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Ideas and Opinions |

Retainer Medicine: An Ethically Legitimate Form of Practice That Can Improve Primary Care

Thomas S. Huddle, MD, PhD; and Robert M. Centor, MD
[+] Article, Author, and Disclosure Information

From the University of Alabama at Birmingham, Birmingham, Alabama.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0928. Drs. Huddle and Centor have not now or ever participated in retainer practice and have no future plans to do so.

Requests for Single Reprints: Thomas S. Huddle, MD, PhD, Division of General Internal Medicine, University of Alabama at Birmingham, FOT 720, 1530 6th Avenue South, Birmingham, AL 35294; e-mail, thuddle@uab.edu.

Current Author Addresses: Drs. Huddle and Centor: Division of General Internal Medicine, University of Alabama at Birmingham, FOT 720, 1530 6th Avenue South, Birmingham, AL 35294.

Author Contributions: Conception and design: T.S. Huddle, R.M. Centor.

Drafting of the article: T.S. Huddle, R.M. Centor.

Final approval of the article: T.S. Huddle, R.M. Centor.

Ann Intern Med. 2011;155(9):633-635. doi:10.7326/0003-4819-155-9-201111010-00013
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Retainer medicine has become an important yet controversial form of primary care practice in the United States, coming under attack for its purported failure to measure up to professional ethics. Critics opine that retainer medicine obstructs professional commitments to health care access and social justice. Some ethicists urge that society should restrict or ban retainer medicine; professional organizations have yet to take a stand. The authors believe that retainer medicine is compatible with professional ethics and will more likely aid in solving the difficulties facing primary care rather than add to them. Although professional ethics should evolve to address new conditions, a condemnation of retainer medicine is warranted neither by traditional ethical precepts nor by contemporary developments in medical ethics. Any move to sanction retainer medicine under the banner of professionalism or professional ethics will be counterproductive. The primary care shortage will only get worse if physicians in retainer practice leave primary care altogether, a likely outcome of legal or professional condemnation of retainer practice.





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Submit a Comment/Letter
An easier life, but not more respect
Posted on November 1, 2011
PeterManu, Professor of Medicine
Hofstra University
Conflict of Interest: None Declared

Huddle and Centor have produced a painfully strained justification for a perfectly legal practice. In capitalist and free-wheeling United States it is all right to charge willing patients substantial fees for anything, including the promise of better primary care.

I am amazed, however, by the authors' lack of critical insight with regard to the quality of "retainer medicine". The reader is asked to assume that longer visits, increased availability after usual office hours and "streamlined" access to specialists create the premise for better outcomes. No reliable data are provided and none are in fact available. In their absence we need to use common sense and ask: is "retainer medicine" practiced by a middle-of-the pack recent graduate of a less than stellar residency program better than hurried office visits with Robert Centor?

"Retainer medicine" is an old way of making money, not of practicing better primary care. It is legal and will continue to expand as long as the market for this service exists. If history serves, those practicing "retainer medicine" will have an easier life and possibly more money than the rest of us, but not more respect.

Conflict of Interest:

None declared

Re:An easier life, but not more respect
Posted on November 4, 2011
don a.evans, General Internist
Conflict of Interest: None Declared

I felt the authors took great and unnecessary pains to establish(?) the lack of an MD's obligation to maintain current levels of capacity if he wishes not to. However, the prime attraction of concierge medicine is higher compensation for the time spent.

Any practitioner can reject the hurried through-put of modern office practice by electing to schedule longer visits and 1)work longer hours or 2)accept less income. The notion that there are things that REALLY ought to be done but are not now being done because of lack of time merely indicates a desire for higher compensation. Otherwise the MD's drawn to "retainer medicine" would do be doing them now.

More personal availability and more enthusiasm for meeting patients' convenience desires, beyond the scope of currently established medical practice, does not translate to improved quality or outcomes.

Sometimes patients desire that which is not beneficial and these highly-compensated concierge servant/doctors have abnormal incentive to please them.

Elvis had Dr. Nichopoulos....Michael Jackson had Dr. Conrad Murray....

This scheme of extracting higher payment is not new or good.

Conflict of Interest:

None declared

Chance to Correct the Mistakes of the Past
Posted on November 7, 2011
EdwardVolpinesta, MD
Conflict of Interest: None Declared

Reasonable and opposing arguments regarding the ethical basis of retainer practice have recently been presented (1, 2).

