Want Your Doctor to Pamper You? Pay Extra
By: Source: AARP Bulletin Today Date Posted: 2004-10-12 15:37:00-04:00
"Hey-lo-ho," 85-year-old Lorraine Gelula sings in her telephone answering message, which plays when she's not at home. "I'm probably out having a good time," she says. And you believe her.
Gelula refuses to let arthritis and other ailments prevent her from doing what she likes best—taking short jaunts and weekend getaways.
But an unexpected new medical expense may bring an end to what she calls small pleasures: the $1,500 annual fee her primary care doctor charges since he converted his practice to "luxury primary care."
In this controversial new approach to medicine, patients pay an out-of-pocket fee, usually ranging from $1,500 to $10,000 a year, for promised access to their doctors at any hour, any time.
For Gelula, who lives in a retirement community in Baltimore, paying the fee is a hardship. "It's difficult for me financially," she says. "I'm on a fixed income."
In some instances, the fees—on top of copayments and deductibles—force patients to find new doctors if their physicians switch to luxury care. Such squeezing of low- and fixed-income patients has prompted complaints that VIP care—known, too, as boutique or concierge medicine—is elitist, and in some cases unethical. Critics say luxury care gives wealthier patients greater access and preferential treatment.
| VITAL SIGNS | Regular Doctors | MDVP Doctors (Boutique) |
| Average annual income | $153,200 | $400,000 |
| Patient load | 2,500 to 4,000 | Limited to 600 |
| Average time spent with patient | 10.6 minutes | 30 minutes |
| Patients per week | 112 | 30 |
Sources: Medical Economics Magazine; American Academy of Family Physicians; New England Journal of Medicine
"I think it's scary and unprofessional to think the level of care is scaled to the fee," says Jay Jacobson, chief of the medical ethics division at the LDS Hospital and the University of Utah School of Medicine in Salt Lake City.
But some doctors say they've converted to concierge medicine to escape what they call the constraints of managed care—overcrowded practices, low reimbursement rates, excessive red tape and the rapid-fire pace of patient exams.
Bernard Kaminetsky, 51, an internist in Boca Raton, Fla., almost walked away from his practice in 2001.
"I had absolutely no professional gratification in what I was doing before," he says. "I was seeing 30 people a day and always rushing. Patients were dissatisfied, and I was dissatisfied.
"I was only able to react to acute illness, with very little opportunity for prevention," he says. Now, in his boutique practice, his patient load has dropped from 2,600 to 600, typically the maximum number for a boutique practice. "I spend a lot more time with people."
Doctors in luxury primary care are also likely to make a better living, earning up to three times as much as traditional practitioners.
Some concierge doctors accept private insurance and Medicare, although Medicare and most insurers will not reimburse for annual fees or for services not normally covered. Others don't accept private insurance or participate in Medicare because they don't want the paperwork or constraints insurers impose. Experts say patients need to check payment arrangements carefully if they are considering boutique care.
A SPOONFUL OF SUGAR?
There are currently fewer than 300 concierge physicians in half the states, and while their numbers are expected to grow, no one expects all or even most doctors to open similar practices. But boutique doctors do offer certain enticements that many patients want: round-the-clock cell phone access, same-day appointments, coordination of care among specialists and, in some cases, house calls. Some who charge higher retainer fees say they will accompany patients to specialists and to hospitals when necessary.
Such preferential treatment is apparent in the upscale offices of boutique doctors. At a Bethesda, Md., practice, patients are invited to nosh on cake and assorted fruit while they wait on stylish sofas and chairs.
In a combined regular and concierge practice nearby, patients of boutique doctors are escorted from the reception area, a space with drab furniture and tattered carpeting where regular patients wait, to a separate room decorated with peach chairs, a matching print sofa and a handsome wood table covered with magazines.
The room is small, but it doesn't seem to matter. Boutique patients "don't wait very long," a receptionist says in a hushed voice. "We keep them moving."
OR A BITTER PILL?
That every patient doesn't receive the same level of attention irks the doctors, patients, ethicists, lawmakers and others who question the fairness of boutique medicine and its implications for the health care system.
In addition to limiting the access of low-income patients to care, critics say, concierge medicine may force poorer, sicker patients onto fewer doctors. Patients may also experience disruptions in the continuity of their care if forced to find new doctors.
