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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  • http://pulse.yahoo.com/_6C65YWGCC7P5C6CGMMBK7VMFXE JenniferL

    Important article. 

    I would prefer to to be the patient of someone representing and working for me, rather than someone answering to a corrupt politicized bureaucracy.

  • http://twitter.com/DocWeeds72 Matt Weidman

    The biggest ethical problem with the concierge model is the issue of access to care.  Not enough Americans have access to quality primary care under the current system.  As Dr. Caplan stated in his Medscap Medical Ethics article, 
    We all know that we have too many specialists, not enough generalists, and not enough primary care providers in the United States. If you take a significant number of them out of the pool available to every patient and make them available only to people who can pay additional fees, it results in a bigger workload for the rest of the providers who are doing primary care. No matter how you look at it, if you allow providers to buy out, you are going to leave other patients with lower-quality care, and you are going to burden the remaining primary care practitioners (who don’t take the concierge route) with more work.

    Also, what about healthcare for the impoverished and working poor?  How does the concierge model serve that patient population?  Answer: it doesn’t.  Concierge medicine neglects the neediest among us completely.

    • Anonymous

      If I’m reading you correctly, you seem to be arguing that concierge docs, by not working with (say) a Medicaid population, are being unethical.  Let me generalize then and say that you are saying physicians are ethically obligated to maximize the amount of care they provide to the poor.

      If that is the case, then concierge and specialty doctors are only middlingly ethical, since they do treat patients and thereby let “ethical” doctors not have to spend time taking care of the well-off.  But the real villains in this ethical framework are doctors who leave medicine, retire early, and work part-time.  

      If you’re okay with that, let me point out that, female physicians, who often work part time and choose to leave medicine early, must be seen as real villains for displacing potential male doctors from medical school.  I hope that this reductio can demonstrate the limitations of your ethical system.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      Concierge physicians have the time and resources to volunteer. We volunteer at community screenings like last weekend when 4 concierge physicians did the pre school exams in the Wayne Barton Learning Center when no other physicians stepped up to the task. We volunteer with our medical students working in community health fairs in the poorest south Florida communities through the University of Miami Miller School of Medicine several times per year. We take on pro bono work through our county and state medical societies such as Project Access to treat individuals with no resources or insurance. We offer scholarships to patients unable to afford our membership fees. As a traditional physician in the past seeing 30-40 patients per day and employing 7-8 personnel to support the bureaucracy created by managed care and Medicare I struggled to meet my payroll and rent costs each month with no time for volunteer work.
      As a practicing internist for thirty three years I fought through the system the reckless and destructive changes to health care that destroyed the doctor patient relationship.  Direct pay practices and concierge medicine is my opportunity in a small limited manner to provide complex older patients the time and thought they deserve from a doctor. As I said in the first place, if you are worried about access then train more physicians, pay them well while reducing the disparity between procedural and evaluation and management services and allow them to practice rather than make them bean counters and paper pushers. Your access and manpower problems will then disappear.

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

        Steve, who really cares what that bioethics clown thinks at all?

        Fine, you volunteer your time. But really……why do you think you have to justify your existence to the likes of him?

        The average Zimbabwean would love to have the level of medical care access of a typical Miami barrio resident. Maybe you’re “unethical” because you don’t go to Zimbabwe and be Mother Teresa.

  • http://secondbasedispatch.com/ jackiefox

    I’m glad to see this perspective because my knee-jerk reaction has been that it’s elitist. I remember the big front-page story in the Omaha World-Herald about concierge medicine coming to Omaha and the patient quote was from one of the richer guys in town. I do worry about the haves and have-nots but I guess we already have that with insurance and some other factors, don’t we? Thank you for giving me something to think about.

  • Anonymous

    “Also, what about healthcare for the impoverished and working poor? “The title includes Direct Pay Medicine even if the body of the post only discussed concierge practices.  The direct pay models vary but many are around the price of cell phone service or cable TV.  These are a good choice for the working poor.http://dpcare.org/http://healthaccessri.com/As far as ethics go, I’ve paid for my education and spent many years to become a physician.  It’s unethical to restrict my business and force me to participate in a failing third party payer system, especially one that is destroying primary care.

  • http://twitter.com/#!/CloseCall_MD Close Call

    Wow… I don’t know where to begin.

    If you haven’t seen Dr. Arthur Caplan (of the Ph.D crowd, not MD) and his video after the link, please see it!  Read his article.

    First, I LOVE that that his book is displayed so prominently behind him.  “Wait, how did this book get here? Hmm. Oh, look at that!  It’s MY book!

    Second, did he just bag on NPs and other physician extenders, by saying that patients would be dumped on them?  Poor NPs and physician extenders for seeing patients they wish to see.  And poor patients for being duped into seeing them. 