The growing desperation among primary care doctors that is responsible for the retainer practices is the result of the indifference with which the leaders of medicine responded to their calls for help during the past two decades.

Ignored by the top leadership in their profession , it should not come as a surprise that some doctors have lost the idealism that in earlier times would have made them sensitive to the problem of limited access.

Without the full support of the medical schools primary care never developed an identity or a solid position within the medical hierarchy. As a result primary care physicians are considered as second-rate by insurers, who use it as an excuse to devalue their services and pay them accordingly.

Medical educators should see the present crisis in primary care as an opportunity (maybe the last one) to correct the mistakes of the past.


1. Hudddle TS, Centor RM. Retainer medicine: an ethically legitimate form of practice that can improve primary care. Ann Intern Med. 2011; 155:633-635.

2. Lo B .Retainer medicine: why not for all? Ann Intern Med. 2011;155:641-642

Conflict of Interest:

None declared

Too Cute By Half, or A Case of Irrelevancy
Posted on November 8, 2011
Michael D.Stillman, Physician
Boston University School of Medicine
Conflict of Interest: None Declared

Drs. Huddle's and Centor's recent piece in "Annals of Internal Medicine" ("Retainer Medicine: An Ethically Legitimate Form of Practice That Can Improve Primary Care) leaves the reader befuddled from its very title line. Is the essay to establish that concierge medicine is "ethically legitimate?" Or is it to argue that widespread adoption of the concierge model would improve primary care? Perhaps, ambitiously, both?

Nowhere in this article is there a substantiated or well-reasoned claim that retainer medicine "can improve primary care." The authors argue that in containing our ire over concierge medicine, the silent majority of internists may increase interest among trainees in entering primary care. They also contend that retainer medicine is the form of practice "most conducive to ethical and competent professional work." But this essay specifically and notably lacks data, expert opinions, or even cogent arguments showing that retainer medicine improves anything at all. Other, of course, than a physician's ability to explore "other pursuits."

And what of concierge medicine as an "ethically legitimate form of practice?" Drs. Huddle and Centor advance a complicated argument on this front. They posit that pursuit of social justice is a civic, not a professional obligation. They then opine that "social justice" is a slippery and contested notion, and that we ought not assume that it includes universal access to health care. They then detail the many difficulties of holding individual physicians responsible for shortage of care. This stream of arguments is "too cute by half." While internally consistent, deft, and pretty, it is completely irrelevant to how we are to judge retainer medicine.

I participate in an annual continuing education conference in South Carolina. Attended predominantly by small town internists and nurse practitioners, the audience seems to represent the "real America" of general practice. Care givers struggling with insurance reimbursements, seeing twenty to thirty patients each day, and beating their knuckles raw against systemic annoyances and road blocks.

Last year I was reviewing a piece on concierge medicine which had been submitted to a major medical journal, so I informally polled the attendees on their feelings on the subject. Nearly all of them were against it, many claiming that they couldn't stand to abandon their loyal patients simply because they couldn't afford to pay retainer fees, or that "they wouldn't feel right" so sharply limiting their practices. Poignantly, one rural physician who hadn't yet heard of concierge medicine blurted out, "But that's disgusting."

When Drs. Huddle and Centor glibly write in the first paragraph about patients losing access to care when their physicians go concierge, or in the last about how we should "encourage" retainer medicine, they ignore hard economic realities. According to 2009 census data, the average household income in the United States is just over sixty thousand dollars, and just over forty thousand in the authors' home state of Alabama. To argue in favor of practices which demand "retainer" fees representing a significant percentage of annual family income in this country is unethical. And to argue that a proliferation of such practices will improve access to care is nonsensical and embarrassing.

The truth on the subject is this: dazzling leaps of logic may be made in defense of concierge medicine. There may be no tenet of medical ethics which specifically prohibits internists from charging retainer fees (though the Hippocratic Oath is difficult to debunk). Promoting luxury care may, indeed, attract a few graduating residents to general practice. But all of this is immaterial. Concierge medicine simply does not pass the sniff test, and we all know it.

