October 30, 2005
Being a Patient
For a Retainer, Lavish Care by 'Boutique Doctors'
By ABIGAIL ZUGER
BOCA RATON, Fla. - It was on the plane from Shanghai to Beijing last year that Dorothy Lipson of Delray Beach, Fla., suddenly began to cough up blood: first in streaks, then in frightening, tissue-soaking spoonfuls.
But Mrs. Lipson, who was in China visiting an expatriate daughter, was lucky on two counts. First, her daughter happens to run a corporation that builds gleaming Western-style hospitals in China; Ms. Lipson was rushed to the Beijing hospital on landing. And second, Mrs. Lipson's internist back home in Florida is Dr. Bernard Kaminetsky, one of a new breed of "concierge" or "boutique" doctors who, in exchange for a yearly cash retainer, lavish time, phone calls and attention on patients, using the latest in electronic communications to streamline their care.
Since its debut in 1996, concierge medicine has evoked criticism from many corners. Some ethicists say it is exacerbating the inequities in American health care. Insurance regulators have raised concerns about fraud. Government watchdogs, worried that it threatens the tenuous equilibrium of the health care system, are keeping an eye on trends.
"Concierge care is like a new country club for the rich," Representative Pete Stark, Democrat of California, said at a joint economic committee hearing in Congress last year. "The danger is that if a large number of doctors choose to open up these types of practices, the health care system will become even more inequitable than it is today."
But for Mrs. Lipson, who pays $1,650 a year, the niceties enabled by concierge medicine can make all the difference.
Dr. Kaminetsky was in daily touch with her doctors in Beijing. E-mail messages, X-ray reports and digitalized images flew back and forth. When the bleeding was stabilized and Mrs. Lipson returned home, Dr. Kaminetsky immediately connected her with a local specialist for a biopsy of her diseased lungs, and then with infectious disease experts for treatment of the unusual infection that was found.
Mrs. Lipson's long convalescence was seamless, with none of the snags that can magnify the misery of serious illness: no long hours in strange waiting rooms, no lost X-ray or culture reports, no contradictory pronouncements by specialists confused by missing information. Dr. Kaminetsky's office coordinated all her appointments, tests and treatments. He personally telephoned her with all results and saw her as often as necessary to make sure everything went smoothly.
Now, still on medication over 18 months later, Mrs. Lipson applauds her foresight in signing up for this deluxe model of medical care. The yearly expense, she points out, is far smaller than more traditional luxuries like cruises or late-model cars. "I highly recommend it," she said. "It's well worth the money."
More Money, More Attention
Anyone searching the country for a group of patients who are perfectly happy with their medical care, neither brutalized by the system nor fearful that the onset of a serious illness will plunge them into a morass of confusion and neglect, need look no farther than Dr. Kaminetsky's waiting room here in Boca Raton.
Not that the waiting room usually has anyone in it. One promise made to patients paying for concierge service is that waiting will not be a part of their health care experience. Patients are guaranteed that phone calls will be returned promptly, appointments will be scheduled on a same-day basis if necessary, and appointment times will be honored. A bowl of fruit salad and platters of bagels and sponge cake set out for patients in the waiting room can go barely touched over the course of a day, and the television often plays to an empty couch.
A relatively simple tradeoff is responsible: the extra fees collected from patients let concierge doctors, who leave regular practice for concierge medicine, slash their caseloads. Before Dr. Kaminetsky became a concierge doctor five years ago he had 2,500 patients in his practice - a standard number for most primary care internists. His list now numbers 600.
Sick and well alike, patients are delighted with the results.
Joan Holzman, 69, takes no medicines and has no health problems; she comes to the office once a year for a physical exam, an X-ray, an electrocardiogram and blood tests. "I adore it," Ms. Holzman said. "Before, wherever you went you felt like cattle. But everyone here is top-notch - the doctors, the secretaries, the nurses. They're warm, like family. It's a wonderful feeling of security."