    Third, a doctor’s professional duty is to her patients first and foremost.  Her concern isn’t with the non-concierge/retainer/innovative practice doctor across town who hasn’t come up with a satisfactory model of seeing patients and putting them first.  If seeing less patients results in giving them better access to care, that is an outcome we should applaud, whether patients decide to pay for it or not.

    • Anonymous

      I think you are right. Studies indicate that NPs are just as qualified to care for the GP patient population. They are willing to fill the gap that the doctors can’t afford to. NPs will be happy to accept the insurance reimbursement that is too low for the docs to accept. They’ll spend more time with the patient and deliver better outcomes to boot. Sounds like ‘concierge for the masses’. Let the patients decide if their care with the NP is adequate.

      • http://twitter.com/#!/CloseCall_MD Close Call

        Eh.  Studies don’t indicate that they’re as qualified to care for the GP patient population as MD’s or DO’s – for certain diagnoses… maybe.  And I can come up with a study that shows a high school student can be trained to read mammograms.  For a fifth of the cost as a radiologist.  Anyone want to have their mom’s or sister’s mammogram read by a 17 year old?  No offense to NPs, but I don’t think most NPs want to be act or function in the same capacity as doctors anyway… or do they?

        • Anonymous

          First, YES! NPs are functioning in the same capacity as physicians in their scope of practice. Second, the radiologists may be concerned about the 17 year old reading a mammogram but I don’t see how this supports your position. Are you saying that the NP is equivalent to a high school student? (REALLY?!) Third, a review of the literature reveals the following studies regarding the NP vs MD/DO comparison. The results speak for themselves. [But feel free to post all the studies comparing the 17 years olds against NPs in treating and diagnosing if you REALLY think this is a legitimate argument.] When we begin to look at outcomes and appropriate levels of care instead of protecting turf and bashing other professions, THEN we’ll all be in a better place and the patients will be the real winners.

          NP Quality Studies Information:  Acute Care Studies:  Chang et al. (1999) • Study – Comparison of NP care and MD care in ER setting for 232 patients • Findings – No significant differences were found between NP and MD care.  Gawlinski et al (2001) • Study – NP care for cardiac ICU patients using extubation protocols. • Finding – Decreased mean time to extubation, decreased rates of ventilator-associated pneumonia, shorter LOS, and decreased use of arterial blood gases.  Hoffman et al. (2005) • Study – Comparison of acute care NP care with critical care fellows care for 526 ICU patients • Findings – There were no differences in readmission, mortality, duration of mechanical ventilation, LOS or disposition.  Hooker & McCaig (1996) • Study – Comparisons of emergency room NP and PA care with physician care using data from the National Ambulatory Medical Care Survey • Findings – No differences between the service of the NP–PA group and physicians.  Meyer & Miers (2005) • Study – Acute care NP in cardio-vascular (CV) surgery • Findings – Care given by NPs on the CV team resulted in ↓ LOS by 1.91 days and ↓ cost of care by $5,038.91 per patient.  Sidani et al. (2006) • Study – Comparison of processes of care (roles and coordination of services) of acute care NPs and physician residents. • Findings – NPs engaged in management and informal coordination activities more than MDs while MDs engaged in more formal coordination activities.  NPs encouraged more patient participation in care and provided more patient education.   Thompson (1980) • Study – Contrast of effectiveness of neonatal transport NPs with MDs • Findings – No difference in overall survival rates; NPs demonstrated equal ability to assess, manage, stabilize, and transport ill newborns.  Case Management Studies:  Bargardi (1999) • Study – Chart review of documentation and adherence to best practice guidelines for 180 patients undergoing cardiac catheterizations or percutaneous coronary interventions.  • Findings – NP care significantly increased adherence to best-practice guidelines. The use of all best practice indicators increased; LOS decreased, 12 month LDL goals achieved in 91% to 94% of NP managed patients compared to 10% to 17% of patients managed by primary care physicians.  Bevis et al. (2008) • Study – Comparison of outcomes of thoracostomies performed by nurse practitioners (NPs) vs medical doctors (MDs) • Findings – Thee were no difference in insertion complications, LOS, or morbidity.  Charney & Kitzman (1971) • Study – Comparison of NP-MD team care to newborns (n = 703) vs MD care (n = 517) • Findings – There was no difference in total number of visits made between the groups; NP group had twice as many calls and were able to handle 153 of 158 calls independently; NP presence resulted in ↓ MD telephone time by 1/5; parents reported positive satisfaction with NP care.  Paez & Allen (2006) • Study – NP management of hypercholesterolemia following coronary revascularization • Findings – Case management by an NP resulted in significant reduction in LDL cholesterol levels.  Sakr et al. (1999) • Study – Randomized control trial in United Kingdom of ER patients care for by NP (n = 704) or by MD (n = 704) compared to junior doctor  (n = 749 patients) • Findings – There were no differences in the % of NPs and junior doctors making clinically important errors (9.2% for NPs versus 10.7% for MDs); NPs were better at recording medical history and fewer  patients seen by NP had to seek unplanned follow-up advice about their injury; there were no differences between NP’s and MDs in accuracy of exams, adequacy of treatment, planned follow-up, or requests for or interpretation of X-rays.   Chronic Disease Studies:   Boville et al.  (2007) • Study:  Impact of NP care in chronic disease management care of 110 patients with diabetes • Findings:  NP care resulted in improved glycemic control, lipid management, and control of hypertension  Kutzleb & Reiner (2006) • Study – Prospective quasi-experimental study assessing the impact of NP care on patients with heart failure. • Findings – NP directed care resulted in increased patient quality of life, health, and functioning (p =.0003) over a 12 month period.  Lindberg et al. (2002) • Study – Impact of asthma NP care for 347 patients. • Findings – NP managed patients reported less asthma symptoms and more self-management, documentation quality of NP care was high.  Neff et al. (2003) • Study – Impact of NP care for home care patients with chronic obstructive pulmonary disease • Findings – NP directed pulmonary disease management resulted in shorter re-hospitalization LOS and fewer re-hospitalizations; a significantly higher number of patients in the NP group were discharged and remained at  home compared to the control group (p < .05).  Runyan (1975) • Study – Experimental study of care provided by NP to 1,006 patients, compared to MD care to 498 ambulatory patients with diabetes, hypertension, and CV disease • Findings – Patients with hypertensive disease experienced greater reductions in diastolic blood pressure.  Patients with diabetes had greater reductions in blood glucose levels and patients had fewer hospitalizations days (p < .05).  Ziemer et al. (1996) • Study – 6-month prospective study of 325 type II diabetes patients at 2, 4, 6, and 12 months at hospital-based clinic. • Findings – Significant decreased in HbA  ; 52% of obese patients lost weight; 59% of patients were maintained on diet control along; 35% of patients using pharmacologic agents discontinued oral agents or insulin by 1 year.  