Conflict of Interest:

None declared

Posted on November 15, 2011
martin tdonohoe, adjunct associate professor
School of Community Health, Portland State University
Conflict of Interest: None Declared

Social justice is a fundamental component of medical ethics and professionalism.(1) Physicians have an obligation, borne of their privileged status, the public's investment in their training, and their roles as stewards of the public's health, to work for social justice by addressing, individually and collectively, the social, economic, gender, racial and cultural factors which contribute significantly to morbidity and mortality.(2)

Retainer practices will adversely impact the growing shortage of primary care physicians available to care for our aging population. While there are some lower-cost retainer practices, many provide luxury/concierge care, in which physicians limit their practices to the wealthiest. Retainer-practice physicians have much smaller patient panels and care for fewer African-Americans, Hispanics, and Medicaid patients than non-retainer-practice physicians.(3) Physicians who convert to a retainer practice keep a small percentage of their former patients, increasing the burden on other primary care providers.(3)

Many retainer practices (especially luxury care clinics) are sponsored by academic medical centers, traditional providers for the poor and underserved.(4,5) For teaching institutions to promote such clinics will worsen growing cynicism among medical students, practicing physicians, and the general public. While medical centers might justify sponsoring luxury clinics via a utilitarian argument, there are only two programs which use income from these ventures to cross-subsidize indigent care or teaching programs.(4,5)

There is no evidence documenting a higher quality of care in concierge practices, and little data support the clinical- or cost- effectiveness of many of the unnecessary tests offered to their asymptomatic clients.(4,5) Over-testing may result in false-positive results, which lead 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 and runs counter to physicians' ethical obligations to responsibly manage limited health care resources.

Finally, access for all is unlikely to be achieved soon. The Patient Protection and Affordable Care Act will only provide insurance to an additional 26 million Americans, leaving 23 million without insurance. It is complex; perpetuates current inefficiencies; will increase bureaucracy; and benefits insurance companies, which fulfill their primary responsibility to maximize profits for their shareholders by minimizing "medical loss ratios." Physicians should advocate for a single payer national health care plan, which would (justly and cost-effectively) provide coverage for everyone.


1. ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Int Med 2002;136:243-246.

2. Donohoe MT. Roles and responsibilities of health professionals in confronting the health consequences of environmental degradation and social injustice: education and activism. Monash Bioethics Review, 2008;27(Nos. 1 and 2):65-82.

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. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1525- 1497.2005.0233.x/abstract. Accessed 11/9/11.

4. 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).

5. 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://onlinelibrary.wiley.com/doi/10.1111/j.1525- 1497.2004.20631.x/abstract. Accessed 11/9/11.

Martin Donohoe, MD, FACP Adjunct Associate Professor, School of Community Health Portland State University Member, Board of Advisors, Oregon Physicians for Social Responsibility Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center

Conflict of Interest:

None declared

Ethics are Important
Posted on November 16, 2011
Stanley J.Zimmerman, M.D., FACP, FACE, FACN
Conflict of Interest: None Declared

To the Editor:

I read with interest the article Retainer Medicine: An Ethically Legitimate Form of Practice that can Improve Primary Care. They explain very carefully in their article about the mechanics of Retainer Medicine or Concierge Medicine. There is still a third process in which the physician takes no insurance and charges $600.00 per visit. The facts are that physicians are experiencing a decrease compensation for care due to the fact that insurance companies and Medicare limit the reimbursement for services provided. There is no question that Retainer Medicine or Concierge Medicine, if it is successful, provides the physician a much larger income. It also limits the number of patients that the physician sees. Dr. Huddle and Centor discuss the issue of social justice and professional ethics. I am concerned about the issue of ethics. In other words, if a patient pays more he will get the time and expertise for the patient's complaints and illnesses. However, if the patient does not pay this extra fee, they will not be entitled to the same time and care as the patient who does pay the extra fee. Does this really follow the Hippocratic Oath and the ethics of a true physician? Medicine is truly an honored profession and each and every physician should consider it a privilege to be able to practice medicine and to have patients that have trust and faith in their physician to handle their health needs in the best possible manner. We are losing more and more physicians in family practice and Internal Medicine due to stresses placed upon them, both in terms of patient care and also financially. The majority of patients are unable to pay the extra fees since they are already paying for medical insurance and are struggling thru a weakened economy. Fortunately, we live in a country that allows freedom of choice, so that if a physician has the patient clientele that can afford the thousands of dollars extra for care and he wishes to practice in that way, he can do so. Does the patient who cannot afford the extra thousands of dollars deserve less care?


