Quietly emerging across the country are a handful of innovative concierge medical practices catering to a specific clientele. Some call them revolutionary and long overdue; others brand them as unethical or, at the least, not in the public's best interest as the nation faces continual increases of uninsured persons.

Concierge medical practices are steadily growing in numbers and captivating the public's attention in the process.  The topic is being discussed by physicians in hospital corridors, debated in the halls of Congress and the Harvard Medical School generating considerable controversy.

At issue are patients' rights to purchase more time and attention from their physicians, the physicians' moral and ethical obligation to treat all patients, and the potential emergence of a two-tiered, and some say multi-tiered, health care delivery system.

Large health care organizations are finding it increasingly difficult to ignore the social and economic potential of this type of practice.  Large medical centers until more recently have avoided this practice model.  Instead they have chosen to offer patron patients luxury hospital suites that provide specially prepared meals and other amenities.  These VIP patients are often given prompt side-door access at the request of the CEO's office or foundation.

Concierge patients often receive service that includes 24/7 cell phone access to their doctor, who actually answers his own phone.  Doctors make house calls and business office calls, have time for longer appointments and pay more attention to their questions and requests.  Suddenly the common buzzwords "access," "patient-centered" and "quality" take on an entirely different meaning. Standard concierge benefits include: same-day appointments, longer appointments, house calls and business office calls.

How Do Concierge Practices Work?

Physicians charge patients an enrollment fee in exchange for more personalized and convenient health services. In the most typical concierge practice model patients pay an annual fee to the physician in exchange for services that are not otherwise available and not billable to insurance carriers as covered medical services.  This exchange does not impact the flow of dollars from a health plan or insurance company to the physician for traditional medical services.  Services covered by the fee often include guaranteed same-day or next-day appointments, no waiting time at office visits, in-depth medical evaluations, customized healthcare and lifestyle plans, around-the-clock access to physicians via cell phones, pagers, and e-mail, coordination of care with specialists, and even house calls.

While all concierge practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the amount of the concierge fee charged. While some concierge physicians charge well over $10,000 per patient per year, others charge considerably less, and roughly half charge between $1,500-$2,000 annually. Some practices provide service for both concierge and non-concierge patients, while others see only concierge patients. Some accept Medicare and traditional insurance coverage, while others do not.  Several concierge practices have begun "franchising" their operations.

So What's All the Noise About? While at first blush they may seem to be little more than a medical novelty, concierge practices raise a host of ethical, legal, and medical issues that have stirred controversy.

Arguments in Favor:

• physicians cite their ability and desire to spend more time educating and treating their patients. To them, concierge medicine represents a return to old-fashioned medicine.
• Availability to spend time with a terminally ill patient and her family in the waning hours of life. By reducing their patient load, concierge physicians are freed up to practice medicine in a more personal and caring fashion.
• Some argue that they are able to provide truly superior treatment in addition to more personalized treatment to their patients.
• Physicians spend more time with patients and  less time worrying about paperwork, red tape, and coverage restrictions.
• Physicians are able to focus on wellness and prevention instead of treating health problems after it is too late.

On a more pragmatic note, physicians say that another reason they made the jump to concierge medicine is because of patient demand. Simply put, many patients are clamoring for a more personal, convenient, and effective form of healthcare. The numbers seem to bear this out.  Physicians who make the switch seem to be filling up their patient rosters with patients who are happy to pay the concierge fee. Defenders of the idea argue that concierge medicine provides a desirable option for many who seek a different type of healthcare.

Arguments Against:

• Charges of "country club" elitism and favoring the rich at the expense of the poor are routinely made.
• Perhaps more stinging is the claim that with between 40 and 50 million uninsured Americans, a physician's decision to drop his or her patient load from 4,000 to 800 is almost unconscionable. Rather than helping the system, critics argue, concierge practices merely increase the burden shouldered by other physicians who remain behind in the trenches.
• Similarly, with physician shortages in many rural areas where only nurse practitioners and physician assistants are available, the reduction of caseload by “elite” doctors takes a toll as well.

