The other example given by Dr Palumbo is that of the Academic Retainer Practice (ARP) model at Tufts University in Boston, Massachusetts. Physicians split their time between the ARP “concierge” practice, where patients paid a retainer fee of $1800, and the general medical practice model.4 The retainer fee charged by the ARP model was used to subsidize the general medical practice model and improved access for those patients already enrolled in the practice. Again, as with all concierge models, the improved access and attention came at the cost of limiting access for other potential patients. In this example, the physician panel of patients was restricted to half the typical panel for a general practitioner in an academic medicine practice for both the ARP and general medicine sides of the practice.4

It seems that “improved access” is misconstrued in discussions about concierge medicine. On one hand, there is improved access for enrolled patients who now have access to same-day appointments, a 24/7 on-call physician, and same-day lab services. However, from a population health perspective, there is decreased access because physicians in concierge practices see fewer patients, which will worsen the predicted physician shortage if an increasing number of established physicians downsize to concierge models. That is not to argue that the concierge medicine model is bad for public health. On the contrary, it may offer improved quality of care. However, the increased demand for physicians resulting from more practices moving toward a concierge practice model will throw a wrench into an already struggling healthcare system.

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Access aside, there is also the question of whether or not concierge practice improves quality of care. Proponents argue that physicians in concierge practices have more time to spend with patients, can delve deeper into patient concerns, and can offer more extensive education.1 Although this is a sound argument, there are few data to support these claims other than a series of articles published by authors either affiliated with or who have their research funded by MDVIP, which is a commercial marketing agency for concierge physicians.5,6 The argument is not to refute their findings; however, given the potential benefit of favorable findings to MDVIP, these studies should be approached with some degree of skepticism. There ought to be more emphasis on the concern for bias in addition to other limitations, such as the small sample sizes and poor generalizability of the study population.6 Nonetheless, there may be good reasons to believe that concierge practices can offer better care based solely on the fact that patients have quicker and more thorough access and physicians tend to be less overworked and experience improved satisfaction in their practices.

From a physician point of view, there is certainly an attraction to concierge medicine. Economist Uwe Reinhardt described the concierge model as “quintessentially American” and has set aside concerns about forming a 2-tier system by arguing that we currently have a 3-tier system in which the wealthy and the poor (subsidized by Medicaid) have access to their own tier of medicine, and the middle class struggles for access to care altogether.1 Maybe the ACA offered a temporary solution to the problem of funding, but the issue of access remains untamed. There are not enough physicians to meet the increased demands imposed by the ACA, and it certainly has not offered physicians reason to stay in primary care. Concierge medicine may offer a future solution, but for now it leaves us with more questions than answers about its long-term viability and the role it may play in future healthcare delivery models.

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