Why concierge and direct pay medicine is not unethical

A response to Concierge Practice: Unjust for Patients and Doctors Alike.

Like the shots fired at Concord and Lexington in 1776, concierge medicine and direct pay practices are the initial shots fired by concerned primary care physicians in the revolution against health care systems which limit access to physicians and destroy the doctor / patient relationship. Concierge medicine arose as a result of government, private insurance, and employer intrusion into the health care field destroying primary care and a physician’s ability to spend the time required with patients to adequately and comprehensively prevent and treat disease.

The only thing that is unjust or unethical about concierge and direct pay practices is that they had to be formed to begin with. They formed after 30 years of:

  1. Primary care doctors lobbying unsuccessfully for adequate compensation for evaluation and management services and for protesting the widening gap between cognitive services and procedural specialty practices.
  2. Going through channels protesting the unfair bureaucratic and administrative burdens placed on primary care practices by Medicare, Medicaid and private insurers.
  3. Warning that the population is aging and their chronic health care problems are far more complex requiring more time with a physician rather than less.
  4. Primary care physicians leaving medical practice for early retirement or for paid jobs with pharmaceutical companies, medical device manufacturers and hospital administrations where hard work and achievement were rewarded without having to deal with system imposed overheads of up to 65 cents on the dollar.
  5. Legislators providing no relief from frivolous lawsuits which makes seeing complex patients in 5-10 minute sessions for “single problem directed visits” a legal liability.
  6. Medical students realizing that the time and financial commitment to the practice of primary care medicine didn’t cover the bills essentially directing them toward more lucrative procedure dominated specialties.

Physicians also left after salaried academic physicians, who never took risk and invested a cent of their own money in building a practice, pontificated and moralized in peer journals supported wholeheartedly by biased pharmaceutical company ads that generating passive income through shared labs and imaging centers was a kickback.

If we look at the data accumulating on care from concierge and direct pay practices, we find that despite a sicker patient population these practices generate fewer visits to emergency departments and fewer acute emergent hospitalizations saving the system money.  These practices provide coordinated care for their patients steering them through a complex and confusing health care system riddled with inappropriate advertising and claims and, get the patients to the best people to treat their problems.

Concierge physicians have more time to spend with their patients thus, achieving unheard of levels of retention and patient satisfaction while giving pro bono scholarships to patients who cannot afford their membership fees but were with them prior to their conversion to a retainer model.

After years of being on the conveyor belt of having to see more patients per day, every day, to stay abreast of system generated overhead cost increases and declining payment for services, concierge physicians now have time to teach students, volunteer at health fairs and screenings and participate in the stewardship of what remains of their profession.

If anything is unjust and unethical it is salaried academic non-physicians writing articles about morality and justice about issues they have no hands-on experience practicing. As a primary care physician for 32 years, I feel like a chameleon having to change colors and practice style every few years based on new rules imposed by private insurers, employers and government programs. At no time were these new rules designed to improve the patients’ access to care or total care.  In each case the new rules were designed to save money and do nothing else.

Concierge and direct pay medicine is the first volley in a revolution to take outstanding care of a smaller panel of older sicker patients on a long term basis.  Its proponents have worked hard for decades to change the system through channels. Failure of legislators, government bureaucrats, health insurers, employers and professional associations such as the AMA and the ACP to react and fix the inequities has generated these practices which cost less than a cup of Starbucks grand latte per day to be a patient of and provide comprehensive care and access.

Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.

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