, August 18, 2011, by Arthur L. Caplan PhD,  —  Hi. I am Art Caplan at the University of Pennsylvania Center for Bioethics. Today I am going to talk to you a little bit about the growing practice of “concierge” or “boutique” medicine. What is concierge medicine? Basically, in concierge medicine you ask your patients to pay an additional fee (usually $1500-$2000 a year), and in return they receive better service. You promise that if they join the plan, you will answer their phone calls. You might give them your cell phone number. You might be in a situation in which concierge patients have more time available when they come in for an office visit, and you are going to help them wend their way through the hospital and gain access to specialists. In other words, patients are going to get more of you for the money.

What is fueling this shift toward concierge practice, particularly in primary care? It is the red tape, hassles, bureaucracy, micromanagement, and too much overhead cost that primary care providers in particular are facing in the current healthcare environment. There is just not enough time to see patients, and people feel as though they are on an assembly line. It’s understandable that the idea of having patients pay more as a way of getting out of a broken system might come to the fore. A lot of people are doing this. There are probably 6000 primary care physicians alone who have shifted over to a concierge practice. To be honest, concierge medicine for the superrich has always been around. The person who has an addiction who goes off to the Betty Ford Clinic and the executive who takes a jet for an executive physical at the Mayo Clinic: These are versions of concierge or boutique medical practice. Now it’s expanding into the middle class.

What is the downside, and what are the ethical worries about this growing type of practice? First, there aren’t enough primary care providers around to begin with. We all know that we have too many specialists, not enough generalists, and not enough primary care providers in the United States. If you take a significant number of them out of the pool available to every patient and make them available only to people who can pay additional fees, it results in a bigger workload for the rest of the providers who are doing primary care. No matter how you look at it, if you allow providers to buy out, you are going to leave other patients with lower-quality care, and you are going to burden the remaining primary care practitioners (who don’t take the concierge route) with more work.

There is also the issue that if patients aren’t in a boutique or concierge practice, they are going to wind up getting lower-quality care because they might see more physician extenders. There are certainly great physician extenders — both nurses and physician assistants — but patients don’t understand that they may be seeing someone with a bit less training and may be paying the same money or fees for someone with less qualification.

At the end of the day, we have a justice issue. Concierge practice is a business solution to what is essentially a broken system. We must find different ways of solving the problems with healthcare, other than having people pay a fee to escape the broken system. Concierge medicine is fundamentally unjust. We have to come up with a better answer. It will probably be something along the lines of what is being proposed for healthcare reform. Concierge medicine is more a symptom of a broken system than it is a solution.

Thanks for listening. I’m Art Caplan at the University of Pennsylvania.




Rebuttal: Concierge Practice Is a Doctor’s Right

Leslie Kane, MA; Bernard Kaminetsky, MD


Editor’s Note:

Medscape’s recent video commentary by ethicist Arthur Caplan, PhD, “Concierge Practice: Unjust for Patients and Doctors Alike,” provoked a flood of heated responses. To present the contrasting point of view, Medscape interviewed Bernard Kaminetsky, MD, board certified in internal medicine and nephrology.

Dr. Kaminetsky is the Medical Director of MDVIP, a company with a national network of primary care physicians who provide personalized care, focusing on wellness and prevention, and use a concierge-type model. Dr. Kaminetsky was a founding partner in a primary care practice based in Boca Raton, Florida. In 2001, he transitioned his practice to the MDVIP model. He recently left his primary care practice to serve as the national representative for MDVIP. Dr. Kaminetsky has testified before the Joint Economic Committee of the US Congress on the importance of wellness and prevention. He is a graduate of Albert Einstein College of Medicine and a former assistant professor at New York University School of Medicine.




Medscape: In a concierge medical practice, doctors generally charge an annual access fee, have a smaller number of patients, and spend more time with each patient. Some have said that this is unjust or unfair, particularly given the shortage of primary care doctors. How would you respond to that?

Dr. Kaminetsky: Let’s look at it from the patient’s perspective: Is it fair for patients to have an experience — as is common in conventional practice — where visits are very short and doctors are essentially reactive to acute problems because they have very little time for prevention and wellness? And the doctor knowingly is neglecting his or her ability to spend the time necessary with the patient to actually prevent the heart disease or diabetes from forming because there simply isn’t time. Is that fair to patients?

