A few physicians in my community began to try concierge medicine in the mid nineties. My first reaction was, “Harley Street has come to Beacon Street”. If you watch Downton Abbey, Lady Mary Crawley probably took her maid, Anna Bates, to Harley Street when they went to London to get the help of a gynecologist because of Anna’s recurrent miscarriages. Harley Street is synonymous with expensive private care. The English who want to avoid the wait for specialists in the National Health Service (NHS) can still go to “Harley Street” for private care.
Robert Wachter is a Professor of Medicine at UCSF, author of The Digital Doctor, and a medical blogger. A few years ago he posted The Awkward World of Private Insurance in the UK, where he revealed the the strange relationship between private care and the National Health Service. Most Brits are quite satisfied with access to their salaried NHS PCP, but they complain about waiting times for specialists. Many NHS specialists take advantage of their option to practice in both the public and private systems. Wachter thinks that the care in the private facilities is poor because of a lack of support and staffing shortages compared the NHS facilities. In the private system profitability is a function of low overhead.
Reading Wachter’s piece reminded me that my tangential experience with ulta exclusive care in Boston had been similar. It seems paradoxical but my observations suggested that if one were really sick, the last place in the world you would want to be is in a very private environment. For many years at the Brigham and Women’s Hospital the exclusive rooms were on the top floor. You needed to be “buzzed in” to to this posh environment even if you were a doctor. The service was Ritz-like and the accommodations were more like small apartments than hospital rooms. My bias was summed up by my quip that the patients in this exclusive setting were “near a hospital”.
In the UK the private specialists are splitting their time between the care of their NHS patients and their private patients, with the private clientele in less well staffed hospitals and lacking the backup that the NHS patients have in the public facilities. Healthcare is not a solo act. To be good, healthcare requires the coordinated services of many professionals, which can be hard for a concierge system to engineer. Is the ability to get your care in extraordinary accommodations with unlimited access a status symbol? Perhaps it is an illusion that money buys better care. It is hard to beat that feeling of being “special” even if it means your care could be compromised when you are really sick.
After thinking about “Harley Street” and the disadvantages of the elite, my next thought was to explore whether the same principles existed between concierge medicine and standard care that exists between private education and public education. Segregated public schools and public colleges were the norm where I grew up. I experienced cultural shock when I came to Boston for my graduate education. I was surprised by the region’s tradition of highly selective private education. In my “private” elite medical school that depended on huge amounts of federal grant support of faculty and research I discovered that many of my classmates had never experienced a “public school”.
For a while I felt disadvantaged. I envied my classmates who had received a “concierge” education. Their classes had been smaller. They had had better access to experienced faculty with better known accomplishments. The capabilities and goals of the average students in their classes may have been higher than those with whom I had studied. Gradually, though, I realized that because resources in the public world had been a bit more scarce and the environment a little bit more difficult to navigate, I had been forced to develop skills that all but the very best of my classmates did not have, since their way had been defined by the wealth of opportunities that had been given to them without much effort on their part. After an initial period of shock and an early concern that I was hopelessly “behind”, I realized that what made the most difference for all of us lay in the future. What I had learned was more than enough.
As I continued to think about concierge “education” and concierge medicine, it was obvious that there was an element of class difference in it that I did not like and that confused me. I wanted to believe that this is a free country and if someone choses to buy a first class ticket on an airplane, that is their right. If my neighbor wants to pay more than 30K a year for each of his several children to ride a bus across town to a famous private school, or send them away to a boarding school, even though the town where we lived offered a great public school education, that was none of my business.
It did not take me long to reject my rationalization that first class travel, private education and concierge healthcare could all be rationalized the same way. If you choose a first class ticket it does not usually affect my ability to go economy. Both ends of the plane will arrive. As long as public vouchers were not used to support the existence of private schools, my neighbor’s sense of satisfaction with his children’s private school did not necessarily limit the education my children received in the public school.
