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Motivations for making the switch to concierge care vary.

BALTIMORE -- Some of the physicians who embrace concierge care are ideologues who want the government and insurance companies to stop interfering in the doctor-patient relationship. And others? They're in it for the money and the lifestyle, John R. Marquis said at a meeting of the American Society of Law, Medicine, and Ethics.

"A large portion of these doctors have as their primary motive that they want to earn more money," said Mr. Marquis, a partner in a Holland, Mich., law firm. However, while money plays a big role, other factors also influence the decision, said Mr. Marquis, who helps physicians set up concierge practices.

Another reason for the move to concierge care is lifestyle, he said. "If [I've] heard the analogy to the hamster wheel once, I've heard it a million times. "I get up every day, I get on the hamster wheel, I run for 10 hours, I get off, and I hope to God I've seen enough patients to pay the light bill.' Concierge medicine does offer them some degree of better lifestyle as they perceive it."

Another reason physicians give is to improve patient care. "You'd be surprised at the number of physicians who list [improving patient care] as their top priority," he said. But there are two levels to the patient care issue.

"Some say, 'I could practice better medicine if I spent more time with patients." But there has been no proof of that whatsoever. I think that is bogus," said Mr. Marquis, adding that from an ethical perspective, physicians are not supposed to imply that concierge care will mean better care for their patients.

Others profess the desire to provide better preventive care, Mr. Marquis said, noting that, to him, this seemed like a legitimate reason for moving to concierge care.

"Physicians don't get paid for doing preventive care, generally speaking. You'd be surprised at the number of physicians who say, 'I really would love to see healthy patients, because I have a lot to say to them. I'd like to plan their diet, their lifestyle, get them on nonsmoking programs, and I want to be part of their lifestyle.' It sounds hokey, but I think they're being sincere when they tell me that," he said at the meeting cosponsored by the University of Maryland.

According to Mr. Marquis, there are two basic models of concierge practice. The first, practiced by the ideologues, is a "fee-for-care" model, in which the physician charges a set fee--say, $100 per month--in exchange for giving patients access to all the primary care they need, including sick visits, physicals, immunizations, and lab work. These physicians opt out of Medicare and don't bill insurance, though they may remain on some managed care panels.

The second model, used more by physicians interested in increasing their incomes, is a "fee-for-noncovered-service" model, in which the doctor charges patients a per-visit fee but also charges an annual fee for services not covered by Medicare, such as a yearly physical. "These people are driven more by money," said Mr. Marquis. "They just want to game the system a little bit, and get a little more money out of it."

Proponents also say that the type of intensive medical care provided is very good for sick people with chronic illnesses, and that the increased income ultimately will make medicine more attractive and lead more people toward a medical profession. Frank Pasquale of the Seton Hall University School of Law in Newark, N.J., agreed. Mr. Pasquale noted that concierge practices provide preventive care; "directly therapeutic" care, in which patients have the ability to jump the line and be seen the same day; and nonmedical amenities such as fluffy exam robes or a private waiting room.

"The current [critics] are attacking concierge care as a unitary phenomenon," Mr. Pasquale said. "I say, don't attack preventive care, but the other two [directly therapeutic care and non-medical amenities] are a problem."

Concierge care has "amazing benefits" for the doctors and patients who participate, such as more income for the physicians and more attention for the patients, he continued. But there are also problems, such as a disruption of care relationships for patients who can't afford or don't want to join the concierge practice.

"There's the worry of the 'death spiral,' where all the better physicians will go into concierge practice and everyone who can't afford a concierge practice will be left with physicians who don't have quite as good a reputation," Mr. Pasquale said.

Proponents of concierge care say that such a disaster scenario is not likely, because concierge medicine is not apt to spread. "It's just a new product," Mr. Pasquale said.

Rather than regulating concierge care out of existence, Mr. Pasquale suggests that lawmakers tax directly therapeutic care and nonmedical amenities, and use the tax proceeds to help provide access to care for the poor.

Sandra J. Carnahan of the South Texas College of Law in Houston suggested that private insurers consider dropping concierge practices from their networks. In the case of physicians who treat Medicare patients, because taxpayer money is used to pay for the physicians' medical education, "that ought to [dictate] that they have a reasonable patient load ... and physicians should not be able to use the system to choose the wealthiest, healthiest patients who can pay the fees."


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Title Annotation:Practice Trends
Comment:Motivations for making the switch to concierge care vary.(Practice Trends)
Author:Frieden, Joyce
Publication:Family Practice News
Geographic Code:1U5MD
Date:Sep 15, 2006
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