"It's our responsibility as physicians to be attentive," says medical ethicist Jacobson. "When I agree to see somebody [for 10 minutes or for 30], regardless of the fee, I owe him my attention. I don't have a sliding scale based on attentiveness."
The American Medical Association, in adopting guidelines last year for boutique practices, warned that such contracts "raise ethical concerns that warrant careful attention."
"In general, the AMA supports a variety of patient-doctor arrangements," says William A. Hazel Jr., a trustee of the association. "Physicians should consider whether they're removing themselves from the general pool, and will that have an adverse effect on the community."
Federal and state governments are looking into concierge medicine. The Office of the Inspector General in the U.S. Department of Health and Human Services is investigating whether some boutique practices violated the law by charging retainer fees to Medicare enrollees, says OIG associate counsel Greg Demske. The agency issued an alert in March warning that it was unlawful to bill beneficiaries for more than their copayment for covered services.
"We may bring civil monetary penalty cases in the future if we can establish that physicians asked for more than the copayment amount for covered services," Demske says. Doctors can be fined up to $10,000 for each improper request for payment and can be dismissed from the Medicare program.
The Government Accountability Office, the investigative arm of Congress, is expected to issue a report in December on its own review of boutique medicine.
Some state regulators are examining whether concierge physicians can legally accept insurance, because doctors who contract with insurers are not permitted to charge above the fees negotiated for their services.
In Virginia, the state's largest health insurer is telling doctors to stop charging retainer fees or be dropped from its network.
After a year of evaluating concierge medicine, says Sharon Hall of Anthem Blue Cross Blue Shield in Virginia, "Anthem believes [the practice] is in direct conflict with our contracts with providers. It's seeking to discriminate against our members on their ability to pay."
Hall says patients should not be required to pay more for a standard of treatment that every physician should provide. "If you're not getting top quality and quick access from your doctor, what are you getting? All our members should have prompt scheduling and prompt callbacks," she says. "That shouldn't be something you have to pay extra for."
One of the first boutique practices in the nation opened in Seattle in 1996. MD2 (pronounced "MD" squared) charges patients an average of $10,000 a year and does not accept insurance. It recently opened new offices in Bellevue, Wash., and Portland, Ore.
Other luxury care practices have since been started in Washington, giving state regulators—who have held ongoing discussions with boutique practitioners—a chronic headache.
"We have serious reservations whether this is appropriate or legal," says Deputy Insurance Commissioner Beth Berendt. "It's a difficult situation. We find the access fee very troubling." Oversight of boutique medicine may not be far off. Berendt says state lawmakers are drafting regulatory legislation to be introduced when they convene in January.
In Maryland, U.S. Rep. Ben Cardin, D, says he believes boutique doctors are charging retainer fees as a way to "circumvent billing limits." He introduced a bill last year that would prohibit doctors from charging such fees to Medicare beneficiaries.
A DOCTOR'S RX
William Schofield, a Henderson, Nev., internist, grew weary of trying to manage his 2,500-patient practice and still have a life of his own. After two failed marriages and 15 years of 14-hour days, he wanted to spend more time with his family.
He recently joined MDVIP, a Florida-based company that helps doctors convert to concierge practices. Patients pay $1,500 annually ($1,800 in California) for an MDVIP-affiliated doctor. In return, they get a 90-minute physical the first year (after that, a 60-minute annual checkup), a wellness plan, same- or next-day appointments and 24/7 access to doctors.
"The pressures of managed care have been very intense," Schofield, 44, says. "Some doctors are OK with herding patients like cattle. I'm not."
John Blanchard, who helped found the Society of Concierge Physicians, says Americans have a right to decide how their health care is delivered. "There are a lot of things people spend money on," he says, "that are less important than health care."
Harriet Locke, 60, a retired teacher who lives in Boca Raton, Fla., doesn't mind paying $1,500 a year to stay in concierge care. Last year, when she was diagnosed with cancer, her doctor coordinated specialists' appointments for her.
"As you get older, it's very comforting to know your doctor is there for you," says Locke, whose cancer is in remission. "This is the way medicine used to be when I was growing up. You need the doctor, he'd get on the phone and talk to you, and you'd go right in.
"It is a luxury, but it's wonderful."
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