Your Own Private Doctor

Responding to the frustrations of managed care, a growing number of doctors now offer clients "concierge" service. But does it work? asks Mary Duenwald.

There he is. Hi, Chuck!" The receptionist calls out, smiling as Chuck Eucker walks in the door. She has been expecting him for his two o'clock appointment. The waiting room is empty and James Benoist, M.D., is ready to see him. Eucker, an athletic-looking 48-year-old man who runs a construction and real-estate development business in Denver, will receive his annual physical exam and then sit down for a lengthy chat with Benoist. They will review his health, which is generally quite good except for the recurring earache on the right side of his head, possibly the result of too-frequent scuba diving. They will also discuss the status of Eucker's mother, who suffers from periodic breathing difficulties which are a result of asthma and age (she's 74). Benoist, who regularly checks in on her at her home, keeps Eucker up to date on her condition.

See anything unusual in this picture? The friendly receptionist? The empty waiting room? The personal attention? The leisurely consultation between physician and patient, and the doctor who makes house calls? The whole place resembles a scene from Marcus Welby, M.D. Could it be a flashback to the early seventies?

Actually, it's concierge medicine, a style of medical care that may soon be coming to a clinic near you. Patients pay an extra fee—$3,000 in the case of Higher Care, the Englewood, Colorado, practice to which Eucker belongs. In return, patients enjoy ample time with the doctor, personal attention, and service with a smile.

People often recoil when they hear about concierge medicine for the first time. Some say it is just another ploy to separate the rich from the poor and establish a two-tier, class-based medical system. And given how expensive medical care already is in this country—an estimated $5,440 a year per person and rising—do we really need to pay more just to get some personal attention?

But listen for a while to the doctors and patients involved in this new form of health care and you realize it's not simply an extravagance for the wealthy. Concierge medicine has emerged as a reaction to, if not a revolt against, the managed care medical system that has physicians handling 25 to 35 or more patients daily, and often spending a mere ten or 15 minutes on the average visit. Doctors have set up concierge practices in order to dedicate more time to individual patients and to stop working grueling 14-hour days.

Concierge services are not necessarily only for the rich. Yes, some are very expensive, averaging $10,000 annually per family member. But many cost less than $100 a month, affordable even for those with moderate incomes. Eucker gladly pays $250 monthly for himself and is even more eager to foot the bill for his mother. "When she would feel bad, I used to pick her up and take her to the doctor," he says. "But now the doctor goes to her."

The big question is—for both patients and for people who care about ethics in medicine—do patients of concierge practices receive better medical treatment than the rest? The answer depends on whom you ask and what exactly you mean by better.

Katherine Harmer, the founder and president of Higher Care, a premium-quality provider network, says no. "We don't say better care," she explains, "because, quite frankly, when you walk into a concierge practice you will probably walk out with the same diagnosis and treatment that you would get at a traditional practice."

The Ethics Council of the American Medical Association (AMA) has advised that concierge doctors not suggest their care is superior to that offered by any other doctor. "A retainer [the AMA's word for concierge] contract is not to be promoted as a promise for more or better diagnostic and therapeutic services," the AMA's guidelines state. "Physicians must always ensure that medical care is provided only on the basis of scientific evidence, sound medical judgment, relevant professional guidelines, and concern for economic prudence."

So spending more time with patients may be a luxury, but it should not translate to mean that the doctor possesses greater skills than those who help you in a hurry.

Still, anecdotal evidence suggests that periodically, a doctor's extra time and attention can make a difference. Consider the case of a woman who joined Higher Care several months ago after complaining about severe dizziness, nausea, and constant fatigue. She had seen many doctors and none had been able to get to the bottom of her condition. She informed Benoist that she was reaching the end of her rope and contemplating suicide. After two weeks of tests and intensive research, Benoist discovered that she suffered from Addison's disease, a rare disorder of the adrenal glands that afflicted former President John F. Kennedy.

"He changed her treatment and now her life has improved," Harmer says. Since diagnoses and treatments arrive faster with concierge medicine, doesn't that make it better?

Benoist steps around the question by pointing out that his abilities do not surpass those of his counterparts in traditional practices. "There isn't any difference between myself and them," he says. "The system is what holds them back."

Jon Moses, chief executive officer of MD Squared, America's first—and possibly still the most expensive—concierge practice, is less coy on the subject. "I'll dare to tell you that what we do is better," he said in a speech at the first annual meeting of the American Society of Concierge Physicians (ASCP), held in Denver in May. Quality, he noted, is in the eye of the beholder. "What matters is what the patients perceive as quality," he said.

Physicians are not the only ones who are driving the growth of concierge medicine. Harmer is not a doctor but a 33-year-old entrepreneur who was inspired to open Higher Care after her father died from cancer more than three years ago. His doctors took six months to discover he had cancer. Harmer's father, who was 60 at the time and had just retired from teaching at the University of Dayton, died six days after the diagnosis. "I could not believe that he could be so far gone and nobody knew earlier," Harmer says. "If I can just give somebody sixteen days instead of the six I had, it will be worth it."

