PhotoWhile millions more people now have access to health insurance under the Affordable Care Act, it might not make it any easier to see a doctor.

Some think the law is creating a tiered system of U.S. health care, increasing the number of private practice physicians converting to what are known as concierge practices.

A concierge practice only accepts patients willing to pay a sometimes hefty “retainer” in order to be a doctor's patient. Retainers typically run from $1,200 to $5,000 a year – and in some posh locales, tens of thousands more.

In return for that retainer, a patient gets more direct access to his or her doctor. Some services include telephone consultations and same-day appointments. In short, the patient receives more personalized care.

The retainer, however, comes out of pocket. The patient pays it in addition to other health insurance premiums.

For doctors, the workload declines. They see fewer patients and fill out fewer forms. They still bill patients' health insurance companies while the retainers make up for any lost revenue.

Win-win, but not for everyone

It's a win-win – except for the people who can't afford a concierge doctor and must compete to be seen by physicians who keep their practices open to everyone. And the number of those practices may be declining.

A 2012 report by Merritt Hawkins, a physician recruiting firm, predicted the move to concierge practices could exacerbate a current doctor shortage.

It cited a survey of more than 13,000 doctors that predicted more than 50% of physicians will cut back on patients seen, work part-time, switch to concierge medicine, retire, or take other steps likely to reduce patient access.

All in all, it said the survey indicates this will lead to 91 million fewer annual patient encounters.

Fewer Medicare patients

The survey further found that more than half of physicians have limited the access of Medicare patients to their practices, or are planning to do so, while one out of four physicians have already closed their practices altogether to Medicaid patients.

The doctors pointed to rising operating costs, time constraints, and declining reimbursement as the main reasons why they are unable or unwilling to accept additional Medicare and Medicaid patients.

But writing in Forbes last year, healthcare industry expert John Goodman says Medicare and Medicaid – as well as many other health insurance plans – don't pay doctors to provide personalized care. That's why he thinks consumers should strongly consider paying for a concierge physician.

“In most cases, they give their patients same day or next day service,” he wrote. “They talk to their patients by phone and email. If their patients have to go to the emergency room, they are likely to meet them there. They serve as agents for their patients in dealing with the rest of the system: ordering tests, getting appointments with specialists.”

In other words, it's healthcare the way it was a few decades ago. Only today, it seems only those willing and able to pay for it will get it.  

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