          Healthcare Costs Studies:  Blue et al. (2001) • Study – Randomized controlled trial of NP care for 165 heart failure patients • Findings – Compared with usual care, patients in NP group had fewer readmissions for heart failure (p = .018) and spent fewer days in hospital for heart failure (p = .0051).  Carzoli et al. (1994) • Study – 6-month retrospective chart-review comparison of neonatal NP, PA, and resident physician care • Findings – No difference in outcomes of NPs, PAs, and resident MD staff; NP-PA care was associated with overall cost savings in terms of annual costs and hospital charges.  Cintron et al. (1983) • Study – Chart review of 15 patients with congestive heart failure in a cardiology clinic before and after introduction of NP in a heart failure clinic • Findings – Decrease in number of hospitalizations from 2.8 to 0.7 per patients; decrease in number of hospitalized days from 62 to 9; decrease in in-hospital costs of $8,009 per patient; patient satisfaction and reports of better care, rapport, and less wait.  Dahle et al. (1998) • Study – Impact of NPs on cost of managing 215 inpatients with heart failure. • Findings – Total hospital costs and length of stay were significantly lower, with an estimated annual total cost savings of $133,000.  Feldman et al. (1987) • Study – Synthesis review of 56 studies of NP effectiveness • Findings – NPs effectively delivered care of equal quality to that of MDs; NP use increased volume of care; utilization of NPs saved MD time, decreased costs; health outcomes similar to MD; patients had more discussion and satisfaction with NPs; more likely to provide patient education than MD.  McCauley et al. (2006) • Study: Impact of ANP care on elderly patients with heart failure • Findings: ANP care resulted in ↓ hospital readmission, ↓ length of stay of readmissions, and decreased overall health care costs.  Paul (200?) • Study – Retrospective review of impact of NP managed heart failure clinic for 15 patients with congestive heart failure. • Finding – 6 months after implementation of heart failure clinic, hospital admissions ↓   (from 151 hospital days to 22); mean LOS ↓ (from 4.3 days to 3.8 days) and mean inpatient hospital charges ↓ from $40,624 per patient admission to $5,893; % of recovered charges from reimbursement ↑ from 73% to 87%.  Reigle et al. (2006) • Study – Impact of acute care NP care on cardiology patients • Findings – NP – managed patients undergoing cardiac catheterization or percutaneous coronary intervention resulted in ↓ LOS, more prescription of indicated medications, and more documentation of patient status and patient education.  Russell et al. (2002) • Study – NP care for neuroscience ICU patients • Findings – Patients managed by NPs had shorter LOS (p < 0.03), shorter ICU LOS (p < .001), lower rates of UTI and skin breakdown (p, 0.05), and shorter time to discontinuation of Foley catheter and mobilization out of bed.  Salkever et al. (1982) • Study – Participant observation comparing efficiency of MD and NP in  treating  otitis media (409 cases) and sore throat (390 cases) in pediatric medicine department • Findings – NP per-episode costs were 20% below MD costs; NP care was less costly but not less effective.   Spitzer (1997) • Study – Evaluation of 4 models of nurse faculty practice: primary care, physician partnership, outsourcing of NPs and employee-based health care. • Findings – NPs delivered health care at 23% below average cost of other providers; NP inpatient rate was 21% below average, lab utilization was 24% below average, prescription drug use was 42% below average and 82% of patients reported being very satisfied with the quality of care.  Long Term Care Studies:  Mahoney (1994) • Study – National random-sample comparison of prescribing decisions of NPs (n = 298) and MDs (n = 373) using 3 standardized geriatric case vignettes • Findings – NPs scored higher on the index of appropriateness than physicians (p < 0.001), a difference that remained weather or not the NP had prescriptive authority.  NPs made more recommendations for non-drug therapeutic interventions, compared to MDs (p < .001).  Ryden et al. (2000) • Study – Randomized controlled trial of NP intervention for long-term-care residents • Findings – Uncertainty decreased significantly in the intervention group of 1, 3, and 6 months with the strongest effect on subscales of complexity, inconsistency, and unpredictability.  