ACP Recommendations on Concierge, Other Direct Patient-Contracting Practices

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Physician interest in concierge and other direct patient contracting practices is driven by frustration with reimbursement and billing hassles and a desire to spend more time with patients, but there is limited evidence on these practices' impact on cost, quality, and access to care.

As physicians seek different practice models, one that has gained ground are the so-called “boutique,” retainer, concierge, or cash-only direct primary or specialty care practices that contract with patients to pay directly for some or all services. The American College of Physicians (ACP) published a position paper in Annals of Internal Medicine exploring the factors driving the growth of direct patient-contracting practices (DPCPs) and the limited evidence on their impact on patient care.

The paper, “Assessing the Patient Care Implications of ‘Concierge’ and Other Direct Patient Contracting Practices,” finds that physician interest in concierge and other DPCP arrangements is largely driven by frustration with reimbursement and billing hassles with payers and the strong desire voiced by physicians to spend more time with each patient. Yet there is limited evidence on the impact of such practices on cost, quality, and access to care, notes ACP President Wayne J. Riley, MD, MPH, MBA, MACP. This paper provides food for thought for physicians who are considering DPCPs and proposes an agenda for additional research on the efficacy of this expanding practice type.

The ACP defines 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.


The paper states that growing physician interest in DPCPs is based on the premise that access and quality of care will be improved if patients have a greater responsibility to pay directly for services provided by physicians and other health professionals in the practice, without third-party payers putting themselves between patients and physicians.

However, the ACP notes that there is little high-quality, independent research on the impact of DPCPs on quality and access. A review of the literature notes that there are potential benefits to DPCP models, including providing patients with better access and more time with physicians and fewer administrative burdens on practice, but there are concerns that these practices may cause access issues for patients, especially those who cannot afford to pay directly for care.

The ACP cautions that there are policy and ethical issues that should be considered by physicians thinking of entering into this practice model, as well as steps they should take if they are already in a DPCP to ensure that lower-income and other vulnerable patients are not disadvantaged.

While the ACP supports physician and patient choice of practice and delivery models that are accessible, ethical, viable, and that strengthen the patient-physician relationship, the ACP reminds physicians that whatever practices they are in, they must honor their professional obligations 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.

The paper provides 9 points of consideration and calls for independent research to address the important concerns about access, barriers to care if these practices do not accept insurance payments, and quality of care associated with DPCPs.

“This paper neither endorses nor opposes concierge and other DPCPs, rather, it offers ACP’s assessment of the evidence on the policy and patient care implications of DPCPs in order to inform discussion among policymakers, researchers, the public, and physicians themselves about the potential implications of DPCPs,” Dr Riley said in a statement.