Earlier this year, the health system at the University of Michigan in Ann Arbor became the latest to roll out a “concierge medicine” program, joining the ranks of other prominent academic health centers, including Duke Health, Stanford Health Care, and Partners HealthCare, which is affiliated with Harvard Medical School.
As a science writer, I wondered what sort of empirical evidence exists to show that concierge programs provide any benefit to anyone, rich or poor?
If you’re like me circa five months ago, you may not know what “concierge medicine” is (hint: It doesn’t involve getting an MRI in the lobby of a Four Seasons). Such programs, I’ve since learned, grew out of the private, for-profit sector, and they have traditionally had a fairly straightforward, market-driven mission: For a lot more money — sometimes as much as $80,000 annually per family — you can purchase a lot more personalized health care attention than you would get from a typical insurance plan. The migration of concierge medicine into academic health care settings is a newer thing, and while the fees are far less mercenary — I found programs online ranging anywhere from $2,500 to $6,000 per person in annual fees, on average, plus the cost of traditional insurance — they offer subscribers similar benefits: Access to a primary care physician at any time of day or night, unhurried appointments, and specialty care coordination.
To some, the whole concierge medicine concept — in any context — sounds like a revolutionary model of health care delivery that enhances the doctor-patient relationship. To others, it looks like an elitist program whereby scarce medical resources are siphoned off from the vast majority of patients and delivered to the wealthy. Those divergent views can become even more pointed in an academic health care setting, where backers position concierge medicine not just as a fast-lane for campus power brokers, but as a beneficent money maker — one that allows academic health centers to play Robin Hood by using concierge philanthropy and fees to fund the rest of the health system, including care for poor patients.
That all sounds great, but when concierge medicine first came to my campus, I had some basic questions: Is such a system fair and ethical? Do its luxury aspirations belong at my public alma mater, which recently renewed its commitment to diversity, equity, and inclusion? And most importantly, as a science writer, I wondered what sort of empirical evidence exists to show that concierge programs provide any benefit to anyone, rich or poor?
I first became aware of the program in early 2018. This was several weeks after the university health system, Michigan Medicine, mailed invitations to select donors announcing the Victors Care program — its name a nod to the university’s fight song. With the slogan “Health Care Reimagined,” the invitation promised members “an unprecedented level of access, convenience, and individually tailored support.”
In leafy Ann Arbor, Victors Care went down like a Styrofoam cup at a zero-waste party.
A January 29 letter to the health system administration, now signed by more than 300 faculty members from 16 departments, outlined an array of concerns. The Michigan Nurses Association, expressed their disapproval, too: “Nurses … are speaking out with concerns that this program is a move towards separate and unequal health care,” they wrote in a February press release. And in March, more than 100 medical residents and fellows issued their own letter, arguing that programs like Victors Care “cater to the privileged and threaten to widen the health disparities gap that so many of us entered into medicine to help narrow.”
These arguments reflect pressing health care concerns across the United States, which has a well-documented health care gap that falls along socioeconomic lines. In 1980, a wealthy 50-year-old man could expect to live 5.1 years longer than a similarly aged poor man. Thirty years later, that difference had more than doubled to 12 years. Further, from 2000 to 2014, the number of seniors reporting good health increased by 21 percent among non-Hispanic whites. During that same period, the number of black seniors reporting good health decreased by 17 percent.
One might assume that given their relatively worse health, poor Americans would account for a higher proportion of health care spending. While this was true for the decades following the creation of Medicare and Medicaid in 1965, things began to change in 2004, when per capita health care spending for the poorest 20 percent of Americans fell annually for 8 straight years. At the same time, per capita health care spending for the wealthiest 20 percent was rising. By 2012, spending for the wealthiest 20 percent of Americans exceeded that of the other groups.
“Does that put them at the front of the line for [specialists]?” Greenson wondered. “Because if it does, then that’s just wrong.”
And then, of course, there’s the waiting. According to a 2017 survey of 30 regions across the U.S., people in large metropolitan markets can expect to wait an average of 24 days for a new patient appointment, 30 percent longer than in 2014. Break the data down further and things look even worse: In Boston, the average new patient appointment with a family medicine physician requires waiting 109 days. Not great, but better than Albany, New York, where the average wait is just over four months.
The survey didn’t include Ann Arbor, but I assure you, we’ve got long lines here, too — and I’m not just referring to traffic jams on football Saturdays. “Some sub-specialties, [such as] endocrinology and neurology, have traditionally been impossible” to get into, says Joel Greenson, a pathologist at Michigan Medicine. He knows from personal experience. When he suffered a bout of back pain, he waited three months for an appointment for an epidural injection. And it’s not just sub-specialties. In mid-June, I scheduled an appointment with my primary care physician. Her next available appointment was September 10 — a mere 13 weeks away.
This, too, is a problem that concierge medicine promises to fix — for a price. Like several physicians I spoke with, Greenson learned about Victors Care when he received the invitation to sign up as a patient. He went to the Victors Care website (which has been revised in light of the blowback) and noticed that the program promised to assist patients with specialist appointments.
