Question: Is Concierge Medicine Ethical?

“Concierge medicine,” “retainer medicine,” “platinum medicine,” or what some refer to as “executive health programs” is a new concept but one that is here to stay. The basic concept entails a situation whereby a patient pays a set annual fee for “special medical services.” The cost of such membership ranges from $1,500 to $20,000 depending on the services that are provided, as well as the age and health of the patient. As stated above, there are numerous benefits and disadvantages to this new alternative medical practice. The main ethical issues focuses on whether concierge medicine will result in a two-tiered medical system based upon economics; is this a form of patient abandonment; and how does this new form of medical practice address the age old notion that physicians have a professional obligation to provide care for all those in need, especially the most vulnerable of patients? To determine if concierge medicine is ethical it will be evaluated by the basic ethical principles of respect for persons, beneficence, nonmaleficence and justice47.

Respect for persons incorporates two ethical convictions: first, individuals should be treated as autonomous agents; and second, persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy48. The physician-patient relationship is a covenant that is based on mutual trust. It is a fiduciary relationship that is based on honesty. Ethicists Edmund Pellegrino and David Thomasma, who have written extensively in this area, argue that among the obligations that arise from the physician-patient relationship is technical competence: the act of the medical professional is inauthentic and a lie unless it fulfills the expectation of technical competence49. This means that patients can expect their physicians to offer the same standard of diagnostic and therapeutic services to all patients.  The American Medical Association is quite clear regarding this issue:

Concern for quality of care the patient receives should be the physician’s first consideration. However, it is
important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic
services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence,
sound medical judgment,relevant professional guidelines,and concern for economic prudence.50

Autonomy gives physicians the right to offer concierge care and patients the right to take advantage of these exclusive services. Many concierge physicians argue that this type if medicine is not only in the best interest of the patient but also in the best interest of the physician. Physicians can practice more personalized medicine without being constrained by time and income issues. Having more time to spend with patients will allow physicians to focus not only on treating diseases and injuries but also preventing them. Preventive medicine has been proven to save patients money and suffering.  The problem area that arises is the issue of patient abandonment.  The cost of concierge medicine can eliminate a number of patients from a physician’s practice as was discussed earlier in the paper. Critics argue that this could be seen as a form of patient abandonment. Advocates respond to this criticism by arguing that as long as physicians have a careful transition process that assists patients in finding new physicians and allows for continuity of care then this objection can be negated. The American Medical Association offers a strict guideline on this matter which was referred to on page thirteen.  Abandonment of patients violates their basic human right of respect for persons, because they are not being treated with dignity and respect. If a patient is abandoned for economic reasons this patient can be considered vulnerable because their medical conditions are being untreated and their quality of life suffers. This violates the principle of respect for persons because we are failing to protect those individuals with diminished autonomy.

Another area that relates directly to the principle of respect for persons is the issue of informed consent. Most commonly, informed consent refers to surgical procedures and operations.  However, in this paper, informed consent also refers to the legal contract between patient and physician.  Patients have a right to be informed about the services that are covered and not covered as well as the retainer fees for their medical care.  This contract should also provide termination language. Patients have every right to be informed about the duration of the contract and renewal arrangements. Physicians need to be very careful in following all the rules and regulations regarding opting out of Medicare and/or other third-party payers and patients need to be informed about these arrangements and their payment responsibilities. Patients cannot give informed consent unless they have adequate knowledge about their options.  One of the basic aspects of the principle of respect for persons is that a person should never be treated simply as a means, but always as an end. Failure to treat a patient because of economic issues or failure to inform a patient of the cost and extent of contracted medical services is to use patients as a means rather than an end. However, if concierge physicians have a plan of continuity of care with other physicians in the community that provide adequate notice and appropriate referrals, do not leave patients in an unstable condition and the concierge contract is clearly understood, then this objection of using a patient as a means to an end can be eliminated. Respect for persons entails giving patients the right to select their physicians and to be treated with dignity and respect.  Following the guidelines outlined by the American Medical Association regarding retainer contracts would provide the needed safeguards for patients that would show a basic respect that all human persons deserve.

