Only a tiny fraction of America's doctors practice an elite new brand of "boutique" medicine, charging annual membership fees of up to $20,000 for personalized care to wealthy patients.
Yet these few practitioners and their select clientele have attracted enough negative national attention in recent months to trigger a wide-ranging examination of both the legal and ethical implications of this new caste system of medical care.
Angry federal lawmakers already are urging the government to halt the practice. Meantime, at least one national doctors' group has entered the debate, questioning the ethics of fellow physicians who accept only patients willing to pay an annual membership fee for such perquisites as preferred appointments, quick access and luxurious waiting rooms.
"Even though the absolute numbers (of doctors practicing boutique medicine) are small, it sends the wrong message," said Lois Snyder, director of the Center for Ethics and Professionalism at the 115,000-member American College of Physicians-American Society of Internal Medicine. "It further undermines trust in the profession. We have various statements within our ethics manual that certainly show these types of practices are suspect."
The organization's ethics manual, she said, states that physicians should not discriminate against a class or category of patient. Snyder's organization, along with most other big doctors' groups, including the American Medical Association, also strongly encourages physicians to provide care to the uninsured or underinsured.
"Obviously," Snyder said, "that's not going to be going on in these physician practices. I don't know if I'd say point-blank that this is unethical, but it raises a lot of red flags. And it may very well be illegal."
In the first legislative volley against so-called concierge medicine, Sen. Bill Nelson (D-Fla.) introduced legislation last fall that would outlaw the payment of Medicare funds to healthcare providers who charge membership fees. It has not come up for a vote.
Earlier this month, five Democratic lawmakers followed Nelson's lead by petitioning HHS Secretary Tommy Thompson to "halt a growing national problem of physicians overcharging senior citizens in the Medicare program."
Two potential violations of federal law were listed in the letter, signed by Sen. Richard Durbin (D-Ill.) and Reps. Henry Waxman (D-Calif.), Pete Stark (D-Calif.), Sherrod Brown (D-Ohio) and Benjamin Cardin (D-Md.). First, the lawmakers contended that the membership fees violate a provision that physicians cannot charge more than 115% of standard Medicare rates. Concierge practices exceed that limit because membership fees are required before Medicare beneficiaries receive services. Also, physicians might violate the federal False Claims Act by submitting inaccurate bills that do not include the membership fee, the letter said.
The lawmakers asked Thompson to accelerate the pace of an ongoing investigation into the legality of concierge practices by the Centers for Medicare and Medicaid Services. The CMS began its inquiry about the time last summer that the first media reports surfaced about the membership structure of a Florida boutique physician practice called MDVIP.
"Further delay will only encourage the spread of these practices, raising concerns of access and affordability in the Medicare program," according to the letter.
A spokesman for the CMS acknowledged that it "could be some time" before a decision is reached on the legality of concierge medical groups. "We're still monitoring it," he said.
Like Snyder, Warren Jones, M.D., president of the 93,500-member American Academy of Family Physicians, voiced concerns about boutique medicine. He said regulatory burdens and lower reimbursement rates do not justify limiting access to patients.
"We have a problem when so many millions of people can't get access to physicians," Jones said. "From that perspective, I hate to see anything serve as a barrier. And, to me, charging a fee for access to a physician might serve as an additional barrier. We see that as problematic."
Proponents of the practice, however, say concierge medicine provides another alternative in a healthcare system that is already multitiered. Darin Engelhardt, chief financial officer of Boca Raton, Fla.-based MDVIP, said the concierge alternative is the same as a parent's decision to send a child to a private school.
Engelhardt's company, which employs six doctors serving 1,800 patients in South Florida, stirred up a hornet's nest when its debut got widespread publicity last year (Oct. 22, 2001, p. 38).
"People are dissatisfied with the current healthcare environment," he said. "For people in that niche, who choose to invest their personal funds, I think we offer a solution. The backlash is focused on the idea that we've created a `second tier' of healthcare. The reality is that healthcare in this country is multitiered and has been for 40 years."
A top official of the Chicago-based AMA, the largest doctors' group in the U.S., defended the rights of patients to choose the kind of care they receive and how they pay for it. The organization's Council on Medical Services will produce an informational report on boutique medicine at its annual meeting in Chicago in June.
"Patients have the right to make choices," said Yank Coble, M.D., a Jacksonville, Fla., endocrinologist and the AMA's president-elect. "It seems like patients should have the right to make these arrangements."
The number of doctors involved in this new model of medicine is quite small-several dozen of the nearly 647,500 patient-care physicians nationwide. But the backlash continues to grow because critics believe the concept will further stratify medicine by forcing an increasing pool of less-privileged patients onto a smaller group of busier physicians.
MDVIP's Engelhardt said the lawmakers' letter "indicates a misunderstanding of both our business model and applicable laws." He also dismissed concerns that the concept would spread across the nation, suggesting that only as many as several hundred doctors would ultimately set up shop in boutique practices.
"It's a niche," Engelhardt said. "But people who want to enhance their lives shouldn't be denied the opportunity to do so with their personal funds."