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Concierge Medicine For All?

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Recently one of my regular patients stopped by to just check in. The patient’s last visit was very comprehensive; we spent a lot of time completing a review of her health and risks that she would benefit from addressing. At the end of the visit she seemed very satisfied and grateful that I had spent the extra time to address all her needs with no extra payment. So it was to my surprise that she informed me that she had subscribed to a concierge medicine practice where she paid an extra fee every month for extra time with the clinician and to be able to access them whenever she wanted to. I enquired further and she admitted that our practice was already providing what she thought she was missing, but because she had the extra resources she felt it would not hurt to pay extra and see what the outcome would be. We finally both agreed that our practice set up was meeting her needs and she didn’t need to pay extra to get all the benefits. 

The American health care system continues to be broken and the gap between the population health outcomes and the investments made towards health care are still not acceptable. Great advances have been proposed especially since the inception of the Affordable Care Act but there is still room for improvement. It is estimated that 5% of the population is responsible for half of the nation’s health care costs. Therefore, it would be of the nation’s best interest to aggressively meet the needs of this population’s unique needs to lower our health care costs.

One of the more trendy forms of health care delivery is membership based medicine, also known as concierge medicine, or direct care practice. Patients that subscribe to this form of health care delivery system usually report great satisfaction with their care. They are afforded privileges such as same day appointments, extended time with clinicians, and no wait times. Clinicians maintain modest revenue and sustainable schedules. Currently most health care organizations’ goal is to focus on outcomes versus volume. However, most organizations have not changed clinicians’ payments structure so patient volume continues to be necessary to sustain most health care practices. Concierge membership patient costs can vary anywhere from $1000 to $20,000 per year. Some memberships provide the services and bill the health insurance and some do not bill the insurance. Another interesting factor is that concierge practices do not have to comply with many of the Affordable Care Act provisions including those for patients with pre-existing conditions, though some states do require that the arrangements do not discriminate on the basis of health.

When you consider all the benefits afforded through concierge membership it’s safe to conclude that these are the benefits that would significantly improve the health of all Americans. These services would especially benefit patients living with comorbid conditions requiring extensive care coordination and medication management. The downside of the concierge medicine arrangement is that only the elite and wealthy can afford the services long-term without straining their financial resources. The health advantage offered only to the elite is a practice common in most of the developing nations. In most of the developed nations the wealthy pay out of pocket for extra customized health care benefits that the ordinary citizen cannot afford. As a result, there are many health and health care disparities that arise or continue to exist in developing countries that are now prevalent in our nation. Some proponents of concierge medicine agree that some of the plans such as those that charge $50 a month are cost effective not considering the many individuals that live on minimal or fixed incomes that cannot afford the extra charges not offered through their health insurance.

The question is why can’t we as Americans work toward overhauling the health care system to meet the needs of all patients, rich and poor, as well as all clinicians? We can do this by providing access to customized high quality care and also by finding pathways for clinicians to keep reasonable revenue streams as an incentive. 

Mercy Bashir, DNP, ANP-C, GNP-BC, is an assistant professor and coordinator of the Adult-Gerontology Nurse Practitioner program at Salem State University in Salem, Massachusetts. Her passions include health and wellness, chronic disease management and population health.

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