Robert Doherty, BA; for the Medical Practice and Quality Committee of the American College of Physicians *
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Acknowledgment: The authors thank Michelle Koltov for conducting the initial review of literature and preparing an early draft of the manuscript and Kolton Gustafson for his administrative support to the authors.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Mr. Doherty reports the following outside of the manuscript: board membership, consultancy, employment at ACP, expert testimony, grants (or grants pending), payment for lectures (Department of Medicine, Jefferson Hospital, Philadelphia; honoraria [pending]), payment for manuscript preparation, patents, royalties, payment for development of education presentations, stock or stock options, travel (Utilization Review Accreditation Commission [URAC]; no compensation received for board membership but travel expenses to attend URAC board meetings were reimbursed), other travel/accommodations/meeting expenses, and other. Mr. Doherty reports the following during the composition of the manuscript: grant(s), consulting fees or honorarium, support for travel to meetings for the paper, fees for participation in review activities, payment for writing or reviewing the manuscript, provision of writing assistance or administrative support, and other. Dr. Fuisz reports that she is a Managing Partner of a small private practice group; this is a direct payment practice that does not participate in Medicare or other insurance products. Dr. Hunter reports that her input to the manuscript reflects her own views and not those of the U.S. Office of Personnel Management where she is employed as the Chief Medical Officer. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0366.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Robert Doherty, BA, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 2001; e-mail, email@example.com.
Author Contributions: Conception and design: R. Doherty, N.S. Damle, A.L. Fuisz, R. McLean, F. Syed, M.P. Tschanz.
Analysis and interpretation of the data: R. Doherty, N.S. Damle, M. Newman, C.M. Soppet.
Drafting of the article: R. Doherty, N.S. Damle, J.W. Fincher, M.D. Leahy, A.L. Clark, F. Syed.
Critical revision of the article for important intellectual content: R. Doherty, N.S. Damle, M. Auron, J.W. Fincher, A.L. Fuisz, C.S. Hunter, R. McLean, A.L. Clark, M. Newman, C.M. Soppet.
Final approval of the article: R. Doherty, N.S. Damle, J.A. Blehm, C.M. Reimer, E. Barrett, J.W. Fincher, A.L. Fuisz, C.S. Hunter, M.D. Mignoli, R. McLean, A.L. Clark, M. Newman, C.M. Soppet, F. Syed.
Administrative, technical, or logistic support: R. Doherty, C.S. Hunter, R. McLean, J. O'Neill Jr.
Collection and assembly of data: R. Doherty, N.S. Damle, C.S. Hunter, F. Syed.
As physicians seek innovative practice models, one that is gaining ground is for practices to contract with patients to pay directly for some or all services—often called cash-only, retainer, boutique, concierge, or direct primary care or specialty care practices.
Such descriptions do not reflect the variability found in practices. For the purposes of this paper, the American College of Physicians (ACP) defines a direct patient contracting practice (DPCP) as any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care. This definition encompasses the practice types previously described.
The move to DPCPs is based on the premise that access and quality of care will be improved without third-party payers imposing themselves between the patient and the physician. Yet concerns have been raised that DPCPs may cause access issues for patients who cannot afford to pay directly for care.
This ACP position paper, initiated and written by its Medical Practice and Quality Committee and approved by the Board of Regents on 25 July 2015, assesses the impact of DPCPs on access, cost, and quality; discusses principles from the ACP Ethics Manual, Sixth Edition, that should apply to all practice types; and makes recommendations to mitigate any adverse effect on underserved patients.
Among the retainer-only physicians that could estimate their panel size, patient panels ranged from 100 to 425 patients. The average size was about 250 patients, just over a tenth of the average panel size these respondents reported having before starting their retainer-based practice (2265 patients). The physicians using hybrid models had kept a much larger patient panel, but had many fewer retainer patients. Over half of our respondents wished their practice size was larger (18).
Here's how it works: For a flat fee every month, patients have unlimited access to their doctor–in person and by phone or email–for routine things like checkups, cuts and burns, infections, flu shots and skin exams, as well as chronic-condition maintenance like blood tests for diabetes or high cholesterol. Under the law, every American is required to have medical insurance–but direct-primary-care patients can seek less expensive policies, because they require coverage only for hospitalizations, surgeries and other specialized care. […] Qliance now serves some 35,000 patients; the cost of about half of them is paid by the government through traditional and expanded Medicaid programs. Treating a wide variety of patients—young and old, healthy and chronically sick, well-off and poor—Qliance claims to be saving approximately 20% on the average cost of care compared with traditional fee-for-service providers” (8).
