Letters to the Editor  |   April 2006
Author Affiliations
    Ohio University College of Osteopathic Medicine Athens, Ohio, Medical Director, Respiratory Care Technology Program Bowling Green State University–Firelands College Huron, Ohio
    Clinical Professor of Pulmonary & Critical Care Medicine
    Bowling Green State University Bowling Green, Ohio
    Distinguished Teaching Professor of Economics
    Bowling Green State University Bowling Green, Ohio, Director, Northwest Ohio Consortium for Public Health Toledo, Ohio
    Professor of Public Health
    University of California at Los Angeles Los Angeles, Calif
    Associate Clinical Professor of Medicine
Article Information
Endocrinology / Geriatric Medicine / Practice Management / Preventive Medicine / Professional Issues / Diabetes
Letters to the Editor   |   April 2006
The Journal of the American Osteopathic Association, April 2006, Vol. 106, 215-218. doi:10.7556/jaoa.2006.106.4.215
The Journal of the American Osteopathic Association, April 2006, Vol. 106, 215-218. doi:10.7556/jaoa.2006.106.4.215
To the Editor:  
We appreciate the letter and comments by Garrison Bliss, MD, regarding our special communication article that appeared in the November 2005 issue of JAOA—The Journal of the American Osteopathic Association (Linz AJ, Haas PF, Fallon LF Jr, Metz RJ. “Impact of concierge care on healthcare and clinical practice.” 2005;105:515–520). As president of the Society for Innovative Medical Practice Design, Dr Bliss expresses some concerns that we feel are worthy of additional dialogue. In our article, we attempted to remain objective and nonjudgmental in our review of the merits, as well as the shortcomings, to healthcare and medical practice of concierge-/boutique-/retainer-type medical practices. Our article's authors included an osteopathic physician from traditional healthcare (A.J.L.), an allopathic physician from concierge-style medicine (R.J.M.), a professor of public health (L.F.F.), and an economist (P.F.H.). We expected that this mix would help provide an unprejudiced and balanced perspective on this emerging nontraditional practice model. 
In the present response to the letter of Dr Bliss, we would like to further examine the issues of equity, costs, marketplace forces, physician and patient satisfaction, and insurance as they relate to concierge care and other monthly fee practices representing comparable financial arrangements. 
Dr Bliss describes concierge-style practices as an innovative concept in creating a genuine marketplace for healthcare. We do not argue that concierge care is an alternative method to address the financial issues that exist between healthcare providers and patients. However, access to such care is limited to those having financial means. This type of care is not a marketplace that is accessible to all Americans. Although it is laudable, as Dr Bliss points out, that some physicians practicing concierge care set a range of fees to permit lower-income patients to gain access, marketplace incentives suggest that such a practice is not typical. Markets work on the principle of profit maximization. To the extent that higher-income families will gain more access to concierge care, concerns about equity in healthcare will remain. 
Dr Bliss discounts the availability of concierge care for only the rich by citing his personal observations of lower-priced models of concierge care that provide patients with extra access to services and greater availability of physicians—models that, according to his letter, “[m]any critics and pundits have chosen to ignore.” We feel that these models are certainly worthy of note. Yet, it must also be acknowledged that some researchers1 have concluded that both concierge and nonconcierge care provide many of the same kinds of services. 
For example, Alexander et al1 found that, despite notable differences between concierge-style (retainer) care and nonconcierge (nonretainer) care, there was considerable overlap in the types of services provided. In a nationwide mail survey of retainer physicians (N=144, 58% response rate) and nonretainer physicians (N=463, 50% response rate), the researchers noted that a considerable proportion of nonretainer physicians reported providing 24-hour access (40% vs 91% for retainer physicians), same-day appointments (83% vs 96% for retainer physicians), and coordinated hospital care (59% vs 86% for retainer physicians).1 Alexander et al1 also found evidence that many patients discontinued their association with physicians after the physicians converted to concierge/retainer practices. 
Furthermore, Alexander et al1 noted the tendency of retainer physicians to have a different mix of patient cases than their nonretainer counterparts, with smaller proportions of patients with diabetes mellitus (and perhaps other chronic diseases) being seen in retainer practices. Physicians in retainer practices also cared for fewer African-American and Hispanic patients than did physicians in nonretainer practices.1 The authors proposed that part of this dissimilarity in patient populations may be the consequence of most retainer practices emerging in high-income locations.1 
The American College of Physicians has expressed its concerns about equity in concierge care in an official position paper.2 The paper submits the opinion that physicians who participate in concierge-type practices should be aware that, by limiting their patient populations, they “risk compromising their professional obligation to care for the poor and the credibility of medicine's commitment to serving all classes of patients who are in need of medical care.”2 
We agree with Dr Bliss that the costs for healthcare services have increased. However, we do not attribute all the blame for this to the lack of market forces in the healthcare industry. Some of the cost increases are the result of other factors, including innovations in technology. Unlike nonmedical industries in the marketplace, the healthcare industry has had rising costs of technology that have not been accompanied by decreased profit margins in products, services, and insurance.3 Advances in technology, including methods for earlier detection of illnesses and better treatment of patients, have improved life expectancy and mortality rates in the United States at soaring expense. Yet, attempts to reduce cost factors in other areas have not been achieved. 
