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Editorials: Point and Counterpoint |

COUNTERPOINT: Is It Time for Pulmonary Concierge Practices? Not Yet FREE TO VIEW

Marilyn G. Foreman, MD, FCCP; Victoria Lopez, MD; Eric L. Flenaugh, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURE: None declared.

aPulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA

bDepartment of Medicine, Morehouse School of Medicine, Atlanta, GA

CORRESPONDENCE TO: Marilyn G. Foreman, MD, FCCP, Pulmonary and Critical Care Medicine, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(2):257-259. doi:10.1016/j.chest.2016.09.042
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Published online

Concierge medicine is a form of direct patient contracting in which patients are responsible for payment of an annual fee for enhanced medical services and greater face-to-face physician contact. Direct patient contracting practices have a variety of names: membership medicine, boutique, retainer, direct primary care, and direct subspecialty care. Compounding the nomenclature, significant variability exists in how these practices are structured. Although limited in frequency (grossly estimated to represent 3%-6% of total practices) and geographic distribution, these practices are promoted as innovative alternatives to traditional insurance-based care (Fig 1).,, From the patient’s perspective, the purported advantages include greater physician contact, transparency in costs, and the potential for additional amenities and personalized services. Physicians may find this arrangement advantageous due to the reduced administrative burden, smaller patient panels, consistency in reimbursement, less burnout, and greater work satisfaction. In this Counterpoint editorial, we argue that pulmonary concierge practices require careful consideration and additional unbiased study before their widespread implementation. Despite the obvious benefits, these practices have inherent disadvantages and downstream consequences.

Figure Jump LinkFigure 1 Practice type prevalence (%) over time.Grahic Jump Location

In the United States, significant health-care disparities persist. The smoking paradox provides one such example. Despite initiation of smoking at older ages, shorter smoking duration, smoking fewer cigarettes per day, and greater smoking prevalence in other groups such as American Indian/Alaska Natives (29.2%), African-American patients have higher mortality and shorter survival for lung cancer.,,,, Similarly, African-American patients may develop COPD at earlier ages with similar smoking histories.,, Alexander et al surveyed 144 concierge practices and 463 traditional practices, finding that the concierge practices serviced fewer minority patients (African-American subjects, 7% vs 16% [P < .002]; Latino subjects, 4% vs 14% [P < .001]) or Medicaid patients (5% vs 15% [P < .001]). In addition, significantly fewer patients with diabetes were managed in the concierge practices (17% vs 24%; P = .008). There were nonsignificant associations, but trends were suspected for other common disorders, such as hypertension (30% vs 35%; P = .26) and coronary artery disease (21% vs 25%; P = .26).

Because most concierge practices are located in urban areas or on the East and West coasts,, this geographic distribution would not improve the delivery of health care in rural areas; states with high rates of self-reported smoking; states in the “smoking belt” that includes Arkansas, Alabama, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, and West Virginia; or states that cluster along the Ohio and lower Mississippi River valleys where the prevalence of COPD is highest nationally (Alabama, Kentucky, Ohio, Oklahoma, Indiana, Tennessee, and Mississippi) (Fig 2). Hargrave et al reported greater concentrations of concierge physicians (defined as the ratio of concierge physicians as a proportion of the population) in Los Angeles, California; Miami, Florida; Washington, DC; and Naples, Florida. This aggregation suggests a predilection for affluence that could negatively affect the care of active smokers, who are primarily individuals with reduced socioeconomic status; that is, subjects insured with Medicaid alone (29.1%; 5.5 million) or the uninsured (27.9%; 8.8 million)., Limited medical access for minorities or exclusion of patients with medical complexity could disastrously impact health disparities, further contribute to the unequal distribution of the workforce, and create greater pressure on safety net facilities.

Figure Jump LinkFigure 2 States with high rates of self-reported smoking (178,000 Americans from 50 states surveyed for the Gallup-Healthways Well-Being Index).Grahic Jump Location

Although most physicians in concierge practices are generalist physicians, they are often experienced. Substantial losses of physicians with special skills, such as interventional bronchoscopists with navigation bronchoscopy, could reduce access to procedures that allow identification of early malignancies, contributing to unequal distribution of resources. In the absence of data regarding the impact of concierge medicine on respiratory care and respiratory outcomes, more research is needed.

