By addiction treatment, I assume it is understood we are discussing buprenorphine medication management products, and not methadone, naltrexone, or strictly counseling. Concierge medicine typically involves a yearly "retainer fee" for concierge services, typically $1200-4000 per year. This is different than "cash pay" where the patient pays cash for the office visits. There are many problems when applying either of these to addiction medicine.
1. At least half to 2/3 of the patients are borderline homeless or in severe financial distress, therefore it makes it impossible for them to pay the up front fees of concierge addiction medicine. Depending on the locality, some will be able to afford cash pay while some will use only Medicaid accepting physicians.
2. Because they have the ability to sell the prescribed medications on the street, there is a fine line between cash pay for office visits and a criminal enterprise in which the physician may receive directly from the patient several times the rate that would be paid by insurers for the exact same service. The only way some of these patients can afford outlandish rates are by selling the drugs. The DEA is aware of this, and holds cash pay only physicians up as drug dealers in some situations. Some cash pay physicians charge $500-600 for an initial visit and $350 for subsequent visits- these rates paint a red target directly on the physician's back. Most physicians in my area with cash pay charge $350 for the initial visit and $200 for subsequent visits. To be safe, it is prudent to accept cash rates much lower than the going rate in the area if you wish to have some protection against a "cash for drugs enterprise" charge.
3. Some patients will go to a cash pay clinic due to the fact they were bounced out of an insurance accepting medical practice for nefarious reasons, including dirty drug screens (these patients are not paradigms of virtuous living), arrested for dealing, etc. The DEA and police follow these patients to their new supplier, and may engage in additional scrutiny of these clinics.
4. There is some concern a combination opioid prescribing pain practice/addiction practice is a self dealing revolving door. When possible, it may be better to have a reciprocal agreement with a like minded physician to cross refer the addiction patients for buprenorphine treatment. In any case, documenting such an arrangement was attempted, even if not successful, speaks loudly to your understanding of the concerns regarding the "revolving door"
5. If a person does not meet the DAST or DSM-V or COWs criteria for addiction treatment, consider a "Third Path" rather than kicking them completely out of medication management- convert to buprenorphine SL or nucynta for pain control if they are on the higher dosage meds, or Butrans if they are on lower dosages, and engage in more frequent followup visits- as often as every three days initially, then gradually extend this time period.
