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Is 'concierge' care an ethical alternative? (Pro & Con).


Boutique medical practices are spreading across the nation and generating a chorus of moral outrage.

In boutique or "concierge" practice, patients pay a yearly fee in return for services superior to those offered by governmentsponsored health care or private plans.

In my view, boutique medicine is not immoral, but the opposition to it is.

The entrepreneurial doctors opening these practices are restoring an element of freedom to American medicine. They have found ways to offer same-day appointments and 24-hour cell-phone access, make house calls, and accompany patients on visits with specialists. They are producing services no longer available under government-regulated health care. They are restoring the ability to practice medicine in the way that many doctors think it should be practiced. Properly and morally, they expect to reap the rewards.

Patients, disgruntled by the rationing of medical services necessitated by government price controls, are eager for the freedom to once again decide how much they will spend on health care and what services they will purchase.

For both doctor and patient, it is a winning situation-as is any voluntary trade.

Critics, however, oppose it. They worry that taking fewer patients per physician will create a further shortage of doctors. This is false.

The shortage of doctors has been created by government regulations that make the profession unprofitable and unrewarding. Physicians are no longer free to decide whom to treat at what price and with which medical procedures. Medical decisions are determined by a Byzantine set of regulations and the outside whims of government bureaucrats and HMO administrators. As a result, physicians leave the profession and fewer young minds enter it.

The supply of doctors will increase only when being a physician is once again an attractive and profitable career. Boutique medicine is a step in that direction. The critics' worries are as absurd as worrying about a shortage of chefs because the salaries of chefs have increased.

Critics denounce boutique medicine by labeling it "two-class" medicine. According to these egalitarians, everyone should have the same level of health care regardless of what they earn and are willing to pay for. How can this be achieved? Only by depriving physicians and patients of their actual rights.

For the same reason, the government must deprive patients of the right to spend their earnings on medical care beyond that rationed by the government. The only way to achieve the egalitarian's immoral ideal, in other words, is to pull down doctors and patients by force to the lowest common denominator of care-which in this case means making the doctors' boutique services and the patients' voluntary purchase of them illegal.

The sacrifice of the productive to the nonproductive is the essence of communism, whose guiding principle is "From each according to his ability, to each according to his need."

We must not let that immoral principle become our guide in America, a nation founded on the noble ideal of the individual's right to think and produce for himself.

Yaron Brook, Ph.D., is the executive director of the Ayn Rand Institute in Marina del Rey, Calif.


Beyond the potential ethical, professional, and legal issues raised by this approach, it is not clear that concierge care is the best practical solution to the problems that physicians face.

Many physicians continue to use an obsolete model of care delivery that was developed a century ago when the average life expectancy was only 50 years and multiple longstanding chronic diseases were rare.

Today, the reverse is true, but physicians still see patients on a patient-generated demand for symptom-based care, on a one-on-one basis that requires running from room to room as fast at they can.

Although few physicians have adopted specific innovative approaches to delivering care, there are alternatives that serve people in all sectors of society, including those unable to pay.

Over the past several years, the Institute for Healthcare Improvement (IHI) has promoted innovative approaches designed to deal with the changing landscape of medicine.

The IHI alternative offers better strategies for scheduling, arranging office visits, communicating with patients outside the office, and using a planned approach to care that has demonstrated dramatic improvement in physician and patient satisfaction, major increases in net income, and free time for physicians.

Visit for further information.

Becoming a physician is a privilege not available to all Americans. The number of openings in medical schools is limited. Training positions are not awarded relative to a candidate's commitment to serving the public need and the interests of society.

Yet getting accepted to medical school depends on the beneficence of society. Those who are accepted are subsidized by tax dollars and also by patients paying out of their own pockets (part of fees of care paid to medical training facilities).

In addition, students are entrusted with access to patients and their highly personal medical information.

In return for this privilege and acquisition of skill, it is expected that physicians will serve the interests of individuals and the public in general. This service could take the form of providing care to underserved populations, taking an active role in promoting policies and practices to benefit the public, or numerous other options.

The issue of repayment for the privilege of becoming a physician partly at public expense would suggest that physicians should offer their services to all patients at fair rates and not limit access solely on ability to pay exorbitant fees. In this sense, concierge care that offers care only to those who can pay out of pocket would seem unethical.

The choice should be clear: Faced with declining physician income and dissatisfaction with practice pressures, the right path lies not in responding by ignoring the needs of large percentages of the population but in shedding obsolete ways of practicing.

This will bring substantial benefits to all physicians and patients alike.

Dr. Ira Mandel is a family physician in Tampa, Fla. He is the cofounder of the Tampa Bay Alliance Inc., a public-private health care partnership.
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Publication:OB GYN News
Date:Mar 15, 2002
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