Earlier this week, a friend of mine called to ask my opinion of an oncology concierge program. A friend of hers had been referred to one for further evaluation. She wanted to know what I thought of a practice offering concierge to not only cancer patients, but also those still undiagnosed.

It’s an interesting and somewhat complex question. I am of course a believer in concierge medicine, specifically hybrid programs as well as for specialists such as cardiologists, gynecologists, rheumatologists, and other specialties that provide a majority of core medical services to their patients. But I was a bit surprised at an oncologist — a physician who provides intensely episodic and often urgent care to highly vulnerable patients with a range of emotional, physical, and therapeutic needs — offering concierge.

While surprised on one level, it’s certainly understandable why a specialist today would turn to concierge. Specialists’ fees are being ratcheted downward at rapid rate. Their economic future is especially uncertain and many are looking for options to bring stability to their revenues, maintain the quality of care they can provide, and ensure business viability.

Intrigued by my friend’s question, I asked if the practice required the patient to join the concierge program, even before the diagnosis was confirmed, or if it was volitional. In other words, was it a hybrid program where she had a choice or was it a mandatory concierge program where she would not be seen if she did not pay?

To me, that is a critical distinction. I have always had a personal problem with full models that did not give a patient an opportunity to get to know the physician before offering a concierge medicine option. It seems even more important when treating a disease such as cancer to have that choice.

Now, I firmly believe that specialists should have the right to participate in whatever plans that they wish. I also believe that they should be able to implement a concierge program if they so choose. We now offer services to various specialists whose practices have the necessary characteristics to support hybrid programs.

However, I do think there are important business issues and principles for all specialists to consider regarding full and hybrid programs. For example:

1. Do you rely largely on a referral base or are your patients self-referring?

2. Does your specialty deliver primarily episodic care or do you have a large portion of ongoing care patients?

3. Do you have a significant number of core patients who rely on you for more help in managing their medical needs?

4. Does your rate of turnover of patients mean that you would have difficulty replacing members as they leave the practice?

My experience shows that a full concierge program for specialty care is full of problems. Full programs often interfere with insurance contracts. They also can compete with primary-care physicians who are a referral source. Specialists who “steal patients” from their referring doctors find that those referrals soon end. Most specialists also do some episodic care or procedures. As a result, going “full” takes them away from their specialty. The answer is a hybrid program.

When I was asked about a concierge oncology practice, I thought that it really did not work for business reasons as well as other concerns. Cancer patients — especially those newly diagnosed — not only have many fears and uncertainties, but also intense therapeutic needs requiring intensive attention and time. In addition, limiting a practice to only those patients who can pay a concierge fee would automatically exclude many patients — at a time when they most need a supportive physician to provide vital clinical information and guidance. A hybrid program addresses this problem, but I am not yet convinced that it is the right type of practice for concierge care.

Which brings us back to the woman facing the dilemma on whether or not to join the oncology concierge program; she’s leaning toward joining in order to get a quick diagnosis. While I understand the issues for specialists and why many are considering concierge, ultimately it is up to the patient/consumer to decide if they are willing to pay for the benefits that the program offers. Perhaps that’s at least part of the guidance we’ll all have to look to when considering what specialties are suitable for a concierge program.

Do you think oncologists or other specialists should offer concierge? What concerns do you have?