The Rise of “Boutique Medicine”

Boutique medicine (also known as direct-pay, retainer-based, or concierge medicine) refers to medical practices—almost always in primary care—that charge patients a yearly administrative fee in addition to any charges for medical care. In some practices the administrative fees cover all provided medical services, but in other practices patients must pay all costs not covered by their health insurance. Still other practices do not accept health insurance, and so patients must pay all costs for care out of pocket—even though the ACA requires all Americans to have health insurance.

Although boutique practices remain rare, increasing numbers of doctors are turning to this option. Charging administrative fees allows doctors to dramatically cut their caseloads and work hours while dramatically increasing their incomes. This is particularly appealing to primary care doctors because their incomes are on average substantially lower than that of specialists. In addition, doctors who refuse insurance coverage don’t need to spend time and energy dealing with insurers. Finally, reducing patient load gives doctors the time to really get to know their patients and their health care concerns.

Patients who join boutique practices can also benefit. Among other things, patients typically receive benefits such as phone or e-mail access to their physicians, same-day appointments, less-rushed appointments, and even home visits and immediate access to top-ranked specialists.

Although boutique medical practices remain rare, their rising prevalence has raised concerns about access and equity. By definition, patients who join boutique practices receive services that others do not. And when doctors drastically cut the number of patients they serve, those who can’t afford their services typically find it harder to find a doctor. By the same token, doctors who don’t join boutique practices will face greater pressure to increase their own caseloads, which they can only do by shortening the time they spend with each patient. Finally, allowing wealthier people to buy their way out of some of the difficulties of our health care system makes it less likely that these influential individuals will support real and constructive change for everyone.