“Does that put them at the front of the line for these things?” Greenson wondered. “Because if it does, then that’s just wrong.”
Concierge medicine — sometimes referred to as “luxury” or “retainer” medicine — is not a new approach to delivering health care. The former team doctor for the Seattle Supersonics founded the first concierge clinic in 1996. Four years later, Virginia Mason Health System in Seattle opened the country’s first hospital-based concierge medicine program, and in 2004, Tufts Medical Center opened what is believed to be the first “general internal medicine retainer practice embedded within the structure of an [academic health center,]” according to a 2010 Academic Medicine article.
As far as I can tell, exact numbers are not available, but a host of academic health centers have followed suit, including UNC Health Care, under the helm of Dr. Marschall Runge, who came to Michigan Medicine in 2015 and now serves as executive vice president for medical affairs and medical school dean.
If staff at any of these other academic health centers revolted, I can find no record of it, but on February 28, at the request of University of Michigan faculty, a panel discussion was convened at University Hospital to discuss the ethics of Victors Care. At the outset, Runge explained the program’s various justifications — including an insistence that patients had expressed interest in it. But the real mic drop came when Runge said that Victors Care is designed “to bring U-M supporters … into our system in a way that they will learn more about health care and they will donate toward health care for people not as fortunate as they are.”
That reasoning initially struck me as odd, given that the proportion of uninsured adults has fallen dramatically across the country as a result of the Affordable Care Act. Here in the Wolverine State, 16 percent of adults lacked insurance in 2013. Three years later, that number was 8 percent.
Nevertheless, if, like me, you care about Michigan Medicine because of its social mission — teaching, research, and caring for vulnerable populations; because you met your husband during his first year of medical school in Ann Arbor; because you gave birth at Michigan Medicine twice; and you once brought your son to the ER, where he was swiftly diagnosed and received emergency surgery for a potentially life threatening-condition. If you’re like me, then the possibility of providing better care to vulnerable populations is worth pursuing — perhaps even if it means creating a health care fast-lane for the rich.
Other health systems, after all, do use concierge funds to cross-subsidize their endeavors. For example, in the 2010 Academic Medicine article, a team from Tufts Medical Center outlined how Tufts’ concierge program cross-subsidizes the Division of General Medicine, using surplus funds to promote economic viability of the entire division, and to support teaching and care to “impoverished patients” within the division. Similarly, an article in Healthcare Dive summarizes the comments of Misty Hathaway at Massachusetts General Hospital, a Harvard Medical School affiliate, describing the impetus behind its concierge program: “The primary motivation … she concedes, was finding ways to tap into new revenue sources. The entire margin from the concierge practice helps to fund programs like a substance misuse disorders clinic and community initiatives that might not otherwise have the same level of funding.”
“The entire margin from the concierge practice helps to fund programs like a substance misuse disorders clinic and community initiatives that might not otherwise have the same level of funding.”
The Tufts authors are commendably transparent in describing the origins of concierge medicine: “The growth of retainer medicine is emblematic of the disquieting trend away from traditional primary care,” they write. That trend has produced overworked, undercompensated primary care physicians, as well as dissatisfied patients. Thus, there are incentives for both “to move toward retainer-medicine practices.” Who can blame a physician for wanting to spend more time with each patient? And who can blame patients with complex conditions for paying extra to get the one-on-one attention they may need? Wouldn’t this be like blaming a ship’s passengers for running toward the lifeboats on a sinking ship?
Toward the end of Michigan Medicine’s panel discussion, Andrew Shuman, an otolaryngologist and co-director of the Program in Clinical Ethics in the Center for Bioethics and Social Sciences in Medicine, noted that at other institutions, luxury care programs “happen in the shadows.” Roughly a minute later, he added, “If we are truly using a Robin Hooding example, where we are taking philanthropic donations from those who have the capacity to do so, and reinvesting them in those who cannot, I think that is very clearly a transparent mission that we can get behind, or at least many of us can get behind.
“When this is opaque, though, I think is where we run into problems,” he said.
By spring, things still felt opaque to this University of Michigan English major, so I decided to look for data that would help me better understand how concierge medicine works at other health systems. I searched the academic literature, assuming I’d find case control studies comparing health outcomes for concierge vs. non-concierge patients, or comparing rates of health care utilization (number of prescriptions, tests, and referrals) among groups. Do concierge patients have shorter waits to see a specialist? How do non-concierge patients fare when their doctor decides to take part in a concierge program? And are revenues generated by concierge programs really helping to extend care to the wider community?
In the private, for-profit, sector, concierge programs often cite “proven” outcomes — though such assertions have been called into question. When it comes to studies comparing concierge to non-concierge patients specifically within the setting of an academic medical center, I found just one. It was published by researchers from Tufts, the University of Washington, and Blue Cross Blue Shield of Massachusetts in 2009, and it compared concierge and non-concierge patient satisfaction scores over a 12-month time period on a variety of indicators such as helpfulness of office staff, ability to get an appointment, and physician-patient interaction.
