Although there have been articles about concierge medicine, none that I have read have truly addressed the question of why this phenomenon has emerged at this particular time. What is usually offered are economic explanations revolving around the idea that concierge medicine makes sense from a marketing perspective. After all, provided he or she can afford it, who wouldn't want the promised amenities, considering what the experience of going to the doctor is like all too often in today's world, and what physician wouldn't prefer to have financial security right out of the starting gate and to be able to practice the unhurried medicine they learned in medical school? Unfortunately, this superficial answer doesn't explain why the phenomenon makes sense now and didn't, say, twenty years ago. It is my belief that the real answer is that concierge medicine is a direct result of the dire, unprecedented state of disarray in current healthcare on a worldwide basis. In fact, there are those who evoke the metaphor of the perfect storm to describe the current situation, particularly in the United States.
There have been a number of problems plaguing medical practice over the last quarter-century or so, but never have there been so many all converging at the same time. Concurrently, we are seeing aggressive medical cost containment; personnel and equipment shortages; expanding technology; strenuous and appropriate efforts at medical error reduction; soaring litigiousness and settlement awards; rising ancillary costs; a bewildering multiplication of health-insurance products, including managed care with its associated intrusion into medical decision-making; and even the changing role of hospitals. All of these forces have contributed to making the bedrock of medicine – the practice of primary care – a night-mare, if not impossible. For a primary-care physician to stay in business, meaning earning enough to keep the doors open and the lights on (or staying employed in a managed-care environment), he or she must see patients at an extraordinary rate with an entirely predictable result: dissatisfaction on the part of both the doctor and the patient, and, ironically enough, increased utilization and cost and rising litigation.
Consider the following example: A patient with some mild ongoing medical conditions (for example, high blood pressure and elevated cholesterol) visits his primary-care physician with new complaints of shoulder pain and abdominal discomfort. In the current practice environment, the doctor has a mere fifteen minutes to deal with everything, including basic social civilities. Understandably, the conditions the doctor had previously taken responsibility for would take precedence (the high blood pressure and cholesterol level). Only then would the new symptoms be addressed. With the clock ticking and a waiting room full of disgruntled patients because the schedule was thrown off by an earlier minor emergency (an almost daily occurrence), the doctor resorts to the most expeditious approach: for example, ordering an MRI or a CAT scan for the shoulder and referring the patient to a gastroenterologist for the abdominal discomfort. With the pressure to meet the practice overhead, there is no time for the doctor to investigate each complaint properly with a careful history and examination. The result is a tendency for overutilization and inconvenience for the patient, much higher cost, and less than satisfaction for both the patient and the doctor. The doctor is forced by circumstance to function more like a triage assistant than a fully trained physician. This is especially true if the doctor is a board-certified internist, many of whom practice primary care.
Getting back to the question of why concierge medicine has evolved now and not in the past, it is my belief that it is a direct result of the "perfect storm" in healthcare and the resultant physician disillusionment and dissatisfaction with medical practice, which is reaching epidemic proportions as indicated by numerous polls. Doctors are unhappy, particularly primary-care doctors. In this light, concierge medicine is a reactionary movement rather than a mere marketing stratagem. It is an attempt to rectify the disconnects physicians have come to face between the medicine they learned in the academic setting and had hoped to practice and the medicine they are forced to practice, whether constrained by bureaucracy (government or managed care) or poverty (no equipment or facilities), and between the expectations of patients and the reality of what the physicians are actually providing [1]. Concierge medicine has started in the United States, but because current physician disillusionment and dissatisfaction is a worldwide phenomenon, it will spread, if it hasn't already, to other countries.
Intellectually, I have trouble with the concept of concierge medicine for the same reasons Dr. Herman Brown offers during his testimony for the plaintiff in Crisis. In short, concierge medicine flies in the face of traditional concepts of altruistic medicine. Indeed, it is a direct violation of the principle of social justice, which is one of the three underpinnings of the newly defined medical professionalism, requiring physicians "to work to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic status (italics mine), ethnicity, religion, or any other social category" [2].
But there is a problem. At the same time that I am philosophically against concierge medicine, I am also for it, which makes me feel decidedly hypocritical. I fully admit that if I were a practicing primary-care physician in today's world, I would certainly want to have a concierge practice rather than a standard practice. My excuse would be that I would prefer to take care of one person well rather than ten people poorly. Unfortunately, it would be a rationalization and a rather poor one. Instead, perhaps I'd say I have a right to practice medicine the way I want to practice medicine. Unfortunately, that would be denying the fact that a lot of public money is spent training all doctors, including me, which comes with an obligation to take care of all comers, not just those capable of up-front fees. Maybe then I'd say that concierge medicine is akin to private school and that patients with means have the right to pay for more service. Unfortunately, that misses the point that those people who send their kids to private school also have to pay for public school through their taxes. It also misses the point that medical service, even basic medical service, is inequitably distributed, and I'd be adding to that inequality. Ultimately, I'd have to admit to myself that the reason I wanted to practice concierge medicine was probably more because it provided me with day-to-day professional satisfaction, even though deep down I'd lament that I'd become a doctor different from the one I had started out to be. Such an admission means that I don't fault M.D.'s practicing concierge medicine but rather the system that has forced them to do so.
It is always easier to be a critic than a problem solver. Yet, in regard to concierge medicine, I do think there is a solution to limit its growth, and it's a rather simple one. It involves merely changing the mechanism of reimbursement for primary care, which today is based on a simple, flat rate of slightly more than fifty dollars per visit as determined by Medicare (Medicare serves as the de facto trendsetter for health policy). Primary care is, as I have mentioned, the bedrock of healthcare, and accordingly this low, flat-rate reimbursement is counterintuitive, as evidenced by the example I gave. Patients and illnesses vary considerably, and if the patient needs fifteen minutes, thirty minutes, forty minutes, or even an hour, the physician should be paid accordingly. In other words, the reimbursement for primary care should be predicated on time and should include phone and e-mail time. It should also be on a sliding scale, depending on the level of training of the physician. It is only reasonable.