Some time ago, I rented a car during a visit to another city. I chose among the various categories of vehicles which are listed from the last expensive to the most costly. Here were my choices.


• Economy

• Compact

• Intermediate

• Standard

• Full Size

• Premium

• Luxury

As I have pointed out on this blog with regard to medical care, people spend other people’s money much more easily than they spend their own. This is why I have argued that patients need to have some ‘skin in the game’ to serve as a brake on profligate medical spending. There may be other effective brakes to consider, but diagnostic and therapeutic restraint demanded by patients is a potent and reasonable option.

In the rental car case, I was not on someone else’s expense account, but was handing over Kirsch cash. I chose a standard sized vehicle. Of course, I could have saved $$$ by driving off in an economy vehicle, but rental cars are priced like movie popcorn. For a few dollars more per day, you can drive a bigger car. It is a brilliant pricing strategy that encourages the consumer to upgrade.

Here’s the point. I ordered and paid for a standard sized car. I cannot expect that I will be presented with a luxury automobile when I arrive at the rental car lot. Of course, I can upgrade to a higher category, but I will have to pay more. Isn’t this fair? If you are paying for a Chevy, don’t expect to drive away in a Cadillac. 


This concept relates to the practice of concierge medicine, also known by the even more derogatory description of boutique medicine. In these practices, patients pay a premium to the physician in return for higher level medical services. These physicians can earn the same income, or more, while caring for much fewer patients.

Why Do Insured Patients Pay More For Concierge Care?


• Same day appointments

• On time office visits that last as long as needed

• Direct access to the physician’s cell phone

• Physicians accompanying patients to specialists’ offices

• Comprehensive annual physical examinations and health review

• Emphasis on preventive medicine, nutrition and wellness

• Posh waiting rooms with New Age soothing music

Concierge Medicine Criticisms


• It’s not fair

• Insured patients should be getting these services anyway

• It’s elitist

• It siphons primary care physicians away from those who can’t afford concierge care

Concierge medicine didn’t emerge in a vacuum. It was not concocted by greedy physicians who were seeking to provide Cadillac care so they could continue to drive Cadillacs.


Boutique medical practices have become popular because private practice primary care physicians faced three mounting challenges.

• Financial pressure with declining reimbursements and rising overhead

• Declining quality of care from seeing higher volume of patients

• Burnout

Concierge medicine is a response to this reality. Concierge practices are financially solvent and provide premier quality medical care to a smaller group of patients. This is not exclusively a benefit for the wealthy. Many average income folks have decided that spending $100 each month for superior medical services is worth it for them and their families. How much do you spend each month on your cell phone? Is concierge medical care more important to you than an iPad, a smart phone or joining a pricey gym? We all make choices in how we spend our money.

For those who want this higher level service for their families, they may need to cut back on other expenses. What kind of car are your driving now? Full size? Luxury? Sports Car? Hybrid? Perhaps, it is worth downsizing your wheels and upgrading your medical care.

I realize that many folks don’t have this option right now, particularly under current economic conditions. We all wish that they, and everyone, could receive concierge level medical care, but this is not how our society works.

Concierge medicine isn’t the avaricious aggressor here. It’s self-defense.