SRA Research Group, Inc. -



Marc Serota for The New York Times

Barbara L. Allan, president of a research company in Florida, tried using a concierge doctor to save time, but switched because he didn't offer some routine services.

SUNDAY MONEY: SPENDING
The Concierge Doctor Is Available (at a Price)
By AMY ZIPKIN (NYT)
Published: July 31, 2005

LAST October, Barbara L. Allan, 57, received a letter from her family physician, Dr. David Rosenberg, asking her for $1,500 annually to remain a patient. He would be offering longer appointments, with no waiting, and giving out his cellphone number for after-hours calls. Ms. Allan would be one of just 400 patients, the letter said, and she would have his help navigating the local health care system. Dr. Rosenberg said he was switching to a concierge practice to maintain the highest quality of patient care.

To her, it was an attractive pitch. "I was tired of going in for routine things and waiting an hour and a half," said Ms. Allan, who is president and chief executive of SRA Research Group Inc. in Jupiter, Fla. She recalled walking out of the doctor's office two or three times when he made her late for a meeting.

As the nation's health care debate focuses on the broader picture - rising costs and those without insurance - a small but growing number of doctors are shrinking their practices and asking patients to subsidize their decisions. The annual costs of these "concierge practices" can range from around $1,500, as in Ms. Allan's case, to $20,000 for some practices in places like Seattle and Key Biscayne, Fla.

Health care experts say consumers should consider various factors, as well as the additional costs, in deciding whether to go to a concierge practice. If the patient has a chronic illness, for example, the readily available care from such a practice may be important.

Even as the popularity of concierge practices increases, some are facing regulatory hurdles and skepticism. Insurance companies are reviewing some physician contracts after receiving consumer complaints about charges for services they thought were covered.

The Office of the Inspector General, part of the Department of Health and Human Services, said that it received information about one concierge physician who offered his Medicare patients a comprehensive health assessment, for which they would pay out of pocket; but the government said that this was a reimbursable charge. The physician, whose identity was not disclosed because it would have violated federal privacy law, paid a fine, agreed to a settlement and stopped offering concierge contracts, the Office of the Inspector General said.

The office said that it then issued an alert, in March 2004, to all physicians participating in Medicare, telling them that they were liable if they charged for expenses that were already covered by the federal program.

Critics of concierge medicine call it elitist. Thomas William Mayo, an associate professor of law at Southern Methodist University who writes about legal and ethical issues in medicine, said, "It creates an explicitly tiered medical system based on ability to pay."

Proponents disagree. Michael L. Blau, a partner at McDermott Will & Emery, a law firm in Boston and the co-author of "Developing and Managing Physician Networks" (Thompson Publishing), says the doctors are putting their practices on the line to deliver what they believe to be quality care.

Having a concierge physician generally means entering into a personal contract. Because many such practices are new, health care experts advise consumers to find out what the annual fee covers, what the contractual obligations are and what is covered by insurance. They also recommend learning what hospital the doctor uses and whether insurance covers a stay.

Prospective patients also need to know their alternatives if the physician leaves the practice before the contract expires or if they have a complaint about care or services. In most states, health insurance is regulated by a state insurance agency. But because concierge practices are contractual agreements, a consumer may need to contact the office of the state attorney general in a contract dispute.

Concierge practices are "totally unregulated with no oversight," said David Barton Smith, professor of health care management at Temple University in Philadelphia. "You're putting up a fairly large sum of money," he added, "and there isn't really any assurance you are going to get your money's worth." He said his 90-year-old mother left a concierge physician in Key Biscayne who wanted $20,000 annually to continue to treat her.

Dr. Smith also says that just because a concierge network or doctor offers a certain level of service now, that could change if its business model shifts.

As many as 250 physicians nationwide have these practices. MDVIP, a concierge network in Boca Raton, Fla., has 85 doctors in 14 states serving 27,000 patients. It plans to add 50 physicians this year. Another concierge practice, PartnerMD in Richmond, Va., wants to expand to North Carolina and the Washington, D.C., area.

