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Concierge, Wellness, and Block Fee Models of Primary Care: Ethical and Regulatory Concerns at the Public–Private Boundary

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Abstract

In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models (concierge care, executive wellness clinics, and block fee charges) in which physicians provide insured services (whether publicly insured, privately insured, or privately insured by public mandate) while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician–patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy.

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Notes

  1. See [42] for a numeric accounting of the funding split in various countries and [44] for a discussion of the various roles these sectors play.

  2. These issues are discussed in the context of hospital-based VIP care in [25, 32].

  3. Such fraud exists but is less well-known in the Canadian system [40].

  4. For a discussion of the ethical considerations involved in physicians soliciting for charity, see [46, 61].

  5. I understand the undertaking to act as a fiduciary to be an undertaking insofar as one is ‘entrusted with power or property’ to use that ‘for the benefit of another’ [49, p. 243]; one is expected in that role to behave ‘impeccably’. It is common in physician codes of ethics to assert the aspiration to act as a fiduciary. This is in important ways a metaphor, as Rodwin points out: the law does not in fact hold physicians to the standards to which it holds fiduciaries in financial and other property matters. But, Rodwin argues, it is a metaphor that offers concrete guidance (that physicians must not use their access to patients to pursue their own interests, or anything other than the health-related purpose for which the patient has consulted the physician) and that has at its core a concept that is becoming more, not less, pertinent to physician practice even as former ideals of the physician as loyal and exclusive advocate for an individual patient is fading: accountability [49, p. 255]. The undertaking to act as a fiduciary would include not taking advantage of patient information, confidence, and attendance for purposes other than the purpose the patient brings to the medical encounter: to seek medical care. This raises question about e.g. the status of time spent in necessary administrative tasks; however, being submitted to repeated offers of special bundled deals is not a necessary administrative task.

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Acknowledgments

This study was funded by academic salary. I produced a report by commission and testified as an independent expert opinion witness for the Alberta Health Services Preferential Access Inquiry into queue-jumping, a report which briefly discussed the regulatory college response to block fee and wellness clinic models.

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  1. Department of Bioethics, Dalhousie University, PO Box 15000, Halifax, NS, B3H 4R2, Canada

    Lynette Reid

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Correspondence to Lynette Reid.

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Reid, L. Concierge, Wellness, and Block Fee Models of Primary Care: Ethical and Regulatory Concerns at the Public–Private Boundary. Health Care Anal 25, 151–167 (2017). https://doi.org/10.1007/s10728-016-0324-4

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