Consider the following example: A patient with some mild ongoing medical conditions (for example, high blood pressure and elevated cholesterol) visits his primary-care physician with new complaints of shoulder pain and abdominal discomfort. In the current practice environment, the doctor has a mere fifteen minutes to deal with everything, including basic social civilities. Understandably, the conditions the doctor had previously taken responsibility for would take precedence (the high blood pressure and cholesterol level). Only then would the new symptoms be addressed. With the clock ticking and a waiting room full of disgruntled patients because the schedule was thrown off by an earlier minor emergency (an almost daily occurrence), the doctor resorts to the most expeditious approach: for example, ordering an MRI or a CAT scan for the shoulder and referring the patient to a gastroenterologist for the abdominal discomfort. With the pressure to meet the practice overhead, there is no time for the doctor to investigate each complaint properly with a careful history and examination. The result is a tendency for overutilization and inconvenience for the patient, much higher cost, and less than satisfaction for both the patient and the doctor. The doctor is forced by circumstance to function more like a triage assistant than a fully trained physician. This is especially true if the doctor is a board-certified internist, many of whom practice primary care.
Getting back to the question of why concierge medicine has evolved now and not in the past, it is my belief that it is a direct result of the "perfect storm" in healthcare and the resultant physician disillusionment and dissatisfaction with medical practice, which is reaching epidemic proportions as indicated by numerous polls. Doctors are unhappy, particularly primary-care doctors. In this light, concierge medicine is a reactionary movement rather than a mere marketing stratagem. It is an attempt to rectify the disconnects physicians have come to face between the medicine they learned in the academic setting and had hoped to practice and the medicine they are forced to practice, whether constrained by bureaucracy (government or managed care) or poverty (no equipment or facilities), and between the expectations of patients and the reality of what the physicians are actually providing [1]. Concierge medicine has started in the United States, but because current physician disillusionment and dissatisfaction is a worldwide phenomenon, it will spread, if it hasn't already, to other countries.
Intellectually, I have trouble with the concept of concierge medicine for the same reasons Dr. Herman Brown offers during his testimony for the plaintiff in Crisis. In short, concierge medicine flies in the face of traditional concepts of altruistic medicine. Indeed, it is a direct violation of the principle of social justice, which is one of the three underpinnings of the newly defined medical professionalism, requiring physicians "to work to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic status (italics mine), ethnicity, religion, or any other social category" [2].
But there is a problem. At the same time that I am philosophically against concierge medicine, I am also for it, which makes me feel decidedly hypocritical. I fully admit that if I were a practicing primary-care physician in today's world, I would certainly want to have a concierge practice rather than a standard practice. My excuse would be that I would prefer to take care of one person well rather than ten people poorly. Unfortunately, it would be a rationalization and a rather poor one. Instead, perhaps I'd say I have a right to practice medicine the way I want to practice medicine. Unfortunately, that would be denying the fact that a lot of public money is spent training all doctors, including me, which comes with an obligation to take care of all comers, not just those capable of up-front fees. Maybe then I'd say that concierge medicine is akin to private school and that patients with means have the right to pay for more service. Unfortunately, that misses the point that those people who send their kids to private school also have to pay for public school through their taxes. It also misses the point that medical service, even basic medical service, is inequitably distributed, and I'd be adding to that inequality. Ultimately, I'd have to admit to myself that the reason I wanted to practice concierge medicine was probably more because it provided me with day-to-day professional satisfaction, even though deep down I'd lament that I'd become a doctor different from the one I had started out to be. Such an admission means that I don't fault M.D.'s practicing concierge medicine but rather the system that has forced them to do so.
It is always easier to be a critic than a problem solver. Yet, in regard to concierge medicine, I do think there is a solution to limit its growth, and it's a rather simple one. It involves merely changing the mechanism of reimbursement for primary care, which today is based on a simple, flat rate of slightly more than fifty dollars per visit as determined by Medicare (Medicare serves as the de facto trendsetter for health policy). Primary care is, as I have mentioned, the bedrock of healthcare, and accordingly this low, flat-rate reimbursement is counterintuitive, as evidenced by the example I gave. Patients and illnesses vary considerably, and if the patient needs fifteen minutes, thirty minutes, forty minutes, or even an hour, the physician should be paid accordingly. In other words, the reimbursement for primary care should be predicated on time and should include phone and e-mail time. It should also be on a sliding scale, depending on the level of training of the physician. It is only reasonable.
If primary care was reimbursed in such a rational fashion, quality care would be encouraged, significant autonomy would be appropriately returned to the primary-care physician, and satisfaction of both the physician and patient would go up. As a corollary, the impetus toward concierge medicine would go down. I also believe such a reimbursement scheme would have the paradoxical effect of lowering overall healthcare costs by lowering utilization of subspecialty services. To help in this regard, reimbursement should be tipped away from procedure-based specialty care, which is the case today, and toward primary care.
Some people might worry that basing reimbursement on time would throw open the door to the kind of abuse that is seen in those professions where charges are based on time, but I disagree. I think abuse would be the exception rather than the rule, especially with the strong movement afoot to reassert medical professionalism with the newly promulgated Physician Charter.
On a final note, I want to say something about medical malpractice. When I finished my long medical training in the 1970s and opened a small private practice, I was welcomed into the throes of the first medical malpractice crisis, which had been provoked by a surge in litigation and plaintiff victories. What I experienced, like many other physicians, was a difficulty in obtaining coverage, since a number of the major malpractice insurers suddenly abandoned the market. Luckily, things settled down with the creation of alternative methods for physicians to find malpractice insurance, and everything was fine until the 1980s, when a second medical malpractice crisis loomed. Again, there was a sudden upswing in malpractice suits as well as a marked increase in the size of awards, resulting in a sharp and unsettling increase in insurance premiums.
During these two crises, the healthcare system was resilient enough to absorb the increased costs, mainly by ultimately passing them on to patients and the government through Medicare. As a result, the system didn't suffer any huge disruption other than a marked hardening of the medical profession's dislike for the legal profession, particularly what they considered the "greedy" malpractice plaintiff attorneys. I can remember the time well, and I shared the feelings. With my close association with academic medicine, it seemed to me that only the good doctors who were willing to take on the difficult cases got sued. Consequently, I was fervently behind what most doctors thought was the solution, namely tort reform, such as capping noneconomic rewards, capping attorneys' fees, adjusting certain statutes of limitations, and eliminating joint and several liability.