The real problem with concierge medicine

Luxury or “concierge” medicine has become increasingly prevalent in the past few years. Concierge practices are private medical services that charge an expensive retainer fee to guarantee more personalized, in-depth care and availability.

As Nelson D. Schwartz wrote in his New York Times article "The Doctor Is In. Co-Pay? $40,000," concierge medicine raises significant ethical concerns among practitioners, while simultaneously solving the problems of a select niche' market and helping some institutions obtain more funding for pro-bono work. We believe that, while there may be serious ethical issues with concierge medicine, these concerns are but a symptom of a much deeper problem: America just doesn’t have enough healthcare professionals, and the ones we have may not be used properly.

Concierge medicine is a simple concept: rather than wait in crowded waiting rooms for care from over-worked doctors who might not be available for an appointment for days or weeks, some wealthy individuals choose to pay a large retainer fee to a doctor who will only treat about 50 patients per year. How high are the fees? Schwartz writes that one doctor, Jordan Schlain, charges anywhere “from $40,000 to $80,000 per family” to retain his services. The benefits flow both ways: families receive individualized, highly attentive care that are almost always available, and the doctors receive salaries of upwards of $500,000 per year. And what does a retainer purchase? The annual fee for one company, Private Medical, “covers the cost of visits, all tests and procedures in the office, house calls, and just about anything else other than hospitalization, as well as personal annual health plans and detailed quarterly goals for each patient.” While such care might seem mundane, some visits can be more serious: Dr. Schlain advised one patient to come in to have his broken leg set, rather than go to a local hospital.

Naturally, many people, including concierge practitioners themselves, have raised concerns about the ethics of charging such high rates for access to healthcare. Access to healthcare should theoretically be egalitarian, accessible to all people regardless of race, gender, sexuality, religion, or, in this case, money. It seems odd to think it’s okay for someone to “cut the line” just because they happen to have a lot of money. Using concierge medicine to “cash out” early in one’s career may also be morally problematic from an educational standpoint: such individuals take spots from medical school applicants who may have planned to put their talents to wider use. The result is a growing system in which a small segment of students can soak up medical school resources and then use them to treat a small number of wealthy clients, potentially at the expense of many others.

We agree that concierge medicine raises serious ethical concerns. However, we also think the situation might not be as bad as it seems. Concierge medical services cost a great deal of money, more than many Americans make in a single year. That price point significantly narrows the pool of people who might actually benefit from such practices anyway. While concierge practices might theoretically enable some individuals to “cut the line” and receive care more quickly, it is unlikely that this might become a systematic issue, even if concierge medical practices proliferate in the coming years. From a systematic perspective, some practices, like those housed in luxury hospital suites, allow medical services to acquire funds that can be used to cover pro-bono services for individuals who might not normally be able to afford care.

The bigger issue at stake with concierge medicine is the system that produces it. Many concierge practitioners turn to expensive private practices because they were forced to see so many patients in the course of a day in a traditional healthcare setting that they didn’t feel they could give all of them the attention, and thus the quality of care, that they deserved. Why does this happen? As a system we may not have enough doctors. As of 2013, the United States ranked 23rd of 28 countries that reported data to the Organization for Economic Co-Operation on their ratio of doctors to patients, with 2.56 doctors for every 1,000 patients (for comparison, Australia was first with 4.99). The raw numbers can be quite staggering as well: in a 2016 report, the Association of American Medical Colleges predicted that America will experience “a projected total physician shortfall of between 61,700 and 94,700 physicians by 2025.”

It’s also possible we have quite enough doctors, but that they’re not being used correctly. Aaron E. Carroll argues that the problem isn’t a shortage, but that our system is inefficient: we underuse nurse practitioners and physician’s assistants, clinicians who could shoulder much more of the burden in services like primary care than they do currently. Additionally, the overall distribution of practitioners is far from balanced: there are both financial and personal incentives that push clinicians toward practicing in major cities. While such cities need more clinicians in raw numbers to handle the greater patient loads placed on the system, the result is that other areas of the country suffer a disproportionate shortage of caregivers.

We can fix these issues by making a few changes to our system, though none of them will be an easy task. First, we could allow nurse practitioners and physician assistants to carry more of the burden in primary care. We could also try to increase the number of doctors we have, which could be achieved in a number of ways. One way would be to allow more clinicians to immigrate from overseas. However, as CBS News’s Mary Brophy Marcus notes, whether or not this is feasible largely depends on the Trump administration’s immigration policies. Another option would be to reduce the financial burdens placed on medical students and potential applicants, burdens that both persuade graduates to flock to higher-paying practices and that likely discourage large numbers of applicants from entering the profession at all. Medical schools could lower tuition costs, which can cost hundreds of thousands of dollars. While schools might be hesitant to cut their profits, it’s possible that the move would be financially justified if larger class sizes brought in more fees overall. Even if schools broke even with the changes, making the effort to solve the shortage is the right thing to do. Another path could come with government incentives: for example, much like in the City University of New York educational system for training new teachers, clinicians could receive a discount, or even tuition remission, if they agreed to practice for a certain number of years in locations where doctors are desperately needed. This option has the dual benefit of increasing the total number of doctors while also balancing distribution levels.

While it might be true that luxury, concierge medical practices raise serious ethical concerns, trying to solve them misses the forest for the trees. We can go a long way to avoiding them and greatly improve access to care by making the American healthcare system more efficient as a whole.

Michael S. Dauber, M.A., is a philosopher, bioethicist and writer with an MA in Bioethics from NYU and a BA in Philosophy and Journalism from Fordham University. He has served as a clinical ethicist and currently works on an Institutional Review Board. He has given numerous talks on topics in medical ethics, research ethics, and normative philosophy.

Jon Newlin, C.I.P., received his BA in Anthropology and Philosophy from Connecticut College. He is the Assistant Director of an Institutional Review Board, and has presented his work in research ethics at professional conferences.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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