Beneficence involves the obligation to prevent and remove harms and to promote the good of the person by minimizing possible harms and maximizing possible benefits. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others. In medical ethics this principle has been closely associated with the maxim Primum non nocere: Above all do no harm51. Advocates argue that concierge medicine is in the best interest of the patient. Patients receive special medical services that are not now provided by most primary care physicians. They receive priority same day or guaranteed next day appointments, 24/7 access to physicians, house calls, preventive care, enhanced yearly health exams, telephone and e-mail consultations, etc. Having immediate access to a physician gives many patients a special peace of mind. It also allows a physician to be proactive with patients focusing on wellness and preventive care.  Concierge medicine allows physicians to intervene early before medical issues become problematic. “Patients undergo a comprehensive yearly exam that goes well beyond the typical physical, with chest x-rays, extensive blood work, and electrocardiograms, among other tests. With the information gathered from these extensive checkups, each patient gets a unique ‘wellness plan’4.” According to recent studies, patients in a concierge practice had 61.3% fewer hospitalizations compared with similar patients in commercial insurance plans, and 74% fewer hospitalizations compared with Medicare patients of similar age, gender, and disease risk. Practicing medicine in this manner is not practicing better medicine but it is giving better care. It is maximizing medical benefits and minimizing medical harms.

Concierge medicine is also in the best interest of the physician. As stated above, many primary care physicians feel overworked, underpaid and under appreciated in their current medical practices. Due to time and financial constraints placed upon them, physicians believe they are not providing the treatment that their patients deserve. As a result, many physicians in family practice are contemplating leaving the medical field and many medical students are not opting for family practice residencies.  Concierge medicine maximizes benefits for physicians by allowing them to have a reasonable number of patients and a salary that approaches the salaries of specialty physicians. It also minimizes harms by sustaining physicians who might otherwise abandon the medical field and encourages new physicians to seek family practice as a viable professional option.

Critics argue that concierge medicine violates the principle of nonmaleficence because it could cause more harm and even injury to patients.   These critics argue that with 47 million people uninsured and with the new Patient Protection and Affordable Care Act set to be initiated, if we continue to drain the healthcare system of qualified physicians then who will care for the majority of Americans who need primary care?  It is true that concierge medicine does benefit patients in these practices and is in their best interest medically. However, critics argue that instead of concentrating on a minority of individuals why not spend this time and money on reforming a deeply flawed healthcare system.  Concierge medicine does offer the patient, who is a consumer, a choice. Those who can afford concierge medicine have the right to exclusive medical services, because medicine is now a consumer driven market. This may be true but unlike other consumer goods, physicians should be held to a higher standard than other ordinary drivers in the marketplace.  Physicians are professionals and have an obligation to provide the “gold standard” of medicine to all patients equally. Failure to do so could inflict harm, injury and even death on the most vulnerable in society, especially minority patients, Medicare patients, and those with chronic diseases.

Advocates argue that this new sense of competition between traditional and concierge medicine may be in the best interest of patients, physicians and society as a whole. The high renewal rates in concierge practices, even in this economy, demonstrate how dissatisfied many patients are with the standard medical practice in the United States. In order to maintain their patients, concierge practices might be setting a new standard for medical practice or may be returning to a standard that once existed in medicine.  Emphasis on preventive medicine may become the new standard of care. This is not better medicine but it is better care. If studies continue to prove that taking the time to listen to patients causes physicians to order fewer expensive tests because their physical exam would have told them what they need to know and preventive medicine keeps patients out of hospitals and emergency rooms, then the cost of healthcare will decrease. If the government and insurers begin reimbursing physicians more for their time and clinical services and offered salaries comparable to specialists, then the shortage of physicians could be averted and more medical students would be attracted to primary care residencies. Instead of being accused of draining the healthcare system of primary care physicians, concierge medicine could maximize medical benefits by bringing a new sense of excitement to the field of primary care both medically and financially. The result might be that “doctors in traditional practices could offer more boutique-like services without the boutique prices4.” It is possible that concierge medicine could fail not only the test of beneficence, but also fail the test of nonmaleficence if proper safeguards are not imposed by the medical profession. However, with these safeguards in place, concierge medicine could also raise the standard of patient care to a level that is in the best interest of patients, physicians and society as a whole. As a result, prevention and wellness could become mainstream and affordable, healthcare costs could decline, physicians contemplating leaving the medical field may extend their careers, and medical students may be lured into family practice if salaries approach those of specialty care. This would satisfy the tests of both beneficence and nonmaleficence by maximizing benefits and minimizing harms.

