Fed up, some doctors turn to 'boutique medicine'
From the October ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By William Hoffman
Tired of haggling with health plans and disgusted at having to squeeze more patients into their schedule to stay afloat financially, some internists are adopting a radical new model of service.
Under "boutique medicine" or "concierge care," physicians ask patients to pay an annual retainer fee. In exchange, patients receive guaranteed same-day or next-day appointments, no-wait access at appointment times, longer examination times and off-duty access to their physician via cell phones and pagers.
Participating physicians report better pay, dramatically reduced patient panel sizes, less paperwork and fewer hours. They also say they have more time to devote to patient care and advocacy, along with continuing medical education and family life.
Despite rave reviews from physicians who are involved, however, few expect the model to revolutionize American medicine. In part, that's because boutique medicine has so far been largely confined to areas like Seattle and Florida. The model's limited appeal may also stem from the ethical and legal concerns it raises.
Ethicists, for example, decry concierge care as another step toward a medical system in which the rich get no-wait exams and the poor sit for hours to see an HMO doctor for 15 minutes.
Regulators are also keeping an eye on the practice. The Centers for Medicare and Medicaid Services (CMS), formerly HCFA, is monitoring practices that accept retainers to make sure physicians aren't violating Medicare regulations. And in Florida, the state insurance commission is also monitoring the practice.
Perhaps the biggest challenge facing physicians interested in boutique medicine, however, is the lack of any kind of roadmap. "There's no manual for doing this," said John N. Kirkpatrick, FACP, section head at the Lewis and John Dare Center concierge medicine program at Virginia Mason Medical Center in Seattle.
Because concierge care is a relatively new phenomenon, the benefits tend to vary. Many of these practices, however, are operated by internists and offer a set of core benefits.
In return for an annual retainer fee of $900 to $20,000, patients receive perks like no-wait access and around-the-clock access. Some practices offer personalized service in the form of physician-initiated research on difficult or unusual patient complaints and concerns (sometimes extending to patients' family members) and in-hospital advocacy-helping expedite hospital procedures, for instance, and consulting directly with referring physicians to reduce communication delays.
Some practices go even further and transport patients to appointments. At least one practice claims it will fly its physicians to patients to give emergency care.
Besides providing premium services, some retainer practices cover the cost of all in-office primary care medical exams, tests and procedures. These vary by practice and are usually spelled out in contracts that patients sign.
In most cases, patients are responsible for getting reimbursed by insurers for tests and procedures that can't be performed in an office, such as orthopedic surgery or CT scans.
"We don't want to do any billing," explained Howard G. Maron, MD, cofounder of the Seattle-based retainer practice MD2. MD2 gives its retainer patients all their primary care services-antibiotics, exams, in-house diagnostics-along with enhanced access.
Dr. Maron said he first became interested in the idea of boutique medicine when pondering a simple question: "What would you do if you could practice medicine in the ideal?"
The Seattle internist, who claims he pioneered the concept of retainer medicine, was working as team physician for the Seattle Supersonics basketball team in the mid-1990s when he realized that financial success did not necessarily have to mean overwork. The pace of care was sluggish, he said, but his role was clear: Spare no time or expense to assure that players got the best, expedited, comprehensive medical attention he could provide.
Dr. Maron opened MD in 1996 with cofounder I. Scott Hall, FACP, with the goal of limiting their patient panels to no more than 50 individuals or families. While Dr. Maron admitted that limiting his patient base to 50 was "scary" at the time, he and his partner crunched the numbers and calculated a retainer fee that would make the practice profitable. (They have adjusted the fee only once, when they raised it 10% across the board last year to cover increased costs.)
While Dr. Maron would not reveal what his practice charges, he did say that a Forbes magazine report stating that individuals pay his practice $13,200 a year ($20,000 a year for couples or families) was "in the ballpark."
MD2 maintains an unabashedly gold-standard price, but other retainer practices use a wide range of structures. Some charge much lower retainer fees, and not all refuse to work with patients' insurance companies.
Companies like Platinum Health Service LLC (PHS), in Boca Raton, Fla., for example, sign up patients, collect retainer fees and then let each patient choose and sign up with a doctor from a list of PHS-contracted physicians. PHS charges $1,800 a year per patient-more than half of which is given as a retainer to the patient's physician-for special service including 24-hour phone or beeper access, same- or next-day appointments and abbreviated waiting room times.
While most retainer practices treat subscribers only, some practices integrate concierge service into more traditional practices. Robert C. Cava, FACP, a partner at Miami Medical Consultant PA in Coral Gables, Fla., offers concierge service for $1,500 a year to 150 patients under age 45. (That amount goes up to $3,000 a year for patients 65 and older.) Yet he still treats non-concierge patients.
Bernard Kaminetsky, FACP, an internist at Colton & Kaminetsky P.A. in Boca Raton, Fla., charges patients a $1,500 annual retainer fee that covers services including travel-related vaccinations, flexible sigmoidoscopies and X-rays. Under the contract he signed with MDVIP, a company that recruits his concierge patients, he agreed to limit his panel to 600 patients (down from his previous patient panel of 3,000) to assure quality of service and care.
The Dare Center in Seattle charges patients $3,000 a year, and $5,000 per couple. (Families can add two additional dependents aged 18 to 25 for an additional $500 each annually.) The center requires participating physicians to keep their panel size to 300 patients.
At the low end of the spectrum, Mitchell A. Karton, MD, with Seattle Medical Associates, charges his panel of 800 subscribers (down from 3,000 in his old practice's panel) $75 a month for individuals age 35 and up; $45 a month for those aged 21 to 35; and $15 for ages 18 to 21. For those fees, patients receive services including routine exams, X-rays and flexible sigmoidoscopies.
