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Two Tiered Medical Care for Haves and Have Nots

Not long after Cynthia Thek gave birth, her gynecologist opened a new practice in Englewood, N.J. Gone was the traditional waiting room, replaced by a reception area with spa-like ambience. Instead of a hospital gown, patients got a plush bathrobe. “It’s a beautiful space. The staff is superfriendly. You don’t feel rushed by the doctor or even the staff,” Thek, 32, explained recently. “However, [the doctor] also stopped accepting any insurance.”

Thek stuck with her doctor, Jennifer Ashton, for one post-delivery visit, paying $250, about half of which her insurance reimbursed. But when she learned that care for her next pregnancy would run $8,000 to $10,000, much of it not reimbursable, she decided to look for a new OB-GYN.

A small but growing number of physicians are pursuing Dr. Ashton’s approach: abandoning traditional insurance-based practice to offer VIP treatment, including more time with patients, in return for upfront fees. In one common setup, often called concierge or retainer-based medicine, a primary care doctor charges an annual fee ranging from $1,000 to $20,000 just to get in the door. When doctors shift to this model they can cull their patient loads, selecting only those who can foot the bill. The services they provide often include a deluxe annual physical, 24-hour direct cell phone access to a doctor and escorts on visits to specialists. Some doctors still accept insurance and Medicare and bill normally for routine care. Others, like Dr. Ashton, opt out of that system in order to charge what the market will bear. Ashton did not respond to requests for comment.

The Haves, The Have-Nots

Doctors say the concierge system makes life much easier for them and assures better care to their remaining patients. “At the end of the day, you can look yourself in the mirror and you know that you did a good job with the patients you saw,” said Dr. Steve Reznick, a Boca Raton, Fla., physician who cut his roster of patients from 3,500 to fewer than 400 five years ago.  “You couldn’t do that seeing 40 or 45 senior citizens a day in the past.” While that may be true for the doctor and remaining patients, it’s not always easy for the thousands who didn’t or couldn’t pay, and who had to find a new doctor. Some health care experts view this as an ominous trend that could exacerbate socioeconomic disparity in the health care system in light of a looming doctor shortage. They say this development could be especially troublesome once the new health care law adds millions of Americans to the health insurance rolls and sends them looking for doctors. “Doctors love it. But in fact, from a societal point of view it’s a tragedy,” said Dr. Richard Cooper, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

The health care legislation recently signed by President Barack Obama is aimed at lowering costs and adding insurance coverage for more than 30 million people starting in 2014, including 16 million new Medicaid and Children’s Health Insurance Program members.   But it does not account for the projected shortfall of 35,000 to 44,000 new primary care doctors, nurses practitioners and physician assistants that are choosing alternate disciplines because of increasing workloads, low reimbursements, a paperwork burden and a huge gap in pay compared with medical specialists. 

The Doctor Is Out

A 2009 survey of general practitioners by the American Academy of Family Physicians showed that 42 percent were not accepting new Medicaid patients. 65 million Americans are already living in areas the government has deemed short of primary care practitioners. And they’re not the only ones dropping out of the system. Recently, Walgreens and two other pharmacies in Seattle, Wash., decided to deny coverage to new Medicaid patients because of low reimbursements. And in a shocking move by one of the most revered hospitals in the country, The Mayo Clinic shuttered its Medicaid facility in Phoenix, Ariz., because it was losing too much money.

Dr. Marc Siegel fired a warning shot about the doctor dearth in an op-ed in the Wall Street Journal last April.  “With more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have,” he said. He cited a 2008 report by the Medicare Payment Advisory Commission stating that 28 percent of Medicare beneficiaries had trouble finding a primary care physician; another survey that year by the Texas Medical Association found that only 38 percent of primary care doctors in Texas took new Medicare patients. Texas is not alone, as more and more physicians try to find acceptable ways to practice medicine without feeling like they’re being exploited.

Top-Of-The-Line Care For Top-Of-The-Market Fees

Concierge-style medicine is one way that overloaded doctors have chosen to respond. The American Academy of Private Physicians, the trade group representing the concierge care movement, says more than 1,000 doctors have gone this route. By another measure, 1.2 percent of respondents to AAFP’s survey say they practice concierge, boutique or retainer medicine.

