'Concierge' medicine: The doctor is in, for a fee (Vote in poll)

A few years ago, Dr. Michelle Eads was working for a large local medical practice, cramming in dozens of patients a day for visits that lasted 10 minutes, if that.

It wasn’t what she bargained for when she decided to go into medicine.

“I was burning out early in my career. I was 35 and ready to quit,” she says.

Fed up, she quit the practice about seven years ago and opened her own so she could limit her patient load, give people more time during office visits, provide 24/7 access to her via her home or cell phone, and offer same-day appointments.

Now she has fewer than 100 patients, compared with 2,100 in the group practice. She’s markedly happier, she says, and her patients like the more personal relationship.

“I feel like she knows me and cares about me,” says patient Becky Harlin, who followed Eads when she went out on her own.

But full-time access to and unhurried visits with Eads come with an upfront cost: About two years ago, she started charging a fee to be her patient. The fee can range from $360 to $5,000 a year, depending on which of four plans her patients choose.

Eads was one of the first doctors, if not the first, in the Pikes Peak region to switch to what is often called “concierge,”  “boutique” or “retainer” medicine, a business model that allows physicians to dramatically pare their patient load and offer personalized service for an annual fee.

But she won’t be the last. In October, Dr. John Norton of Mountain View Medical Group linked up with a Florida-based umbrella group, MDVIP, to change his practice to a retainer-based model, and Dr. Laura Feldman is doing the same in April.

“Really, I’m interested in spending more time with people on wellness and prevention, which has always been my interest since I started practicing,” Feldman says. “It’s hard to really do that in a traditional practice when you’re rushing to see the next person and trying to multi-task all the time.”

It sounds like a win-win for doctors and patients, but some medical ethics and health law experts have raised concerns that retainer-based practices may shut off quality medical care to people who can’t afford the fees, and widen the gap in access between have and have-nots.

“The dark side of this new practice form is that for the physician with a traditional managed care practice, conversion to a concierge practice may mean that as many as 2,000-3,000 of the physician’s former patients who cannot afford the fee must now look elsewhere for another primary care physician, at a time when primary care physicians are in short supply, and fewer physicians are accepting Medicare patients,” South Texas College of Law health law professor Sandra J. Carnahan wrote in a 2006 article in the Stanford Law & Policy Review.

Variations on a theme
The first concierge practice in the U.S. is said to have started in Seattle in 1996. Since then, according to estimates from some industry experts, as many as 5,000 physicians — most of them primary care providers — have gone the concierge route, and at least a half dozen umbrella businesses and organizations, including MDVIP and the nonprofit American Academy of Private Physicians in Virginia, have sprung up to help them make the switch, support them in their work and connect patients with their practice.

But there is no one-size-fits-all model. Some doctors, like those who participate in MDVIP, charge a flat annual fee — in their case, $1,500 per patient, which includes an in-depth physical and customized wellness plan. Some offer a range of fees that include more services the higher they go, with amounts that can soar to tens of thousands of dollars. Some participate in insurance plans, some don’t. Some accept Medicare patients, some don’t. Some go solo, some remain in group practices.

The one thing they all appear to share is the desire to limit the number of patients they see, spend more time with the patients they have and focus on keeping them well while being available to them posthaste when they get sick.

“I try to exceed patients’ expectations,” says Eads. “I want them to feel supported here, and when you see fewer patients, you can provide better care.”

Feldman expects her participation with MDVIP to boost her job satisfaction. She even has visions of being able to go beyond the typical responsibilities of a doctor.

“They are other things a physician might do in this model,” she said. “They might have healthy cooking classes, or go to the grocery store with patients to read labels, or have a walking group, so there’s a lot of fun things I might do.”

Fees affordable, or not?
Critics say that’s great for people who can afford the fees, but they believe there are too many who can’t — especially in a wobbly economy where people who have been laid off struggle to afford even the most basic health care.

“Even for most people who may get insurance through their employer, and a particular concierge doctor might take insurance, they still won’t be able to afford that extra fee,” says Carnahan. “I’m all for letting the market work: If you can’t afford a fancy TV, you don’t get one,” she adds. “But health care is different.”