Her point is easy to grasp. Nevertheless, some leading doctors are wary of the trend. "I certainly understand where this has come from," says Michael Fleming, M.D., a physician in Shreveport, Louisiana, who is the president of the American Academy of Family Physicians. "It's grown out of frustration with the failed managed care experiment. But what I'm concerned about is that we're going to further erode the safety net we have. As family physicians, we take care of people who fall through the insurance safety net. In rural and inner-city areas of this country, there are a lot of people who cannot afford concierge care."

Fleming notes that because his own personal physician is one of his partners, he has the benefit of 24-hour access to medical care. "I understand why people want that," he says. "Why wouldn't everybody want that? But it really should be available for everyone, whether they can pay for it out of their own pockets or not."

Harmer, also a cofounder of ASCP, estimates that there may be two hundred or more concierge services in the United States, and the number is growing. They come in many varieties: Some are private offices, others are hospital- and university-affiliated practices. The elite MD Squared—which was launched in 1996 by Howard Maron, M.D. (the former team physician for the Seattle Supersonics basketball team), and his partner, Scott Hall, M.D.—charges $13,200 annually for an individual member, $20,000 for a couple, and $2,000 for each child living at home. The average cost per patient works out to about $10,000 a year, Moses says.

In return, MD Squared's members get to see doctors whose total number of patients never exceeds one hundred (compared with the 3,000-plus for some traditional physicians). "These patients enjoy the physician's time, the physician's brain, and the physician's thought and care, rather than I-just-blinked-was-that-my-doctor-who-just-came-here," says Moses. All patients receive a complete physical exam once a year, 24-hour telephone access to their doctors, house calls, and same-day appointments without waiting. If the patients need to visit a specialist, the primary care physician will go along, at the patient's request, to ask the pertinent questions and oversee the procedure.

MD Squared does not bill the patient's insurance company, Medicare, or Medicaid for any charges. Patients maintain insurance to pay for emergencies, visits to specialists, and anything else that falls outside the realm of the care it covers. MD Squared operates three practices—one in Seattle, one in Bellevue, Washington, and one in Portland, Oregon—each with two physicians.

Other concierge operations are less expensive than MD Squared, but they provide fewer services. Higher Care charges less than a third as much, but it still offers house calls, 24-hour phone access to one's physician, and same-day appointments without waits. Benoist will accompany patients to specialists, and he will accept as many as three hundred patients.

Another difference is that Higher Care accepts insurance and Medicare for treatment costs. (Medicare is a government-funded medical care program.) For concierge physicians like Benoist, the trick here is carefully distinguishing medical care (setting a broken bone, treating asthma, diagnosing the flu) from the additional services that are included as part of concierge care (some screening tests, greater access to the doctor). Anything within the category of medical care is billed to the patient's insurance company. If the insurance company pays only 70 or 80 percent of the charges it allows, the patient is responsible for the rest. Or if the insurance agreement requires a co-pay, the patient is obliged to cover that amount.

Medicare is likewise billed for the medical expenses of qualified patients. "I am of the opinion that we must be able to take Medicare," Harmer explains, "because about half of our clients—and quite frankly, the ones who really need us—are on Medicare."

MDVIP, a Boca Raton, Florida-based company, has established 57 concierge practices in ten states. In each location, patients are charged $1,500 per year, which covers an annual physical exam, as well as a consultation regarding preventive care. The costs of actual treatments are taken to the patients' insurance companies.

Medicare authorities are keeping a close eye on concierge practices, making sure the doctors don't bill both the patients and Medicare for the same services. In March the Office of Inspector General issued a general warning reminding concierge doctors not to bill Medicare patients for any Medicare-covered services. It is not always crystal clear which patient charges are considered improper. In one case, the Inspector General's office found that a concierge doctor billing Medicare patients additional fees for care coordination with other providers and extra time spent on health care was violating his agreement with Medicare. It is clear that the relationship between concierge medicine and Medicare is a work in progress.

The new system is the natural outgrowth of other strategies that doctors have long used to circumvent insurance and Medicare cost caps, says Arthur L. Caplan, a medical ethicist at the University of Pennsylvania. Many doctors, for example, have simply switched to a cash-only system, in which patients pay a fee for all services and take responsibility for receiving reimbursements from their insurance companies. For several years hospitals have charged extra for luxury accommodations. And many large U.S. medical centers have sought out wealthy patients from around the world who can afford to pay the full cost of care. "You could say that the Mayo Clinic is concierge medicine," Caplan says.

Yet when you look at the American health care system as a whole, Caplan questions why such a need should exist. "What the hell kind of system is this, where you have to hire a guide?" he asks. "I thought the whole point of managed care was that we were going to get efficient and streamline things." But managed care failed to turn out that way, as most concierge doctors will tell you.

