ACP Weighs Ethics of 'Concierge' Medicine

Marcia Frellick

November 10, 2015

The American College of Physicians (ACP) has released a policy position paper on the effect of direct patient contracting practices (DPCPs), or "concierge" practices, on medical quality, cost, access, and workforce.

The paper was published online November 10 in the Annals of Internal Medicine.

Robert Doherty, the ACP's senior vice president for governmental affairs and public policy, writing for the Medical Practice and Quality Committee, said the ACP felt the timing was right to lay out practical and ethical considerations for such practice models, although scant research makes it hard to pinpoint how many physicians either use the model or plan to. Surveys studied for this paper estimate the proportion at between 1.3% and 9.6% of primary care practices.

"There has been some evidence in the literature, but also anecdotally, that many primary care physicians are so frustrated with not getting to spend time with patients, [with] administrative burdens, [and] dealing with insurance companies, etc, that many of them are considering or looking into various forms of what we're calling [DCPCs]," Doherty told Medscape Medical News.

ACP does not take a position on whether such models are good for medicine: "We support patient and physician choice of practices," Doherty said. But the new policy statement does set out pros and cons and considerations if physicians choose the model.

ACP defines a DPCP as any practice that contracts with patients, who pay out-of-pocket for some or all services along with or without traditional insurance. In a DPCP model, the physician may charge an administrative or concierge fee in exchange for a promise of more personalized and accessible care.

More Time With Patients, but the Potential to Exclude

Key factors in favor of DPCPs, the group says, are that physicians can spend more time with patients, patients can see their physicians any time they like, and physicians are more satisfied. Factors against the model include the potential of excluding low-income patients, who may not be able to pay the fees up front, and downsizing patient panels at a time when primary care demand is expanding, both of which create ethical considerations.

Even downsizing panels could be considered a plus if that keeps physicians practicing instead of leaving the profession, the authors note.

For these practices, as with any practice model, the guiding mantra is the same, Doherty said. "You have an affirmative, ethical responsibility to meet the profession's obligations to serve all types of patients, including, and especially, the poor."

The paper gives some examples of ways to counteract the potential of exclusion, such as waiving the concierge fee for lower-income patients or having a sliding-scale fee.

Not taking insurance lowers the administrative burden for physicians, but also can reduce access for patients. Delaying collection of fees may allow patients to file through insurance and pay the fees later.

Some concierge models have designed their practices for lower-income people. The paper mentions one model in Rhode Island profiled in the ACP Internist, called HealthAccess RI, which is a network of doctors working in subscription-based primary care.

"The fee is $35 per month plus an $80 enrollment fee. After that, each doctor's visit costs $10. Per its website, the company is targeting several groups, including those without insurance, immigrants without documents, or persons with high-deductible insurance plans," the authors write.

The ACP includes several recommendations for physicians in the new policy paper, including that physicians should consider the patient-centered medical home as a practice model that has been shown to improve physician and patient satisfaction with care, outcomes, and accessibility, and has been shown to lower costs and reduce healthcare disparities.

Also, physicians in practices that choose to downsize their patient panel for any reason should consider the effect these changes have on the local community, including patients' access to care, and should help patients who do not stay in the practice find other physicians.

When transitioning to a DPCP model with a smaller patient panel, physicians need to be aware of local and state patient abandonment laws that impose requirements, such as adequate notice, when a physician terminates a relationship with a patient.

Physicians in all types of practice arrangements must be transparent with patients and offer details of financial obligations, services available, and typical fees.

Robert Doherty has no financial disclosures. A committee member reports that she is a managing partner of a small private practice group; this is a direct payment practice that does not participate in Medicare or other insurance products. Another committee member reports that her input to the manuscript reflects her own views and not those of the US Office of Personnel Management Medical Officer.

Ann Intern Med. Published online November 10, 2015. Full text

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