Going offensive against defensive medicine

A Quiz: Name That Health Care Model

What do these characteristics bring to mind?

  • Flexible appointment scheduling
  • Advanced electronic communication
  • Care coordination
  • Counseling and education
  • Electronic prescribing
  • Electronic health record with patient portal

If you thought Level 3 Medical Home, you were correct. If you thought retainer (concierge) practice, you would also be correct.

To me, it seems eminently rational for people who have sufficient discretionary income to choose to use it to obtain more rapid access to a personal physician of her/ his choosing through a retainer (concierge) practice. The advantages might be more time spent in conversation (in the office, over the phone, via e-mail or text messaging, in video conferences), more in-depth condition or prevention education, coaching, counseling, and/or less waiting time.

Some in the medical profession have raised the question of the ethics of retainer practices. An excerpt from an Annals of Internal Medicine editorial:

“I am less charitable, however, toward concierge physicians and am surprised by the neutrality with which the medical community has addressed their work. First, each of us has vowed to treat without exception all who seek [our] ministrations,and limiting one’s practice to several hundred wealthy patients undermines this tenet of our profession. Even though economic realities and schedule limitations dictate that some physicians maintain a certain payer mix or eventually close their panels to new patients, I am certain that the legendary physicians of our profession would be embarrassed by the criteria some of our colleagues have used in selecting which patients they will and will not see.” Ann Intern Med. 2010;152:391­392.

“Treat without exception all who seek [our] ministrations” is from the Hippocratic Oath, a poignant ethical pledge believed to have been written in the late 5th century BCE. Our modern reality is that there are many constraints on how clinicians practice, the scope of that practice, where they practice, the patients that they treat, and the machinations of how that care is reimbursed.

As a volunteer faculty physician in a Federally Qualified Health Center, I find this challenge of ensuring adequate access to care to be abundantly evident. My own view: Health care practitioners should dedicate some time to service in situations with wider access, often pro bono, whether the field be medicine, nursing, pharmacy, or allied health professions. This may be difficult or impossible in a retainer medical practice, but that does not preclude service elsewhere.

Retainer practices have their place, but they will only be viable if the clinicians engaged in that model meet or exceed the expectations of their patients by providing a comfortable medical home for them.

It’s that rational.

Steven R. Peskin, MD, MBA, FACP is executive vice president and chief medical officer of MediMedia USA, which publishes Managed Care. He is Associate Clinical Professor of Medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School

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