Medicare.gov defines concierge care by its membership fee.¹ This article covers what surveys of concierge physicians found, what Medicare rules say a membership fee can’t include, and how the AAFP distinguishes concierge medicine from direct primary care.

What concierge medicine is

Medicare.gov defines concierge care as “when a doctor or group of doctors charges you a membership fee before they’ll see you or accept you into their practice.” It is also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice or direct care.¹

The American Medical Association’s Code of Medical Ethics uses the term “retainer practices.” It states that physicians are free to enter into contracts “to provide special non-medical services and amenities” with patients who are willing and able to pay additional costs out of pocket. It also calls on physicians to “ensure that all patients in the physician’s practice receive the same quality of medical care.”²

How the AAFP distinguishes concierge medicine from direct primary care

The American Academy of Family Physicians (AAFP) distinguishes the two. According to the AAFP, concierge practices “may continue to accept insurance plans and government programs and bill patient’s insurance company for covered services,” while direct primary care (DPC) practices “rely solely on patient fees, not accepting insurance or participating in government programs.”³

AAFP policy describes DPC as a model in which patients pay their physician or practice directly “in the form of periodic payments for a defined set of primary care services,” through fees that “replace the traditional system of third party insurance coverage for primary care services.” It adds that most DPC patients, depending on affordability, still carry insurance for services such as specialty care and hospitalizations.⁴

Medicare.gov, however, lists “direct care” among the other names for concierge care.¹

What surveys of concierge physicians found

In 2005, the U.S. Government Accountability Office (GAO) published a report on concierge care that included survey responses from 112 physicians practicing concierge care as of October 2004.⁵

• The most frequently reported features the physicians offered were same- or next-day appointments for nonurgent care, 24-hour telephone access and periodic preventive-care physical examinations.⁵
• The physicians reported caring for an average of 491 patients in October 2004, compared with an average of 2,716 patients in the year before they began practicing concierge care.⁵
• Among physicians who remained in the same community, the average number of patients they reported seeing on a typical day fell from 26 to 10.⁵
• Eighty-five respondents, about three-fourths, reported that they billed patients’ health insurance for covered services.⁵

GAO noted that the survey results “cannot be projected to any other concierge physicians.”⁵

A separate national survey, published in 2005 in the Journal of General Internal Medicine, found that retainer physicians had much smaller patient panels than nonretainer physicians, with a mean of 898 patients compared with 2,303. The authors also found “substantial overlap in services provided” between retainer and nonretainer practices.⁶

What the AMA asks of retainer practices

AMA Opinion 11.2.5 lists these obligations for physicians who enter into retainer contracts:²

• Present the terms of the arrangement clearly, including implications for the patient’s current health insurance if known, and “take care not to imply that more or better medical services will be provided under a retainer contract.”
• Ensure that patients’ decisions to accept retainer contracts are voluntary and that patients are free to opt out of entering into a retainer agreement.
• Facilitate transfer of care for any patient who chooses not to participate. If a transfer to another local physician is not feasible, continue to provide care under the terms of the patient’s existing insurance until other arrangements can be made.
• Ensure that treatment recommendations for all patients are based on scientific evidence, relevant professional guidelines, sound professional judgment and prudent stewardship.
• Uphold standards of honesty and transparency in billing, and clearly distinguish charges for special services or amenities under a retainer contract from medical services reimbursable by the patient’s insurance or another third-party payer.
• Uphold professional obligations to promote access to health care and to provide care to those in need regardless of ability to pay, in keeping with ethics guidance.

What Medicare rules say a membership fee can’t include

“Medicare doesn’t cover membership fees for concierge care.”Medicare.gov¹

Medicare.gov also explains a limit on what the fee can include. It states that doctors who accept assignment can’t charge patients extra for Medicare-covered services, which means the membership fee “can’t include additional charges for items or services that Medicare usually covers, unless Medicare won’t pay for the item or service.” In that situation, Medicare.gov says the doctor must give the patient a written notice called an Advance Beneficiary Notice of Noncoverage (ABN).¹

A 2004 alert from the Office of Inspector General of the U.S. Department of Health and Human Services (OIG) described the same principle. It stated that “Medicare participating providers can charge Medicare beneficiaries extra for items and services that are not covered by Medicare,” that they may also charge for applicable Medicare deductibles and coinsurance, and that when participating providers request any other payment for covered services from Medicare patients, “they are liable for substantial penalties and exclusion from Medicare and other Federal health care programs.”⁷

Questions that clarify a membership’s terms

The AMA calls on retainer practices to present their terms clearly, including implications for the patient’s current health insurance, if known.² These questions cover the points addressed by the AMA guidance, the Medicare rules above and the features GAO found most frequently reported:

• What does the membership fee cover, and what is billed to insurance or Medicare separately?
• Does the practice accept my insurance or Medicare for covered services?
• How are appointments scheduled, and how is the practice reached after hours?
• Is the membership required to remain a patient, and what happens to my care if I choose not to join?

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This article is for general information only and is not medical advice. It does not replace a conversation with a licensed health care professional about your own health. Do not start, stop or change a prescribed medication without talking to your prescriber. In an emergency, call 911.