Individualized care may feel like a huge improvement for patients who can afford it, but what about those who can’t? Many researchers and public-policy experts say doctors who limit their practices to patients who can afford an annual fee create a two-tier system, a “wealth care” some find ethically dubious.
Every doctor who transitions to a concierge practice leaves behind patients who can’t afford to come along, raising the ethical issue of “patient abandonment.” Critics note that when freshly minted physicians take the modern Hippocratic oath, they vow to “treat without exception all who seek [their] ministrations.” In other words, an ethical doctor can’t just walk away, letting the chips fall where they may. It is a transitioning physician’s duty not only to suggest other doctors for patients who do not take the concierge route but also to make certain that -patients are not unleashed on a community without enough practitioners to absorb them.
The latter is a major issue, notes Dr. Jay Jacobson, an internist and professor emeritus at the University of Utah School of Medicine. “If an individual who is responsible for 2,000 patients quits a practice, taking only 300 of those patients along, that leaves 1,700 patients for the partners who remain in the practice to divide among them,” he says. “Unless those doctors weren’t very busy, which would be unusual, some—or many—of those patients will have a prolonged search for a new physician and in the meantime may wind up in the ER for routine problems.” For this reason, many concierge doctors dedicate 10 percent or more of their practice to “scholarship patients,” the sickest and most dependent people from their traditional practice. But no one believes that people are never left behind.
Public health experts also worry that concierge medicine limits the general public’s access to primary care physicians, which inarguably it does. Primary care doctors, underpaid and overworked relative to specialists, are already in short supply. More than a quarter of today’s primary care physicians are 56 or older and will probably retire within a decade. There are not nearly enough primary care doctors in the pipeline to replace them. One medical group estimates that in 2015 the country will have 62,900 fewer doctors (in all specialties) than needed.
And if it’s hard to find a new primary care doctor now, expect things to get worse. While I was writing this article, the U.S. Supreme Court announced its decision to uphold most provisions of the Patient Protection and Affordable Health Care Act. Assuming the law is fully implemented by the federal and state governments, it will open the door for health insurance to 30 million patients who are currently not covered.
The Bottom Line
I asked my go-to ethics guy—Arthur Caplan, head of the division of medical ethics at NYU Langone Medical -Center—for his take on concierge medicine. From a public-policy standpoint, he doesn’t like it. “Concierge medicine is a symptom of not having enough primary care doctors,” he states. “Our standard of care has just collapsed. Now you’re being asked to pay for what you once expected as routine, like having the doctor return your call or not keep you waiting an hour in the office.”
But the medical system doesn’tfunction the way it should. So for many of us, the $1,500-to-$2,100 annual retainer makes sense, even if we have to sacrifice some other purchases to pay for it. Sylvia Sanchez Lindsey, a patient of Dr. Tung’s who recently retired after many years in human resource development in Las Vegas, has made that calculation.