When you add the caveat of “given the limited number of primary care physicians,” that is predicated on the notion that if a doctor does not transition his or her practice to concierge or boutique practice, that doctor would still be seeing their regular panel of 2500 or 3000 patients. That’s a very flawed assumption.

There’s ample literature documenting that among physicians over age 55, as many as 50% indicated a desire to stop practicing primary care within 5 years. Yet we have quite a few doctors in our network over age 70. They very clearly and unequivocally would have hung up the shingle if they did not have a model where they could practice at a slower pace, with greater interaction with the patient. They find it more fulfilling. Doctors are staying in practice because this model exists.

With only a small percentage of medical students going into primary care, if we have a method for attracting more to primary care while fulfilling our obligation to patients to give them the best care possible, who could argue with that?

Medscape: We’ve heard concierge care criticized because many patients can’t afford it.

Dr. Kaminetsky: Let’s qualify “afford”: $1500 [an annual amount commonly charged for concierge access] is clearly a middle class expense. That’s about $125 a month. It’s what people spend in Starbucks. Smokers spend more than that on cigarettes. We have patients who very clearly have said, “We make choices. My health is of primary concern to me. I will order my priorities in a way that $1500 is more important for my health and wellness and potential longevity than some other luxury.”

Medscape: What about those for whom $1500 is a lot of money?

Dr. Kaminetsky: How is that different from the fact that when I was in practice, I didn’t know a single physician who accepted Medicaid because the reimbursement is so abysmally low? Every patient who has Medicaid is also denied the opportunity to see any physician they want. The system is not predicated on the notion that anyone can see any doctor of their choice. We have tiers of insurance: If you’re enrolled in an HMO, you generally can’t see any doctor you want to. So everybody is limited or circumscribed by the situation in which they find themselves or by their insurance.

Medscape: Some have said that a concierge practice is merely a bad response to a bad healthcare system– that two wrongs don’t make a right — and that the solution should be to fix the system. Is there validity to that statement?

Dr. Kaminetsky: Actually, no. Concierge care is an excellent solution because it addresses those patients who desire to have an emphasis on wellness and prevention and those doctors who feel a professional obligation to provide it.

No one suggests that this model is a solution to the healthcare crisis in this country. No one would make so bold a statement. But it is a solution for a niche population, which by its nature will always be a niche population. We have a many-tiered pluralistic system of healthcare delivery in this country, and this is one more offering.

In its small manner, it’s actually a very good solution.

Medscape: When doctors transition to a concierge practice, many of their patients will choose to — or will be forced to — find new physicians. Do doctors who make the switch to concierge medicine express that they feel guilty about doing so or feel badly about patients who decide to leave?

Dr. Kaminetsky: Every doctor does. When you take care of people for years, you have a relationship with them. But with my own patients, when I did this in 2001, the overwhelming sentiment expressed by my patients was “I understand why you’re doing this, even though I choose not to participate.” And of course doctors feel ambivalent; I felt ambivalent. When I’m in the hospital and see a former patient there, I invariably greet them and talk to them.

A physician who doesn’t feel some ambivalence does not have appropriate feelings for a physician.

Medscape: Primary care doctors may go into concierge practices because they want to earn more money. Yet they get criticized because some people feel that doctors have an obligation to society and should stay in a traditional practice and see more patients, even if they earn less doing so. How would you respond to that?

Dr. Kaminetsky: A number of years ago, I saw a poll showing that doctors’ incomes were way overestimated by the population at large. The public more than doubled the average primary care salary. Based on those assumptions, people say that doctors can certainly afford to make less.

But the public and patients are sometimes surprised to find out that there are very hard-working primary care doctors who are struggling with their kids’ tuition, do not take any vacations, and haven’t saved a nickel for retirement. One can’t honestly expect people to live their lives in that fashion, as their incomes keep dropping, without thinking, “Oh my God, what am I going to do?”

In many ways, I don’t consider doctors that different from clergymen in our relationship to our patients and the emotional support that we offer them. That being said, many physicians in a concierge practice say that it’s never been about money. The benefit is that it does allow them to practice in a different way.

With this practice model, because people are members of a smaller practice, the doctor is able to spend more time with the patient and this translates into better care.





Why Be a Doctor?