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Much more abundant in the academic literature, it turns out, are voices pointing to a lack of data on the benefits of concierge medicine. In 2004, the surgeon James W. Jones wrote in the Journal of Vascular Surgery: “There is … no evidence that boutique medicine and surgery improve or do not improve outcomes.” In 2010, Michael Stillman wrote in Annals of Internal Medicine: “Yet until data demonstrate that the longer visits, ‘executive’ physicals, or annual ancillary testing offered by so many luxury practices yield better clinical outcomes, no one should … be allowed or led to believe that prompt or expensive care is necessarily the best.” And finally, in 2015, the American College of Physicians released a position paper noting that while retainer fees may cover special amenities such as extended patient visits and coordination with specialists, “No research is available to indicate the cost-benefit of such amenities.”
If concierge patients fare better than their non-concierge counterparts, would health systems be obligated to offer this evidence-based medicine to all patients?
I started to wonder if there was a reason for that. Data on outcomes, after all, could open a Pandora’s box of ethical issues. If concierge patients fare better than their non-concierge counterparts, would health systems be obligated to offer this evidence-based medicine to all patients? And if concierge patients don’t fare better, would health systems be obligated to inform their patients?
As it stands, academic health centers market their concierge programs with a bevy of what seem to be deliberately opaque terms. Few actually promise “better” care. Instead, they use words like “enhanced” and “new model.” Concierge medicine programs also target “busy” patients — though presumably not those busy working two minimum wage jobs. I wrote to Michigan Medicine, asking if any faculty experts could speak with me about data supporting the efficacy of concierge programs. In particular, I wondered: Do they improve the health of patients who can afford to pay? And does everyone else benefit from trickle-down largesse? A spokesperson informed me that she was not arranging interviews on the topic. I also contacted Massachusetts General Hospital, Duke Health, and UNC Health Care with a series of questions, including whether they could point me toward outcomes data for concierge patients.
All initially promised to get back to me; only UNC did. Phil Bridges, a UNC spokesperson, wrote: “We are not prepared to speak to outcomes.”
Toby Citrin, a professor at the University of Michigan’s School of Public Health, appears to be chuckling at the question I’ve just posed in our video interview: Can the University of Michigan fulfill its mission without offering concierge medicine?
“Without Victors Care, our health system has grown enormously, is able to expand on a continuing basis, has built new health centers. Now, that doesn’t guarantee that that will continue in the future, but it seems to me that the system has proven that without stratification of this type, it can provide very high quality of care, can grow, make more money, expand, all those things. I haven’t seen a case made that absent Victors Care, this might slow down,” he said.
I reached out to Citrin after he published an op-ed titled “Victors Care does not belong at Michigan” in the Michigan Daily, the University of Michigan’s student newspaper. In that article, he argued that the stratification of care based on ability to pay is inconsistent with the goals of a public university. “What’s the next plan to capture revenue by further stratifying the University experience?” he wrote. Perhaps “concierge education?”
That might seem like an absurd slippery slope argument until you consider that in 2006, university faculty were busy protesting the incorporation of luxury boxes in the remodeling of Michigan Stadium, warning of “the growing stratification of our society and a sad corruption of our university’s defining traditions.”
In light of the blowback here at Michigan, the Victors Care website has redacted the word “concierge” from its homepage and replaced it with the term “direct primary care” — though that could well prove problematic in itself. While the terms are sometimes used interchangeably, they are not the same thing, with DPC arising in the 2000s as a way to address the problem of extending health care to the uninsured, not as a way to generate revenues by catering to elites. (Indeed, one DPC clinic owner here in Michigan told me that people are frustrated that the university is generating bad press for direct primary care by making it seem elitist.)
As for me, I’m still looking for data and for answers that offer more than chicanery. And in the meantime, I offer this sample of email correspondence with Mary Masson, a spokesperson for Michigan Medicine:
Me: Dr. Runge mentioned that specialists will eventually participate in [Victors Care]. By “specialists,” does he mean people outside of primary care? And if so, which in which specialties?
Masson: Victors Care specifically provides primary medical care. We do not have anything to announce about specialist care.
Me: Can someone please explain the connection between offering VC and bringing in philanthropy? Since the invites went out to people who have already donated to Michigan Medicine, one might assume they’d be happy to continue giving — even to vulnerable populations — without a special primary care program.
Masson: Victors Care is not a fund-raising effort. It is an optional way of providing primary care.
Me: Is Victors Care better than [the university’s] standard primary care?
Masson: [No response.]
Sara Talpos is a freelance writer whose recent work has been published in Mosaic and the Kenyon Review’s special issue on science writing. Sara has an MFA in creative writing (poetry) and is interested in the connections between science and literature. She taught writing classes at the University of Michigan for 10 years.