The American College of Physicians (ACP) released a position paper on Nov. 10 on the increasing popularity of concierge medicine and direct patient contracting practices (DPCPs), outlining the patient care implications of the arrangements.

The paper was simultaneously published in the Annals of Internal Medicine.

The report’s authors noted that proponents of DPCPs believe they improve the access and quality of care, although others have noted patients who cannot afford to pay directly for care would be left out.

The ACP defined a DPCP as “any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care.”

Direct patient contracting practices vary. Some patients pay a monthly or annual fee to get access to doctors and personal attention, while other patients pay directly for all services at the time of care.

Although a survey from 2013 found approximately 6 percent of physicians were in concierge or cash-only practices, an ACP membership survey from 2014 found 1.3 percent of members selected “retainer-based practice, concierge” as the best description of their basic source of compensation.

The ACP offered the following recommendations with regards to DPCPs:

1. ACP supports physician and patient choice of practice and delivery models that are accessible, ethical, viable, and that strengthen the patient-physician relationship.
2. Physicians in all types of practice must honor their professional obligation to provide nondiscriminatory care, to serve all classes of patients who are in need of medical care and to seek specific opportunities to observe their professional obligation to care for the poor.
3. Policymakers should recognize and address pressures on physicians and patients that are undermining traditional medical practices, contributing to physician burn-out and fueling physician interest in DPCPs.
4. Physicians in all types of practice arrangements must be transparent with patients, offering details of financial obligations, services available at the practice, and the typical fees charged for services.
5. Physicians in practices that choose to downsize their patient panel for any reason should consider the impact these changes have on the local community including patients’ access to care from other sources in the community and help patients who do not stay in the practice find other doctors.
6. Physicians who are in or are considering a practice that charges a retainer fee should consider the impact that such a fee would have on their patients and local community, and particularly on lower income and other vulnerable patients, and consider ways to reduce barriers to care for lower income patients that may result from the retainer fee.
7. Physicians participating, or considering participation, in practices that do not accept health insurance, should be aware of the potential that not accepting health insurance may create a barrier to care for lower income and other vulnerable patients. Accordingly, physicians in such practices should consider ways to reduce barriers to care for lower-income patients that may result from not accepting insurance.
8. Physicians should consider the Patient-Centered Medical Home (PCMH) as a practice model that has been shown to: improve physician and patient satisfaction with care, outcomes, and accessibility; lower costs; and reduce health care disparities, when supported by appropriate and adequate payment by payers.
9. ACP calls for independent research on DPCPs that addresses:

• The number of physicians currently in a DPCP, where DPCPs are located geographically, projections of growth in such DPCPs, and the number of patients receiving care from DPCPs.
• Factors that may undermine the patient-physician relationship, contribute to professional burnout, and make practices unsustainable, and their impact on physicians choosing to provide care through DPCPs;
• The impact and structure of DPCP models that may affect their ability to provide access to underserved populations;
• The impact of DPCPs on the health care workforce;
• Patients’ out-of-pocket costs and overall health system costs;
• Patients’ experience with the care provided, and on quality and outcomes;
• The impact of physicians not participating in insurance and therefore not participating in national quality programs, interoperability with other electronic health record systems, and the associated impact on the quality and outcomes.