Are “concierge” practices good for patients?

A new survey finds that physician dissatisfaction with practice "has reached a tipping point with more than half of US physicians experiencing professional burnout."  And this is bad news for patients:

"Given the extensive evidence that burnout among physicians has effects on quality of care, patient satisfaction, turnover, and patient safety . . .There is an urgent need for systematic application of evidence-based interventions addressing the drivers of burnout among physicians. These interventions must address contributing factors in the practice environment rather than focusing exclusively on helping physicians care for themselves and training them to be more resilient."

Rather than waiting for policymakers to make the practice environment better, though, some physician on their own are looking for an off-ramp from the daily frustrations of too much paperwork and too little time with patients.  Some retire early, take non-patient care administrative positions, or sell their practices to large hospital systems.

Others form practices that see far fewer patients, don't participate in health insurance, and/or charge their patients a monthly retainer (or administrative) fee; in return, patients are promised more immediate and frequent access to their physicians, either in person or by phone and email.  Such practices are often described in the literature as "concierge" practices, although this label does not do justice to the wide variation that can be found in practices that have one or more of these characteristics.

In a new policy paper that I wrote on behalf of the American College of Physicians, the nation's largest physician specialty society, I discussed the College's assessment of the impact of practices that "downsize" their patient panels, don't accept insurance, and/or charge monthly administrative (or retainer) fees on cost, quality, and access to care.

The assessment found that there isn't much independent evidence on the impact of these practices overall, and much of what is known comes from anecdotal reports that profile the characteristics of individual practices. It found, for instance, that there are examples in the literature of "direct primary care practices" that reportedly see fewer patients and don't participate in insurance, but have structured themselves to provide care to patients with modest means, usually by charging low monthly administrative fees and negotiating discounts on their patients' behalf with other providers, while providing their patients with better access and more time with the physician.

There are also examples of concierge practices that see far fewer patients than traditional practices and charge relatively high administrative fees, allowing them to offer better access and other amenities to their patients—although there is concern that their high fees may make them inaccessible for poorer patients.

"Practices that, by design, exclude certain categories of patients should be understood to create a greater potential of being discriminatory against underserved populations and require special attention by physicians to the ethical considerations involved" the assessment cautioned.  "Practices that downsize their patient panels also must be aware of ethical and legal considerations relating to patient abandonment."  The College proposed specific actions that physicians in such practices should consider to mitigate any adverse impact on low-income patients, such as waiving or discounting the monthly administrative fees.

The assessment concluded that the growing physician interest in these practices reflects "frustration with the paperwork, low reimbursement, and restrictions on time spent with patients that are associated with traditional practice arrangements that accept insurance. It is essential that policymakers address and ameliorate these and other factors, which may contribute to physicians leaving medicine; closing their practices; or entering into [practices] that charge retainer fees, do not participate in insurance, and/or see fewer patients."

Finally, the College proposed a robust research agenda to learn more about what drives physician interest in such practices, their characteristics, and their impact on quality, access and cost.

Physician burn-out is real, and something patients should be concerned about.  Physicians who are going into a concierge, direct primary care, and cash-only practice are trying to find a way out of the very real pressures that otherwise would lead them to burnout.

For most of these physicians, their principal motivation is to be able to spend more time with their patients, and who can blame them for that? And there is evidence that some direct primary care practices have been able to provide better, more accessible care to all types of patients—including those of modest means.

Yet at the same time, physicians need to be aware of the possibility that by charging administrative fees, downsizing the number of patients they see, and not accepting insurance, there is a greater risk that poor patients could be excluded.  Physicians' professional and ethical obligations require that they provide care to all types of patients, so they need to be attuned to any adverse impact changes in their practices could have on the poor, and take steps to mitigate any adverse impact on them.

Finally, there is an urgent need for more and better evidence on the potential impact of such models on quality, cost and access to care, especially for lower-income patients.

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