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Letters |

Academic Medicine and Concierge Practice FREE

Robert Doherty, BA
[+] Article, Author, and Disclosure Information

From American College of Physicians, Washington, DC.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0366.


Ann Intern Med. 2016;165(5):375-376. doi:10.7326/L16-0104
© 2016 American College of Physicians
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IN RESPONSE:

I appreciate Dr. Donohoe's observations about academic medical centers that sponsor “concierge” clinics. He is correct that our paper did not specifically address academic medical centers; rather, we looked at the broader movement to practices that charge retainer fees, do not accept insurance, and/or limit the number of patients they see. (We called such practices “direct patient contracting practices” [DPCPs] because descriptions of concierge practices commonly used in the literature lack consistency.) I agree that attention needs to be paid to the ethical, educational, and patient care implications of academic medical centers that operate such practices and on their potential effect on the poor.

However, our paper does provide a policy framework for evaluating DPCPs, which can include academic medical centers. We state, “Physicians in all types of practices must honor their professional obligation to provide nondiscriminatory care, serve all classes of patients who are in need of medical care, and seek specific opportunities to observe their professional obligation to care for the poor”; this includes physicians in academic medical centers who operate concierge clinics. We advocate that physicians consider the potential effect of changes in their practices that could make it more difficult for poorer patients to access medical care and that they consider steps to mitigate any such effect. We note that some evidence shows that concierge practices are at a greater risk for excluding poor and other vulnerable populations. However, we also note that the literature includes examples of direct primary care practices (1 variation of DPCPs) that have structured themselves to provide accessible, low-cost care to the poor, including patients enrolled in Medicaid. We conclude, “Although the growing physician interest in DPCPs may be an understandable reaction to such external factors, it must also be recognized that such models potentially exacerbate racial, ethnic, and socioeconomic disparities in health care and impose too high a cost burden on some lower-income patients.”

We agree with Dr. Donohoe that little high-quality evidence is available on the clinical impact and cost-effectiveness of the “extra” services often offered by DPCPs. Because good evidence on this and other effects of such practices is lacking, we propose a robust research agenda. We especially endorse the need for research on “the impact and structure of [such] models that may affect their ability to provide access to underserved populations.”

I believe that it is important that, as we research and consider the policy and ethical implications of DPCPs, we also consider the external factors that are driving many physicians toward them—including excessive paperwork associated with insurance interactions, electronic health records that are designed to meet the needs of payers and regulators and not the clinical needs of physicians and their patients, and productivity-based payments that penalize physicians for spending more time with their patients. I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients. Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient's income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.

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