Retainer-based or concierge medicine may seem like a strange topic for the Medicare Payment Advisory Commission to be studying, but concerns have been raised about whether the spread and continued growth of these practices might negatively affect the ability of Medicare beneficiaries to access physicians. MedPAC therefore commissioned a report to describe the state of retainer-based medicine and whether there was evidence of negative impacts. (MedPac Report) The report was based on a literature survey and 28 interviews with experts, physicians and Medicare beneficiary advocates.
Many concierge practices continue to see non-retainer patients and most continue to participate in Medicare and private insurance plans. They charge patients the flat fee for either extra services or to cover a set of primary care services. Some physicians have only retainer-based patients and others see a mix. The typical concierge physician has a panel that is half the size or less of their patient load before switching to the flat-fee model. MedPAC identified at least 750 concierge physicians, largely concentrated in urban areas, in almost 40 states. Most of these are primary care doctors and most practice solo. They were attracted to the model because it allows them to spend more time with patients and is less stressful. The physicians often don’t make more money, but work less to earn the same.
The authors found little research on the topic of whether retainer-based patients had either better health outcomes or lower medical costs, although some of the physicians they interviewed believed that to be the case. The patients most likely to pay to be in concierge medicine were either high-income individuals or patients with multiple chronic illnesses and complex health needs. Some elderly patients’ fees were paid by their children. No evidence was found of systematic access problems caused by the growth of concierge medicine, although some individual beneficiaries faced a difficult financial decision in staying with a physician who converted his or her practice. A very small minority of doctors currently practice retainer-based medicine, but the number is growing. The most sensible policy for Medicare might be to explore paying the retainer for beneficiaries, especially if evidence indicates that it results in better care coordination and lower overall costs.