Phoebe Kupps, 81, made a same-day appointment with Dr. Kaminetsky recently to discuss a scribbled list of minor problems, including her insomnia, her sinus congestion and an unpleasant sour taste in her mouth. For a half-hour (uninterrupted by ringing phones or any other distractions) she and Dr. Kaminetsky methodically reviewed her medications and considered ways to get rid of the bad taste and improve her sleep, including avoiding afternoon naps and alcoholic nightcaps, and turning the bedroom clock to the wall.
"It's like having insurance and not using it," Mrs. Kupps said. "I've been a well person. These little things are ridiculous. But here I can get them dealt with right away, they don't build up. I've heard stories from my friends, when they get ill, they can't get in to see their doctor for weeks."
Herbert Glickman, 75, has seen more than a dozen specialists since both of his knees were replaced in 2003, trying to find the cause of his persistent knee pain. He periodically drops off wads of consultation and test reports to add to his bulging file at Dr. Kaminetsky's office, and during long phone calls and appointments the two sort through the results.
When a month went by recently without a word from Mr. Glickman, Dr. Kaminetsky called him at home. "He was calling to find out how I was," Mr. Glickman said in the tone of one discussing a miracle. "I never heard that from any doctor!"
Dr. Kaminetsky's practice is affiliated with a corporation called MDVIP, which he helped found. It processes the retainer fees, oversees the office's electronic capabilities and runs quality control to make sure the clerical staff members are courteous and make appointments with the promised alacrity. Nationwide about 250 medical practices and 100,000 patients have signed up with MDVIP and similar corporations, according to the professional society of concierge physicians, the Society for Innovative Medical Practice Design, founded in 2003.
These doctors charge fees as high as $10,000 a year, depending on the services promised. The majority charge $1,500 to $2,000. Basic services consist of same-day or next-day appointments and 24-hour telephone access to the doctor. The most expensive may also promise the doctor will make home visits, deliver medications and accompany patients on visits to other doctors.
In Dr. Kaminetsky's practice of three doctors all the patients are concierge patients. Retired patients are sometimes enrolled by their children, who may also cover the retainer fees. About 10 percent of the patients are seen free of charge, "scholarship patients" who the doctors have decided are in real need of the extra services and whose yearly retainer fees are waived. Because the practice has a 96 percent annual retention rate, its waiting list of several hundred names moves up slowly.
"We turn people away every day," Dr. Kaminetsky said.
All About Numbers
Despite the drastic decrease in patient load after he changed the way he ran his practice, Dr. Kaminetsky's personal compensation and the salaries of his office staff members increased by about 60 percent.
The arithmetic behind this seeming contradiction results from the low per-visit reimbursement rates set by Medicare for primary care office practices. Medicare now pays an internist like Dr. Kaminetsky slightly over $50 for an average office visit. Thus, a regular internist might earn about $200 a year from Medicare for caring for the average older patient with high blood pressure or elevated cholesterol but no other major health problems.
Other medical insurers follow Medicare fees closely, which is why office-based primary care doctors who accept insurance say they must see dozens of patients a day just to break even.
A concierge doctor charging the $1,650 MDVIP fee, though, makes at least $1,150 a year per patient (MDVIP retains $500 for its services). This huge increase in per-patient reimbursement allows the patient loads to be kept low.
Primary care doctors also occasionally lower their patient loads by participating in only a few insurance plans, or, sometimes, in none at all. No one knows how many of these partly or completely "fee-for-service" practices operate in this country, or whether their number is increasing.
For office visits, these doctors set their own cash fees, which can be hundreds of dollars a visit, rivaling concierge medicine in out-of-pocket expense for the patient. Unlike concierge doctors, though, fee-for-service doctors do not enter into a formal legal contract with patients that enumerates the services patients will receive for the money.
Some concierge practices operate exclusively on a cash basis. Others - generally those with lower annual fees, like Dr. Kaminetsky's - still participate in Medicare or other insurance plans.