Stanley J. Zimmerman, M.D., FACP, FACE, FACN

Conflict of Interest:

None declared

Re:"Too Cute By Half, or A Case of Irrelevancy"
Posted on November 18, 2011
Josh JUmbehr, MD, CEO
AtlasMD Concierge Family Practice
Conflict of Interest: None Declared

Although I think there is plenty of room for debate on many of the points you mentioned, I'd to focus on a different point: not all retainers models are the same. I think we are making a basic mistake of assuming all "insurance free" models are designed for the upper crust.

My model is not. We charge $10-100/mo/pt based on age only (all pre- existing conditions welcome) for unlimited home, work, office or technology visits (no copays). We also have steep discounts on meds and labs by contracting directly with the labs and rx wholesalers.

Ex: cbc $2, lipid panel $3, tsh $4, cmp $4.50, A1c $6 etc. 4mg Zofran,#30 $6 20mg omeprazole, #100 $10 50 imitrix, #9, $8 20mg Simvistatin #100, $3 300mg Gabapentin #100, $10 50mg setraline #30, $2 to name just a few... (all prices are rounded up to the closest half dolla to cover our costs, not to make a profit.)

All procedures in the office are free including: ekg, spiro, DEXA, laceration repair, biopsies, joint injections, ultrasound screenings, medical laser treatments, breathing treatments, holter monitor, audiotmetry, splinting, UAs, pregnancy tests, rapid streps and soon to include xrays, over night pulse ox screenings and more. Some medicines are so affordable, we also provide them free of charge, like mobic, prednisone, difulcan, injectable toradol, phenergan and zofran.

Due to this broad menu of services, we're able to work WITH insurance companies to decrease the cost drastically. We've save young families over $1000/month and businesses 30-50%.

We feel that this model, compared to the usual retainer models, will answer many of your concerns. Each physician will focus on 400-600 patients. This improves quality of life, time with patients, allows for moderate income, yet still insures for flexible after hours visits to decrease ER usage. I believe this will drive doctors back into primary care, keep them their longer, decrease the fragmented system and improve patient care for less cost.

A full 30% of our practice is uninsured and it works beautiful for them.

The answer will not be found in insurance comapanies or the gov't. We physicians only have ourselves to blame for not employing sound business principals to help lower cost and improve quality.

I am VERY curious about other physicians opinion of a model like this? Does this change anything? Does it help?

Conflict of Interest:

Owner, Operator of a Concierge Medical Practice

Retainer Medicine: Ethically legitimate, but not the best future of Primary Care
Posted on November 21, 2011
Douglas MVan Zoeren, MD, MPH, FACP, Chief of Adult Medicine
Kaiser Permanente Mid Atlantic States Region
Conflict of Interest: None Declared

Huddle and Cantor argue that "retainer medicine is compatible with professional ethics and will more likely aid in solving the difficulties facing primary care than add to them". The purported benefits of retainer medicine for patients include enhanced access, streamlined specialty referrals, and other perquisites. Benefits for practitioners include a manageable practice size and a more satisfying practice experience. The ethical defense of retainer medicine that is presented is reasoned and presents an ethically legitimate vision for the practice of primary care medicine.

However, given the current and projected shortages of primary care physicians, there are better alternatives to the concierge model of practice. Primary care practice in an integrated health care system achieves significant benefits for patients and for physicians, without the public health implications of significantly reduced panel sizes. By leveraging technology and physician leadership, large systems such as Kaiser Permanente have achieved unparalleled access to primary and specialty care, market leading preventive health outcomes, and a culture of primary care practice that is both sustainable and rewarding. Members of Kaiser Permanente can send secure Emails to their primary and specialty care physicians, see specialists within days (sometimes within the hour), and reap the benefits of the nation's largest civilian EMR. Primary care physicians and patients both have the unique advantage of being supported in preventive health care by every specialist within the system, in which sophisticated tools, standardized processes and a culture of prevention have come together to create a system in which preventive health care is every physician's responsibility. The benefit to physicians is a rewarding practice environment, while patients receive perks similar to those they would otherwise pay extra for in a retainer practice.

There are important implications for the future of primary care medicine and for the nation's health care work force. In contrast to retainer practices, physicians working within an integrated system do not need to limit their practice size to a few hundred patients in order to provide superior service to their patients, or to help them attain the best outcomes. The concept of the Medical Home is already well- established in integrated systems of care. The Kaiser Permanente model for the care of populations has demonstrated the ability to significantly improve health outcomes.

