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Hi. I am Art Caplan at the University of Pennsylvania Center for Bioethics. Today I am going to talk to you a little bit about the growing practice of "concierge" or "boutique" medicine. What is concierge medicine? Basically, in concierge medicine you ask your patients to pay an additional fee (usually $1500-$2000 a year), and in return they receive better service. You promise that if they join the plan, you will answer their phone calls. You might give them your cell phone number. You might be in a situation in which concierge patients have more time available when they come in for an office visit, and you are going to help them wend their way through the hospital and gain access to specialists. In other words, patients are going to get more of you for the money.

What is fueling this shift toward concierge practice, particularly in primary care? It is the red tape, hassles, bureaucracy, micromanagement, and too much overhead cost that primary care providers in particular are facing in the current healthcare environment. There is just not enough time to see patients, and people feel as though they are on an assembly line. It's understandable that the idea of having patients pay more as a way of getting out of a broken system might come to the fore. A lot of people are doing this. There are probably 6000 primary care physicians alone who have shifted over to a concierge practice. To be honest, concierge medicine for the superrich has always been around. The person who has an addiction who goes off to the Betty Ford Clinic and the executive who takes a jet for an executive physical at the Mayo Clinic: These are versions of concierge or boutique medical practice. Now it's expanding into the middle class.

What is the downside, and what are the ethical worries about this growing type of practice? First, there aren't enough primary care providers around to begin with. We all know that we have too many specialists, not enough generalists, and not enough primary care providers in the United States. If you take a significant number of them out of the pool available to every patient and make them available only to people who can pay additional fees, it results in a bigger workload for the rest of the providers who are doing primary care. No matter how you look at it, if you allow providers to buy out, you are going to leave other patients with lower-quality care, and you are going to burden the remaining primary care practitioners (who don't take the concierge route) with more work.

There is also the issue that if patients aren't in a boutique or concierge practice, they are going to wind up getting lower-quality care because they might see more physician extenders. There are certainly great physician extenders -- both nurses and physician assistants -- but patients don't understand that they may be seeing someone with a bit less training and may be paying the same money or fees for someone with less qualification.

At the end of the day, we have a justice issue. Concierge practice is a business solution to what is essentially a broken system. We must find different ways of solving the problems with healthcare, other than having people pay a fee to escape the broken system. Concierge medicine is fundamentally unjust. We have to come up with a better answer. It will probably be something along the lines of what is being proposed for healthcare reform. Concierge medicine is more a symptom of a broken system than it is a solution.

Thanks for listening. I'm Art Caplan at the University of Pennsylvania.