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Boutique practices remain controversial
Some say they fill a need
Boutique; concierge; retainer. These are all words used to describe physician practices that charge patients an annual fee for access. And while there don't appear to be firm numbers on such practices, some say they are meeting an important need in a broken health care system.
According to Felicia Cohn, PhD, director of medical ethics at the University of California, Irvine, School of Medicine, the "harsh reality" of today's health care system is that "there's a finite amount of resources."
"Because there's just no answer — it's so hard, and everyone is so frustrated by it, and it's even affected the way that physicians practice medicine," she says.
Indeed, she says, these new physician practices present "a huge ethical issue, especially for physicians who've already been in practice, who are now going to leave this practice and essentially abandon some of their patients — who say to their patients, 'I'm moving to this type of practice, so you have the choice of either finding a different physician or paying me this retainer."
Retainer vs. public access
Carol Taylor, PhD, MSN, director, Center for Clinical Bioethics at Georgetown University in Washington, DC, compares the provision of health care to the public education system. While most people accept the fact that not every hopeful and qualified student can afford to go to an Ivy League school, she says we tend to accept that as reality in the United States, because there is still public access to education.
"I have incredible sympathy for physicians who want to be able to spend enough time with their patients to practice good medicine, and I know there are some people who have chosen boutique medicine for that reason," Taylor says. "On the other hand, until everybody has access to good, quality care, what these boutique [practices] are doing is oftentimes siphoning off, if you will, the best patients."
And the so-called "best" patients are "those who don't have multiple complications; those who are motivated to pay; [and] those who are sufficiently health-motivated to spend that much money."
Taylor notes that she has heard first-hand from patients who were not accepted into boutique practices, not because of an ability to pay, but due to their health co-morbidities.
That, in turn, "further diminishes the resources that are available for everybody else," Taylor says.
Taylor says anecdotally, she has heard of many physicians choosing to transition to this type of practice.
"I think it's increasing, because physicians are increasingly frustrated with the reimbursement strategies, and they need to employ people who know what all the payers will pay, and to bill accordingly — the hassle of running an office," she notes.
Taylor says she also thinks there are "two types of people going into boutique medicine," which includes those physicians who "really value the bond they have with patients."
"There are some who are going in because you can increase profit and decrease hassle," she says.
Still, she notes that "until everybody has access," it's troubling to see the level of resources that are being steered to these types of practices.
What family practitioners say
Lori J. Heim, MD, FAAFP, who is president-elect of the American Academy of Family Physicians (AAFP) in Leawood, KS, says that her organization also does not "track" the number of retainer practices, but it is something AAFP is likely to begin monitoring.
Heim says such practices are "meeting a need of patients in certain markets, so I would think it is probably not something that was just a flash." The emergence of boutique practices, she says, is "indicative of a [problem] with our medical system."
As to whether such practices are good or bad for medicine, Heim tells Medical Ethics Advisor, "It is not something I would say is an up or down. It works for certain types of physicians, and it works for certain patients."
She also notes that there are critics of retainer practices and that " there are certainly issues surrounding [them] that one has to review carefully." For example, the American Medical Association in Chicago has official policy on retainer practices, developed in 2003.
"[The AAFP is] not in a position to judge people who set up a practice like this," Heim says. "When you talk to physicians in a practice like this, and their patients who are involved, they are very satisfied with their practice, and the patients are very satisfied with the way the care is set up."
Heim notes that one "ethical dilemma people cite" with such practices is that this is a "have vs. have-not" dilemma.
"And while I think that that is absolutely true, again, it's simply a way of stating what we already have," she says. "If you have insurance, I can assure you, your care is very different than if you are uninsured or underinsured in this country.
She points to a U.S. health care system where disparities in care exist and where there are disparities in outcomes by both race and gender.
The fact that there are retainer practices in the United States is not the problem.
"As it relates to retainer practices, I think that it's true that we overestimate their importance and underestimate the need we have for systematic reform," Heim says.