Editor’s Note: Death by Bureaucrat?

March 1, 2009

Maryland’s state insurance commissioner recently toyed with the idea of reclassifying retainer-based practices as a type of insurance. Shaking your head, too? Read on to see what our executive editor has to say.


It was bound to happen: Government bureaucrats are starting to notice the small pocket of primary-care physicians who are happy and successful, and are wondering what they can do to put a stop to it.

Maryland’s state insurance commissioner, for instance, recently considered whether to classify retainer-based practices - sometimes called concierge or boutique - as a type of insurance, a move that would effectively kill them. He backed off.

But it wasn’t the first time a state administrator has looked at ways to end retainer medicine. And as more fed-up primary-care doctors turn to such models as a way out of the mess they’re in, more bureaucrats, lawmakers, and activists will seek ways to thwart market innovation in the name of access.

Maybe I’m being alarmist but I predict the next few years will see a growing number of skirmishes at state and local levels over whether to regulate or outright criminalize practices that charge membership fees and limit their patient panels. After all, “[D]octors who go boutique are harming their communities by seriously decreasing the availability of primary care.” So goes the argument of Peter Beilenson, MD, a county health commissioner in Maryland (writing in The Baltimore Sun), and many others.

For a typical yearly fee of $1,500 to $1,800, most concierge practices offer patients an extensive annual physical plus increased access to the doctor, sometimes including 24-hour phone access. Actual medical services (beyond the annual exam) are not covered by the fee, and most patients keep their insurance for this purpose. What patients are really paying for is the extra attention that an unhurried physician can give: The practice closes after it reaches its cap - usually about 600 patients, roughly one-fifth the patient panel of the average primary-care office.

Thomas LaGrelius, a geriatrician who owns a concierge practice in Torrance, Calif., thinks my concern about bureaucratic intervention is overblown, though the president of the Society for Innovative Medical Practice Design agrees that as different retainer models gain traction, “they’re going to be attracting government scrutiny.”

The fact that many concierge practice patients are well-heeled and politically connected offers some cover, but LaGrelius says the best protection will come from what officials will find when they scrutinize the concierge model: healthy and happy patients. No concierge physician to his knowledge has been sued for malpractice. Ever. “We don’t make mistakes, and if we do make a mistake, most of the time we have a good enough relationship with the patient” that a lawsuit is unlikely. “I don’t get where the criticism is coming from.”

It’s coming from the genuine concern about the deep hole American primary care is in, combined with the wrongheaded idea that doctors’ first responsibility is to their communities rather than their patients. You didn’t break healthcare but because you are a doctor you must endure its dysfunctions whatever the cost to you or your patients. That’s the thinking.

It’s true that retainer practices with closed panels reduce the number of primary-care doctors available to everyone who can’t or won’t pay. But the idea that the price is unaffordable to all but the rich is dubious. How many people who “can’t afford” $150 a month for a better level of healthcare access think nothing of paying that amount on cable television or cell phone service? What’s affordable has as much to do with one’s priorities as with one’s income.

It’s also true that primary care is in grave trouble. The AMA predicts a shortage of perhaps 40,000 primary-care physicians in the next 15 years. It makes little sense for medical students, knowing they’ll be starting their careers with an average student-loan debt of about $150,000, to choose low-paying primary care. That is why only 2 percent of them now do so. It doesn’t make sense for primary-care doctors to continue in a field that crushes their souls - in denying them so often of even the satisfaction of knowing they’re treating their patients the way they’d like to be treated. “You just can’t do adequate preventive medicine and detailed care in seven minutes with your hand on the doorknob,” LaGrelius says. That is why half of them told the Physician’s Foundation that they want to quit the business in the next three years.

Beilenson’ solution to all this is laughably naïve: “[I]nsurers must do two things: increase reimbursement rates to primary-care doctors and drastically streamline their administrative requirements.” Medicare should pay more, too, he says.

I’m sure those reforms will be coming right up, but in the meantime I’m at a loss to understand why anyone would blame doctors for innovating their way out of a deep, dark hole.

Bob Keaveney is the executive editor of Physicians Practice. Join the conversation he’s started on this topic at our physician forum, or e-mail him directly at bob.keaveney@cmpmedica.com.

This article originally appeared in the March 2009 issue of Physicians Practice.