One doctor at the ASCP conference described his experience with managed care as a total nightmare. Now, Garrison Bliss, M.D., of Seattle Medical Associates (another concierge practice), says he revels in his office's inefficiency. "We have too many people assisting us, too many examination rooms, and we pay our staff too much money," he says with a smile. "And eventually we hope to pay ourselves too much money, as well."

Concierge medicine won't be the solution to the problems of managed care because it will most likely always remain a very small part of the system, Caplan says. But it is "a symptom of a medical system that's fallen apart," he says. "It's a symptom of the big, big problem in which the health care system has put too much emphasis on cost control and too little emphasis on the patient."

In most cases, when a doctor switches to concierge medicine, he or she sends out a letter to existing patients explaining the change. The one recently written by James J. Berman, M.D.—now a concierge physician practicing internal medicine at Newport Beach Medical Associates in California—to his 2,000 patients was typical. He informed them that although he was staying with the practice, he was going to start charging $1,800 a year and would render more services, such as annual physicals. Those who wished to join were welcome to stay with him—though his clientele would now be limited to 600 patients. And for those who preferred not to join, he referred them to one of the other five nonconcierge physicians in the practice.

"Most of my patients understood what I was doing even if they didn't join me," Berman says. "I could count on one hand those people who were upset or annoyed by the change."

Berman and many other concierge doctors say they are glad to keep patients who cannot afford the fee, but not those who are merely unwilling to pay it. Harmer estimates that 30 percent of Higher Care's patients are people who received waivers for the $3,000 fee and all medical fees.

Many private doctors feel that to gain greater acceptance, it would be best to lose the word "concierge." Doctors at the ASCP conference expressed their distaste for it. But what name would suffice? The AMA refers to the practice as retainer medicine, but the word "retainer" implies that the patient makes a deposit that is gradually used up with services, and that's not how all these practices operate. "Boutique" is another name that has cropped up in the press, as has "Macdocs for the McRich." But these are hardly an improvement on concierge.

"We've also been called SOBs and everything else," Moses notes. He suggests "intensive primary care."

Harmer defends the use of concierge, indicating that the word is immediately understandable. "At least with concierge, people have a general idea of what we're doing," she says. But she acknowledges that many of the doctors would like a name change.

"Whatever this movement is, it's not concierge medicine," says Bliss of Seattle Medical Associates. "I see it more as a movement to right the ship of medicine."


VITAL SIGNS: FOCUSING ON INTERNAL MEDICINE

HIGHER CARE Englewood, CO; 303-806-6400; www.higher-care.com • MD SQUARED Seattle; Bellevue, WA; Portland, OR; 208-725-2292; www.md2.com • MDVIP Boca Raton, FL; 866-696-3947; www.mdvip.com • SEATTLE MEDICAL ASSOCIATES Seattle; 206-215-2550 • JAMES J. BERMAN, M.D. Newport Beach Medical Associates; Newport Beach, CA; 949-722-1441


PATIENT ADVOCACY PROGRAMS

Another type of medical service tapping into the dissatisfaction with standard health care is the patient advocacy program. Here, patients pay an annual fee, but not to see a specific primary care doctor. Rather, they pay for a patient advocate who locates reputable doctors to help with specific medical problems and then makes sure the patient receives immediate attention.

Arthur Benjamin of Las Vegas and Salt Lake City joined one such program, PINNACLE CARE, based in Baltimore, after his wife developed breast cancer. He had been frustrated by the limited way her doctor treated the cancer, and he was gratified when, upon joining Pinnacle, his wife got an appointment right away with San Francisco oncologists who were able to improve her condition fairly quickly. Benjamin was relieved on two scores: His wife had better care and he no longer had to be the one in charge of navigating the medical world for her.

"It's the best psychological insurance policy that you can buy," says Benjamin, who is chairman and CEO of Datamark, a business that recruits students for hundreds of career-training schools, colleges, and universities.

Pinnacle memberships come in silver, gold, and platinum levels. A silver membership costs $5,000 a year, plus a $10,000 initiation fee. Gold is $10,000 yearly, with a $15,000 fee. And platinum is $25,000 a year, with a $30,000 fee. Members tend to be frequent travelers or those who own multiple homes and therefore need to find doctors in more than one area. The doctors referred by the advocates aren't paid by Pinnacle, yet they find it worth their while to respond promptly to the company's requests.

"If Pinnacle calls me about someone with a specialized ear problem, I will often squeeze that person into my schedule," says Lawrence R. Lustig, M.D., who until recently was associate professor of otolaryngology at Johns Hopkins Medical Center. He is now director of otology at the University of California San Francisco Medical Center. "The advantage for me is that it's a wealthy clientele base, a prestigious group of patients," Lustig says. "My reputation would spread as they talk about the care they received from me."

Pinnacle Care International, Baltimore; 866-752-1712; www.pcistaff.com