As an alternative to concierge medicine, we should recognize the inherent advantages of integrated health care. The future of primary care lies in physician leadership of systems designed to utilize technology in new and powerful ways, and physicians working collaboratively to achieve the best access and outcomes. In doing so, the professional satisfaction of all physicians will be enhanced and the practice of primary care medicine will be improved.

Conflict of Interest:

None declared

The concierge is open, at what cost?
Posted on November 26, 2011
James R.Webster, Professor of Medicine, None
Feinberg School of Medicine of Northwestern University
Conflict of Interest: None Declared

Retainer/concierge practices (1) make a commercial contract with selected affuent patients who pay a fee covering future services. The primary goal of this endeavor, no matter how it is presented, is revenue enhancement for the proprietors. In so doing these physicians breach their pact with society. They clearly violate, reject, and disregard the faith and implied contractual duties arising from the large Federal and State subsidies that generously supported their undergraduate and postgraduate medical education. They should repay those dollars or, if they choose not to do so, at the very least they must be required by the profession to donate public service time to help resolve the problems of access and health disparities as Lo (2) suggests. At its foundation medicine is a calling to service, not a business. Retainer practices turn this principle upside down.

James Webster, MD, MS, MACP

1. Huddle Ts, Centor RM. Retainer medicine: An Ethically legitimate form of practice that can improve primary care.Ann Intern Med. 2011;155:633-635 2. Lo B. Retainer Medicine: Why not for all? Ann Intern Med. 2011;155:641- 642

Conflict of Interest:

None declared

Affordable Personalized Care DOES Improve Health Outcomes
Posted on November 29, 2011
Andrea B.Klemes D.O., Medical Director, Stephen H. Glasser, M.D.
Conflict of Interest: None Declared

The articles on retainer medicine were of great interest to us at MDVIP (1,2). The MDVIP primary care model focuses on personalized preventive healthcare by delivering noncovered screenings and diagnostics for a membership fee, as well as limiting the number of members in each practice to be able to logistically deliver the service. This model allows physicians to provide more personalized attention to disease screening and prevention programs, not just the diagnosis and treatment of illness. In this model, the additional time and focus on prevention and wellness do lead to better health outcomes and ultimately lower healthcare costs.

Physicians join MDVIP because they are frustrated that they cannot deliver the quality of care they want to. Many were going to leave medicine before transitioning to this model. This is not a social or ethical issue, but rather a practical issue as to the number of patients that one can see to render comprehensive, thorough care and thought. This is affordable care as patients come from all walks of life. And MDVIP physicians and patients have unparalleled satisfaction (over 95%) with the model.

Dr. Lo states, "It is not known how the quality and cost of care provided by different types of retainer medicine compare with other practice models" (2). MDVIP has data to show that this model of care has better clinical outcomes, decreased hospitalizations and readmissions and a lower cost of care and has submitted this data for publication.

One study showed that in a population of patients with chronic diseases (diabetes, hyperlipidemia, hypertension and atrial fibrillation), MDVIP physicians' outcomes beat all HEDIS measures as well as the top 10% of HMO/PPO benchmarks. This included BP control, HgbA1c, lipids and preventive screenings like colonoscopy and mammograms.

Another study that looked at hospital discharge rates over the last five years shows that MDVIP patients are in the hospital less than non- MDVIP patients. In 2010, MDVIP commercially-insured patients had 72% less hospital discharges per thousand than non-MDVIP patients and 79% less in Medicare patients. The same study looked at readmission rates for acute MI, CHF and pneumonia and these were all under 2%. The savings to Medicare alone in one year is over 300 million dollars.

We feel that the MDVIP model is the only option to deliver affordable, proactive, personalized care. MDVIP physicians are giving better care, practicing longer and saving the system money.


1. Huddle TS, Centor RM. Retainer Medicine: An ethically legitimate form of practice that can improve primary care. Ann Int Med 2011; 155:633- 635.

2. Lo B. Retainer Medicine: Why not for all? Ann Int Med 2011; 155: 641-642.

Conflict of Interest:

Andrea Klemes is an employee of MDVIP. Stephen Glasser is an MDVIP-affiliated physician.

