For many years, Dr. Edward Legare was my primary care physician. My wife chose him for me. “He served in the military; you'll like him.” She was right. I liked the citation from the Army's Tenth Mountain Division on his wall, and I liked his succinct dietary advice — “Eat less fat” — which I assiduously ignored.
After some soul-searching, Legare decided to join a high-end “concierge” practice a few years ago, and asked his patients to pay an extra $1,500 for his services.
His group practice shunted me to another talented young internist, Dr. Eric Serrano. Then — poof! He's gone concierge, too. He wants $1,800 a year, he explains in a letter, “to ensure we have unhurried time together whenever you need me, and you continue to receive the individual attention and services you deserve.”
I'm paying about $10,000 a year for a family health plan, and, like most Americans, I see my doctor about twice a year. Harvard Pilgrim Health Care can't keep decent doctors around for me to consult with? What's going on here?
Harvard Pilgrim didn't want to discuss this issue, but plenty of other people did. Legare and a colleague, Dr. Harold Solomon, praised the concierge doctoring model because the extra income allowed them to get their patient load under control. BC (before concierge) Legare was responsible for 3,800 patients, “It was overwhelming,” he said. “I was worried that I was starting to miss things. I was involved in only about half of my patients' major medical decisions.”
Both Solomon and Legare said they retained “scholarship” patients, people who they knew might not be able to pony up the $1,500-$1,800 premium for their services. Then Solomon turned the tables on me: You have the money, don't you, Mr. Beam? Why didn't you pay?
Fair question. I just bought a new rowing shell, which would have paid for two years' worth of concierge care. But the concept makes me sick. I entered the workforce just as Health Maintenance Organizations came on the scene, and I never had a problem with semi-collectivized health care. The system provided me with competent doctors and access to decent hospitals if I needed it. Why should I submit to this “concierge” shakedown when I'm already paying so much for health coverage?
But enough about me. In truth, not all of America's great doctors are moving to the gated communities of concierge care. According to the most recent Medscape survey of over 21,000 doctors, “The percentage of physicians in a concierge or cash-only practice increased very slightly from the previous year, from 4 percent to 6 percent.” More ominously, 15 percent of family physicians said they would no longer accept Medicare or Medicaid payments.
The American Medical Association isn't overly concerned about concierge care, which it calls “retainer practices.” They “are consistent with pluralism in the delivery and financing of health care,” according to the AMA. “However, they also raise ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care.”
“Right now it's a small trend,” says James Burgess, a health care economist at Boston University. “Some people are worried about creating multiple classes of medicine in the U.S.,” but he isn't one of them, for now. “It's going to take a while for the system to find its equilibrium,” he says.
Burgess and others think that retainer practices, sometimes called “direct primary care,” may be part of the health care solution rather than the problem. The idea is this: You pay for your primary care out of pocket, and pay insurance premiums to protect yourself from high-cost medical procedures and hospitalizations.
Companies like Cambridge-based Iora Health Care and others already offer reasonably priced ($50-$70 a month) primary care plans that allow doctors to keep their patient load at manageable (i.e. 600-700) levels. Insurance coverage would be reserved for the big-ticket procedures delivered by, say, hospitals.
“Your auto insurance doesn't cover new brakes, or basic maintenance,” explains consultant Thomas Charland of Merchant Medicine, “and these direct payment plans work on that model. You pay for primary care completely outside of insurance — it's concierge medicine for the masses.”
Meet the future, like it or not.