John Carroll
Contributing Editor

Medical directors have been hard-pressed to come to a consensus on just how — or whether — this new wrinkle in the managed care business fits in.

John Carroll

Contributing Editor

About two years ago, James Fanale, MD, the chief medical officer at Blue Cross and Blue Shield of Massachusetts, sat down with a group of physicians who had come in to make an unexpected pitch: What if, they asked him, their practice began charging patients a retainer fee? Patients would get more personalized care, phone consults, easy-to-make appointments and a larger share of face time for more in-depth, personal care. And Blue Cross would continue to pay for routine insured care.

These were good doctors, says Fanale, well known in the state and valuable members of Blue Cross's network. And eventually he decided that what they were proposing would probably never claim more than a tiny slice of the market. After all, with the economy sputtering in neutral, how many patients would voluntarily pay extra for the kind of boutique practice these physicians wanted to offer?

No consensus

"The practical business response is that it makes sense," says Fanale. "Members should be able to access what they want to access. It's not right for us to make decisions on who people should see. Quality docs should be in the plan and it's up to the patient" to pay extra or not.

Fanale makes it sound like a simple conclusion, but this is one new wrinkle in the managed care business where consensus is hard to come by. As a small but growing number of boutique practices have begun sprouting up around the country offering to give well-heeled patients some appetizing extras, a widening circle of chief medical directors has been forced to start grappling with some vexing questions.

At the top of the list: Does a managed care organization have an obligation to include these concierge physicians in its network? And will their presence encourage the development of a tiered insurance system, with those able to afford more getting not only better care than members with standard coverage, but leaving some in the medical cold with no physician at all?

The answers may depend a lot on just how big a trend this turns out to be.

Doctors haven't exactly been clamoring to give up their traditional practices or threatening to clip their ties to managed care's huge phalanx of members. Practices have been making the switch in only a handful of states, with Massachusetts one of the first. But for all the interest, only about 14 pioneering physicians have made the switch to concierge medicine in a Blue Cross and Blue Shield of Massachusetts network, hardly enough to topple an HMO business plan.

With some of the leading physicians in the nation calling this a wave of the future, though, there's also more than a hint of unease about where this may be headed.

"Yes, if this becomes much more prevalent, I'm concerned," says Fanale. But he's still betting against it. "If all docs thought this was the right thing to do, they'd be doing it," he adds. "But they don't. Docs want to take care of patients and do the right thing."

Not surprisingly, quite a few doctors have a completely different take on where concierge medicine is headed in the U.S.

"I think it is popular already," says Yank Coble, MD, the immediate past president of the American Medical Association, "and people just aren't sure how to access it."

First, patients are pushing the trend with a desire to have easier access, for longer periods, to the physician of their choice — rather than picking a name off a network list. And don't expect a turgid economy to slow it down, either. Americans spend $8 billion a year on bottled water, Coble points out.

It's logical to see more and more consumers opting to pay doctors directly for professional services.

Just don't call it concierge or boutique medicine.

"Retainer medicine" is more accurate, Coble insists. No one hesitates to pay a lawyer or accountant a retainer, he asserts. That's a widely accepted business model for professionals — as well as a solid reason to believe that today's medical novelty may well become tomorrow's widely copied health care norm.

You won't find the AMA resisting, either. Just last June, the AMA devised an ethical guideline for physicians involved in or about to offer "retainer" care. While endorsing the notion of patients paying a retainer, the AMA expects doctors to make sure that nonparticipating patients are placed with other physicians — with no fee for transferring records — and to continue to care for anyone who can't find another physician. And they need to go an extra mile for those who badly need medical attention, actively seeking out new ways to provide pro bono care.

But the AMA's position hasn't taken the sting out of a thorny debate that boutique practices pose.

"It's unprofessional," says Jay Jacobson, MD, "and for me that's what is important."

Jacobson is a professor of internal medicine at the University of Utah School of Medicine, but it is when he assumes the role of medical ethicist that he struggles with the implications of retainer practices.

"I think it's very understandable," says Jacobson, "not unethical per se. But at the same time, I'm not sure it's laudable. What professional value is served?"

There's no evidence that more concierge practices will lead to better outcomes. No one makes the case that it's more compassionate or more competent. It doesn't lead to more care for more people or give priority to caring for the people who need it most.

All the arguments for concierge medicine, says Jacobson, are purely personal: "It enhances income and also enhances convenience for some patients."

If doctors feel too pressed by the current insurance system to treat patients properly, he adds, then perhaps they should push for a change in the system rather than for a practice method that simply makes their own lives simpler and individual doctors more successful but misses the mark on physicians' collective goal: "To provide more and better care for more people."

For Harvard Pilgrim Health Care, the argument came down to a simple question. "How does this mesh or not mesh with Harvard Pilgrim's mission and products?" asks Roberta Herman, MD, the MCO's chief medical officer.

"The whole founding mission of Harvard Pilgrim was based on improving the health of the general population," says Herman, "with access to affordable, high quality health care. This didn't seem in concert with that."

There was another problem, this one purely contractual. Harvard Pilgrim required its practices to accept new health plan members when possible, and to not restrict access by any particular criteria.

So after some of Harvard Pilgrim's network physicians asked the HMO to consider the issue, Herman and her colleagues decided to say "no."

"One thing that concerned us greatly was the implication that some of the things most doctors do as routine business ought to be separately reimbursable," says Herman. A timely return of phone calls? Careful, expert advice? Personal care? Every doctor in Harvard Pilgrim's network is expected to offer these things. The concierge movement, she says, makes standard aspects of care into special services.

Once the issue hit the state association of health plans, flags were raised on several levels: What regulatory concerns needed to be addressed? How were consumers to be alerted to what they were responsible for and what the health plan would pay? And how would the possibility of widespread adoption affect lower income families who couldn't pay the extra freight?

Access issue

"For those members who decide not to pay," says Marylou Buyse, MD, president of the Massachusetts Association of Health Plans, "this really is a disruption in care. We raised our concern about potential access problems, particularly of access of the poor in areas of a physician shortage," adds Buyse, the former president of the Massachusetts Medical Society. "If this becomes a trend it could present an economic and access issue for certain people."

The association started its own internal review by studying the effect that concierge services would have on member health plans. "We feel that these practices do create significant administrative burdens on the plans," says Buyse.

The success or failure of that trend, she adds, will have more to do with consumer demand than physicians' desires. "Consumers will decide with their pocketbooks and their feet," says Buyse. "I view these practices as really pilots in boutique medical care."

As for the thorny ethical questions: "I'll leave ethics to the ethicists," says Buyse. "The real issue in health care today is not access or convenience. It's really cost. There's nothing in these practices that deal with the underlying cost issues."

After adding it all up, Buyse decided to make common cause with Health Care for All, a universal health care advocacy group that has pushed for legislation that bans concierge practices. Headed for debate as Senate Bill 633, it remains to be seen whether her arguments will make any headway with lawmakers.

Until then: "It's a free market," says Buyse. "Let's see what the free market decides."

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