Retainer Medicine
Posted on November 30, 2011
Choice Care
Conflict of Interest: None Declared

Thanks to Drs. Huddle and Centor for a very thoughtful exposition of the social obligations of primary care physicians and their understanding of the ethical commitment those of us practicing retainer medicine have toward our patients.

I would like to offer some additional thoughts. When I decided to leave traditional medicine, I did so because I had a visceral need to do my job and I could not be the professional my patients deserved if I spent 9-15 minutes with them per visit. I found it disquieting to charge a patient to sit in my waiting room for 4 hours just to ask me a question when I knew that a phone call would be more appropriate.

Retainer medicine allows me to work directly for my patient without conflict. About 10% of my patients don't pay me a dime and they get the same individualized attention my paying patients get. I enjoy the privilege of giving and can do that without hesitation in my retainer practice. We answer the phone, "how can we help you?" not "what insurance do you have?"

I surely gave my ethical responsibilities a lot of thought when I decided to enter into a private contract with my patients and I am very comfortable that I am fulfilling my duty as a professional better and without conflict as a retainer physician than as a doctor working either for a hospital, an insurer, or a group.

I sell my patients a better more productive day. In the end, society is better off when every person has a physician advocate who has their personal interests as their primary focus. That said, every person needs a primary doctor not necessarily a primary care doctor. That might be an endocrinologist or a rheumatologist.

The discussion of healthcare reform should concentrate on the care we offer rather than the financing of the system. We can never get back to every doctors instinctive need to do right by their patient only because it is the right thing if we continue to direct reforms at financing systems.

Thank you for respecting the opportunity retainer doctors provide for thousands of patients, rich and poor.

Conflict of Interest:

None declared

Re:Retainer Medicine
Posted on December 1, 2011
ChrisEwin, MD, family physician
past president, AAPP
Conflict of Interest: None Declared

Thank you Marcy...(past president, AAPP) and thank you Drs. Huddle/Centor for a well written article.

As the third president of AAPP ( American Academy of Private Physicians), we established a clear and well thought out set of ethical standards for physicians with innovative medical practice designs.... Garrison Bliss, our second president, headed up the committee.

Our standards are high....which is no different (hopefully) than other physicians... It's all about the patient.


Further, I wonder sometimes about whether fellow physicians/policy wonks/politicians...etc. have ever been to many (or any) retainer practices that they so passionately comment about. Most have never run a primary care clinic and aren't on the front lines of medicine....nor are they physicians.... It's amazing to me looking back to med school where my academic mentors commented on practice settings that they never had experienced...Sounds kinda dumb to me.

There seems to be such a misunderstanding about how the free market works....It's the patient that decides whether the price is worth it to them....Access to quality care with their physician...

Regardless, the idea that retainer medicine is "luxury" medicine has been debunked a long time ago...

(like the heroine addict I just spent an hour with who I detoxed off of heroine {$60-70/day} when he weighed 115 lbs and now weighs 135 lbs and almost off his Suboxone).... For his medical problems (Asthma/etc.), I charge him $2.31/day).....he likes that deal.....

Conflict of Interest:

None declared

Posted on December 12, 2011
Thomas S.Huddle, Professor of Medicine, Robert M. Centor
UAB School of Medicine
Conflict of Interest: None Declared

Drs Zwelling and Umbehr describe experiences with retainer practice that comport with the highest standards of medical ethics and professionalism, as these have been traditionally understood. Dr Van Zoeren argues that primary care physician shortages make integrated practice a better alternative. Drs Webster and Donohoe press an ethical case against retainer medicine, elements of which are alluded to in Dr Lo's editorial (1).

Drs Webster and Donohoe's contention that retainer medicine breaches the social contract between our profession and society is unsupported. To our knowledge, society has not (so far) stipulated to physicians that in exchange for benefits granted they will be required to sacrifice some given portion of income, quality of work, and job satisfaction to take care of given numbers of the medically indigent. Drs Webster and Donohoe presumably find such an obligation not in a de facto social contract but in the ethical dictates of medical professionalism. We agree that some have asserted such obligations in the recent past, but medical professionalism, understood as the tradition of medical morality articulated by physicians from the time of Hippocrates up to the recent past, has not. American society treats physicians very well, and we have obligations to do exemplary professional work in exchange for the work settings and remuneration it provides. We also have obligations to provide some free care to those who cannot afford it. Traditional understandings of professionalism do not extend to the further social and political obligations that Drs Webster, Donohoe and Lo would claim for it.

