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Direct pay and instant access

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6603 (Published 01 November 2013) Cite this as: BMJ 2013;347:f6603
  1. Edward Davies, US news and features editor
  1. edavies{at}bmj.com

“Doctors are exhausted. They’re burned out. The stress of their work is causing marital and family discord. And nearly 60 percent of physicians who participated in a recent survey have considered leaving the practice of medicine behind.” So began a 2006 report from the American College of Physician Executives, and it seems little has changed since http://net.acpe.org/Resources/Articles/Doctors_Say_Morale_is_Hurting.pdf).

A more recent survey around pay and happiness found that job satisfaction is in steady decline: “Doctors were concerned about their falling incomes, and some resented that other specialties made more money. They also said that the demands of increased regulation and documentation took the joy out of medicine.” (doi:10.1136/bmj.e3109)

So why does Karen Josephson, a geriatrician in Long Beach, California, describe her own life quite differently?

“This is a beautiful life,” she says. “I would never go back to a regular practice.” When she meets doctors in regular practice, “all of them are miserable, absolutely miserable,” she says. “All they have to look forward to is ICD-10 [international classification of diseases 10th revision], EMRs [electronic medical records], and Obamacare. I don’t have to deal with any of that.”

Josephson is one of the increasing numbers of direct payment, or concierge, doctors in the US and this week we look at the ever-expanding phenomenon and what it means for both medics and patients. (doi:10.1136/bmj.f6465)

The private physician model is hardly a new one, but as doctors look for a better work-life balance and patients look for ever more personalized services, the model is a growth industry. Practices charge patients a regular fee, making it possible for physicians to cut back their panels to only a fraction of what they used to be. Appointments are longer and the physician can delve more deeply into each patient’s case. Patients are also allowed to phone or email their doctors, a benefit not covered by most health insurance.

Although satisfaction with the model among direct pay physicians is far from universal, its 18% dissatisfaction rate seems well below the national picture and best estimates are predicting up to a 10-fold increase in concierge doctors over the next three years.

There are also downsides to the model: the transition requires business, legal, financial, and marketing nous. David L Albenberg, who opened a direct pay practice 10 years ago, says that patients can be difficult to please, and with medics already in short supply it leaves some difficult questions over how the growth of such businesses would hit the wider healthcare economy.

But these are problems that may have to be surmounted. It seems this is an area that is only likely to grow.


Cite this as: BMJ 2013;347:f6603


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