Participatory Medicine: Must You Be Rich to Participate?



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Keywords: Participatory medicine, concierge medicine, digital divide, uninsured patients.
Citation: Graedon J, Graedon T. Participatory medicine: must you be rich to participate? J Participat Med. 2012 Feb 1; 4:e2.
Published: February 1, 2012.
Competing Interests: The authors have declared that no competing interests exist.

“Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.[1]”

Our lofty definition of participatory medicine requires patients who are both interested and capable of taking an active role in their health care as well as providers who have time to listen and work together in a partnership with patients.

We fear that this movement may be leaving too many people behind. Those without insurance are rarely in a position to participate fully in their health care. When problems arise, the emergency room is far too frequently the only access such patients may have. That is not a great place to initiate participatory medicine, especially if you are in distress.

Providers frequently complain that their biggest challenge is time, whether in the ER or in the clinic. They just don’t have enough time to listen to a long story; do a complete workup; review all medications for incompatibilities; and counsel the patient on lifestyle issues, treatment options, and what to expect from a new prescription.

The exception to this model is concierge care. In this approach to health care, time with the patient is at the top of the priority list. Many such practices promote the possibility of patient empowerment and personalized care. The only hitch is the personalized bill, which can start around $1500 a year and go to several thousand dollars per patient. This doesn’t include any tests, procedures, specialists, or hospitalization. It gets the patient same-day or next-day appointments, 24-hour access, and unhurried visits.

If you think of health care as if it were air travel, the difference between a regular doctor visit and a concierge visit is a bit like the difference between coach and first class. First class passengers board first, have room for their luggage as well as their legs, are treated respectfully, and get served “free” beverages and food. In coach you’ll be lucky to find room in a bin for your carry-on, you will be squeezed into a tiny space with no legroom and the flight attendants may seem overwhelmed and impatient.

We don’t doubt that people who are able to pay thousands of dollars out of pocket just to get in the door of a patient-centered medical practice could be getting a more personal relationship with their physicians. Not only are they getting more time and attention, they probably have the skills and resources to negotiate a partnership before they even walk in the door.

Most of us cannot afford concierge medicine — or concierge hospitals featuring privacy, gourmet meals, and luxurious bathrooms — any more than we can afford to fly first class. That’s doubly true for poor people, who often take the bus because they can’t fly at all. In many cases, they can’t even afford insurance that would provide minimal health care. As a result, they often end up seeking care in crowded safety net clinics or emergency rooms where there is precious little time to consider empowerment or engagement. Is the participatory medicine movement leaving them behind?


  1. Society for Participatory Medicine. Available at: Accessed January 28, 2012.

Copyright: © 2012 Joe Graedon and Terry Graedon. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.


10 Responses to “Participatory Medicine: Must You Be Rich to Participate?”

  1. Mindy Schwartz Brown says:

    Yes, a huge portion of our population is left behind,
    not primarily by the participatory care movement, but
    because they have become invisible.
    This movement arose out of the individual interests
    of seekers of care, and perhaps the next question,
    as a matter of evolution is whether it can expand to
    include those who have not been included in the past.
    The first step is to understand the magnitude of
    the gulf between those who have access and those
    who do not.

  2. Alex says:

    A great start to a big important question. However I would like in addition some suggestions how patients who are “underserved” can be more empowered and engaged. For instance, I have vanilla medical insurance. I am on long term disability. (I am not destitute). Only through learning the hard way did I become an engaged empowered patient. So, how do we get to being participatory? I would like to hear some of your suggestions. Thanks

    • abby ovitsky says:

      I agree and I think we are coming from similar places. In my youth, I worked for insurance counsel at times, on the end where they got the claims they disputed…for experimental treatments. Someone has to pay, doctors have to eat, so how do we work this?

      What if, MedCare/MediCal gave “credits” and each patient could exchange those with a licensed practitioner or in any licensed pharmacy or dispensary? One unit is 15 minutes, 15 dollars, etc. When you run out of time, you start using it more wisely, like cell phone minutes. Texting is cheaper. If patient cannot read wiki and figure out what MD (for instance) is saying, then they asked to pay more, not because they are being punished for being poor and sick but for not reading. I see doctors less now that I am also in same situation (long term disability not destitute but it’s a fixed income) where I have insurance but do not use it because it does not cover what I use, so I already pay 100% out of pocket. One could conceivably go to the MD appointment with the questions written out, with all the copies of previous medical records in hand and with very specific goals, instead of “it hurts, fix it” without telling MD anything more and letting him or her guess. Most people can manage that much, but it takes motivation…it costs insurance companies the same if patient comes every month for 15 minutes or twice a year an hour or so…or has a live chat if it’s not urgent.

  3. Actually the medical home model is another cost effective alternative. I get my primary care from a medical home for $55 a month and it doesn’t require insurance.

    My yearly deductible on my very expensive individual insurance policy is now over $1000 a year so it works out perfectly for me.

    This clinic uses medical residents but the University of Washington also often uses medical residents and I am rarely sick so it works for me.

    Qliance is a for profit primary care direct pay model here in Seattle that runs between $54 and $129 a month and many of their patients are people without insurance who have chronic conditions.

    Finally – Group Health Cooperative also uses the medical home model for all of its 620,000 members (if they use a GHC doc).

    The common theme is that all of them use a different payment model that keeps the savings in the providers office.

  4. Teru says:

    I was a medical doctor in Japan and now practice Traditional Chinese Medicine in Canada. Since I have lived 2 countries where minimum healthcare is reasonable or entirely free (Japan 70% covered and in Canada it’s free), it is really surprising that in the US even minimal healthcare is not covered…I know there are a lot of issues and political sentiments behind it but I feel sad whenever I read an article like this.(I’m mostly talking about the last paragraph)

  5. Elizabeth Rankin says:

    I am new to this site and organization and know little about the abstract but from what I am reading, with the title, “Participatory Medicine” …I take the words literally and think the idea here would be to consider the patient and the professional work together through mutual respect, “participating ” through both understanding what is needed to resolve issues the patient has or those the physician sees he can help the patient with. The very word participation suggests parties work together but this takes good listening skills and not all have these skills. Medicine is still one sided with the doctor “telling or giving” instruction that the patient may need and welcome BUT if the patient does not understand or disagrees, only one side is “participating” and the issues are not likely to resolve for the patient.


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