A Visit With Dr. Deluxe
Imagine a doctor who takes time to ask you about your family or chat about a movie. Who guarantees that you won’t have to wait long for an appointment and even makes house calls. A doctor, in short, who provides the same VIP service you’d receive flying first class.
You’d have to pay first-class prices, of course.
One of the latest signs of the continuing backlash against managed-care medicine is so-called boutique doctors who promise red-carpet service to patients for a fixed fee, usually from $1,000 to $4,000 a year. These doctors, working individually or in groups, promise round-the-clock access, comprehensive annual exams and longer appointments, as well as other niceties.
For the doctors, these arrangements allow them to see fewer patients while preserving--or enhancing--their incomes. While a typical primary care doctor may have 2,000 to 3,000 patients under his or her care, boutique doctors aim to trim their patient load to fewer than 600.
“It’s the difference between night and day,” said Dr. Bernard Kaminetsky, who set up a boutique, or “retainer,” practice in Florida a year ago through a company called MDVIP . He used to see up to 35 patients a day; now he sees no more than 10. Patients tell him they’re happier, and so is Kaminetsky: He gets home in time to eat dinner with his family.
The concept, which originated in Seattle in the mid-1990s, has since spread to Arizona, California, Massachusetts and Florida. Consumer interest in such first-class service reflects widespread frustration with the confusion and anonymity of modern medicine, in which patients often are bounced among doctors and health plans, straining the doctor-patient relationship. The “boutique” solution is especially appealing to more affluent middle-age and older people who have ongoing health concerns, and little patience for the hassles and rules of managed care. The yearly premiums are not covered by insurance, and many of the medical services, including office visits, may be only partly covered, if at all.
“We have business executives, professional people, older couples who want more time with their doctor,” said Amin Neghabat, director of the Lewis and John Dare Center retainer program at Virginia Mason Medical Center in Seattle. The Dare Center has more than 1,000 members, with an average age of 62, who each pay $3,000 a year for the deluxe services.
Nationwide, the number of doctors charging retainer fees is small--probably no more than 200, according to Dr. F. Maxton Mauney, who investigated the practices for the American Medical Assn.--and it’s still too early to say whether the practices will be a cornerstone of medicine or a curiosity, he said. Nonetheless, they already have captured the attention of some members of Congress.
“If every doctor started doing this, it’d be the end of Medicare,” said U.S. Sen. Bill Nelson (D-Fla.), who recently introduced a bill that would prevent Medicare and Medicaid from reimbursing doctors who charge a retainer fee. “We believe it’s wrong, and we’re going to try to stop it.” In March, five Democratic congressmen signed a letter calling on the Bush administration to review retainer practices to make sure they don’t already violate Medicare laws.
Doctors themselves are divided on the ethics of retainer medicine. Said Dr. Richard Roberts, chairman of the American Academy of Family Physicians, “I feel I’m already available to my patients 24-7, and so are most family physicians. We don’t need to do a wallet check first.” The American Medical Assn. has no objection to retainer contracts, however. A report delivered to the AMA board by Mauney last month raised concerns about doctors dropping patients to go boutique, but otherwise it found that the practices present no threat to patient care. “Our position is that citizens have the right to strike a contract with their doctor, just like they do with their lawyer or any other professional,” said Dr. Yank Coble, president of the AMA.
In California, health-care regulations do not specifically address the arrangements. Any business that charges up front for medical services is considered a health maintenance organization, and is subject to licensing fees, financial disclosure and a host of other regulations, said Daniel Zingale, director of the Department of Managed Health Care, which regulates health plans. But it’s an open question whether doctors who charge retainer fees are in fact providing medical care in return--or simply more time and better service, he said. “It’s very new, and we’re still sorting through it,” Zingale said.
If the practices are regarded as HMOs, the licensing fees and other requirements could stop them before they get off the ground, said Daniel Yakoubian, a California attorney who specializes in representing medical groups and hospitals.
