Physicians, frustrated with the economics of running a medical practice in the current climate, where reimbursement for medical services is declining and costs are escalating, are turning to “concierge” or “retainer” models for their practices. Under this model, physicians significantly reduce the size of their practice to only those patients who have paid an annual fee, which is typically between $1,000 to $3,000 per year. The annual fee does not cover the actual medical services provided, other than a comprehensive annual physical exam. Patients are still required to pay the applicable office fee for the physician’s services. Ancillary services, which may be performed by other providers outside the physician’s practice, are usually not included in the annual fee and patients are billed directly by the provider of such services. A smaller practice allows the physician to spend more time with the patients, provide same or next-day appointments and 24/7 access to the physician via pager or e-mail. Concierge physicians have found that this model permits them to be more proactive with their patients and promote wellness and preventative care, rather than short, rushed appointments to treat a discreet illness or injury. Commercial payors have generally not been receptive to the concept and argue that the arrangement constitutes an improper “access” fee. As a result, many concierge practices have terminated their contracts with third-party payors and function as out-of-network providers. Another potential issue relates to Medicare, which does not allow physicians to charge patients for services that are already reimbursed by the Medicare program. It is important to structure the benefits members receive in exchange for the annual fee to ensure that Medicare enrollees are not charged in a manner that violates the regulations. The American Medical Association (AMA) does not track the number of concierge practices there are in the United States, however, in 2004 the Government Accountability Office counted 146 such practices. In 2003, the AMA issued “Code of Medical Ethics Opinion 8.055 Retainer Practices,” in which it discussed ethical concerns with this type of practice.

(See AMA Retainer Practices). A handful of companies have introduced concierge care into their executive health benefits.