Recently, a doctor in my community decided to go concierge. Under that model, practices still accept insurance but charge patients a membership fee — often more than $100 per month — in exchange for stellar service, such as same-day appointments, longer visits, and phone access. (Concierge practices are different from “direct primary care” practices, which typically charge lower monthly fees and do not accept insurance.¹)

It got me thinking. In many ways, I have a concierge practice. I've had one for 45 years. For all that time, I have seen my patients when they need to be seen. Everyone has received same-day or next-day appointments. I've returned all phone calls promptly and personally, my telephone number has always been listed in the phone directory, and I've even made house calls. I've provided extended visits and comprehensive medical services, and it never occurred to me to charge an extra fee for this. I thought it was what primary care doctors were supposed to do.

As my local colleague has shifted to concierge practice, I've been getting a few of his patients who don't want to pay the new membership fee — or can't afford it. “Heck,” one of them told me, “I only see him once a year!” The monthly fee clearly wouldn't be cost-effective for this patient, but I suppose it might be a boon for hypochondriacs. I worry that, at a time when primary care doctors are in short supply, patients who can't find another doctor to take them on may have to pay up. An elderly friend of mine did just that. She paid the membership fee for her husband because his doctor had been taking care of him for years and she feared he wouldn't get the same level of care elsewhere.

I wonder about the effects of this model on the economically disadvantaged and underserved. If more physicians narrow their panels to only those who can afford their membership fees, won't more patients be left disenfranchised?

Concierge medicine seems to be focused on making more money at our patients' expense. But here are a few alternatives for doctors who aren't making it financially:^2–4

• Learn how to run your practice with a minimum of overhead, especially payroll. A dollar saved is just as good as a dollar earned.

• Become skilled at using your practice management software so you can show your staff how you want things done and optimize revenue. That means knowing how to create aging reports, get claim reports, print statements, and schedule patients efficiently.

• Learn how to code effectively and maximize your billings to insurance companies. To paraphrase Willie Sutton when asked why he robbed banks: because that's where the money is.

• Focus on providing personal, proactive care especially for vulnerable patients who need you most. This will create happier, healthier patients, increasing your value as payment models evolve.