Response

To the Editor:

We thank Drs Alrajab and Uysal for their interest in our commentary.¹ We are pleased that their two-tiered recommendation for solving the current health-care crisis includes provision of basic coverage for all, suggesting that they agree that the solution should not result in two standards of care created by ability to pay. However, “encouragement” of community and charity clinics, rather than incentivization, is insufficient to guarantee access to the second tier. The lure of better reimbursement or the ability to charge for access to a concierge practice and bill insurance providers may provide much stronger incentives.

The administrative and bureaucratic requirements intrinsic to the current practice of medicine are pervasive. Exhaustion, depersonalization, and perceived inefficacy in the workplace are the hallmarks of burnout, and professional organizations are actively addressing the issue of work/life balance.² However, the larger public health issue, and the one addressed here, involves health equity and how wholesale adoption of concierge practices could tip the balance. Even countries with single-payer systems (single tier) are concerned with the issue of health equity and the provision of safety net mechanisms to counteract exclusion.³ Ethically, the imposition of financial barriers to health-care access opposes the principle of health equity. Concern also exists for the sustainability of a consumer-driven, medical-care model and allocation of limited resources from the medically complex and underserved poor with high health-care use despite insurance to the care of the “wounded wealthy.”^{3, 4} Despite the enormity of the problem, progress in reducing health disparities and improving health equity is occurring.⁵

Our position is not in absolute opposition to concierge practices; hence, the title of our original commentary included the caveat “not yet.” We advocate caution with careful and deliberate consideration of the consequences of broader implementation.