In focusing on Dr Bliss's main argument, describing the effectiveness of market forces in providing healthcare, we wish to urge caution. As we stated in our article, “Often, the availability of [market forces] provides an incentive for increased or improved output by producers. Similarly, concierge care should remain a viable option for consumers as long as it does not drain resources devoted to the mainstream healthcare system.” Dr Bliss is correct in stating, “Unfortunately, nothing worthwhile is free.” But it should also be noted that, given limited resources, increased amounts of care will result only if there is increased efficiency, a greater number of providers, or a reduction in healthcare access for some patients. Dr Bliss apparently expects that improved efficiency and the entry of new caregivers will solve problems related to access to care. However, we are not so certain. 
Dr Bliss writes, “The beauty of the marketplace is well known and time tested. The predictable evolution in market systems is toward increased consumer and vendor satisfaction, lower prices, greater availability, higher efficiency, improved services, and constant innovation.” We agree that such results can be predicted in a system that has all the characteristics of a competitive marketplace—that is, many buyers and sellers, easy entry and exit of sellers, and adequate knowledge on the part of all participants in the marketplace. Unfortunately, two of these three characteristics are not readily found in healthcare: entry into the marketplace is not easy, and an asymmetry of information exists between a physician and patient. When an individual purchases a car, there are many available sources in which a consumer can obtain useful and reliable information. Similar sources of information about healthcare providers are not usually available. Thus, the pressures to achieve competitive results are altered so that the market's “predictable evolution” cited by Dr Bliss is not inevitable. 
Henderson4 explains that markets and pricing serve as the most efficient ways to allocate or ration scarce resources. He describes the concept of healthcare rationing as affecting how dollars existing in short supply (rather than technologies or services) are distributed. Although competition exists in the healthcare industry, it is dramatically altered by societal interventions. Patients cannot rely on the usual competitive market forces and conventional economic models to achieve desirable outcomes in healthcare. 
There are many aspects of healthcare that reach beyond the marketplace to have great importance in the public sector. Certainly, each individual should benefit from the care that he or she receives. But society as a whole also stands to benefit from a good healthcare system. The healthier the society, the more productive and resourceful it will be. In addition, to the extent that certain health problems are transmissible, appropriate healthcare is a public good that requires government intervention. 
Thus, we have a dilemma. It is true that market forces tend to make markets more efficient, but these forces do not necessarily make healthcare more effective. As stated by economist Uwe E. Reinhardt,5 “a cost-minimizing (efficient) policy that succeeds in immunizing only, say, 80% of a target population is not necessarily superior to a more wasteful (inefficient) policy that succeeds in immunizing the entire population.” 
Several related models of innovative practice appear to be evolving in the healthcare marketplace. We speculate that this may be, to a certain extent, one reason that the American Society for Concierge Physicians changed its name to the Society for Innovative Medical Practice Design.6 The former name suggests ultraluxurious services for the wealthy, whereas the newer name suggests many different practice designs or models that the marketplace may find easier to accept. Although lower-fee monthly payment plans as described by Dr Bliss may be available, these are just one type of concierge model. Other plans purportedly charge much higher annual fees.7 Many of the higher-cost plans accept a small percentage of patients who are unable to afford the retainer fee.1 In this way, the physicians in these plans may contribute to the community. Still, it is also true that many patients who cannot afford retainer fees are forced to find other physicians to care for them.1 
Whatever the healthcare model used, more time and focus on the needs of each patient would likely promote better care. Eventually, healthcare market forces may determine which practice designs become more successful, provided that intrusions from government and the insurance industry do not cause serious restrictions. We agree with Dr Bliss that the most important relationship in any healthcare system should be between the patient and physician. We also agree that market justice and the availability of more than one type of healthcare model would support the ability of patients to maintain the right to choose their own physicians and the types of practice they believe will give them the best value for their needs. 
Dr Bliss notes that concierge care has the potential to address concerns about physician dissatisfaction with various aspects of traditional healthcare models, such as insufficient time spent with patients. Surveys support the idea that healthcare models that allow physicians to better manage their time will improve physician satisfaction. Landon et al8 studied career satisfaction among primary care and specialist physicians who spent at least 20 hours per week administering direct patient care. In a series of three nationally representative telephone surveys conducted between 1996 and 2001 (>12,000 respondents in each survey), physician satisfaction varied greatly among geographic sites. The surveys found that the highest satisfaction levels were mostly associated with physicians' ability to manage their time, provide high-quality care to patients, and preserve their autonomy.8 
Murray et al9 examined physician satisfaction involving various delivery system settings in Massachusetts. The researchers concluded that physician dissatisfaction was most closely related to limited amounts of time they had to spend with individual patients, as well as to limited amounts of leisure time and few incentives for delivering high-quality services.9 Such findings suggest that physician satisfaction could be enhanced by a healthcare delivery system similar to concierge care. 
