I have quickly found two prominent critiques of retainer medicine. Both critics dismiss the message of the retainer medicine movement, rather they assume that the alternative to retainer medicine is practicing with the under-served.
The problems of the under-served are complex, but we should not blame physicians who are providing high quality medicine to those who want to pay extra. Could we not just as easily criticize all the subspecialists, dermatologists, radiologists, etc. for not entering primary care? Unless we have a fully socialized medicine system which tells you what specialty you can do, how can we criticize a general internist who chooses to practice in a way that his patients desire and fund. Afterall, most retainer fees cost less than 1 pack per day – and an amazing proportion of our population finds the money for their nicotine habit.
Troy Brennan, in a JGIM editoral, states:
The bad news is that every unfortunate, yet predictable, side effect of the concierge practice has come true. The concierge doctors do tend to build their practices by shipping those who cannot pay off to other doctors. Those transferred patients are more likely to be Medicaid recipients. What was not necessarily predicted might be even worse news. The concierge doctors are getting rid of their sicker patients (at least those with diabetes). And they are not as likely to care for patients of color, raising concerns about worsening racial disparity in care. If it were to grow in popularity, concierge medicine would likely push more patients of color, poorer patients, and sicker patients into the remaining primary care practices.
Here he criticizes the physicians on the basis of discrimination. Should he not rather understand the driving forces here. He admits that we have serious problems in outpatient medicine:
Fortunately, it has not caught fire. But we cannot be complacent as the field of primary care appears to be set for a conflagration. The decline of interest in primary care internal medicine demonstrated by residents is striking,3 although not surprising. Long practice hours with relatively poor reimbursement, lack of significant exposure to primary care in training programs, and fewer mentors capable of exciting interest in the field are all factors that contribute to this sense of malaise. The result is that while other areas of medicine are growing and practitioners thriving, primary care internal medicine is moving toward crisis. If this decline in interest persists, most primary care practices will be completely reliant on the pool of foreign educated physicians to find replacements, and that supply may be tenuous as well.
Note that he has no problem expressing prejudice against foreign educated physicians. I suspect that he does not even realize that he commits a major insult here.
Thomas Bodenheimer in the NEJM has this quote in an otherwise excellent article:
 Yet these efforts have touched only a fraction of primary care practices, with small private offices offering the greatest challenge. Moreover, these models have not sufficiently confronted the reality that primary care physicians lack the time to provide all evidence-based preventive and chronic care services for the average patient panel.4 This problem is addressed in a misguided fashion by concierge practices with small patient panels. Such practices are rarely available to lower-income patients, and if the approach were widely adopted, the primary care workforce would become grossly insufficient to care for the entire population.
He throws in this “misguided” quote without further explanation. He assumes that all readers view this movement with indignation, as does Dr. Brennan.
I urge these authors and their ideological colleagues to look beyond the trappings. I urge them to perform a thought experiment. Why are patients increasingly willing to pay? Why are highly ethical physicians opting for this style of practice? If they are honest, they will find some truths that knee jerk opposition obscures.
