The Trend towards Concierge Medicine

April 5, 2011- On April 2, an Associated Press article appeared “Doctor Trend Raises Medicare Fears.” The article concerned AARP and Medicare fears that doctors entering concierge practices would create an access crisis for Medicare beneficiaries.

The crux of the crisis is that primary care doctors who enter concierge practices often downsize their patient panels from to 2500 to less than 500, thereby leaving 2000 patients to seek care elsewhere. Abandoned Medicare patients may be left out in the cold, with no doctor to whom to go.

After the article appeared, I began to receive numerous emails from an organization with an e-mail address of AMA-TBPAG, which I learned stood for “Take Back The Profession Advisory Group.”

The Take Back the Profession Advisory Group (TBPAG) is a coalition of Delegates and Alternate Delegates to the AMA House of Delegates from various state and specialty medical societies. The Group is working, it says, to ensure that physicians retain control of their profession to protect and serve the best interests of their patients. The group is not an official arm of the AMA. TBPAG is led by David McKalip, MD, a neurosurgeon who is an alternative AMA delegate from Florida. The emails I have been receiving defend and explain the practice of concierge medicine.

In the Associated Press article, John Rother, policy director at AARP and members of MedPac, a commission created by Congress to instruct them on Medicare matters, express alarm over the rise of concierge medicine, wherein patients pay a primary care doctors an annual fee of about $1500 a year, or $125 month, or $4.25 a day, for the privilege of being seen on the day they call, for the doctor’s undivided attention, for a 15 minute to a one hour session, for preventive counseling, and for referrals to the best specialists and hospitals.

• Rother remarked, “If concierge medicine goes beyond a thriving niche, it could lead to a kind of insurance caste system. What we are looking at is the prospect of a more explicitly–tiered system where people with money have a different kind of insurance relationship than most of the middle class, and where medicine is no longer as universal as it used to be."

• “MedPAC chairman Glenn Hackbarth, is quoted as saying. “ My worst fear- and I don’t know how realistic this is – is that this is a harbinger of our approaching a tipping point. The nightmare I have - and, again, I don't know how realistic it is - is that a couple of these things come together, and you could have a quite dramatic erosion in access in a very short time."

Commissioner Robert Berenson, a physician and policy expert, adds, "The fact that excellent doctors are doing this (concierge medicine) suggests we've got a problem. When a primary care doctor switches to concierge practice, it means several hundred Medicare beneficiaries must find another provider.”

MedPac, fearful of dangers of limited access of Medicare recipients to doctors, investigated the growth of concierge practices and issued a report last September. The report found national listing of 756 concierge practices, a 5 fold increase since 2005.

The truth is that nobody knows how many concierge practices exist. Estimates vary from 2000 to 5000 concierge practices. Word on the street is that the number of these practices is growing rapidly, as doctors bail out of Medicare and other third party arrangements, and as they ponder the consequences of health reform, which proposes to cut their reimbursement below those of Medicaid by 2019 and to pay them 2% less by 2015 if they do not install electronic health record systems .

Thomas W. Legelius, MD, chairman of the concierges’ physician professional society, claims the number of patients joining concierge practices is “not just in the thousands but the millions, and the current number of physicians is not just in the hundreds but the thousands, perhaps in the tens of thousands. Most are under the radar. They just quietly do it and are never counted by the bureaucrats.”

Legelius maintains concierge practices cut costs of Medicare, citing studies that indicate concierge physicians cut ER visits by 25%, specialty visits by 50%, and prescription drug use by 50 to 95%.

I cannot confirm any of these numbers, but suspect they are over-hyped.

Nevertheless, I know at least a dozen patients and doctors in my circle of contracts have chosen to enter concierge relationships. And I know these practices serve as a haven for primary care physicians, particularly older primary care physicians, some suffering from burnout, others seeking a way out of third party relationships, still others trying to find a way to spend more time with patients, free themselves of regulations and overhead these regulations entail, and, to find a way of earning a decent income.

There is an ideological element to those who join or create these practices. These physicians argue: we live in a free country, we can still practice where and how we please, and we are not yet indentured servants of government. Concierge medicine, they are wont to say, is about bringing back the physician-relationship to the center of the health system, away from government rules, regulations, and restraints, and towards more patient and physician choice.

If concierge physicians were to answer their critics, it might go like this.

Dear Mr. Rother, MedPac members, and Medicare officials:
Concierge medicine isn’t about satisfying government beneficials.

It’s about kicking patients upstairs.
and knocking third parties downstairs.

It’s about spending more time with loyal patients,
not frittering way time on government relations.

It’s about cutting overhead expenses,
and returning to our collective senses,

It’s about attention to patient-physician priorities,
rather than priorities dictated by outside authorities.

It’s about direct one-on-one care,
rather than remote managed care.


Tweet: Patients and doctors are flocking to concierge medicine, which may threaten access for Medicare patients not in concierge practices.


Richard L. Reece, MD, has posted 1721 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation but his opinions are his alone. He has written ten books. His latest book, The Health Reform Maze, is now at the publishers and will be released in June. Doctor Reece’s website, www.doctorreece.com, will be up and running in several days. He invites comments on his blog and will respond to each comment on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.