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updated 11/23/2009 8:23:53 AM ET 2009-11-23T13:23:53
COMMENTARY

One sure sign that something is very broken in America’s health care system is the rise of so-called “boutique” or “concierge” medical practices.

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These are arrangements where doctors expect patients to pay extra premiums to see them, on top of what insurance pays. There are already some 5,000 primary care physicians in the United States who’ve shifted to this model.

Why is this notion of first-class medicine for an extra fee a bad idea? There are two reasons. First, you shouldn’t have to pay a bribe to get decent service from your doctor. And, second, the expansion of these fee-based practices means fewer doctors left for those who cannot pay the luxury rates.

Letters have gone out to tens of thousands of patients across the country in the past few years, solicitations from doctors shifting to concierge care.

It works like this: The family doctor, general practitioner or internist writes to say that if  patients don’t pony up a fee of $1,500, $2,000, or more, then they’ll be dropped from the practice.

Of course, these letters don't openly threaten extortion. Instead, the offer to join a concierge or boutique practice comes in the form of an invitation for patients to pay more for something better. Patients are told they'll get better service for the extra fees, with bonuses like comprehensive physical exams, longer appointments with no waiting, prompt responses to phone calls, access to the doctor's cell phone number and help negotiating access to specialists if they're needed.

Patients may not be told that if they don’t pay the fee, they’ll likely be seen by a less-skilled staffer, usually a nurse practitioner, a physician assistant or a newer, perhaps younger, doctor.

Extra cash for extra care nothing new
Of course, boutique medicine is nothing new. We always have had first-class medicine in the United States. When you spend tens of thousands of dollars to get into the Betty Ford Center and other posh in-patient drug addiction programs, you are getting concierge care.  And when CEOs fly to the Mayo or Cleveland Clinics to get their annual physicals, this is medicine for those with money to burn.

What is different about today’s shift toward boutique medicine is that it is aimed at the middle-class. Ordinary physicians, overwhelmed with red tape, tired of arguing with insurance personnel, faced with backbreaking insurance and overhead costs basically are saying, “Enough!”

They want less work, less hassle and more money. So the message to patients is to dig deeper into their wallets to get the kind of decent, unhurried and attentive care they want.

The problem is, no one should have to pay more to get decent, unhurried and attentive care. 

The whole system of primary care has broken down. Doctors are drowning in a sea of paperwork, insurance companies are siphoning off too much money, and managed care and lawyers are making the whole medical experience intolerable. All that, plus the highest prices in the world for drugs, tests and services combine to make it clear that concierge medicine is not a solution but only a symptom of a broken health care system.

Maybe boutique medicine wouldn’t be so bad if what we were talking about was simply adding amenities — plush robes, fresh coffee and WiFi in the waiting room — to the standard care. But that is not what is happening.

Quality of care starting to shift
Concierge medicine is pulling already-scarce primary care doctors out of circulation. They are being replaced by physician-extenders at the same old prices. And the quality of care is starting to shift as the concierge crowd gets thorough exams while those back in medical steerage get a cursory look, if that.

The truth is, we all deserve the kind of attention from our doctors that our grandparents routinely expected and their doctors routinely supplied. 

By turning medicine into just another commodity, it is only natural that the price will be jacked up for what used to be the standard of care. 

Sadly, medicine is following the example being set by the overstressed American airline industry. They charge extra for the bottle of water, the breakfast roll, the right to take a bag on the plane — and the businessmen pushing concierge medicine are following right in their quality-degrading footsteps. 

Before we accept this airline model of medicine, perhaps it’s time to think again about premium fees for basic services, and instead to get Congress to fix what is so obviously wrong with the nation's health care system: too much business and not enough care.

Arthur Caplan is director of the Center for Bioethics at the University of Pennsylvania.

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