Some critics have denounced concierge medicine as injurious to America's system of healthcare. "Change is inevitable, but a change toward elitism in the delivery of healthcare is pernicious," Professor John Goodson of the Harvard Medical School observed in a letter to the Boston Globe. "It undermines the most fundamental commitments of our profession."

That has been critics' central objection. "I have a great concern that this is going to provide care to the 'healthy wealthy,' but may limit the access of the rest of the population," says Michael Fleming, MD, president of the American Academy of Family Physicians (AAFP).

"Nobody" in the concierge movement "likes to use the word 'access', John R. Marquis cautions.  Marquis is a Grand Rapids, Mich., healthcare attorney who also heads the American Society of Concierge Physicians. "But if you take a practice that has 4,000 patients and you institute a concierge model and you reduce your practice to 1,000, well, you have 3,000 patients who don't have a physician." In the end, "we have this large body of people who may be displaced" by retainer practices. Even advocates, says Marquis, recognize "that there is an ethical issue involved."

In June of 2003 the American Medical Association (AMA) issued ethical standards to guide physicians who operate or are contemplating concierge medical practices. The AMA largely endorsed these practices so long as physicians communicate clearly with patients and insurers about their fee arrangements and do not tout their practices as providing better diagnostic and therapeutic services.

Regulatory and Legislative Criticism

Legally, various regulatory and legislative bodies have been fitfully hostile. Regulators in Washington and Florida have challenged the model.  Washington contended that, by accepting retainers, physicians were accepting risk without having the insurance licenses to do so. Florida investigated discrimination against patients who could not afford medical retainers. Massachusetts legislators introduced a bill in 2003 that would require insurers to prohibit their network doctors from accepting retainers.

Nationally, Medicare has forbidden patients from using its funds to pay up-front physician fees. Congress last year debated bills to prohibit retainer-based physicians from contracting with Medicare at all. (As of this writing, none of the state or federal bills has become law.) 

Among other claims, Congressmen have asserted that certain concierge arrangements may violate Medicare billing laws and the federal False Claims Act. To address these perceived abuses, in 2003 they introduced federal legislation aimed at preventing certain concierge doctors from receiving Medicare payments. Although all these bills have fizzled thus far, a similar bill in the future may eventually become law.

In addition to proposing legislation, several members of Congress petitioned the Department of Health and Human Services ("HHS") to clarify the law regarding concierge practices. In May of 2002, HHS responded that concierge practices, if properly structured, do not conflict with Medicare's requirements. HHS further indicated that physicians may proceed with concierge arrangements, but "they are responsible for complying with Medicare requirements. [HHS] will advise physicians contemplating use of such agreements to seek legal counsel ensuring that the agreements comply with the law."  This study was later verified through a separate review by the Government Accountability Office in August 2005.

For instance Medicare reimbursement for standard office visits will not pay above the standard usual and customary fee even if the physician spends an hour with a patient instead of 15 minutes.  Medicare also states that the enrollment fee must not result in additional charges already covered by Medicare.  The GAO stated that because concierge physicians are still few in number they were not concerned with the new business model impacting Medicare enrollee access to care.

Nationally, Medicare has forbidden patients from using its funds to pay up-front physician fees. Congress last year debated bills to prohibit retainer-based physicians from contracting with Medicare at all. (As of this writing, none of the state or federal bills has become law.)

Notwithstanding the controversy that has encircled concierge medicine, an increasing number of physicians across the country are deciding that such practices make sense for them. Patients with their pocketbooks open appear to be following them. In the view of many, concierge medicine is no different than choosing to fly first class, buy a luxury vehicle, or order a satellite dish TV package with hundreds of channels. Certainly the debate will go on. In the meantime, watch for an increasing number of physicians to give concierge medicine a try.