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Christine Wiebe Fed up with the pressures of managed care, a small
cadre of physicians is forming "concierge"-style practices that offer
top-notch accessibility and service - at a price.
Imagine getting in to see a doctor the same day a medical problem
arises, or being able to call the doctor's cell phone at any hour for a
consultation or prescription. Imagine a primary care physician
accompanying a patient to a specialist's office in order to coordinate
their care, or actively managing a patient's weight-loss program.
About a dozen or so doctors in a few pockets of the country are
working to make that version of medical utopia a reality. Fed up with
the harried and depersonalized approach demanded by managed care
payers, a small number of doctors have formed new "concierge"-style
practices that offer that a high level of accessibility and service.
The services offered through these practices don't come cheap, of
course. Physicians are able to offer them by reducing patient loads and
charging extra service fees. Although the medical concierge trend is
still fairly new, these doctors have been successful enough that they
are spreading their vision across the country, enlisting other doctors
to follow their lead.
Meanwhile, critics have lobbed harsh accusations of greed and
elitism at this physician cadre. They argue that America should be
closing the widening gap between the insured and the 40 million
uninsured, rather than adding yet another tier of medical care.
"It's adding an obscene third level to the way we deliver health
care in this country," declared Martin Solomon, MD, a prominent Boston
internist and instructor at Brigham and Women's Hospital. He was
solicited by the largest group, called MDVIP and based in Boca Raton,
Fla., but he remains unpersuaded.
"I did not go into medicine to just take care of rich people," he said.
Doctors involved with these special-services practices take issue
with that characterization, however. In fact, the prices and range of
services vary considerably, from the most exclusive, called MD2
(pronounced MD-squared), which costs $20,000 a year per couple, to the
more affordable services of MDVIP - "the cost of a latte a day," as
backers like to say.
Serving Different Clienteles
There's a reason why the price of latte is bandied about: The medical
boutique trend started in Seattle, where a daily expenditure for coffee
is considered the norm. Founders of MD2 believe they were the first to
design and promote a boutique practice in 1996 that provides
first-class service to an elite clientele. In 2000, they opened the
first "franchise" across town, and are planning to expand across the
country.
"Most
of these patients are incredibly mobile people, with multiple homes,"
said Duane Dobrowits, chief executive officer. The company is in
discussion with 30 practices across the country, seeking to build a
network that could provide services wherever its clients travel.
An annual retainer paid by patients covers the costs of all primary
care, but they are expected to carry insurance for hospitalizations, he
explained. Physicians care for a maximum of 50 "family units," and they
do not deal with any managed care restrictions or insurance claims. "We
simply don't go there," he said.
Dobrowits is unfazed by charges of elitism just because the company provides special services to its clients.
"There is a niche of people who want this access," he said. "These
are the same people who send their children to private schools. We're
simply filling that demand."
Although the MD2 clientele is undoubtedly wealthy, other
service-oriented practices are catering to the middle class for much
lower fees. Services range from priority phone lines to broader
preventive care, and clients still carry medical insurance and are
responsible for co-pays and deductibles, in addition to the annual
service fees.
"Patients interested in our practices are definitely different than
the ones paying $20,000," said Ed Goldman, MD, president of MDVIP, a
group of eight Florida doctors that charges $1,500 a year for
non-insured services.
"By charging for these services, we're able to generate enough
income to reduce the patient size of the practice," he explained.
Patients wait less than two minutes on average for their appointments,
which usually are scheduled the same day they call.
Doctors have enough time with patients that they can focus on
preventive care, which is only given lip service in most traditional
practices, Dr. Goldman said.
"I see this as being a niche for patients who are interested in
preventive care and for physicians who are interested in providing
that," he said. The group is planning to expand and eventually could
include 100 or so doctors nationwide. Doctors who have expressed
interest in joining tend to be older, locally prominent and pro-active
in preventive care, "and they are not happy with what they're doing
now," Dr. Goldman said.