There is a potential conflict in healthcare between those wanting to go first class and those forced to fly tourist. There should be real concerns about a healthcare system with economic tiers. As I thought more about the scarcity of primary care physicians potentially being made worse by good PCPs opting for concierge practice, I was concerned. I became further concerned when I thought about the overuse and waste that could be generated by a system where people were paying for access to doctors. For business success those physicians might be overly solicitous in an attempt to satisfy expectations and order tests and procedures that added no value. A system of concierge care could disproportionately contribute to the medical loss ratio and the rates everyone else pays when physicians make clinical decisions to accommodate concerns or fears of patients who are not amenable to “choosing wisely”. I became concerned that concierge care could theoretically make the climb to the Triple Aim harder.
Then I realized that we have a huge “public investment” in healthcare that made concierge care even more objectionable in its inherent inequality in access. I had received large amounts of government support in the form of grants and low interest loans for medical school. Harvard, the “private elite medical school” that I had attended, had received many hundreds of millions of dollars of direct and indirect public support over the years. If the public had paid to create me as a resource and had invested in every other physician, did I, or any other physician, have the right to use a special payment process, like a retainer payment, as a de facto denial of access to patients who could not pay more? Was it right for a hospital that accepted public funds for training programs and financial support for new buildings to skew its book of business to better serve the rich?
As I thought about the six domains of quality: patient centeredness, safety, efficiency, effectiveness, timeliness and equity, concierge medicine was offering patient centeredness and timely service to those who could pay more. Even if care was safe (which my hospital experience with “exclusive patients” led me to question), what did it do to efficiency, effectiveness, and above all, equity? How does concierge medicine support the Triple Aim? I think not at all; I think it is, in fact, a threat.
Can you imagine changing the Triple Aim to “Your personal Aim”?
Care better than you have ever seen, health better than anyone else has, as long as you can pay a little extra, …just for you and yours, every time.
A friend recently emailed me an article from the New York TImes about the Mass General’s foray into concierge medicine. The title says a lot: Founded for the Poor, “Mass General Looks to the Wealthy”. In 1811, the standard of practice was concierge medicine. Indigent patients could not pay for individual attention and were “warehoused” at eleemosynary institutions like the Mass General, which sat in the malaria infested tidal swamp at the foot of Beacon Hill. The MGH is not alone among academic medical centers that once had a mission to serve the poor that are now focused on what they can do for the wealthy that might produce more revenue, not only the wealthy of this country but also from a worldwide market.
The charge will be an additional $6,000 over what the patient’s insurance will pay and will provide 24 hour access for patients to their doctor as well as some wellness services. The article quotes Dr. Michael Jaff, the medical director of Mass General’s Center for Specialized Services and a professor at HMS,
“A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider.”
Dr. Wanda D. Filer, president of the American Academy of Family Physicians, was quoted:
The upside is that it gives more time for patient-physician interaction, and the data shows that generally the more time a patient has with a physician, the better the outcome . . . . The downside is that it can be very exclusive and difficult for middle- and low-income patients to afford. So there’s a concern that you’ll have a two-tier system.
For balance we are offered a quote from Pauline Rosenau, professor of public health at the University of Texas Health Science Center in Houston:
“It’s worrisome, unless you’re rich. As for the hospital’s historical mission . . . I’d say it’s in jeopardy.”
The article has other quotes from people at the MGH who justify the service as a source of revenue to protect its “core” mission. Staying in sync with the times, another quote says,
We wanted the practice to be integrated into the institution.
That last quote is further explained by Dr Jaff:
“We’ve made the institutional commitment that these patients will get the best of the best at a phone call. . . . So if I call and say I need a general surgeon, they’ll have a world-class general surgeon that day.”
I hope that every patient sees a good surgeon the same day if the clinical situation calls for it. But in a system where the concierge patients buy better access to use the same assets as other patients, how are all patients assured of appropriate access?
The article offers a justification for concierge medicine that surprised me. The MGH program is designed to benefit us all by sustaining the MGH in hard times.
“With dwindling reimbursement there needs to be other sources of revenue to help us support our mission to the community at large.”
That should surprise anyone who has ever read the Annual Cost Trends Report from the Massachusetts Health Policy Commission or looked at public reports of their margin. Is there concern that in the future the successful practice of making everybody pay more will somehow be curtailed?
Despite how others look at the future, I am still hoping and working for equity in health care and love to dream of some distant day when we will have:
Care better than we have ever seen, health better than we have ever known, cost we can all afford . . . for every person, every time.