In addition to legal challenges, ethical concerns have been raised regarding the potential for patient abandonment after physicians leave traditional care for concierge care, concern for health outcomes in the subjects left behind, and the risk of creating an economically based tiered health system.,

Wealth profoundly differs across racial groups in the United States. Consumption inequality and household wealth are two of three measures used to analyze the wealth gap. The Gini index is a measure of income inequality that is used by the US Census Bureau and the World Bank. This summary statistic ranges from zero (where all incomes are equal) to one (one person has all the income). For several decades, the Gini index has been rising in the United States. Equivalence-adjusted, the Gini index has risen 28% from 0.362 in 1967 to 0.464 in 2014. In addition, the wealth gap between European-American and African-American families has increased from $85,000 in 1984 to $236,500 in 2009. For Latino households, median wealth is 18 times lower compared with white households. Fiscally, high annual fees for concierge care could price many minorities out of the market.

The pairing of the words boutique and medicine or membership and medicine is disheartening and classist. Concierge medicine also has other sobriquets: platinum medicine and patron medicine. Relegating the quality of medical care to one’s ability to pay demeans the covenant between patients and physicians, and it risks increasing health and health-care disparities. The greatest risk from wholesale conversion to concierge medicine is the resultant impact on at-risk populations. The National Academy of Sciences recommends the following six community-informed and patient-centered system practices for the provision of quality care for socially at-risk Medicare patients: commitment to health equity, data and measurement, comprehensive needs assessment, collaborative partnerships, care, and engaging patients in their care. We should improve the system that is preexisting and gauge the long-term impact of concierge care on health disparities. The goal should be that no patient is left behind.

Doherty R. . Medical Practice Quality Committee Assessing the patient care implications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians. Ann Intern Med. 2015;163:949-952 [PubMed]journal. [CrossRef] [PubMed]
 
Physician Compensation Report: 2015. Medscape.http://www.medscape.com/features/slideshow/compensation/2015/public/overview. Accessed July 18, 2016.
 
Physician services. Concierge care characteristics and considerations for Medicare. US Government Accountability Office.http://www.gao.gov/new.items/d05929.pdf. Accessed July 17, 2016.
 
Bach L. Tobacco use among African Americans. Campaign for Tobacco-Free Kids.https://www.tobaccofreekids.org/research/factsheets/pdf/0006.pdf. Accessed July 17, 2016.
 
Jamal A. .Homa D.M. .O'Connor E. .et al Current cigarette smoking among adults—United States, 2005-2014. MMWR Morb Mortal Wkly Rep. 2015;64:1233-1240 [PubMed]journal. [PubMed]
 
Trinidad D.R. .Perez-Stable E.J. .Emery S.L. .White M.M. .Grana R.A. .Messer K.S. . Intermittent and light daily smoking across racial/ethnic groups in the United States. Nicotine Tob Res. 2009;11:203-210 [PubMed]journal. [CrossRef] [PubMed]
 
Perez-Stable E.J. .Benowitz N.L. . Do biological differences help explain tobacco-related disparities? Am J Health Promot. 2011;25:S8-S10 [PubMed]journal. [CrossRef] [PubMed]
 
Flenaugh E.L. .Henriques-Forsythe M.N. . Lung cancer disparities in African Americans: health versus health care. Clin Chest Med. 2006;27:431-439 [PubMed]journal. [CrossRef] [PubMed]
 
Foreman M.G. .Zhang L. .Murphy J. .et al Early-onset chronic obstructive pulmonary disease is associated with female sex, maternal factors, and African American race in the COPDGene Study. Am J Respir Critical Care Med. 2011;184:414-420 [PubMed]journal. [CrossRef]
 
Chatila W.M. .Wynkoop W.A. .Vance G. .Criner G.J. . Smoking patterns in African Americans and whites with advanced COPD. Chest. 2004;125:15-21 [PubMed]journal. [CrossRef] [PubMed]
 