In the meantime, some California doctors have been testing the waters. Last month, Edward L. Smith of Laguna Niguel began enrolling members at $1,500 a year, which includes comprehensive physical exams, same-day appointments, and around-the-clock access, among other things. He plans to limit the practice to 300 patients. Earlier this month, a Mission Viejo-based outfit called Axis Medical opened with one doctor, Dr. Joseph Nguyen, and plans to add half a dozen more. The yearly fee of about $3,000 will include advice on disease prevention, 24-7 access to doctors and coordination of specialist visits, among other services, said Dr. James Keany, Axis’ founder. Interactive Wellness System, a highly exclusive two-doctor practice in Menlo Park, is planning to add two more physicians.
On a much larger scale, practices such as Palo Alto Medical Foundation, a multispecialty group with more than 450 doctors, also have investigated retainer services. The group would like to give patients the option of paying for more access but may not be able to because of a shortage of primary care doctors in the system. “We’ve had to stop taking patients in primary care because of a shortage of doctors,” said Jill Antonides, a spokeswoman for the group. “We’ve got to address our commitment to the community before trying any premium service.”
The issues are different for doctors in solo practice. “You just become a rat on a treadmill working in the HMO system, taking 30 to 35 patients a day,” said Smith, who quit practicing for a year after almost a decade working at a large group practice in Laguna Beach. “In starting this service, all I wanted was to practice medicine again, to return to an old-fashioned family practice where the patients felt like family.”
The rewards of having a doctor on call are almost immediate, say members. “Just the fact that you can pick up the phone and you’ll be talking to someone who knows who you are--that’s worth a whole lot,” said Bridget Skinner, 42, a mother of two living in Laguna Beach who with her husband has joined Smith’s practice. Skinner recently passed her previous doctor at the mall and nodded to him. He stared back, blankly. “Not a smile, not a nod, not even a look saying, ‘Do I know you from the gym?’ ” said Skinner. “Nothing. He hadn’t the vaguest idea of who I was. I’d much rather pay extra and have someone who knows me.”
At its best, this kind of relationship with a doctor can mean the difference between life and death. Bob Sage, 71, a retired TV producer living in Seattle, has been paying $3,000 a year for two years, to be a part of the Lewis and John Dare Center practice. One night after joining the practice, Sage, who lives alone, had stomach cramps so crippling that he called his doctor, Dr. John Kirkpatrick, at home. From Sage’s description, Kirkpatrick diagnosed a ruptured gall bladder; then jumped in his car, picked up his patient at home and drove to the hospital.
“He helped me get through registration and all that baloney, and two hours after the call, I was in surgery,” said Sage. “Without that kind of help, I don’t know that I would have made it.”
At the same time, said Sage, the VIP treatment ends once you get to the specialist’s office. “I picked out a very good arthritis specialist I wanted to see, and I had to wait a month to get in,” he said. “When you go to the hospital or see another doctor, you’re just like any HMO patient.”
Cushy as it sounds, no one can say for certain whether this red-carpet service actually makes a person healthier than an average HMO plan.
On the one hand, researchers find that simply having a regular primary-care doctor is a strong predictor of long life; people with regular access to a family doctor are less likely to die of a stroke, for example, than those who don’t have a physician readily available, some studies find. A relaxed, 20-minute conversation with a doctor certainly is far more soothing than a rushed, five-minute one--several patient surveys have confirmed this common-sense observation.
On the other hand, it’s not clear that spending more time with a doctor measurably improves a person’s health.
“The more time spent around the doctor, the more medical tests are likely to be done, and sometimes that makes patients anxious about things they don’t need to be worried about,” said Roberts. “There’s the risk that this becomes a diversion, that you’re medicalizing their life too much.
“Then the question is, ‘Have you done them any good?’ ”
The future of retainer medicine depends on how lawmakers treat the issue, and just how exasperated consumers are with their current health plans. As much as health-care costs have gone up, consumers still are not accustomed to paying hundreds or thousands of dollars to see a doctor. As long as the big doctor groups stay out of the retainer market, it will be up to small and solo operators, like Smith and Axis Medical, to sell the idea of membership fees. So far, Smith has enrolled 15 people; Axis has only just launched.
“I think there’s a real limit to the number of people who can afford this kind of service and would be willing to pay for it,” said the AMA’s Coble. “I mean, we’d all like to be sitting in the box seats. But most of us will just as soon take a decent seat if we’re not paying for it. We’re seeing the same game, and it’s cheaper.”
