his medical school class, Wilson learns that some classmates are now practicing "concierge medicine," a controversial new way to regain control of one's office practice.

Back home, Wilson resigns his job with Medibest and becomes a partner in Associates in Internal Medicine (AIM), a free standing group. AIM serves about 1,000 families. With the help of Concierge Choice Physicians (www.choice.md), (1) AIM sends out a notice announcing that the first 600 families to sign a retainer contract and pay a monthly membership fee of $300 may continue in the practice.

Patients are assured that this action has no impact on AIM physicians' hospital privileges at Community General Hospital. Furthermore, if patients choose not to join their AIM physician will be happy to provide the names of three excellent internists in the area. There will be no charge for transferring the patients' records to that office.

Three internal medicine residents in training at Community General plan to open an office together, and build their practice from scratch using the same approach.

Doctors Like Lawyers

That is one version of concierge medicine, a new notion apparently gathering steam among practicing physicians in some parts of the country. (2) Concierge medicine borrows an idea, retainer fees, from lawyers. That's ironic, considering physicians' bitter criticism of attorneys. Just like retained attorneys, retained physicians presumably charge the usual fees for services provided in addition to the retainer.

At the bottom line, concierge medicine is a product of the fight between some physicians, some health care executives, and the government over who will control the flow of patients and dollars spent on medical services. Concierge medicine pioneers and proponents freely admit that while the carrot used to attract patients is better patient service, the actual motivation is to ease pressure on and increase payments to physicians.

Actually, I did learn about concierge medicine at a medical school class reunion ... my own, earlier this year (Washington U. St. Louis School of Medicine, MD, 1959). One feature of reunion weekend was a continuing medical education program. I spoke about trends in 21st century ethics. (3) Thus identified as a wannabe ethicist, I was sought out by several classmates who challenged me to speak up about concierge medicine. They shared concerns about the impact of concierge medicine on the professional ethic, and on the issue of access to medical care.

Impact on the professional ethic

Among other things, a physician is presumed to maintain a sense of social responsibility. That includes putting the patient first, in matters of individual patient care.

At first glance, the impact on this aspect of the professional ethic would seem to be positive. That is, the major goal of concierge medicine is to allow doctors to make more money by seeing fewer patients. Put another way, the purpose of concierge medicine is to shrink the size of existing practices, and limit practice size from the very beginning in a new practice.

Therefore, the sales pitch for concierge medicine is that in a smaller practice each patient will receive sensitive, personalized service and excellent quality care. What my classmates (and I) wonder is: When did doctors come to consider personal attention and quality care an exceptional service requiring a special fee, as opposed to being a definition of the professional ethic? Are concierge physicians certain that this is the image they want physicians to project?

Recent history shows that when physicians lose perspective--when the balance between entrepreneurial initiative and social responsibility gets too heavily weighted in favor of the doctor--then doctors might not even be considered professionals at all.

That history is in the legal arena. A few decades ago, when physicians started playing games with physician credentialing mechanisms in hospitals--a mechanism intended to be patient protective--physicians lost important protection of their own. That is, they were no longer considered "learned professionals," excluded in certain circumstances from application of anti-trust laws.

Is any activity that results in diminution of physicians' professional status really that good for doctors in the long run?

Impact on accessibility

What is the impact of concierge medicine on accessibility of care? In ethics-speak: How does concierge medicine relate to the ethics of exclusivity?

At the bottom line, concierge practice changes the face of the American medical profession, which traditionally has been about providing services to patients. In contrast, concierge medicine is about denying services to patients. One could not find a better example, even in socialized medicine, of taking away free choice of physician.

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Wait a minute. Isn't this picture familiar? A denier of care? A charger of monthly premiums? Signing a contract that specifies clearly what services are covered and what are not? Remind you of anyone? Ah, yes--the insurance business.

Some suggest that legal problems might be around the corner for concierge practices because the argument might be made that they are unlicensed insurance companies. One purpose of these columns is to avoid conflating legal aspects of a situation with ethical aspects. We leave legal analysis to attorneys.

Ethically speaking, by extending the private insurance principle to private primary care practices, concierge medicine expands the number of uninsured in the United States. Thus concierge medicine is arguably part of that problem, not part of the solution.

Fix the system first

I agree with concierge physicians' basic premise, which is: Primary physicians, the patient's important entry point into the health care system and provider of many important medical care services, have always gotten a raw deal in insurance systems, and in Medicare and Medicaid.

However, I think participating in wide-ranging efforts to fix the whole system is more morally intelligent, including more self-serving, believe it or not, than the concierge approach.

For example, reformers should heed the advice of Dr's Bodenheimer, Grumbach, and Berenson. (4) They urge priority attention to primary care, including issues of "physician payment, practice infrastructure and organization, and the training pipeline." Of particular importance to doctors and patients alike, they argue, is attention to harnessing amazing modern technology--the Internet, pocket computers--to improve consistency, availability, and patient understanding of health care information. There is little talk of such agendas so far from concierge doctors.

An emerging concept is the idea of merging the best of single payer health care and entrepreneurial initiative into a uniquely American health care system. Designers of concierge practices could be extremely helpful in working out the details of this model.

Admittedly, this is a hard concept to understand. To paraphrase Paul Starr, (5) if people hear single payer first they stop listening and cry, "socialized medicine!" If they hear entrepreneurial initiatives first they stop listening and shout, "greedy exploitation!" Progress will only be made when someone succeeds in lessening the degree of polarization in the health care reform argument.

Meanwhile, for my own personal physician, give me a doctor who practices good medicine within an integrated system that considers his or her needs as well as mine. Again I say, in chorus with concierge physicians, that will only happen when health care reformers truly listen to and heed guidance offered by reasonable and experienced clinical practitioners.

References

(1.) http://www.choice.md Concierge Choice Physicians website.

(2.) Knope SD. Concierge Medicine: A New System to Get the Best Healthcare. Praeger Publishers. Westport, CT. 2008. (www.praeger.com)

(3.) Thompson RE, Ethics is dead: What do we do next? Presented as part of the Reunion Weekend CME program at Washington University St. Louis School of Medicine, May 8, 2009. The Physician Executive 35(4), July/August 2009.

(4.) Bodenheimer T, Grumbach K, and Benson R, A lifeline for primary care. NEJM 360:26. June 25, 2009.

(5.) Starr P, The Logic of Health Care Reform. Whittle Direct Books, The Grand Rounds Press. Knoxville, Tennessee. 1992.

Richard E. Thompson, MD

Former vice president of the Illinois Hospital Association, author of Think Before You Believe, Xlibris, 2005

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