Without reiterating the argument in our paper as to why we ought not to shift our moral understanding of medical practice in the direction advocated by Drs Webster and Donohoe, we observe that doing so would shatter what professional unity amid political diversity our profession has so far been able to maintain. All physicians should, of course, favor the diminishing of social ills, including health disparities and lack of access to health care. But any given practical stance toward these ills implies not merely ideals for a good society but a given prioritizing of the myriad public and private roles that we each play in combinations as various as our professional membership. While medicine prescribes a moral approach to our professional work, it has not until now extended its prescription to the broader patterns of our personal, social and political lives (beyond, that is, conformity to norms embodied in law). Imposing specified political duties on physicians, or supposing that particular arrangements for health care financing are condemned by medical morality (even if such arrangements encourage exemplary professional work by physicians on behalf of their patients) are steps in the direction of unwarranted political division and exclusion. We should each fulfill our social responsibilities but as a profession we should allow a wide range of views on just what these responsibilities are (2).

While medicine is not just a job, it is, contra Webster, business as well as service. We should welcome retainer medicine, integrated health care systems such as Kaiser's, and other attempts to combine high quality health care with physician and patient satisfaction. And we should permit physicians to make their own decisions as regards political participation and the importance of societal health as compared with other societal goods. Those physicians who form retainer practices should offer some free care; if they otherwise conduct their medical practice in conformity with the ideals of professional ethics (excluding any putative bearing of professional ethics on politics), they are exhibiting anything but "a rather thin view of moral responsibility" (1). In performing exemplary professional work they are providing society exactly what it asks of them and, in so doing, giving the medical profession everything that our profession should demand of us.


1. Lo B. Retainer medicine: why not for all? Ann Int Med 2011;155: 641-2.

2. Huddle TS. Medical professionalism and medical education should not involve commitments to political advocacy. Acad Med 2011;86: 378-83.

Conflict of Interest:

None declared

Re Annals, 1 November 2011 Volume 155 No. 9 article on Retainer Medicine, p. 633 and accompanying editorial on p. 641
Posted on December 20, 2011
RobertGong, MD
Sienna Hills Primary
Conflict of Interest: None Declared

I wish to respond to the above article by Drs. Huddle and Centor in which they discuss ethically legitimate aspects of the "Retainer practice" of medicine. I am a general internist in a small group practice that declined an invitation to convert to a retainer, or "concierge", type practice in the MDVIP program four years ago. My associate at the time did convert. This experience has given me a perspective that brings to light several ethically dubious aspects related to the marketing of and transition into a retainer practice which were not addressed in the article or editorial.

First, the management company MDVIP heavily advertises to the existing patients in a physician's practice imploring them to join the program and pay the annual fee. This is done through group meetings and numerous direct telephone calls to the patients' homes. In the marketing pitch, the company claims that the patient will receive superior care in a concierge practice in comparison to a traditional practice. This claim has not been academically substantiated. I take issue with their marketing technique which tries to denigrate traditional physicians as providing inferior care.

The second aspect of the retainer practice which I find unethical involves the transition from a traditional practice typically containing 2000 or more patients to a concierge practice capped at a few hundred pre- paid customers. Those patients who choose not to join the program are often not given appropriate transfer of care to another physician. The marketing company claims to offer a process in which patients are referred to other doctors, but this process is very superficial and lacking in appropriate quality and safeguards. The usual routine is that patients are simply given a list of traditional doctors and told to call for an appointment. Many patients left behind by their physicians departing to a concierge practice include the vulnerable elderly who find it overwhelming to search out and find a new doctor. Although the departing physician may send records, there is usually no transfer summary or doctor-to-doctor conversation which discusses salient features of a complex patient's condition.

The final issue involves the management company's indoctrination of prospective physicians. These doctors are told to expect lower practice expenses compared to a traditional practice, but this is not always the case. Although the concierge practice takes care of fewer patients, the cost of providing more "intense" services may offset the amount saved in the reduced numbers. In group practices containing retainer and traditional practice styles, the concierge physician's expectation of lower overhead costs often leads to disputes about the sharing of such expenses and the eventual break-up of established groups.

In summary, those who tout the growth of retainer or "concierge" medicine need to consider the ethical implications of their marketing tactics as well as the damage to the myriad of relationships pertaining to both the doctor and patient well as between physician colleagues.

Conflict of Interest:

None declared

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