Yesterday the Boston Globe reported that two of the most respected physicians at the Newton Wellesley Hospital, five miles from where I live, are shifting to a mode of practice called "boutique" or "concierge."
In this format physicians limit their practice to 300 - 600, a much smaller number than is typical for primary care, and charge a fee ($1,500 and up) for membership in the practice. Patients are offered prompt appointments, more time for their visits, 24/7 access to their physician, and more. Insurance doesn't pay the membership fee. Patients need insurance to cover tests, office visits, specialty consultations, hospitalization, and other insurance-covered services.
Concierge practice is small in number, but like canaries in coal mines, it's the source of important information. I only know one physician in a concierge practice - Dr. Jordan Busch, co-founder of Personal Physicians HealthCare, a four physician practice near Boston. Jordan is a superb physician with strong caretaker values. He came to feel that he was not able to care for patients in the comprehensive, personalized manner he aspired to while at the same time making a middle class income. Insurance reimbursement (private insurance, Medicare and Medicaid) for primary care pays by the visit, at a relatively low level. Meeting office expenses and earning a middle class income required a large volume practice. For Jordan (and his colleagues), Personal Physicians HealthCare is a way to practice the kind of medicine he believes in.
I've visited the website of MDVIP, a Florida-based entrepreneurial organization that provides support for approximately 225 physicians in the U.S. (16 in my own state - Jordan's practice is not affiliated with it). I wish I could say I was impressed by idealism, but I wasn't. Much of the executive team comes from Proctor & Gamble. The marketing is pitched to affluent patients. I was struck by the absence of any reference to improving the health system. It presents concierge practice as a "solution" to the frustrations of individual patients and physicians by opting out of the larger system. Although the numbers are still small, each primary care physician who moves to a boutique practice makes it harder for patients to find their own physicians and makes practice even busier for those who don't opt out.
When I trained in psychiatry in the late 1960s, many of the best and the brightest chose to become psychoanalysts. I thought of psychoanalytic theory as a source of insight, but the idea of a small panel of affluent patients didn't represent the kind of diverse, population-oriented practice that I aspired to. I can understand the frustration many primary care physicians, perhaps most, feel at present. But if I were a PCP, I'd think of concierge practice the way I thought of psychoanalysis - a failed model from the perspective of societal needs and population health.
Over time, moving to accountable care organizations and other formats that pay physicians for the populations they care for, not for the visits they provide, is a much more promising and socially responsible direction than concierge practice. Concierge practice, like dead canaries in the coal mines, is a symptom of a societal problem, not a solution!