Concern about the impact of the changing practice environment on physicians and insured patients should not distract physicians or society from attending to the unmet needs of persons who lack insurance or access to care.
Physicians have an obligation to promote their patients' welfare in an increasingly complex health care system. This entails forthrightly helping patients to understand clinical recommendations and make informed choices among all appropriate care options. It includes management of the conflicts of interest and multiple commitments that arise in any practice environment, especially in an era of cost concerns. It also includes stewardship of finite health care resources so that as many health care needs as possible can be met, whether in the physician's office, in the hospital or long-term care facility, or at home.
The patient–physician relationship and the principles that govern it should be central to the delivery of care. These principles include beneficence, honesty, confidentiality, privacy, and advocacy when patient interests may be endangered by arbitrary, unjust, or inadequately individualized programs or procedures. Health care, however, does take place in a broader context beyond the patient–physician relationship. A patient's preferences or interests may conflict with the interests or values of the physician, an institution, a payer, other members of an insurance plan who have equal claim to the same health care resources, or society.
Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians' considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches. When patients ask, they should be informed of the rationale that underlies the physician's recommendation (12).
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School of Community Health, Portland State University
November 30, 2015
Academic Medicine and Concierge Practice
Doherty et al. neglect to mention that many luxury care clinics are sponsored by academic medical centers. , Some partner with national concierge care companies. Marketing for such clinics is directed at the heads of successful small and large companies, who are disproportionately white men. Many physicians who staff luxury care clinics limit their practices to the wealthy.1,2 Not only do retainer-practice physicians care for fewer African-Americans, Hispanics, and Medicaid patients than non-retainer-practice physicians, those who convert to a retainer practice keep an average of only 12% of their former patients, thus burdening other, already overworked physicians in the community. The general public contributes substantially, through state and federal taxes, to the education and training of new physicians, and thus might find it hard to accept physicians limiting their practices to the wealthy. Although academic medical centers, traditional providers for the poor and underserved, might justify sponsoring luxury clinics via a utilitarian argument, there are only 2 programs that use income from these ventures to cross-subsidize indigent care or teaching programs.1,2There is no high quality evidence documenting a higher quality of care in concierge practices, and few data support the clinical- or cost-effectiveness of many of the unnecessary tests offered to asymptomatic clients.1,2, Over-testing may result in false-positive results, leading to further unnecessary investigations, additional costs, and heightened anxiety. True-positive results may result in over-diagnosis of conditions that would not have become clinically significant, leading to further risky interventions and possibly impairing future insurability. The use of clinically unjustifiable tests erodes the scientific underpinnings of medical practice, runs counter to the ethical obligations of physicians to responsibly manage limited health care resources, and likely leads to worse care.Most training in professional ethics, as well as the development and teaching of evidence based practice guidelines, occurs in medical schools and at teaching hospitals. No data are available on the participation of medical students and residents in luxury care clinics at teaching hospitals. For such institutions to teach students to treat all patients equally, to combat inequalities in health care access and outcomes, and to practice evidence-based medicine, while supporting clinics that do the antithesis, is troubling. At the least, trainees should not be allowed to work in such clinics. 1. Donohoe MT. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x 2. Donohoe MT. “Standard vs. luxury care,” in Ideological Debates in Family Medicine, S Buetow and T Kenealy, Eds. (New York, Nova Science Publishers, Inc., 2007). 3. Alexander GC, Kurlander J, Wynia MK. Physicians in retainer practice: a national survey of physician, patient, and practice characteristics. J Gen Int Med 2005;20:1079-83. 4. Wolfe SM. The destruction of medicine by market forces: Teaching acquiescence or resistance and change? Acad Med 2002;77:5-7. 5. Donohoe MT. Unnecessary Testing in Obstetrics and Gynecology and General Medicine: Causes and Consequences of the Unwarranted Use of Costly and Unscientific (yet Profitable) Screening Modalities. Medscape Ob/Gyn and Women’s Health 2007. Posted 4/30/07. Available at http://www.medscape.com/viewarticle/552964_print.
Doherty R, for the Medical Practice and Quality Committee of the American College of Physicians. Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians. Ann Intern Med. ;163:949–952. doi: 10.7326/M15-0366
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Published: Ann Intern Med. 2015;163(12):949-952.
Published at www.annals.org on 10 November 2015
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