As physicians seek innovative practice models, one that is gaining ground is for practices to contract directly with patients to pay directly for some or all services. These are known by several names (eg, concierge, retainer, cash-only, boutique, or direct primary care practices. The effect of these emerging practice models on access, cost, quality and other considerations is largely unknown.
Concierge or direct patient contracting practices have one or more of the following features:
Charge an administrative service fees as retainer or concierge fees: Some charge a monthly or annual fee—in addition to or in lieu of some of their usual fees for billable services—which patients pay to have access to the practice. In return, patients are promised increased personalized attention.
Require payment in cash at the time of service: Some do not accept insurance and require that patients pay directly for all services at the time of care. These practices are typically called direct primary care practices, direct specialty care practices, or cash-only practices. Patients that seek care from a cash-only practice may choose to obtain a health savings account or a wraparound high-deductible insurance plan.
Care for a smaller patient panel: Some accept substantially fewer patients than traditional practices, which requires practices to “downsize” their patient panels as they transition to a concierge practice. There is concern that such downsizing, especially when associated with retainer fees, could create a barrier to lower-income persons, patients with chronic diseases, and other underserved populations.
Effect on Cost
While concierge proponents assert that price transparency, competition, lower administrative costs, and patients accepting more personal responsibility for the cost of their care will keep out-of-pocket costs and overall spending down to a competitive and affordable level, others note that these practices can leave the patient at risk for higher out-of-pocket costs for health care. For most families and individuals, health insurance enhances access to health services. This is most certainly true for young families. Plus health insurance offers financial protection against high expenses that are relatively unlikely to be incurred and those that are more modest, but are still not affordable to some.
Effect on Workforce
Downsized patient panels could potentially place an even greater strain on physicians that remain in the larger health system. Yet there is a school of thought that concierge medicine may lead more physicians to stay in practice, rather than close their practices altogether, which could have a beneficial effect on alleviating workforce shortages. The effect on projections of workforce shortages requires more study.
Value of Services
Retainer fees may cover personalized services or special amenities, such as extended patient visits, preventive services, immediate access, private waiting areas, and coordination with specialists, but research supporting this assertion is lacking thus far.
Ethics and Professionalism
The ethical concept that all children should have access to pediatric care is an important consideration for those choosing practices that have the potential of being discriminatory against underserved populations. Practice models that, by design, exclude certain categories of patients should be studied further to be better understood. Additionally, practices that downsize their patient panels also must be aware of ethical and legal considerations relating to patient abandonment.
Some specialty societies have gone on record stating that physicians in all types of practices should strive to take care of patients enrolled in Medicaid. Medicaid is a crucial part of the safety net for poor persons and, under the ACA, is the principal source of coverage for patients with incomes up to 138% of the federal poverty level in states that have agreed to accept federal dollars to expand Medicaid.
Additional Concierge Medicine Resources
AMA Code of Medical Ethics