Physicians wishing to join must close their existing practices and
start over, with no financial guarantees and with severed ties to the
majority of their patient population. Some patients have complained
about being "abandoned" in the process, and have even complained to
Medicare officials, prompting probes by state officials and legislative
debates.
Discontent Spurs Patient Interest
Increased scrutiny by regulatory agencies has been an unwelcome
surprise, Dr. Goldman said. But the high level of patient interest in
the program has exceeded his expectations. "I had totally miscalculated
the level of discontent with the current health care system," he said.
In
Boston, two internists sparked public attention recently when they
announced they were forming a service-oriented practice, scheduled to
open in April, with two more doctors joining the group shortly. They
will charge patients $4,000 a year for special services not covered by
medical insurance.
"What we're selling is the fact that we're far more available and we
can provide a higher level of service coordination than is available in
other practices," said Steven Flier, MD, one of the founders. He
compares the additional fee-for-services with other non-medical costs
patients often incur, such as parking fees at hospitals, or paying out
of pocket for elective procedures such as lasik eye surgery or cosmetic
surgery.
The level of media attention spurred by his announcement has
surprised Dr. Flier, who views his new practice simply as one doctor's
solution to shortcomings in the existing health care system.
"We aren't doing this to be trend-setters," he said. "We're doing
this because we see a need for changing what we do relative to our
patients."
He has also been surprised by patients' reactions; some who he
expected to oppose it have actually enrolled, while others have
switched to another doctor.
One patient accused him of catering to the wealthy. Dr. Flier
pointed out that the patient's two-pack-a-day smoking habit cost him
about the same amount annually as the medical service fee.
"No one goes around saying that smoking is a habit only for the
wealthy," Dr. Flier said. "People do make choices in that range of
dollars."
Overall, subscriptions for the first year have exceeded the doctors'
expectations, he said, and they now will turn their attention to
satisfying patients so that they will re-enroll next year. In the
meantime, he welcomes the public debate about problems with the current
health care system.
A Catalyst for Change?
Even critics of the new VIP practices hope the trend will force greater
public discussion about health care in this country, particularly the
question of whether quality health care is a privilege for some or a
right for all. The trend could even put pressure on the existing system
to provide better service to all patients.
In
Seattle, competition introduced by the concierge-practices drove one
medical center to create its own special-services unit. The Virginia
Mason Medical Center initiated its program, called the Dare Center,
after losing some of its patients to the MD2 practice, said John
Kirkpatrick, MD, who fostered Virginia Mason's program and now cares
for patients who pay the annual $3,000 fee.
As an employee of the medical center, Dr. Kirkpatrick does not
benefit directly from the revenue generated by the program, but the
medical center has used the extra dollars to support its free care of
the poor.
"I'm very confident that this has helped the overall organization," he said.
Patients in the program vary from those who are very demanding and
expect lots of attention, to those who simply do not want to spend
their time sitting in waiting rooms, he said. Patients can call his
cell phone day or night, seven days a week.
"It would be nice to be able to give everybody this kind of
service," Dr. Kirkpatrick said. But the government and private insurers
simply cannot afford everything that Americans demand in health care,
he said.
"This is not the answer for everything," Dr. Kirkpatrick said, "but
it may be a partial answer to get more people who can afford it to put
more dollars into the medical system."
The notion of some people getting better care than others, however, deeply disturbs critics.
"It's contrary to what American medicine has stood for," said Boston
physician Dr. Solomon. He believes that catering to patients'
unrealistic demands will drive an even bigger gap between levels of
health care.
"Not everybody needs to be seen the day they call," he said. "It's a total luxury."
Advocates of the new service-oriented practices insist, however,
that both doctors and patients can benefit from the arrangements, and
that they are simply one alternative to the traditional health care
system.
Boston internist Dr. Flier asks: "If providers and patients are
dissatisfied and want something better that works, why would anyone
oppose that?" |