There were no differences in costs.  Stolee et al. (2006) • Study – Impact of NP role from long term care residents • Findings – NP care significantly impacted the primary care of residents in long term care.   Outpatient/Clinic Studies:  Hill et al. (1994) • Study – Randomized clinical study comparing NP and MD care in rheumatology clinic • Findings – NP-managed patients has significant improvement in mobility, less pain, had acquired grater knowledge and were more satisfied with their care.  Langner & Hutelmyer (1995) • Study – Patient satisfaction survey to 52 patients with HIV, comparing NP to physician provider care in an ambulatory care services clinic. • Findings – Overall satisfaction with patient care was high. NP ratings were higher in areas of provider knowledge, continuity of care, patient educations, and clinic wait time.  Lewis et al. (1969) • Study – Evaluation of NP performance compared to MD using critical-incident technique for care given to medical clinic patients for 86 NP patients and 118 MD patients • Findings – ↑ number of NP patients who had returned to work (40% in NP group vs ↓ in MD group); ↓ in patient systems in NP group vs no change in MD group patients; 50% fewer broken appointments for NP vs MD group patients; no differences in severity of patient disease between groups.  Mundinger et al. (2000) • Study – Randomized trial of NP and physician care in primary care in 4 community-based and 1 hospital-based clinic; care delivered to 806 NP patients were compared to care give to 510 physician patients • Findings – No significant differences found in patient’s health status at 6 months; no differences in health service use at 6 months or 1 year; no differences in satisfaction ratings following initial appointment; satisfaction with provider attributes was higher for physician at 6 months; for patients with hypertension, diastolic value was lower.    Primary Care Studies:  Avorn et al. (1991) • Study – Telephone survey of 54 internists (family practice and general practice MDs) and 298 office-based NPs regarding case vignette of a patient with epigastric pain and endoscopy showing gastritis. • Findings – NPs more likely to collect more historical information before deciding on therapy, less likely to prescribe prescription drug (12% vs 46%), more likely to ask about diet, less likely to take a drinking history, and more likely to suggest nonprescription treatment approach.  Kelley et al. (2002) • Study – Impact of NP preventative care for cervical cancer screening • Findings – NP preventative care for cervical cancer resulted in a significant increase in documentation of cervical cancer screening (from 2% to 69%).  Pioro et al. (2001) • Study – Comparison of NP and MD care for 381 general medical patients • Findings – There were no significant differences between NP and MD care.  Prescott & Driscoll (1979) • Study – Synthesis review of 31 studies comparing NP and MD practice in primary health care. • Findings – Reviewed studies with the intent of assessing comparison criteria and research methods. Concluded NPs are at least as capable as MDs in performing primary care functions. Recommended that random sampling use of multiple data sources and evaluations of NP effectiveness should represent the full range of the NP role.  Seale et al. (2006) • Study – Comparison of treatment advise of primary care NP vs general MD practitioners • Findings – a statistically significant greater proportion of NP’s talk concerned treatments, with discussion of how to use treatments and of side effects.  Simborg et al. (1978) • Study – Chart review of 1,369 patient-practitioner encounters to compare MD (n = 109) to NP (n = 35) in primary care practices • Findings – MDs prescribed more drug therapies (p < .05); NPs recorded more signature symptoms; NPs emphasized patient education more than MDs.  Sox (1979) • Study – Synthesis review of 21 studies comparing NP and PA care with MD care in office-based practice. • Findings – Concluded that NPs and Pas provide office based care equal in quality to care provided by physicians. Spitzer et a. (1974) & Sackett et al. (1974) • Study – Randomized trail of NP (n = 1.058 families) and MD (n = 540 families) care in primary care practices in Canada • Findings – No difference between MD an NP care for mortality rates and patient physical, emotional, or social functioning, management of care was rated adequate for 69% of NP care vs 66% of MD care

