Ethical Implications of For-Profit Physician Care for Indigent Population

Primary health care physicians (PCPs) are facing dissatisfaction in their work environment due to demands of labor, increasing work hours and number of patients, and decreasing insurance reimbursements and salaries. As a result, PCPs have increasingly been exploring different types of practices, one of which is concierge medicine. A 2012 survey of 13,000 physicians reported that 6.8% are embracing this type of practice, with this number expected to grow in the next three years. Concierge medicine is a new health care delivery model in which physicians limit the patients they see. In traditional practice, a PCP cares for 2000 patients annually, but in concierge medicine a PCP sees 400-600. The services provided include longer visits, same day appointments, personalized wellness programs, telephone and email consultations, preventive care, and coordination with fitness trainers and dietitians. In return for providing such personalized care, concierge physicians require their patients to pay an annual retainer or service fee of $2,000-$20,000. However, concierge medicine does pose affordability barriers to indigent populations. Because of the high retainer fee this type of practice requires, low-income populations are less able to participate.  Ethical concerns arise because this creates a “two-tiered” system, dividing healthcare between the wealthy and the poor. Ethical principles such as justice, nonmaleficence, and autonomy are violated by concierge practice. With rapid scarcity of PCPs and increasing numbers of patients needing care in traditional practice settings, patients are less likely to receive adequate and quality care.  To reduce the gap of the “two-tiered” system, physicians offer scholarships and fee waivers for ten percent of their patient population who cannot afford the retainer fee. As an alternative, 600 clinics nationwide opened for Medicaid patients to receive similar services and care as those participating in concierge medicine but at a lower fee.

Conclusion

The growing numbers of people who will be receiving health care under the affordable care act increases the need for PCPs. PCPs entering into a practice like concierge medicine further limits those PCPs available to the general public. Concierge medicine fees limit the economically disadvantaged from being able to participate in this type of healthcare.

Recommendations

Nurse practitioners (NPs), with similar skill sets as PCPs, are a potential and viable solution to this current health care problem. The scarcity of PCPs in traditional care allows opportunities for NPs to provide primary care. Thus, optimal utilization and training of NPs will help improve delivery of care to patients left in traditional practice.

More research needs to be conducted on the impact concierge medicine will make in the delivery of care to all populations, but in particular those more vulnerable, like the poor. Further research into the special programs offered within the concierge model for indigent populations needs to be conducted to assure quality and quantity of care delivered to this population is adequate.