These practices have reached an uneasy truce with insurers. Insurers forbid double billing for visits they cover, so the yearly concierge fees are specifically allocated for services that insurers do not cover, like annual physical exams and health reviews, preventive services like nutritional counseling and frills like a wallet-size CD containing an up-to-date medical history and test results for patients to carry with them.
Even so, critics maintain that concierge services violate the spirit, if not the letter, of federal Medicare law, which aspires to regulate doctors' fees to a uniform standard and streamline access to medical care for the old and infirm.
After five senators wrote a letter of complaint to the Department of Health and Human Services in 2002, a formal examination was begun. Tommy G. Thompson, who headed the department at that time, concluded that as long as the retainer fee was clearly for services not covered by Medicare, collecting the fees did not violate the law.
Subsequently, the Government Accountability Office examined trends in concierge medicine and concluded, in a report in August 2005, that the number of concierge physicians nationwide was still too small for the practice to limit Medicare patients' access to health care, but that the government would continue to monitor trends.
Some argue that concierge services actually save health care dollars. In Florida, for instance, internal MDVIP statistics indicate that concierge patients receive screening exams like mammograms and Pap smears more regularly than those with commercial insurance, and they require fewer hospital admissions, said Darin Engelhardt, the company's chief financial officer.
"As far as I'm concerned, we're saving Medicare money," Dr. Kaminetsky said.
He pointed to cases like that of Philip Novack, 94. For Mr. Novack, who is in fragile health, Dr. Kaminetsky's office often becomes a low-stress alternative to the emergency room. One morning last summer, Mr. Novack woke up at 5 a.m. feeling unwell and asked his wife, Edythe Shane-Novack, to call an ambulance. A veteran of many similar emergencies, she waited till 9:02 a.m. and called Dr. Kaminetsky's office instead.
Less than three hours later Mr. Novack was perched on an examining table, smiling at the familiar faces in the office and receiving the same evaluation he would have had in the emergency room, including blood tests, an X-ray and a cardiogram.
The diagnosis, a slight imbalance in his blood sodium level, was made promptly, and Mr. Novack was better by the next morning. Instead of paying expensive emergency fees, Medicare would pay only for an office visit. "This is the best thing that ever happened to us," Mrs. Shane-Novack said.
Charges that concierge practices violate not financial ethics, but professional ethics, also abound.
"Philosophically, I think it's appalling," said David Barton Smith, professor of health services administration at Temple University in Philadelphia. "It's creating a two-class system of medicine."
Critics have accused doctors who make the transition to a concierge practice from a regular one of abandoning patients who cannot afford to join up. Concierge doctors counter that when they convert their practices they do so over a transition period of several months, and always provide referrals to alternate sources of care, as mandated by the American Medical Association's code of ethics.
Other critics feel that concierge medicine hurts the profession's image. "The public is already mistrustful of doctors' self interests," Dr. Jay Jacobson, a medical ethicist in Salt Lake City, wrote in 2002. "Boutique practices exacerbate the distrust."
Others feel that concierge medicine is deeply at odds with the philosophy of primary care medicine, whose mandate is to care for all comers. Still others say it violates an unwritten code in which doctors must share the medical profession's duties equitably. In other words, if some doctors care for only a few rich patients, everyone else has that much more poorly reimbursed work to do.
Dr. Kaminetsky counters with his own story. Had he not found this way of practicing medicine, he said, he would no longer be seeing patients at all: he would be in a desk job with a pharmaceutical company. A detail-oriented perfectionist who routinely works through lunch and still does his own filing, he was tormented in his previous practice by the impossibility of meeting his own standards.
"I hated it," Dr. Kaminetsky said. "It was awful. Patients always had a litany of complaints. Driving home, I would think, 'Oh my God, I never saw this test, I never called that patient back.' Some people are not as easily distressed by loose ends. I don't like leaving things undone."
Now on his busiest days he sees perhaps half the number of patients he used to, spends twice as long with each one and has the time to make every last phone call.
"I'm really helping a lot of people," he said. "I feel good about what I do. Does everybody deserve this kind of care? Yes, they do. And I don't purport to know the solution."