First, there were the emails alerting me to some exciting changes to the practice. There were phone calls. And mailers. Invitations to Zoom sessions to discuss new options for patients. My primary care physician of several years wanted to make sure everyone got the word — he was about to start offering "concierge" services. I was appalled.
Concierge-based medicine, sometimes called VIP medicine or retainer medicine, is essentially what it sounds like. Patients pay a set fee on top of their insurance premiums for a suite of what used to be standard but are now considered premium physician services, like same-day appointments and longer doctor visits. Fees typically range from $150 to $1,000 a month per patient, but can climb significantly higher.
The concept has been around for over twenty years, but it's really taken off since the COVID pandemic. It's one of the few thriving domains of American health care. The industry journal Medical Economics reported earlier this year that "90% of medical practices reported that their costs rose faster in 2022 than revenues, while only 10% said their revenues kept pace ahead of rising costs." Meanwhile, Kona Medical Consulting reports that concierge doctors saw "an increase of 21% in new patient volumes in the U.S. in 2020," a percentage that's expected to keep jumping over the next decade. Concierge services pulled in an estimated $6.1 billion last year.
The allure of concierge medicine, both for patients and practitioners, is clear. I don't regret ditching my family practitioner, but now I don't have a GP and am struggling to find someone who accepts new patients. Americans wait an average of 18.5 days to schedule an appointment with a new physician practice. In New York, the average is 26 days. In Boston, it's 66 days. Once we're lucky enough to snag a visit, we sit in waiting rooms about 18 minutes per visit — roughly the same amount of time we spend in our actual appointments. And a March JAMA Health Forum study found that visits involving Black, Hispanic and publicly-insured patients tend to run shorter.
We feel rushed and invisible, frustrated with paperwork and left to interpret our lab results on our own. That systemic indifference affects our health, and it does so disproportionately. A 2018 Physician Wait Time Report found that "Only 20% of people who reported having excellent access to top-quality doctors said they’ve walked out of an appointment because of a long wait. In comparison, 53% of people who reported having poor access to healthcare have left a doctor’s office due to long waits."
On the other side of the stethoscope, doctors aren't just struggling with increasing expenses, they're exhausted and over-scheduled. A 2022 Medical Economics survey found that "More than 93% of physicians report feeling burnout at some point and more than 73% say they feel it now." Think it's tough to get an appointment now? The AMA reports that one in five physicians say they plan on leaving their practices within the next two years.
"I wanted to get into concierge medicine because I felt that the health care system is really broken," says Terry Bauer, CEO of concierge medicine consulting firm Specialdocs, "particularly for primary care doctors and doctors who have ongoing relationships with their patients, whether it be internal medicine, family practice, etc." He's sees the current crisis, noting, "Reimbursement goes down and operating costs go up, and the only way to make ends meet is to see more patients. But that becomes a path to frustration. All those dynamics are causing doctors to say, 'I need to do something different. I'm not going to be able to have a life. I'm not going to be able to care for the patients in a way that they deserve in this kind of model. We talk about burnout. I think a better term is what JAMA quoted a couple of years ago, which is moral injury. I think that's a better phrase to describe what doctors are going through."
And psychiatrist Dr. Howard Pratt, medical director at the nonprofit Community Health of South Florida, sees the same challenges. "There are so many reasons that a person becomes a physician, but it's usually bigger than themselves. Having said that, the business side of medicine is taking the doctors' hands and tying one hand behind their back, limiting what I can do, limiting how many people I can see. Managed care is hitting medicine so hard," he says, "And it's really making a lot of doctors walk away from medicine. Right now, it is not a good time to be a doctor."
It's not a good time to be a patient, either. When I looked into the new system at my family practice, among the perks my physician would now offer to members were an "exclusive office phone number" to "conveniently reach a member of the staff at the office and bypass the automated attendant," "dedicated appointment slots for concierge members" and "more time with me" in "longer, more relaxed appointments."
I just couldn't get my head around the notion that if I were to have a respiratory infection, for example, I would be exactly the same, while my ability to see my doctor and the amount of time he would spend with me were now to be contingent on my paying him $200 a month.
"It's very easy to look at the doctor like, 'Hey, why are you doing this?'" says Pratt. "But I know so many people that are frustrated because for whatever reason they're not able to collect from insurance, are having trouble keeping the lights on. And if I'm able to do this and stay open and still treat my other patients, then is it wrong? There are so many shades of grey."
My friend Charlotte had similar concerns as well. But over the years, she's moved over to a concierge practice, one family member at a time. Hers, however, isn't a hybrid like my doctor's — every patient pays a monthly membership fee for the same level of access. And she's been really satisfied with the service, like when she had a fibroid recently. Her service "got me in there in a day," she says. "They did all of the very thorough pre-surgical testing. Then the doctor sat with me and was like, 'So let's talk about the symptoms; let's talk about the bleeding.' It is not one size fits all. It's a very differentiated experience. With my doctor before, I never felt heard. I always felt rushed."
And Bauer says there are potentially lower healthcare costs with concierge service. "With same day or next day appointments, they don't have to go to the urgent care, which is the front door to the emergency room," he says. "Secondly, patients who have concierge doctors typically are more compliant with their treatment plans, because the doctor spends time with you."
The other side of all of this, though, is what sure looks like a widening gap in an already fragile and deeply divided system. . A January piece in the AMA Journal of Ethics by Denisse Rojas Marquez, MD, MPP and Hazel Lever, MD, MPH called concierge medicine "ethically indefensible," arguing, "To allow VIP health care to exist condones the notion that some people — namely, wealthy White people — deserve more care sooner and that their well-being matters more."
"I'm at a federally-qualified community health center," says Pratt. "We're typically the last line before there aren't any services. Most of the people I think, would not have that [concierge] option. You know, residency is paid for typically by Medicare or HOSA dollars. This is something that's supposed to benefit the public."
As someone with TSA PreCheck and an upcoming vacation that includes Express Passes, I get it that sometimes paying more is worth it in time and headaches saved. I definitely don't begrudge any doctor, patient or parent any choices made for their own physical and mental health, or for the people they are most accountable to.
But healthcare access also isn't a ride at a theme park. Those of us with the privilege of choice can respect each other's decisions. We can also recognize that our American health care system is greedy, cruel and wildly unfair, and that most of us don't have an extra $200 or more a month to spend just to feel like we have our physician's full attention. In the end, what made me drop my doctor wasn't just the introduction of concierge services to the practice, but the the sense that I would now have the option of being not a patient, but a customer. I could fly first class or economy, and the next time I got sick, I'd be treated accordingly.