          • Anonymous

            Ok, we all get the point. I think NPs probably do pretty well in a protocol driven environment where you can cookie cutter medicine and focus in on one or two issues, or make sure someone had their mammogram, etc - I (admittedly) didn’t read the titles of all of these citations (do you just keep this list going at home to deploy at a convienent point online?) but several of them were talking about the NP functioning in terms of a team – this is a perfect use of a nurse practitioner, as part of a team. And maybe the future will mean that NPs handle all minor issues like a blood pressure check, or making sure that elderly patients get their zostavax or flu shot.

            BUT, I’m sorry, there is just no way that a nurse practitioner is qualified to practice medicine independently.  And we are all kidding ourselves if we think so.  A physician extender is just that – an NP just doesn’t know what they don’t know. 

             And internal medicine is more than checking a lipid panel. 

            Where you make the difference for people is on the margin, it is in your antennae going up, and I have found that even my 15,000 hours of training (between medical school and residency) wasn’t even enough.  I think you have to be out, seeing patients day in and out for years to really hone your craft.  I have seen thousands of patients and I am still not there yet, so how can someone with such markedly less training, less on the line (if the patient has a bad outcome, not only do I feel horrible sorry and guilty, but my butt is on the line with malpractice litigation) presume to be equal in training or ability? 

            Yes they complete a checklist same as me, sure.  But can they see something abnormal and more importantly recognize it as such? Can they read between the lines of the imaging study report?  Can they put together the various bodily systems, synthesize the data in a complex ICU patient, or for that matter even a complex IM patient?  I submit, no, not to the degree of the trained, board certified physician.  If it was that easy, there would be no need for doctors or even NPs.  Medicine would driven by an algorithm at a computer kiosk.

            Bottom line, NPs and other physician extenders probably do have their place in primary care medicine.  We don’t like to admit that because no one wants to give up the annual physical because 1. is a good time for me to meet and get acquanted with my patients, to learn about personalities and families before something acute happens (as it undoubtably will) and a person really needs my services and 2. it is simple and pays relatively well.  Have I occasionally caught something important on the physical, sure (if it is a real one – that Medicare Wellness Visit is a joke). 

            I am not saying there is no role for the NP, especially a good one.  But give me a doc with an MD any day.  When you have a real problem, you need a real doctor.

          • Anonymous

            “Cookie cutter” or ”best practices”, what’s the difference, right? The bottom line is that in the NP’s scope of practice, the outcomes have been demonstrated to be as good as if not better than an MD. (Perhaps you should read the literature before you present yourself as an authority.) And relative to the comment about where I got them, we post them on our website. (I am a co-owner of an independently run NP business and doing quite well, I might add. And although I accept your disingenuous apology, I respectfully disagree with your statement that an NP can’t work independently. They are already and doing just fine.)

            Your comments are franking typical of the FUD that has been promulgated by the AMA for years. Hey, as a business person, I understand your desire to protect your turf. Perhaps you should read Christensen and Hwang (2009) to understand what is happening. They argue, “These professionals (NPs) will in the future become the primary caregivers for patients with the growing number of diseases that are progressing into the realm of precision medicine (p. 357)”.

            Relative to your statement about experience, the NP in my practice has 2x the hours you have so let’s not use that argument, ok? Because a person has not chosen to go to medical school doesn’t make them ill prepared to work quite effectively in their scope of practice. This is what NPs have been doing successfully for years and now 16 states have recognized this and changed their legislation to permit NPs to practice independently. On the issue of medical malpractice, you probably are aware that NPs ALSO must carry malpractice insurance. The interesting fact is that their premiums are a fraction of yours. Why? Not because the insurance carriers are just nice guys and like NPs; on a risk adjusted basis, they are a lower risk! As the providers are swimming upstream into specialties that offer higher monetary reimbursement rewards to cover their high medical school debt, these specialties also offer higher risk (more complex patients with higher co-morbidities). As a result of their migration upstream, they are leaving a gaping hole in the primary care market. NPs are beginning to step in and providing ‘appropriate care’ (not inferior care as you suggest) and spending more time with their patients, on average, than physicians. And guess what, patients like it. So as the physicians move to concierge services to be able to provide the care that patients want, many NPs are already doing it.