Chatila W.M. .Hoffman E.A. .Gaughan J. .Robinswood G.B. .Criner G.J. . National Emphysema Treatment Trial Research Group Advanced emphysema in African-American and white patients: do differences exist? Chest. 2006;130:108-118 [PubMed]journal. [CrossRef] [PubMed]
 
Alexander G.C. .Kurlander J. .Wynia M.K. . Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics. J Gen Intern Med. 2005;20:1079-1083 [PubMed]journal. [CrossRef] [PubMed]
 
Hargrave E, Mahmud A, Quirk K, Summer L, Hoadley J. Contract report: retainer-based physicians: characteristics, impact, and policy considerations. MedPAC. October 2010: No. 10-9.http://www.medpac.gov/documents/contractor-reports/Oct10_RetainerBasedPhysicians_CONTRACTOR_CB.pdf. Accessed July 18, 2016.
 
McCarthy J. In US, smoking rate lowest in Utah, highest in Kentucky. Gallup. March 13, 2014.http://www.gallup.com/poll/167771/smoking-rate-lowest-utah-highest-kentucky.aspx. Accessed July 18, 2016.
 
Centers for Disease Control and Prevention Chronic obstructive pulmonary disease among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:938-943 [PubMed]journal. [PubMed]
 
Clark P, Friedman J, Crosson D, Fadus M. Concierge medicine: medical, legal, and ethical perspectives.The Internet J Law Healthcare Ethics. 2010;7(1).http://ispub.com/IJLHE/7/1/7969. Accessed July 18, 2016.
 
Carnahan S.J. . Concierge medicine: legal and ethical issues. J Law Med Ethics. 2007;35:211-215 [PubMed]journal. [CrossRef] [PubMed]
 
Desilver D. The many ways to measure economic inequality. Pew Research Center.http://www.pewresearch.org/fact-tank/2015/09/22/the-many-ways-to-measure-economic-inequality/. Accessed July 17, 2016.
 
Shapiro T, Meschede T, Osoro S. The roots of the widening racial wealth gap: explaining the black-white economic divide.Research and Policy Brief. Institute on Assets and Social Policy, Brandeis University.http://iasp.brandeis.edu/pdfs/Author/shapiro-thomas-m/racialwealthgapbrief.pdf. Accessed July 17, 2016.
 
Kochhar R, Fry R, Taylor P. Wealth gaps rise to record highs between whites, blacks, Hispanics—executive summary. Pew Research Center. Social and demographic trends.http://www.pewsocialtrends.org/2011/07/26/wealth-gaps-rise-to-record-highs-between-whites-blacks-hispanics/. Accessed July 18, 2016.
 
National Academies of Sciences, Engineering, and Medicine. 2016. Systems practices for the care of socially at-risk populations. Washington, DC: The National Academies Press.http://dx.doi.org/10.17226/21914.
 

Figures

Figure Jump LinkFigure 1 Practice type prevalence (%) over time.Grahic Jump Location
Figure Jump LinkFigure 2 States with high rates of self-reported smoking (178,000 Americans from 50 states surveyed for the Gallup-Healthways Well-Being Index).Grahic Jump Location

Tables

References

Doherty R. . Medical Practice Quality Committee Assessing the patient care implications of “concierge” and other direct patient contracting practices: a policy position paper from the American College of Physicians. Ann Intern Med. 2015;163:949-952 [PubMed]journal. [CrossRef] [PubMed]
 
Physician Compensation Report: 2015. Medscape.http://www.medscape.com/features/slideshow/compensation/2015/public/overview. Accessed July 18, 2016.
 
Physician services. Concierge care characteristics and considerations for Medicare. US Government Accountability Office.http://www.gao.gov/new.items/d05929.pdf. Accessed July 17, 2016.
 
Bach L. Tobacco use among African Americans. Campaign for Tobacco-Free Kids.https://www.tobaccofreekids.org/research/factsheets/pdf/0006.pdf. Accessed July 17, 2016.
 
