Where Have All Those Doctors Gone?: Coming Back in Boutique Medicine?
With acknowledgment to Pete Seeger :
“Where have all the humanistic doctors gone?
Long time passing
Where have all the beloved doctors gone?
Long time ago
Where have all those doctors gone?
HMOs have picked them every one
And set benchmarks but not for patient benefit
When will HMOs ever learn?
When will the doctors ever learn?
When will they ever learn?”
On the other hand, there may be some doctors who have learned and are returning to private practice. Debra C. Cascardo writing the Medscape article back in 2003
tells us about the “new” concept in medical practice to which physicians are now migrating out of HMO’s into “Boutique Medicine: A New Concept Based on Traditional Ideals”
She writes: “One of the newest trends emerging in medical care is based on one of the oldest business concepts -- exceptional customer service. So-called "boutique" medical practices are borrowing a page from small specialty shops by finding their niche: patients who want specialized services and amenities and are willing to pay extra to receive them. Also referred to as concierge or retainer practices, these medical practices offer patients these extra services for a monthly or annual fee.
Some of the usual services to which the ‘membership’ fee entitles patients are:
· guaranteed same-day appointments;
· email and phone access;
· extended time with the physician;
· specialty newsletters;
· wellness programs; and routine checkups that might not be covered by insurance"
.
Read the complete article and return to discuss the issue. This thread might tie in to the discussion in the Comment section of the last thread. ..Maurice.
ADDENDUM: To read the Medscape article you may have to register. A research article on boutique medicine (also known as retainer or "concierge" practice) which surveys both retainer and non-retainer physicians regarding their practice and considers the ethical aspects of this type of practice can be read free at PubMed Central.
posted by Maurice Bernstein, M.D. @ 3:06:00 PM
5 comments
5 Comments:
I think the underlying issue here is whether the ethical practice of medicine requires that exactly the same range of services is available to everybody -- i.e., whether a "single tier" system in which nobody can get services that are not universally available is ethically necessary. This would mean that there could be no "discretionary spending" for healthcare.
Bob,one argument I can think of with regard to whether a "botique" tier is ethical would be whether those who participated within that tier would create some financial or resource burden on those patients in society who are attempting to get medical care but can't afford "botique". For example, might one expect when this practice gets going that there will be less physicians available for standard care? Might those patients retained by the physician for standard care have their care made "sub-standard" because of less time and perhaps less attention available because of the physician's consierge clientelle? Would the elite group of patients demand and get and utilize more scarce resources than those receiving standard care? All of these issues pertain to the ethical principle of justice as applied to the practice of medicine. ..Maurice.
Maurice - The questions you are raising are central to discussions of distributive justice.
There's no escaping that some medical resources will be scarce -- there are interventions of unquestionable utility for promoting the health of individual patients that simply cannot be provided to everyone who could benefit. We could, as a society, declare that nobody can enjoy these benefits -- but that seems wasteful. Or, we could devise some scheme for distributing the scarce resources, if for no more reason than to at least take advantage of the limited benefits available through limited resources. This might be done in a number of ways; through triage, or lottery, or through market mechanisms (to mention just some of the more obvious alternatives). But the fact remains that in order to utilize scarce resources, we must accept that some will receive services that are not available to others who could have benefited.
I received the following e-mail today from Dena. ..Maurice.
Boutique medicine is a long time phenomenon. NYC had a whole hospital devoted to it until recently, Doctor's Hospital. The long list of physicians who prosper exclusively on liposuction and the like is a common theme.
I'd be surprised that if in ancient Egypt there weren't some guys who practiced mainly on ways to keep longer, harder erections and bigger, more voluminous breasts. Human vanity and avarice are not new--there is a reason why they are listed among the 7 cardinal sins.
Dena
Here is the American Medical Association's ethical policy on Retainer Practices (E-8.055 Issued December 2003)
E-8.055 Retainer Practices
Individuals are free to select and supplement insurance for their health care on the basis of what appears to them to be an acceptable tradeoff between quality and cost. Retainer contracts, whereby physicians offer special services and amenities (such as longer visits, guaranteed availability by phone or pager, counseling for healthy lifestyles, and various other customized services) to patients who pay additional fees distinct from the cost of medical care, are consistent with pluralism in the delivery and financing of health care. However, they also raise ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care. (1) When entering into a retainer contract, both parties must be clear about the terms of the relationship and must agree to them. Physicians must present the terms of the contract in an honest manner, and must not exert undue pressure on patients to agree to the arrangement. If a physician has knowledge that the patient’s health care insurance coverage will be compromised by the retainer contract, the information must be discussed with the patient before reaching an agreement on the terms of the retainer contract. Also, patients must be able to opt out of a retainer contract without undue inconveniences or financial penalties. (2) Concern for quality of care the patient receives should be the physician’s first consideration. However, it is important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence, sound medical judgment, relevant professional guidelines, and concern for economic prudence. Physicians who engage in mixed practices, in which some patients have contracted for special services and amenities and others have not, must be particularly diligent to offer the same standard of diagnostic and therapeutic services to both categories of patients. All patients are entitled to courtesy, respect, dignity, responsiveness, and timely attention to their needs. (3) In accord with medicine’s ethical mandate to provide for continuity of care and the ethical imperative that physicians not abandon their patients, physicians converting their traditional practices into retainer practices must facilitate the transfer of their non-participating patients, particularly their sickest and most vulnerable ones, to other physicians. If no other physicians are available to care for non-retainer patients in the local community, the physician may be ethically obligated to continue caring for such patients. (4) Physicians who enter into retainer contracts will usually receive reimbursement from their patients’ health care plans for medical services. Physicians are ethically required to be honest in billing for reimbursement, and must observe relevant laws, rules, and contracts. It is desirable that retainer contracts separate clearly special services and amenities from reimbursable medical services. In the absence of such clarification, identification of reimbursable services should be determined on a case-by-case basis. (5) Physicians have a professional obligation to provide care to those in need, regardless of ability to pay, particularly to those in need of urgent care. Physicians who engage in retainer practices should seek specific opportunities to fulfill this obligation. (I, II, VI, VIII, IX) Issued December 2003 based on the report "Retainer Practices," adopted June 2003.
You may want to read the commentary by Troy Brennan, MD, JD, MPH in the American Medical Association's Virtual Mentor for November 2003 regarding his view regarding becoming a "retainer physician". ..Maurice.
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