            Lastly, I am not calling for a replacement of the MD/DO. Complexity mandates that specialization is needed and the NPs enjoy being part of that healthcare provider team. They are taught when to refer and they know when something doesn’t sound right. They are professionals that know their scope. Provided they don’t overstep their scope of practice boundary, there will ALWAYS be a place for NPs and I submit that Christensen and Hwang (2009) have it right. The sooner physician’s understand this and stop fighting it, the patient will be the winner, and healthcare costs will be reduced. With the ACO model coming, teaming is going to be key to all our success. BTW, the NP is our practice does have a doctorate.


            (Christensen C Hwang J 2009 innovator’s prescription)Christensen, C., & Hwang, J. (2009). The innovator’s prescription. New York, NY: McGraw Hill.

          • Anonymous

            Maybe I came off a little stridently – if you read my response, I DID say there is a place for NPs in primary care. However, I still dispute that the average NP is qualified to set up a completely independent practice in the style of my academic affiliated IM group.  I have trained NPs, and I like them as people, and I am sure that patients like them too.  But, the NPs that I have trained (I get asked every 6-12 months to preceptor clinicals) would not be qualified to open their own shop based on what I have seen.  I am sure there are exceptions to this – we all know the RN who has been doing this for 30 or 40 years who probably has the clinical smarts (if not the book smarts – before everyone gets their hackles up, not because they couldn’t get a medical degree but becuase they didn’t – I wouldn’t read all my med school textbooks for fun either) to function equivalently to an NP.  
            Recent examples from the last few months:

            1. postoperative patient seen in follow up from the ER for drain infection. Put on expanded MRSA coverage with bactrim per ER resident (reasonable), drain pulled and cultures taken which grow back pseudomonas.  Culture results seen at time of office visit, the drain site is still red and patient with low grade temps although a bit better than before.  NP thinks pt is doing better and says, well, you are better, continue the bactrim but nothing additional needed.  Turns out patient has abdominal mesh in area adjacent to drain site which if any of you has ever seen the result of an infected abdominal mesh, it is pretty horrendous. I find this out, talk with ID, we all agree the risk of not treating this vastly outweighs giving a po course of cipro. Was disaster averted? I don’t know, maybe it would have been fine.  I would not have wanted to find out the hard way, do you think the patient would have?  Lesson: NP was 1. inadequately supervised and 2. is not aware of microbiology as well as does not synthesize the data in its entirety (pseudomonas + adjacent mesh = not a good combination). Also what was the rationale for continuing bactrim in this circumstance?   

            2. post liver transplant patiet on imuran admitted to my service with mental status changes and severe hyperglycemia (>600).  Due to imuran, right? slam dunk no big deal.  Turns out patient was running around with BG in excess of 300 and approaching 400 for at least 2 months.  All transplant labs being reviewed by NP who was focused on LFTs and “didn’t see” the glucose abnormalities.  Lesson: transplant NP was 1. inadequately supervised 2. did not focus on the big picture.  An expensive hospitalization could have been avoided.

            3. middle aged pt seen in followup from minute clinic.  Went for shortness of breath, fever, purulent sputum. Was found to be wheezing.  treated by minute clinic NP with prednisone 60mg qD x 4 days. No inhaler, no antibiotic.  In my office O2 sat 93%RA and patient had RLL pneumonia.  Lesson: maybe the patient didn’t have the overt pneumonia at the earlier visit 2 days before. But the prescribing regimen is very strange.  Lesson: don’t go to minute clinic.

            Maybe these cases are not representative of the typical community primary care fare.  But they are not atypical for my patient population in a major city at an academic affiliated center. 

            I’m not an elitist, when I was a MICU intern you better know I knew the RNs knew way more than me.  And they knew that I knew that they knew more.  But I still maintain, even fresh out of residency (and I am approaching a decade out now), I didn’t know as much as I do now.  And that was 15,000 hours of training.  I am sure your NP with 30,000 hours of experience is great.  But what about the average newly minted NP with 2000 hours?  I don’t dispute that NPs have a “scope of practice” – but what is it?  It sounds to me like you believe that an NP could take over and do everything that I do.  I dispute that, respectfully.  Sometimes you need a doctor to know when you don’t need a doctor.  Deriding me as promulgating turf wars just obscures this question.  What is the NPs scope of practice?  I think that Close Call’s comment below asks it too – Do NPs want to practice as physicians without having gone to medical school?