Eads and other doctors who practice retainer-based medicine counter that their practices are not just for the wealthy, and say the fees are affordable for many people — if they’re willing to put a priority on their health care.

“Our $1,500 fee is $125 a month, and we see that as being affordable for most people,” says MDVIP president Mark Murrison. “It’s the cost of a cup of coffee every day, or Direct TV or cell phones. It’s really about what people value and where they want to invest their dollars. If you look at our membership, we have people from all walks of life — bus drivers, teachers, municipal workers.”

Eads says she structured her fees to reach a broad range of incomes and health needs. Her lowest fee, $360 a year, targets people who are relatively healthy; they still have to pay for appointments, with the cost depending on the amount of time she spends with them, but they still get 24/7 access to her.

Her next level starts at $900, which includes up to 20 office visits, unlimited phone and e-visits, and in-office lab work and services. Those patients also receive a personal health binder and thumb drive with their medical records.

With the costliest plans, she provides all of the above, and will also accompany patients to see specialists and even make house calls.

She doesn’t participate in insurance plans or Medicare, but she’ll process patients’ claims, and encourages them to have medical insurance to cover hospital stays and other costly care. In some cases, she says, patients might save money by getting a lower-cost insurance plan and signing up for a retainer practice.

“Most of my patients are people of means, but I have a few who struggle to pay bills,” says Eads, whose only staff is a a part-time administrative assistant who works out of Iowa, and her office “greeter,” a golden retriever named Murphy.

The 'abandonment' issue
Several medical ethics experts don’t have a problem per se with retainer-based practices, as long as people who can’t afford them can find decent medical care elsewhere.

But some are concerned that there may not be enough primary care doctors to absorb patients who can’t or won’t stay with their physician in a concierge arrangement — especially when headlines about the shortage of primary care providers abound.

“I would suggest that finding another doctor willing to take those patients on is not going to be easy,” says Dr. Jay A. Jacobson, professor emeritus with the University of Utah medical school and a professor and former chief of its Division of Medical Ethics. “If they have that relationship with their doctor and if they can’t find another, what is the solution?”

The American Medical Association addressed the “abandonment” issue in a 2003 policy on concierge care that says doctors have an ethical obligation to find other physicians to take the patients they’re shedding, or continue treating them if no alternative can be found.

Murrison said it’s standard practice for new MDVIP practitioners to help patients find a new doctor if they decide not to stay with them in a concierge arrangement, and  Feldman believes Colorado Springs has enough physicians take care of such patients.

“I would say that some practices are closed (to new patients), but there are plenty of physicians in town who are taking patients,” Feldman says. “I wouldn’t want to embark on this venture if I didn’t feel as if all my patients are going to be taken care of.”

Better care?
The fears about retainer-based medicine might be unfounded unless a lot more doctors sign on.

“I think it will remain a fairly fringe model that I don’t think is likely to be widely adopted for the same reasons it hasn’t in past: I’m not sure there’s that much of a market,” says Dr. G. Caleb Alexander, a bioethicist and professor of medicine at the University of Chicago.

“I think there are many challenges we face in our health care system and many ways it can be improved, but the absence of greater uptake of this model suggests patients are not willing to pay for it,” he says.

Helen Johnston of Manitou Springs decided not to stay with Dr. John Norton, her doctor of nearly 10 years, because she and her husband weren't willing to pay.

“He thinks we qualify for it, and we do, but we’re not going that route because we feel bad for others who don’t,” she said. “We’re most concerned about the Medicare people — the people who can’t afford that fee. I just don’t think that’s American.”

Alexander also questions whether a fee-based model translates into markedly better care. MDVIP says its 150,000 patient members are hospitalized 65 to 75 percent less than non-members, in part because of the greater emphasis placed on wellness and prevention.

But Alexander wonders about the data and research behind the numbers, and says more independent, scientifically based studies need to be done to deem retainer-based medicine a success.

Eads, the Colorado Springs physician, doesn’t need studies to tell her how much happier she’s been since she converted to a retainer practice and doesn’t have to worry about a lot of employees or huge overhead, or dealing with insurance companies.

“I can make my own rules,” she says. “I can do what I love: taking care of patients.”