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ACP Releases Paper on Impact of 'Concierge' on Patient Care

Nov 11, 2015 9:32 am

The American College of Physicians released a position paper exploring factors driving the growth of “concierge” and other “direct patient contracting practices” (DPCPs) and the “limited” evidence on their impact on patient care.

For the purposes of this paper, ACP defines a DPCP as any practice that: (1) directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of, or in addition to, traditional insurance arrangements and/or (2) charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care.This definition of DPCPs therefore encompasses retainer, “concierge,” “boutique,” cash-only, direct primary care, and direct-specialty-care practices.

The paper found that growing physician interest in DPCPs is based on the premise that access and quality of care will be improved if patients have a greater responsibility to pay directly for services provided by physicians and other health professionals in the practice, without third-party payers imposing themselves between the patient and the physician. Yet, ACP notes that there is little in the way of high quality, independent research on the impact of DPCP models on quality and access.

While a review of the literature notes there are potential benefits to DPCP models—including providing patients with better access and more time with physicians and fewer administrative burdens on the practice -- there are concerns that DPCPs may cause access issues for patients, especially among patients who cannot afford to pay directly for care.

In the paper, ACP offers the following recommendations (rationale for each recommendation is available as an appendix to the full paper):

1. The ACP supports physician and patient choice of practice and delivery models that are accessible, ethical, and viable and that strengthen the patient–physician relationship.

2. Physicians in all types of practices must honor their professional obligation to provide nondiscriminatory care, serve all classes of patients who are in need of medical care, and seek specific opportunities to observe their professional obligation to care for the poor.

3. Policymakers should recognize and address pressures on physicians and patients that are undermining traditional medical practices, contributing to physician burn-out, and fueling physician interest in DPCPs.

4. Physicians in all types of practice arrangements must be transparent with patients and offer details of financial obligations, services available at the practice, and the typical fees charged for services.

5. Physicians in practices that choose todownsizetheir patient panel for any reason shouldconsiderthe effect these changes have on the local community, including patients' access to care from other sources in the community, and help patients who do not stay in the practice find other physicians.

6. Physicians who are in or are considering a practice that charges a retainer fee shouldconsiderthe effect that such a fee would have on their patients and local community, particularly on lower-income and other vulnerable patients, and ways to reduce barriers to care for lower-income patients that may result from the retainer fee.

7. Physicians participating, or considering participation, in practices that do not accept health insurance should be aware of the potential that not accepting health insurance may create a barrier to care for lower-income and other vulnerable patients. Accordingly, physicians in such practices shouldconsiderways to reduce barriers to care for lower-income patients that may result from not accepting insurance.

8. Physicians shouldconsiderthe patient-centered medical home as a practice model that has been shown to improve physician and patient satisfaction with care, outcomes, and accessibility; lower costs; and reduce health care disparities when supported by appropriate and adequate payment by payers.

9. The College calls for independent research on DPCPs that addresses the following:

a. the number of physicians currently in a DPCP, where DPCPs are located geographically, projections of growth in such DPCPs, and the number of patients receiving care from DPCPs;

b. factors that may undermine the patient–physician relationship, contribute to professional burnout, and make practices unsustainable and their effect on physicians choosing to provide care through DPCPs;

c. the impact and structure of DPCP models that may affect their ability to provide access to underserved populations;

d. the effect of DPCPs on the health care workforce;

e. patients' out-of-pocket costs and overall health system costs;

f. patients' experience with the care provided, quality of care, and outcomes; and

g. the effect of physicians not participating in insurance and therefore not participating in national quality programs, interoperability with other electronic health record systems, and the associated effect on quality and outcomes.

The author has no conflicts of interest to disclose related to this subject

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