            As for the malpractice premiums rising, as more NPs are out there, they will have their turn in the barrel with the attorneys.  That will be resolved with time, guaranteed.  For interest sake, we all know that malpractice for a procedure based specialty is more.  What is the typical malpractice rate anyway for an NP in primary care?

            And as for the citations, you have to admit it was a bit obnoxious flooding your first post with a zillion citations.  It is kind of like posting in all caps, a bit aggressive.

            Ok, so I bit.  Let’s hear it for healthy debate…

          • http://twitter.com/#!/CloseCall_MD Close Call

            No bashing intended!  =)  I just don’t think NPs want to be physicians.  Otherwise they would have gone to medical school.

            The 17 year old reading mammograms was an example of how we can make costs super low while not compromising quality  - and how it can be easily shown with a study.  Give it an N of 50.  Heck power it even higher than that.  How about 1000.  I bet you can get a decent P value showing that 17 year olds with their eagle eyes and mad pattern recognition skills could read a mammogram better than a radiologist with 9 years of medical school and residency.  But really, would you want a 17 year old reading your mom’s mammogram?  I wouldn’t.  Even with 10 positives studies.  It’s about confidence.  

            Just about every study comparing physicians to NPs could probably be done with a medical assistant who had a semester of specialized training.  What’s the difference between a well trained MA and NP?  For specialized tasks and chronic disease management – asthma, diabetes, weight loss, INR monitoring.   I would say nothing!  An MA can be trained just as well and in less time!  And for cheaper too! And it’s happening in practices more than we think (NPs are expensive).   Getting back to the 17 year old reading mammograms, when does the deconstruction of abilities end?  Maybe it doesn’t.  Is that good for patients?  Who knows.  But I think I’d pay extra not to have a 17 year old read my mother’s mammogram.  I’d probably pay extra not to have an MA manage my father’s INR independently. Would I pay extra not to have a NP fresh out of school with a generous 2,000 clinical hours under their belt to not take care of my hypothetical newborn or grandchild?  Yes.  My hypothetical newborn/grandchild is a special and unique butterfly.  I’d rather have a fresh peds or FP graduate with their 15,000 hours of clinical experience and cases.  

            But I think the NP / physician controversy is really pretty empty.  Doctors need to get over it.  There’s no future where NPs would “take” any patients from physicians – there will be more than enough medicaid and medicare patients to go around.  Do NPs want to see complicated medicare patients at medicare rates?  How about complicated medicaiders at medicaid rates?  Go for it.  But still, it’s an empty controversy.  Move along folks, nothing to see here. 

            Anyhoo… I guess that’s where concierge care comes in – you can market 15,000 clinical hours of experience and let people decide if they want to pay more I guess… even if I can show you a study that a 17 year old can read your mammogram just as well.  

  • Anonymous

    My husband is a PA and opened a direct pay practice on July 1st of this year in response to the strangulating rules of insurance companies and the government. I am the unpaid office manager.  :-) 

    New patients pay $89 a visit and existing patients pay $69 plus labs/procedures – most labs are between $10 and $25. He only sees 2 patients an hour and sees most that call in the same day or next day. As he gets busier, he will add another provider to meet that demand.

    The prices are affordable for most any patients and they do not have to wait long to be seen and they have more time with their provider. We have had many patients tell us that being seen at GracePointe Healthcare is the best experience they have ever had in a health care setting.

    The best part for me is my husband is happy providing care for patients again. He no longer feels likes a rat on a wheel having to see more and more patients to make up for less and less reimbursements. He has cut overhead where ever possible with both supplies and labor and will eventually make just as much or more as he was working for someone else.

    This is how care was provided in days gone by and how it needs to be done again – way more satisfying for the patient as well as the provider.  If you are a provider thinking about moving in this direction I say run, don’t walk! Yes, you will lose some patients as change is difficult for some people but your job satisfaction will go through the roof.

  • http://twitter.com/normwu Norm Wu

    Thanks for posting this Dr. Reznick. As you eloquently state, the current fee-for-service insurance reimbursement system is in large part the cause of our primary care physician shortage. Concierge practices and their more affordable cousin, insurance free direct practices, are the solution for rebuilding the supply—for giving med students new hope to pursue a career in primary care and for extending the career of established physicians who are ready to retire early because they can’t stand the hamster wheel anymore. If we don’t support these, the primary care shortage will get worse and worse, continuing to shift care to much more expensive downstream services. That will deny patients the primary care they deserve and move our entire country towards bankruptcy.