Uconn Medical School Blog, Spring/Summer 2011  —  Why should one even entertain the idea of going into medicine? Many have a notion that becoming a doctor will guarantee a fantastically lavish lifestyle but that is not necessarily the case. Indeed certain specialties “pay” more than others however the path to “high pay” is an arduous one. Medicine is a discipline which requires lifelong learning as well as serious commitment. Needless to say there is quite an arduous path to become a cardiologist who earns six to seven figures.

So why then should one go into a career with so much at stake? The best way I can convince you is by telling you why I chose to go into medicine. I have always been interested in the sciences. My desire to go into medicine was truly solidified in fifth grade, when my grandmother passed away due to cancer came. In that instant I wished I could have done something to help so I told myself I would go into a field which would directly better the lives of others.

Apart from the familial motivations, I was also very motivated to pursue a career in medicine because of the eventual fruits that it would bear. My decision to become a doctor was not completely blind. Over the past few years I have volunteered for patient transport at the hospital near my home, I have seen many liver transplant surgeries, and I have been a part of research endeavors at

UCONN as well as Children’s Hospital in Boston. Going through these experiences not only helped me realize that becoming a doctor was the right choice, but helped me better appreciate the humanitarian aspect of science and medicine. Seeing how appreciative patients were of the doctors’ help made it all the more enjoyable.

My ultimate goal in becoming a doctor is to lift the burden a person is experiencing as much as I can. As a physician, you are the main person a patient trusts with his/her well-being. Having that much of a positive influence in a person’s life is more than one could ask for. I have always felt that there is no greater satisfaction than knowing you have done a positive deed/ brought a smile to someone. That is what defines a doctor- the ability to bring a smile to someone who may be feeling less-than-happy at a particular moment. This humanitarian aspect of medicine has truly attracted me to becoming a physician.

You may ask, “well, yes it is nice to help those in need, but you do not have a life in your 20s.” My answer to that is, no matter what degree one wants to attain, a certain degree of hard work is required. Yes, the path to becoming a physician is a long one, but it is also an extremely rewarding one. If science classes seem difficult to you in high school or in college, one thing to keep in mind is that medical education is vastly different than the education in the preceding years.

I have viewed high school and undergraduateeducation as preparatory for the rigors of medical school. They have taught me how to study, how to allocate my time, and how to deal with success and failure – all of which are important aspects of medicine.

I believe I have become a mature academic scholar from my high school and undergraduate education. Getting back to the rigors of medicine, it is a fact that medical education is expensive, but once you begin practicing, paying off debt will become easier. In addition to that, just as in many other professions, physicians do get paid prior to practice. Residents and Fellows do get some monetary compensation for their efforts ($40-60,000.

In addition to that, the medical profession has many avenues open if one wants to be involved with medicine but not be a physician. One can be a medical assistant or one can even go into teaching. Medicine is a divergent field which has a degree with worldly possibilities. If one is interested in research he/she can do an MD/PhD program which would compound medical sciences with research. Or if one is interested in the business aspect of medicine, he/she can be an MD/MBA. As you can see, there are plenty of choices one has other than just becoming a doctor!!!

More than anything, the one thing I want to stress is passion. Whether you are interested in Chemical Engineering, or Nursing or any other discipline, passion is the key ingredient to success. One can attain a degree without passion but enjoying the mundane days of work requires passion. Medicine especially requires passion because there will be times of great disappointment as well as times of great excitement, and passion will help to deal with both situations. My passion surfaced through my grandmother’s passing and I knew at that point that whether I would be an MD or DO, I would be in a profession that would improve the health of those who are ailing.

So to summarize, why should one even attempt to become a doctor? It is a path that has many avenues (MD/PhD, MD/MBA, DO). Of course, based on the specialty one chooses, pay is quite rewarding



There are new discoveries and new knowledge bases being formed, so it never gets “boring”. I have known physicians who went to Las Vegas or Los Angeles for conferences, and it is essentially a “study abroad” opportunity that doctors are able to have. Personally, there is no better feeling that helping another person improve their life, and I feel that becoming a physician is one of the most direct ways one can do that!!! So when choosing what you want to do with your life, always remember, think about how it will make you a better person. Will it be a job or an avocation for you? And most importantly, is it something you are passionate about? If you are interested in helping others, if you enjoy sciences, if you want variety in your life, and if you are ready for life-long learning and excitement, then becoming a doctor is definitely something you should consider!!!!

Ultimately it is not what you do that defines you, it is how you do it!!!

Good Luck with all your future endeavors!!




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