Jamal A. .Homa D.M. .O'Connor E. .et al Current cigarette smoking among adults—United States, 2005-2014. MMWR Morb Mortal Wkly Rep. 2015;64:1233-1240 [PubMed]journal. [PubMed]
 
Trinidad D.R. .Perez-Stable E.J. .Emery S.L. .White M.M. .Grana R.A. .Messer K.S. . Intermittent and light daily smoking across racial/ethnic groups in the United States. Nicotine Tob Res. 2009;11:203-210 [PubMed]journal. [CrossRef] [PubMed]
 
Perez-Stable E.J. .Benowitz N.L. . Do biological differences help explain tobacco-related disparities? Am J Health Promot. 2011;25:S8-S10 [PubMed]journal. [CrossRef] [PubMed]
 
Flenaugh E.L. .Henriques-Forsythe M.N. . Lung cancer disparities in African Americans: health versus health care. Clin Chest Med. 2006;27:431-439 [PubMed]journal. [CrossRef] [PubMed]
 
Foreman M.G. .Zhang L. .Murphy J. .et al Early-onset chronic obstructive pulmonary disease is associated with female sex, maternal factors, and African American race in the COPDGene Study. Am J Respir Critical Care Med. 2011;184:414-420 [PubMed]journal. [CrossRef]
 
Chatila W.M. .Wynkoop W.A. .Vance G. .Criner G.J. . Smoking patterns in African Americans and whites with advanced COPD. Chest. 2004;125:15-21 [PubMed]journal. [CrossRef] [PubMed]
 
Chatila W.M. .Hoffman E.A. .Gaughan J. .Robinswood G.B. .Criner G.J. . National Emphysema Treatment Trial Research Group Advanced emphysema in African-American and white patients: do differences exist? Chest. 2006;130:108-118 [PubMed]journal. [CrossRef] [PubMed]
 
Alexander G.C. .Kurlander J. .Wynia M.K. . Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics. J Gen Intern Med. 2005;20:1079-1083 [PubMed]journal. [CrossRef] [PubMed]
 
Hargrave E, Mahmud A, Quirk K, Summer L, Hoadley J. Contract report: retainer-based physicians: characteristics, impact, and policy considerations. MedPAC. October 2010: No. 10-9.http://www.medpac.gov/documents/contractor-reports/Oct10_RetainerBasedPhysicians_CONTRACTOR_CB.pdf. Accessed July 18, 2016.
 
McCarthy J. In US, smoking rate lowest in Utah, highest in Kentucky. Gallup. March 13, 2014.http://www.gallup.com/poll/167771/smoking-rate-lowest-utah-highest-kentucky.aspx. Accessed July 18, 2016.
 
Centers for Disease Control and Prevention Chronic obstructive pulmonary disease among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:938-943 [PubMed]journal. [PubMed]
 
Clark P, Friedman J, Crosson D, Fadus M. Concierge medicine: medical, legal, and ethical perspectives.The Internet J Law Healthcare Ethics. 2010;7(1).http://ispub.com/IJLHE/7/1/7969. Accessed July 18, 2016.
 
Carnahan S.J. . Concierge medicine: legal and ethical issues. J Law Med Ethics. 2007;35:211-215 [PubMed]journal. [CrossRef] [PubMed]
 
Desilver D. The many ways to measure economic inequality. Pew Research Center.http://www.pewresearch.org/fact-tank/2015/09/22/the-many-ways-to-measure-economic-inequality/. Accessed July 17, 2016.
 
Shapiro T, Meschede T, Osoro S. The roots of the widening racial wealth gap: explaining the black-white economic divide.Research and Policy Brief. Institute on Assets and Social Policy, Brandeis University.http://iasp.brandeis.edu/pdfs/Author/shapiro-thomas-m/racialwealthgapbrief.pdf. Accessed July 17, 2016.
 
Kochhar R, Fry R, Taylor P. Wealth gaps rise to record highs between whites, blacks, Hispanics—executive summary. Pew Research Center. Social and demographic trends.http://www.pewsocialtrends.org/2011/07/26/wealth-gaps-rise-to-record-highs-between-whites-blacks-hispanics/. Accessed July 18, 2016.
 
National Academies of Sciences, Engineering, and Medicine. 2016. Systems practices for the care of socially at-risk populations. Washington, DC: The National Academies Press.http://dx.doi.org/10.17226/21914.
 
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