    At Qliance, our goal is to make direct primary care accessible and affordable to as many Americans as possible charging only $49-89/month for unrestricted care 7 days/week. Recognizing its potential contribution towards lowering the cost of quality care, Congress authorized the direct primary care medical home in the Affordable Care Act as the only non-insurance solution inside the future insurance exchanges, when bundled with a low cost wrap-around insurance plan that covers specialist and hospital care. There’s useful background on the Direct Primary Care Coalition’s web site at http://www.dpcare.org

  • http://twitter.com/Deasmom Liz R

    Hurray for concierge medicine.  In a city of over a million where 250,000 are on the waiting list for a family doctor, IMO, it was the only way to go.  Voila, I get the care I want and the public lines are shorter by one (I’m in Canada, BTW)

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    My comments on this site of these past two+ years have consistently advocated that a return to free-market principles and voluntary interactions are the way to improve medicine. Concierge medicine and its success, as witnessed by better doctor satisfaction and better patient satisfaction are living proof of this. When I lecture to my medical students, many initially express concern about a dismal future for their career. However, when they learn about this option and the option of doing voluntary pro-bono work, it reignites their passion to work in a setting that rewards excellence as well as gives a opportunity to donate to the world.

  • http://www.facebook.com/gregory.buford Gregory A. Buford

    Agree with this article 100%.  The current administration’s philosophy is that doctor’s are evil people, should not make money (because we are obviously too rich already), and should work tirelessly without complaining.  The fact is that physicians have had enough and are desperate to create a system where they not only can take good care of their patients but can also can be paid fairly while doing so.  Isn’t that the point?

    If someone wants to bad mouth the concierge system and entrepeneurship within this broken medical system, then I encourage them to walk the walk and go through the years of training and financial hardship that we did only to get out and get beaten down by the payer system. 

    It’s about time!

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    thank you for the kind words Mr. Wu and the resource of the website for direct pay care. 

  • http://twitter.com/#!/CloseCall_MD Close Call

    Wow again!  

    Judging by the comments (or lack thereof), it seems that online opinion seems to have turned towards concierge/retainer setups.  I remember just a year or two ago, you would see the comments section ON FIRE whenever a story was done on innovate practices.  It was kind of scary to hear the animosity spewed towards doctors who established these practices.  My how things have changed.  

  • http://www.facebook.com/profile.php?id=1590806474 Michael Tetrault

    This is a great article. As someone who is reporting daily on various concierge and direct care practices across the U.S., I can tell you there aren’t currently enough doctors doing this. Here’s the current downside in concierge medicine: We’ve (CMT) recently been studying the demand for concierge, direct care, cash only and retainer-based medical models by consumers across the U.S. for the past two-three years. We’re finding that the number of patients who are seeking concierge medical care is far greater than the actual number of primary care and family practice doctors available to serve them. It’s extremely difficult to find a physician for those seeking concierge physician services in very rural areas like Idaho, North and South Dakota, Louisiana, Mississippi and others. Often times, we have found that there are less than half-a-dozen practitioners to serve an entire state.    

    But, there are currently four states that have a huge lead in the amount of active concierge physicians in practice and consumers seeking their care. Florida, California, Pennsylvania and Virginia each have a significant number of people (most over age 50) seeking out concierge doctors and there is, fortunately, a sizeable number of concierge physicians to serve them.    

    While the number of physicians entering concierge medical practices needs to increase, more transparent pricing among doctors is also needed. Unfortunately, our nation’s new health care reform law does little in this respect.

  • http://twitter.com/hbrofman Harvey Brofman

    Great Stuff Steven.  The creation of the Copay Cards had within it’s roots similar reasons.  Putting choice back into the hands of the physician when Insurers / PBM’s were dictating what could be prescribed via formularies, driven by rebates rather than their actual safety and effectiveness.

  • Stephen Ferrara

    Sadly, the discussion has once again turned to anti-nurse practitioner rhetoric. I refuse to get into the us vs. them sandbox and will let patient outcomes speak loud and clear for themselves. I believe we can all agree that we play significant roles in patient care. However, the notion that what we do is “simple” care or “cookie-cutter, protocol-driven” practice in woefully inaccurate. There are NPs in all stretches in health care: from critical care units to primary care. Generally, NPs, along with most other members of the health care team, deliver high-quality, culturally competent, evidence-based care. We do not go to medical school nor want to be physicians. We want to care for our  patients in the way that we were educated and trained to do so.

    In doing so, that allows us to embark on a true partnership with our patients. And from what I can tell from my patients and my NP-colleagues patients, they seem to really enjoy this approach from an evidenced outcomes perspective as well as from a satisfaction perspective.

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