Pay-Per-Care in Dermatology, Part 2: Alternative Pay Practices Make Their Case

Advocates of direct-pay models have pointed to ways in which out-of-pocket costs of noninsurance accepting practices are often lower than what would be charged under insurance because of copays, deductibles, and stratification of coverage that often excludes all or portions of treatment.

In Part 1 of this series, Dermatology Advisor explored the emergence of 3 different payment models of care among board-certified dermatologists. Arguments both for and against direct-pay models, and particularly concierge medicine, often revolve around issues of access to care and out-of-pocket costs, which are explored further in Part 2 of this series, presented here.

The concierge, retainer-based model is designed to provide optimum access at a higher cost. According to a 2016 review by Paul and Skiba,1 the fee is designed to increase patient access to the provider, which often requires limiting the number of patients they accept into the practice by as much as 80%. They allow that the concierge model has been characterized as “elitist” by some, while also pointing out that the American Medical Association has acknowledged the legitimacy of concierge medicine as an alternative method of delivering care.2

Access to Care

Nikki Hill, MD, from SOCAH Dermatology Care in Tucker, Georgia, who employs the concierge model at her practice, said, “My patients are thankful for the time and dedication they receive. They like the family atmosphere in our office and enjoy calling on the telephone and knowing people by name. Some might be taken aback, wanting to use their insurances; however, with a little time and explanation, about 80% will book appointments. We learned not every patient is an optimal patient for our practice. We cater to patients that respect our and their time, want to know more about their conditions and treatments, and enjoy a comprehensive approach to their care.”

Jean Holland, MD, a solo practitioner in Riverview, Michigan, who uses a direct-pay model, summed up the basic differences and benefits to both types of nonreimbursed care: “Concierge (as opposed to direct-pay) benefits patients for whom wasted time is an unacceptable cost. Paying for access has value for them. Direct-pay benefits patients by giving them access to a board-certified dermatologist for a predictable price.”

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Dr Holland brought up the issue of scheduling appointments, long considered 1 of the drawbacks to traditional medical practice. “We don’t overbook,” she said. “Consequently, we can get patients with zoster or other urgent problems in on the same or next day. We have been open for 3 years and demand has increased such that nonurgent visits are being scheduled 3 weeks out.”


At the same time, advocates of direct-pay models have pointed to ways in which out-of-pocket costs of noninsurance-accepting practices are often lower than what would be charged under insurance because of copays, deductibles, and stratification of coverage that often excludes all or portions of treatment.

“When people pay directly, prices need to be transparent and reasonable. If they aren’t, people go elsewhere,” said Kathleen Brown, MD, from Oregon Dermatology, a direct-pay provider. “I don’t think that there is any 1 right way to provide dermatology services. I do believe that the third-party payer model, especially with managed-care, has corrupted our values and undermined trust,” she explained further. “Managed care has not delivered on the promises to improve quality and lower the costs of care. It may limit the amounts that are spent, but that is not the same as lowering the costs of care. It actually increases the costs of care, with an excess of bureaucracy.”

Meeting Patient Needs

One of the most striking facts about dermatology practices is the growth in demand for their services across all the payment models. The Global Burden of Disease Study from 2010 found 8 categories of skin disease that were ranked within the top 50 disease burdens, with acne that ranked in the top 5 most prevalent diseases of 2010.3 A follow-up report from 2013 concluded that, “excluding mortality, skin diseases were the fourth leading cause of disability worldwide.”4

The prevalence of skin disease also increases over a lifetime, with approximately 50% of the US Medicare population estimated to have 1 or more dermatologic condition justifying medical treatment, although only 1 in 3 actually seek it.5

In a commentary on the ethical issues of concierge care, Belanger and Grant-Kels suggested that concierge medicine in particular often provides better quality of care through increased interactions, familiarity, and trust between provider and patient.5 For those who cannot afford the costs of concierge care, a direct-pay model offers access to necessary screenings and may introduce dermatologic management to patients who choose to pay by appointment and procedure. Many direct-pay providers, such as Dr Holland and Dr Brown, offer a range of medical services, including initial skin cancer screenings, excisions, and early treatments. “I diagnose a lot of skin cancer and perform electrodessication and curettage and some excisions, but refer out Mohs and melanoma cases,” Dr Holland said.

Dr Brown also provides aesthetic services, including a vascular laser and aesthetic injectables. “My patients span the socioeconomic spectrum,” she noted. “Some of them travel a long way, because they like my practice model and/or like/trust me.”


  1. Paul DP, Skiba M. Concierge medicine—A viable business model for (some) physicians of the future? Health Care Manag (Frederick). 2016 ;35:3-8.
  2. Barr P. Concierge physician practices stay healthy even in ailing economy, but other models of primary-care delivery draw increasing interest. Mod Healthc. 2011;41:28-30.
  3. Hay RJ, Johns NE, Williams HC, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol. 2014;134:1527-1534.
  4. Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global skin disease morbidity and mortality: an update from the Global Burden of Disease Study 2013. JAMA Dermatol. 2017;153:406-412.
  5. Belanger M, Grant-Kels JM. To fee or not to fee? The ethical issues of concierge medicine. Ann Int Med. 2017;163:631-633.