Improvements in patient satisfaction in concierge care, compared with traditional healthcare models, are also suggested by Dr Bliss. We agree that concierge care models that ensure continuity of care with a consistent provider are likely to be particularly beneficial to patients. Nutting et al10 found that continuity of physician care was valued by patients, especially those who were most vulnerable (eg, those who were elderly or less educated, those who relied on Medicare or Medicaid insurance, those who had several chronic conditions and used many medications, and those who visited physicians frequently). 
Gross et al11 found that patient satisfaction increased when office visits were longer than 15 minutes. Dr Bliss argues that increased length of office visits is a likely added amenity of concierge care. Nevertheless, opponents of concierge care counter that such “luxuries” in primary care may promote services that are inappropriate and contribute to healthcare overuse.12 
In regard to medical insurance, we concur with Dr Bliss that health insurance and healthcare are not synonymous. Health insurance, a method to reduce the out-of-pocket expenses of healthcare, initially began as a way of providing protection against catastrophic expenses. In an era of relatively low costs for healthcare, it evolved into a process for reimbursing essentially all medical expenses. Today, the higher costs of healthcare are increasingly shared by patients and providers of insurance. Although Dr Bliss acknowledges that the concierge care movement has experienced some success in overcoming resistance from insurers, as well as from the press and government, we remain unconvinced that concierge care has proven itself to be equally beneficial to both physician and patient. 
Dr Bliss concludes his letter by stating, “In light of such successes, even the detractors of monthly fee practices should be compelled to admit that something that satisfies the needs of both patients and physicians may not be all bad.” Although we agree in part with this assessment, we must counter his argument by reiterating that—because of issues involving equity, access, and cost—concierge care is not available to all persons. 
We would like to conclude by proposing that concierge care is not a universal solution for meeting the healthcare needs of society. However, we concede that this type of practice model satisfies many desirable requests of a very small and select niche of privileged or franchised patients and physician providers. 
The evolution of concierge care and similar innovative styles of medical practice remains uncertain as physicians, patients, insurers, purchasers, healthcare organizations, and government agencies attempt to cope with a healthcare environment characterized by increasing regulation and demand, limited resources, mounting costs, expensive technology, decreasing professional autonomy, and asymmetry of information. Scott13 has suggested that if an alternative model of healthcare similar to concierge care becomes much more prevalent, it is likely to cause increasing inequity between our society's haves and have-nots, further intensifying what many view as a three-tiered healthcare system consisting of one tier for the rich, one for the middle class, and one for the poor. 
As controversy continues between proponents and critics of concierge-style care, an ultimate verdict on this healthcare model will await further study. The jury remains out. 
Alexander GC, Kurlander J, Wynia MK. Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics. J Gen Intern Med. 2005;20:1079 –1083.
Braddock CH, Snyder L. Ethics and time, time perception and the patient-physician relationship [position paper]. Philadelphia, Pa: American College of Physicians; 2003.
Francis DR. Healthcare costs are up. Here are the culprits. Christian Science Monitor. December 15, 2003. Available at: Accessed March 25, 2006.
Henderson JW. Medical care: crisis or conundrum. In: Santerre RE, Neun SP, eds. Health Economics & Policy—Theories, Insights, and Industry Studies with Economic Applications. 2nd ed. Mason, Ohio: South-Western College Publishing; 2001:1 –25.
Reinhardt UE. Economics. JAMA. 1996;275:1802 –1804.
Caplan A. Good health care: for rich people only? Newsday. June 30, 2004. Available at: Accessed September 29, 2005.
Lazarus D. Doctor is in—for a price. San Francisco Chronicle. January 8, 2006; J-1. Available at: Accessed March 25, 2006.
Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997–2001. JAMA. 2003;289:442–449. Available at: Accessed March 23, 2006.
Murray A, Montgomery JE, Chang H, Rogers WH, Inui T, Safran DG. Doctor discontent. A comparison of physician satisfaction in different delivery system settings, 1986 and 1997. J Gen Intern Med. 2001;16:452 –459.
Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Strange KC. Continuity of primary care: to whom does it matter and when? Ann Fam Med. 2003;1:149–155. Available at: Accessed March 23, 2006.
Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Strange KC. Patient satisfaction with time spent with their physician [published correction appears in J Fam Pract. 1998;47:261]. J Fam Pract. 1998;47:133 –137.
Donohoe M. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Intern Med. 2004;19:90 –94.
Scott JS. Boutique health care: opportunity or inequity? Healthc Financ Manage. 2002;56:26 –27.