What should we call it, when doctors decide to not accept with insurance and instead require patients to pay them directly for a healthcare service?
We should call it what it is: direct-pay. As in, patients pay their provider directly.
But most of the world, it seems, calls it concierge.
This is a bit of a problem. Clarity of thought, after all, often stems from clarity in language and word choices.
Now that a growing number of providers are choosing to not accept insurance, or are supplementing insurance payments with annual fees (this too, has been called concierge), we need to be able to have clear, serious, and meaningful conversations about what this means and where healthcare, especially primary care, might be going.
(Disclosure: I’m one of those physicians who has decided to not accept insurance, at least for the time being. I have my reasons.)
The term “concierge medicine” interferes with this conversation. It’s overly broad, freighted with overtones, and allows us to conflate all kinds of aspects of healthcare that would be best considered separately. These include:
- How expensive is the care? Concierge has been used to refer to practices that charge primary care subscription fees ranging from $30/month to $25,000/year.
- How does the pay structure correspond to service? Although a “monthly subscription = all the care you want” model is common, we also find fee-for-visit and fee-for-time. And then some practices charge patients both an annual or monthly retainer, plus fee-for-service.
- Is insurance still accepted? According to Wikipedia, concierge medicine includes practices which accept insurance and charge an additional annual fee to cover extra services. Fees at One Medical in SF are $149/yr; at GreenField Health, they range from $120-$756 per year, depending on one’s age. At MDVIP, the membership fee starts at $1500/year.
- What kind of access to the team and to the personal physician is provided? Some practices promise to give patients the doctor’s cell phone number and invite them to call at any hour. Larger practices seem usually offer 24/7 access to the team. Probably few practices are like my consultative practice, which offers good response time during business hours but no after-hours or weekend coverage.
- How individualized is the care? How participatory is it? This is a tricky one, but I think it’s important to at least consider, given everyone’s recent interest in things like personalized care, patient-centered care, person-centered care, and participatory medicine. Just about all the practices labeled “concierge” do offer a more satisfactory patient experience. Whether this equates to individualized care in a way that is meaningful (i.e. correlates to better health outcomes or a better match of care to the patient’s situation/values/preferences) is another story.
In general, it seems to me that the term “concierge medicine” right now is being applied for a few different purposes.
