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BioEthics: Concierge Medicine: Opening the Door to Better Medicine?

By Bioethics Discussion Blog

SEPTEMBER 16, 2013 –

Whether it is called Concierge, Boutique or Retainer  medicine (all the same), it is here and most likely here to stay.  It is all about patients paying a yearly fee to their doctor for a quality of care not readily available to patients who feel they can’t afford to pay for that system of care.  This current thread is the third in a series I have presented on my blog over the years:  2007: Where Have All Those Doctors Gone?: Coming Back in BoutiqueMedicine?   2009: Primary Healthcare Boutiques and Healthcare Reform
What I think is special about this current thread and unlike the other two, I have had the opportunity to utilize an active practitioner of “retainer medicine”, whom I know, present his view of his profession and critique an article by William Martinez MD and Thomas H. Gallagher MD in the July 2013 issue of the AMA’s  Virtual Mentor titled”Ethical Concierge Medicine?”
 Now go  to that article, read and then return and read the critique below by the practitioner along with his personal description of the practice.
I read with interest the provocative commentary by Martinez and Gallagher in the July issue of the American Medical Association Virtual Mentor.  Their commentary, in fact made more provocative by not addressing specifically the very thoughtful and comprehensive counterpoint Opinion piece by Huddle and Centor in the Annals of Internal Medicine (Ann Intern Med. 2011;155(9)) listed in their references. The ethical role of physicians and the delineation of a physician’s social responsibility beyond professional ethics to their patients are exquisitely described by Huddle. That is not what actually interested me. Rather what has much greater interest is delineating with accuracy what these “retainer physicians” who charge fees that are not recognized as “covered services” by Insurance Companies or Medicare actually do. What these physicians actually do is take the time to listen and educate their patients. These physicians, not constrained by 10 minute encounters can focus on Preventive Medicine, Wellness, Education, and when needed intense Illness care including personal care coordination with specialists. These physicians are not providing “luxury” services. They are practicing Preventive Medicine. They are not merely providing services as a matter of “comfort and convenience” as asserted by Martinez.

Physicians who practice in this manner certainly do recognize that their first responsibility is to the care and wellbeing of their patient. When physicians reduce their practice volume to allow more time for individual patients it is not without concern for those patients unable or unwilling to pay the additional fees for enhanced prevention. Physicians who undertake this transition are not pure profit motivated individuals.  They’re the same physicians who chose to take on the significant financial and personal sacrifice that comes from being Primary Care Physicians in the first place. These physicians did not take the “R.O.A.D” to happiness by seeking the far more lucrative Radiology, Ophthalmology, Anesthesiology, and Dermatology path where their schedules do not carry the same degree of  24/7 burden of responsibility. The physicians who transition their practice are not uncaring individuals with selfish disregard for their current patients who won’t or can’t participate in the preventive medicine practice. In contrast to the unfounded assertion of Martinez, physicians who undertake this transition uniformly assist their patients in locating new physicians who are often associate physicians within their own practice.

 Moreover, in further contrast to the erroneous assertion of Martinez over time the physicians who are practicing in this model have clearly demonstrated significant improved health outcomes– improved outcomes that benefit not only the individual patient but all the other stakeholders in medical care.  There is now clear evidence of a significant cost saving and improved outcomes to the patients, their employers, the Insurers and Medicare by reduced frequency and severity of illness. In December of 2012 Klemes and her group at MDVIP documented in their report published in the American Journal of Managed Care an extraordinary reduction in the frequency of hospitalizations as well as reductions in readmission rates for patients in this model. By the estimates of Klemes there was a $2500 savings per patient as a direct result of decreased hospitalizations alone.

So what is wrong with capitalizing on an enhanced doctor- patient relationship and take the time unavailable in traditional practice to have our patients live longer and better? In a companion Editorial in that same issue of the Annals of Internal Medicine (Ann Intern Med. 2011;155(9)) Bernard Lo posits “Retainer Medicine: Why Not for All?”  In that Editorial Lo correctly points out that “retainer medicine physicians cannot by themselves solve the problem of poor access.” After all, by the calculations of the Kaiser Family Foundation and larger groups of preventive medicine physicians such as MDVIP physicians in this model represent  less than 1.5% of Primary Care Physicians. Yet, even this very small number of physicians practicing in this model of prevention has certainly stimulated a dialogue that hopefully will get the attention of the politicians, the government bureaucrats, and the general society where health policy is made. It is this dialogue about fostering the fundamental relationship and mutual trust of the healthcare provider, the doctor and the patient that will bring better health to us all.

And now my comment.  I think that unless HMO medical practice makes drastic changes in how patients are allocated to their physicians and paid for and/or an impressive influx of general medical practitioners occurs, with the population of new patients enrolled in the Affordable Care Act, medical practice, in general, will be moving away from what Dr. Abraham Verghese speaks out for  and is discussed in my recent blog thread “Eye to  Eye Communication and Laying On of Hands: Anachronistic Medicine?”  .Dr. Verghese says “ the ritual of one individual coming to another and telling them things that they would not tell their preacher or rabbi, and then, incredibly on top of that, disrobing and allowing touch – I would submit to you that that is a ritual of exceeding importance.” Of course, medicine is much more than simply that ritual but without medical system change it may well be that we find that it will only be the “retainer” physician practice that will be providing that superior attention and care toward each individual patient which characterizes the best in the doctor-patient relationship. What do you think?  ..Maurice.

ADDENDUM 9-14-2013:

It is my hope that with the help of the retainer physician who wrote the critique and description above and perhaps other retainer physicians, the retainer practice can be dissected within the Comment section of this thread for the public and other physicians with the anatomy and physiology of retainer practice. Some issues of interest would be matters of patients having developed extreme trust with a physician who now leaves common practice and goes into retainer medicine and the patient, not following, but provided with another physician may struggle to develop and perhaps fail to develop trust with that new physician. Another aspect of the practice is how a scale of various levels of provided services with varying yearly fees is developed and executed. I am sure my visitors will have more questions regarding retainer medicine practice which hopefully will be answered by the knowledgeable practitioners.  ..Maurice.


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