Concierge Medicine for the Rich

 In 1999 I wrote “No Margin, No Mission” for The Physician Executive. The article opened with this paragraph,

“A tough-minded Catholic nun, the CEO of a major not-for-profit health system on the West Coast, captured the dilemma of our health system with this down-to-earth comment:” No margin, no mission.” This article and many others indicate any organization, however noble its mission , whether “for-profit” or “not-for-profit,” must make a profit to survive as an institution and to serve its constituents. Whether a business or a charitable organization runs the enterprise makes little difference. Both need to make profit to survive. No mission is more noble than caring for the sick. That's what medicine and hospitals are for. But to say openly that one must "make a profit" running a hospital, medical practice, or health insurance company or "compete for patients" is unseemly.”

I thought of that article today when I  read “Hospital Care Aimed at the Rich; Mass General, Founded for the Poor, Plans to Open a Concierge Practice,  in the February 13 issue of the New York Times.

Massachusetts General catering to the rich? It’s an unsettling thought,  a liberal institution like Mass General  openly announcing  it would open a concierge practice.   The practice would start with 3 doctors,  would charge an annual retainer of $6000,  would offer 24 hour access,  and would be tied directly to Mass General’s vast cadre of specialists.

Mass General is worried about declining reimbursements from health plans and the government.  It says it wants to make money providing for the rich to carry out its “core mission of providing for the poor.

The upsides of its concierge practice are  more revenue for the hospital and more ability  to care for the poor.   The downsides, in the eyes of critics,  are giving momentum to the concierge movement,  which now has 6000 exclusive practitioners and 6000 more practices  offering part-time concierge care,  and creating a model that exemplifies  “two-tier medicine,” with one level of care for the rich and another for the poor.  In other words,  no margin, no mission.  Or in the words of one cynic, "When they say it's the mission and not the money, it's the money."

My hunch is that this creation of concierge practice  is part of  a larger mission,  which I described in a previous blog.  On December 17, 2015,  the New England Journal of Medicine published an article  “Unfinished Business – Removing Barriers to Access and Coverage.”   Towards completing that “unfinished work,  the NEJM proposes to led the the transformation of health care delivery by launching  a “ NEJM Catalyst.”

The  proposed NEJM Catalyst is a “resource’ will “provide health care leaders with information to provide these leaders with information that can help them redesign patient care, change the structure of their institutions, contemplate new relationships with outside organizations, and reconsider the ways in which incentives are being used.

The NEJM Catalyst will have 4 overlapping themes.

1) The “New Marketplace,” which will focus on health policy and markets impacts on payer and provider consolidation, value-based payment, competition and consumer choice.

2) “Care Redesign” which will concentrate on how to create and sustain the teamwork needed to provide high-value care, and the practical ways of organizing care to enhance health as well as sick care.

3) “Patient Engagement: Behavioral Strategies for Better Health.” This will focus on what is known about the use of incentives (financial and non-financial ) to engage patients in improving their own health.

4) “Leadership.” This will be about engaging clinicians in to enhance the value of care .

Mass General, which is closely linked to the NEJM,  is experimenting in creating a new  marketplace, redesigning care,  engaging a new set of patients to provide for the old set of patients ,  and taking a leadership role in health reform.