While fee-for-service, or “private,” doctors have long existed, primary care doctors began converting to the concierge model about 15 years ago. Companies came along to help doctors set up these practices and handle the administration. The largest, MDVIP, has more than 380 doctors. (This rise of high-cost medical services was accompanied by low-cost fee-for-service programs aimed at the poor or uninsured.)

In 2002, MDVIP attracted the attention of several Democratic members of Congress, who questioned whether concierge physicians were essentially charging seniors for services that Medicare already provided at established rates. That would be illegal. In a letter and subsequent documents, Health and Human Services secretary Tommy Thompson said that this model was fine so long as the fee was for services that were not covered by Medicare. With the exception of one case in 2004, in which a concierge-style doctor in Minnesota paid more than $50,000 to settle a claim that he violated his agreement with Medicare, HHS has left these doctors alone.

But many doctors say that while the current system is not sustainable, drastic cuts in patient load are ultimately misguided. “It’s a short-term solution to say, ‘I’m going to cherry pick some people who can pay me a concierge fee,'” said Dr. Michael Stillman, an internist at Boston Medical Center. “The majority of us think it’s an unethical and ultimately selfish way to practice medicine.”

Dr. John Goldberg, an internist in the Kansas City area, said he could hardly ask a patient who can barely pay for medication to pay a fee for his care. Juggling many sick patients is just part of a day’s work, he said. “I worked in three or four people [Monday] that didn’t have an appointment Friday when we closed the office,” Goldberg said. “They’re not paying a premium; that’s just the right thing to do.”

The American Medical Association says there’s nothing inherently wrong with concierge-type of arrangements. However, its ethics manual cautions that they “not be promoted as a promise for more or better diagnostic and therapeutic services.” That puts concierge doctors, particularly those who offer traditional service as well, in the awkward position of trying to promise patients that they’re getting something for the extra money while telling the rest they’re not giving up any medical services.

Of course some concierge doctors do say they provide services, not necessarily better care. “What I sell my patients is a better day,” said Dr. Marcy Zwelling, head of AAPP and a concierge doctor near Long Beach, Calif., who shed most of her 3,000 patients. “Do I think that sitting in a waiting room is bad care? No, but it’s probably a waste of time. I don’t think people die because they don’t have what we do. But do I think my patients live longer? I know they do.” There are no peer-reviewed studies of the health benefits of this approach. MDVIP cites its own study showing lower hospitalization rates for Medicare patients who are in concierge practices compared with those who are not. One study from 2005 suggests that the pool of concierge subscribers is less black and Hispanic, and has fewer chronic illnesses, like diabetes, than the general patient population.

Changing By Default, Not Design?

Doctors who have adopted this approach say the current system has forced them into it. To break even with reimbursements from Medicare and private insurance, Dr. Susan Wilder said she used to be able to spend no more than 8 minutes with each patient. “You’re forced into a situation of seeing more and more patients in less and less time, and the patients are more and more complex, and the administrative costs go higher and higher,” said Wilder, who converted her suburban Phoenix practice to a hybrid in which some patients pay a concierge fee while others do not. Wilder said her longstanding patients know that they get quality care no matter what. “I don’t think they needed any reassurance. I’m not going to dumb myself down to take care of my routine patients,” she said.

Reznick, the Boca Raton doctor, said he tried everything to keep his practice afloat.   But he couldn’t manage. He now charges an annual fee of $1,800 as well as small payments for office visits.

Like all the concierge doctors interviewed for this story, Reznick found other doctors to take the patients who did not join his program, and kept very ill patients as well as some who could not pay.

Groups that support concierge physicians say the cost – about $4 per day in most cases – is not prohibitive, and that it comes down to a question of choice in the marketplace. “People go to McDonald’s; people go to Burger King, you know,” said Zwelling. “It’s a choice.” Darin Engelhardt, the president of MDVIP, said that most physicians who convert are on the verge of leaving medicine altogether, so it’s not accurate to say that every conversion means one less doctor in the market. To the contrary, the success of MDVIP’s financial model will lure doctors back to general practice, he said.

“On the experienced physician side, we extend the careers of primary care physicians,” he said. “And as far as younger physicians go, we’ve created a model that can prove that primary care can in fact be viable again.”

But for Thek, who quickly found a new OB-GYN who does accept her insurance, it was not worth the price. “I feel like I get the same level of care at the new practice,” she said, “minus the spa-like office and the plush bathrobe.”

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