Concierge Practices Even for Doctors Who Don't Like the Idea

Neil Chesanow


January 09, 2014

In This Article

Is It Ethical to Let Patients Go?

For many doctors, a full concierge practice presents a moral dilemma. First you create a special class of patients who receive better treatment than everyone else because they can afford to pay for it. Then those who can't afford or don't want to pay the annual fee must leave the practice at a time when primary care doctors are in short supply and the healthcare marketplace is about to be flooded with newly insured entrants courtesy of the Affordable Care Act.

LaGrelius, who reduced his panel by well over 50%, doesn't see it that way.

"I take care of a lot of very complicated patients," he says. "The interesting thing about those who joined my concierge practice is that they were the most complex patients in my conventional practice -- the ones who had the most need of care. And the new patients who joined my practice are incredibly complex."

"Being the only boarded geriatrics specialist in the community who is in private practice, I got a lot of very complicated seniors with 25-30 medical problems and who are on a lot of medications. We keep them out of the hospital and we keep them well. I don't think that would happen in any other setting. We're making a huge difference in these people's lives and saving a ton of money."

Some of his traditional patients chose not to join the new practice because they felt they didn't need more care. Others needed it but didn't want it.

"I remember one patient," LaGrelius recalls. "He called me up and said, 'I don't want you to do this, because I just want to come in and see you when I'm sick.' I said, 'George, the last time I saw you was 5 years ago, and I put you in the hospital when you had lobar pneumonia that nearly killed you. You didn't come back for follow-up or get your pneumonia vaccine. I don't do that anymore. I want to take care of people who want optimal care and whose care is optimized. I can only do that with a few hundred patients if I'm going to take care of patients who are complex and difficult, which is what I like to do.'"

George didn't join the new practice.

However, those who opted not to join were not "kicked out," as is often charged by critics of the concierge movement.

"Every one of my patients who left the practice was connected with another primary care doctor if they wanted help connecting," LaGrelius says. "No one who failed to make a decision on whether to join the practice was ever turned away. If they got sick, I took care of them until they were over that illness, and then transitioned them into membership in the practice or to some other physician. That's the obligation of any doctor: to make sure their patients are cared for."

Moreover, patients who wanted to join the new practice but couldn't afford the annual fee received "scholarships" in which the fee was waived.

"A lot of patients are scholarship patients," LaGrelius says. "I made it clear to my patients when I transitioned that if they truly couldn't afford the practice, all they had to do is explain that to me and they would be admitted free. I still take scholarship patients who are referred to me by other people in the practice."

In fact, scholarships and discounts for patients who can't afford the fee are commonly built into the practice models of marketers of concierge services.

"We insist that our doctors reserve about 10% of their membership for scholarship patients, plus another percentage of patients whom we encourage them to discount -- usually by 50%," Roberta Greenspan says. "Additionally, we set up a fee structure for our clients that always includes an 'adult couple' discount and frequently includes a lower annual fee for younger patients -- usually under age 40 or 45, depending on the makeup of the practice."


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