In Florida, Ms. Allan hit a snag after deciding to join Dr. Rosenberg's practice. Her insurer, a health maintenance organization sponsored by Blue Cross and Blue Shield, wouldn't cover the deal because Dr. Rosenberg had notified the H.M.O., along with others with which he was affiliated, that he had changed his practice. Blue Cross and Blue Shield said it advised him that he was no longer eligible for a managed-care contract, under which doctors see patients at previously negotiated reimbursement rates. Dr. Rosenberg resigned from the network, and because he was now classified as an out-of-network provider, Ms. Allan was assigned to a new physician.

Cigna and United Healthcare said they notified Dr. Rosenberg that he no longer qualified for their networks, either. He said that he resigned from them as well but that he remains a provider with many others.

"The patient should have the choice if they wish to pay extra for this type of care," Dr. Rosenberg said.

Ms. Allan refused the H.M.O.'s choice of a new doctor. Then, Ms. Allan said, Dr. Rosenberg suggested that she check whether her company would allow her to enroll in a preferred provider organization, so she could choose an out-of-network physician. It wouldn't, because it participated only in H.M.O.'s. As an alternative, she said, he recommended an H.M.O. physician he knew who would see her for acute care, order tests and arrange hospital admissions under her plan while Dr. Rosenberg would remain her physician, give her a yearly physical and coordinate her care.

Ms. Allan said the financial coordinator at her company found that suggestion to be sound. But she didn't want to visit another doctor and take even more time. Within a few months, Ms. Allan discovered that Dr. Rosenberg's practice didn't offer routine gynecological checkups, so she switched to a nearby practice recommended by several women in her office. She received a prorated refund of the yearly fee.

Because the field is relatively new, some patients turn to their concierge doctors for advice on insurance. Dr. Marcy L. Zwelling-Aamot, who has a concierge practice in Long Beach, Calif., offers her 460 patients group lectures and personal consultations about medical insurance in addition to discussions on medical topics like osteoporosis. "I feel it's my obligation," she said, adding that she wants patients to understand the choices available to them.

She encourages her Medicare-eligible patients to carry "gap" insurance and advises others to open health savings accounts to cover her membership fee. She recommends changing to a fee-for-service plan, if available, for other expenses, like drugs not approved by insurance companies. Although those policies can cost consumers 20 percent to 30 percent more, with deductibles running up to several thousand dollars a year, they allow patients greater flexibility in coverage.

Dr. Zwelling-Aamot has also established a special program for patients who cannot afford her fee. She asks those patients to do volunteer work in lieu of paying her, even setting up recruitment fairs at her office and inviting patients to interview with local nonprofit agencies. She says that she doesn't monitor compliance.

Dr. Rosenberg waives his membership fee for about 20 patients. He offers waivers only for patients who were in his previous practice who have said they have no way to afford his fee but wish to stay with him.

Some patients with chronic diseases may have special reason to pay the additional expense of concierge medicine. Dr. Don Fischer, the chief medical officer at Highmark Blue Cross Blue Shield in Pittsburgh and a cardiologist, said that one of his pediatric patients received a house call by his concierge pediatrician on Easter Sunday. The child, who had a heart problem, received a diagnosis of endocarditis. Dr. Fischer attributes the accurate off-hours diagnosis to the child's getting immediate treatment.

Even patients who decide on a concierge practice may find themselves back in managed care, as those of Dr. Enrico J. Versace, in West Yarmouth, Mass., discovered recently. Dr. Versace said he spent $100,000 on consultant fees and marketing to establish a practice charging $3,000 a patient two years ago. There were complications from the beginning. Although he wanted 40- to 60-year-olds, he said almost half his patients were over 75. Many demanded house calls, often leaving his office unused. Although he told his patients that he was available at all hours, he said he felt that some patients abused the system. "They'd call on weekends, telling me they were feeling better," he said. He sent out a reminder notice that after-hours contacts were only for emergency care.

After two years, as their contracts ran out, he referred patients to other doctors. He closed his practice in March and is now on the staff of Cape Cod Hospital, in Hyannis.

Some people say concierge medicine is too new for them to determine whether patients receive better care for the extra time and expense. "It's an unknown," said Arthur A. Levin, director of the Center for Medical Consumers in New York.

Dr. Barry B. Schwartz, vice president for network management for Blue Cross/Blue Shield in Florida, says simply: "You're not paying for better care. You're paying for better service."

SUNDAYBUSINESS