According to “ Access Denied,” a county-by-county study by the National Association of Community Health Centers and The Robert Graham Center, at least 56 million Americans, almost one in five of the population, are now “medically disenfranchised” due to inadequate access to primary care. In previous postings I’ve discussed this growing crisis, citing reasons for primary care physician shortage, as well as some alternatives practitioners choosing to remain in primary care are employing to increase practice income and/or to reorganize traditional practice to meet lifestyle choices.
Of all the alternatives discussed, the one that seems to generate the most comments is the boutique or “concierge” practice model. Using this model, a primary care physician establishes a retainer to be paid by patients who are in turn provided with services not covered by insurance payments. Patients are also assured that their physician will be available to spend whatever time is required with them because the number of patients in the practice is significantly reduced as a result of the model.
Critics of the concierge practice model point out that it excludes a large subset of the patient population – children, low-income families and the elderly. This in turn leads to a two-tiered system that provides more convenience and quality to those who can afford it while increasing the shortage of primary care physicians. Concierge physicians reduce the number of patients in the practice and leave the remainder seeking a physician in an environment where a profound shortage exists. Terms such as “unethical behavior,” “patient abandonment” and a “violation the Hippocratic Oath” have been ascribed to physicians who have chosen this practice model.
Proponents of the concierge practice model respond that in a healthcare system where free-enterprise competition is the mantra, why shouldn’t primary care physicians have the same opportunity to augment their income? Their specialist colleagues who have ownership interests in surgery centers, specialty hospitals and other free-market options have already done so. Attorneys are placed on retainer by clients, so why should physicians be denied the right to do so?
If the market is to determine the availability of primary care physicians, why not let insurers or the government develop incentives to assure an adequate number of primary care physicians are available to meet the needs and demands of this country’s citizens? This is the dilemma we confront when our free-market, competitive healthcare model meets the reality of what it has produced.