For a Retainer, Lavish Care by 'Boutique Doctors' - New York Times
The New York Times

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.

Perceptions

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."

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The New York Times Company

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