The practice determines discounts on an individual basis for patients who want to subscribe but are financially unable, Dr. Karton said. Like virtually all other retainer practices, Seattle Medical Associates gives patients a variety of payment schedules (monthly, quarterly, annually) and types (including automatic debit and credit withdrawals).
A 'way out' for physicians
While retainer models and fees vary, physicians say all models boost their income. Dr. Karton, for example, said that his practice's physicians have seen their pay increase 10% to 20% since switching to the retainer model in August of 1997.
Participants are quick to point out, however, that the gains are not purely financial. Miami Medical's Dr. Cava said that moving to a retainer practice has given him time he might not have had otherwise to recertify in internal medicine, geriatrics and critical care. He added that he hopes to work with academic researchers on an empirical study of the new model's results.
"If I can prove better outcomes in one setting than in another, that would be very valuable information," Dr. Cava explained. "And if I can't, that would also be very valuable in the debate."
Robert S. Mecklenburg, FACP, who set up Virginia Mason's Dare Center, said the retainer model may give physicians who are fed up with the hassles of American medicine a way out. "One reason I'm interested in sharing my experiences with older physicians," he explained, "is that it might keep them from quitting."
It should come as no surprise that these practices tend to draw patients largely from the upper middle class and above. Many retainer physicians say their patients, many of whom are middle-aged entrepreneurs and wealthy seniors, are strong supporters of the model.
Concierge care physicians said that patients who pay retainers appreciate the added services. Dr. Kaminetsky, for example, recalled making a house call to an elderly man with terminal cancer. The family later told him that the man's wife was "walking on air" after his visit because a doctor had actually come to the house.
Nevertheless, physicians acknowledge that it is often difficult to explain the concept to patients. During a period of several months in 1996, Dr. Maron from MD2 sent letters to his patients announcing his decision to convert his practice to a retainer model.
Though he said "the vast majority" of patients wished him well, he acknowledged that he heard from some who were angry. "The biggest hurdle for anybody is extricating yourself from your previous life," he said. "In essence, you're retiring from private practice."
Dr. Karton from Seattle Medical Associates spent more time educating patients when his practice made the switch. The practice even hired a staff member to coordinate the transition to a retainer system.
"We heard from some people, but not many, who were outraged that anything additional would be charged beyond what their insurance paid," he said. But even among patients who chose not to stay with the practice in its new form, Dr. Karton said, he found very little anger or resentment.
|Dr. Karton (foreground) and his partner Garrison Bliss, MD, hired a staff member to coordinate the Seattle practice's transition to a retainer system. Only a few patients expressed anger about the change.|
Mishandling the transition, however, has placed at least one retainer practice under a regulatory microscope.
Robert M. Colton, MD, is an internist who founded MDVIP, the company that helps physicians recruit retainer patients to their practices. When he converted his own practice to the new model, he sent letters announcing that he would accept retainers from the first 600 of his patients to sign up-and that the rest should start looking for a new doctor. One patient complained to CMS that the practice violated federal rules against billing for services outside the Medicare system, prompting some scrutiny from the agency.
CMS would only confirm that MDVIP is "under review" to make sure it complies with Medicare regulations. The Florida Department of Insurance is also looking at the practice to make sure it is complying with state regulations. "I wouldn't call this an investigation," said spokesperson Nina Bottcher. "We are looking into the issue, reviewing it, and that is ongoing."
Scrutiny from regulators is not likely to go away soon. Though CMS and Florida's insurance department have not taken any action against Dr. Colton's practice or any other retainer physicians, a CMS official in Washington noted that regional offices have been ordered to watch for potential Medicare violations. Officials said that the agency may issue preliminary guidance on retainer practices "sooner rather than later."
There are more complex questions about whether physicians' use of retainer fees to pay for patient care forces clinicians to double as insurers. Les Schlesinger, president of PHS, said, "If you are accepting monies in advance for medical services to be rendered in the future, that is by definition selling insurance."
To make sure his startup company was not violating any insurance regulations, he said he spent more than a year sorting through Florida insurance statutes and Medicare regulations. Patients must be persuaded to sign Medicare "advanced beneficiary notices" that affirm they understand services not provided under Medicare can't be billed to the program. In addition, state regulators must be convinced the new practices don't violate their insurance laws.
Skeptics, however, wonder whether physicians working under a retainer model will be able to separate considerations about risk and money from patient care. If too many patients come to them one month for physical exams or procedures like chest X-rays, critics ask, how can the physician avoid thinking about the financial impact on the practice?
Dr. Maron from MD2, however, said that rather than forcing him to think about financial matters, his practice's large retainer fee allows him to provide care without having to fret about costs. "We charge a lot per month," Dr. Maron said, adding that no single patient's use of in-office services can deplete his group's finances. As a result, he explained, "The cost of what we're doing never enters my decision-making."
What may ultimately keep most physicians from embracing the retainer model, however, is the perception that they are catering to the wealthy and excluding patients who can't pay. Many physicians question the ethics of treating only wealthy patients when millions of Americans struggle to get access to basic health care.
While physicians like Dr. Kaminetsky, who sees both types of patients at his practice in Boca Raton, Fla., insist that all their patients are treated equally, many physicians charging retainer fees do not treat nonretainer patients. That may be why for the time being, at least, retainer practices occupy an intriguing but marginal edge of the health care system.
Even in Seattle, where boutique medicine seems to have peaked, you can count the number of participating physicians on both hands. "Nobody has really penetrated this market yet," observed Michael J. Pulaski, CEO of Peachtree Orthopaedic Clinic in Atlanta, who has watched the retainer model grow. "Medicine is still a very fragmented business."
William Hoffman is a freelance writer in Fairfax, Va.
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