Finally, the principle of justice recognizes that each person should be treated fairly, equitably, and be given his or her due. Justice also pertains to distributive justice, which concerns the fair and equitable allocation of resources, benefits and burdens, according to a just standard. Inequality concerning access to medical care is a well-documented fact52. To allow some patients, in similar situations, to have better access to physicians and medical treatments is an egregious violation of the principle of justice.  Justice dictates that patients should be treated in a similar manner if at all possible. If there are medical treatments that are good for concierge patients, and these are prescribed for some but not others, then failure to treat all equally violates the basic tenet of justice, that is, to treat all people fairly and equitably. The principle of justice can be applied to the problem under discussion in two ways.

First, critics argue that concierge medicine is only affordable for the wealthy.  Having discussed the annual fees, it is clear that one would pay at least one thousand dollars for this practice.  These critics argue that concierge medicine threatens access to care especially for the poor and the uninsured.  Studies have shown that concierge practices see fewer African-Americans, Hispanics and Medicaid/Medicare patients33. This contributes to the growing problem in the United States regarding disparities in healthcare. This criticism is countered by advocates who claim that concierge physicians have not only more time for their patients but also for volunteering. As stated above, MDVIP has opened a clinic for over 600 Medicaid patients who receive the same services as those who pay a retainer fee for concierge medicine. MDVIP also allows concierge physicians to offer scholarships and fee waivers to approximately 10% of their patients who cannot afford concierge care28. In addition, Qliance Medical Management offers concierge type services but with a monthly retainer fee of forty-four dollars.  Qliance is targeting the working poor, the uninsured and small businesses looking for affordable and quality healthcare29. Critics contend that concierge medicine is elitist but upon further examination many practices work out to roughly $4 to $5 a day—about the same amount people spend on cigarettes or a coffee at Starbucks. This does not seem to be elitist but a matter of priorities. If healthcare is a priority, then concierge medicine can become mainstream and affordable, not an unjust practice.

Second, critics are also concerned about reimbursement issues. Physicians in concierge practices do not normally sever their ties with third-party payers. If reimbursement issues are handled improperly, then serious legal issues can arise. The American Medical Association Code of Ethics is quite clear on this issue:
Physicians who enter into retainer contracts will usually receive reimbursement from the patients’ health care plans for medical services. Physicians are ethically required to be honest in billing and reimbursement, and must observe relevant laws, rules, and contracts. It is desirable that retainer contracts separate clearly special services and amenities from reimbursable medical services. In the absence of such clarification, identification of reimbursable services should be determined on case-by-case basis.53

Michael Blau, director of the Health Law Department at McDermott, Will and Emery, in Boston argues that concierge physicians need “to draw a very bright line between the non-covered concierge services for which you’re collecting a fee, and covered services for which you’re billing54.” Blau suggests that concierge practices that bill insurers should consider setting up a complete separate business corporation alongside their professional corporation. “The business corporation, which is not authorized to engage in the practice of medicine, collects the non-covered fees; the professional corporation, which is authorized to practice medicine, accepts payment in fill for covered services from third-party payers, subject to coinsurance, deductibles and copays53.” Justice demands that resources be equitably distributed, fairly priced and properly paid for by patients. Failure to do so is ethically irresponsible and morally objectionable.
If proper guidelines and safeguards are established nationally for concierge medicine it can be medically, legally and ethically justified. However, without these guidelines and safeguards numerous problems can and will arise.