- The Washington Times - Wednesday, November 25, 2009

Alan Sheff, a Bethesda-based internist, thought about leaving medicine. The pressure to see two dozen patients in a day, the mounds of paperwork and the hassles with insurance companies and Medicare left the doctor of more than 20 years wholly dissatisfied. “Medicine changed to the point I felt I wasn’t living up to the standards of care,” Dr. Sheff says. “Especially when it came to prevention and wellness. It was not the kind of medicine I wanted to practice.”

That was nearly seven years ago. Instead of leaving medicine, Dr. Sheff made the transition to a retainer practice. Often called a “boutique practice” or said to provide “concierge medicine,” retainer practices charge a patient an upfront fee. That enables them to reduce the number of patients and dependence on insurance reimbursements.

Proponents of such care say it has enabled doctor and patient to return to the more personal and less rushed relationship Americans used to know. However, critics fear it is highlighting class differences, in which you get what you pay for - but pay you must - in what is heading toward a two-tier medical system.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, says retainer practices are a bad idea in what already is a broken health system.

“No one should have to pay to get decent, unhurried and attentive care,” Mr. Caplan says. “They are putting a premium on getting an appointment. It is also pulling primary care doctors out of the system, so that is creating a worse personnel problem. That could lead to a slippage in the quality of care.”

In Dr. Sheff’s office, which is part of the MDVIP network, patients pay a $1,500 annual membership fee. The fee covers a thorough exam and testing, a patient wellness plan and medical records stored on a wallet-size CD.

More important to many patients, they have 24/7 access to Dr. Sheff via e-mail or cell phone, office visits of at least 30 minutes and little to no time spent in the waiting room. After the initial physical, a patient’s insurance is billed for sick visits and procedures.

MDVIP, which has 120,000 patients and 338 doctors nationwide, says this model actually saves health care dollars. Patients in the MDVIP network, for instance, have a 74 percent reduction in hospitalizations for those on Medicare and 40 percent for those with commercial insurance, says MDVIP President Darin Engelhardt.

“I get to be a lifestyle coach,” says Dr. Sheff, who adds that time to discuss lifestyle changes leads to healthier patients. He also says more than 90 percent of his previous patients stayed with the practice after the switch. Averaged out over a year, the fee, he says, is a small price to pay. Dr. Sheff has top executives as patients, plus government employees and retirees on fixed incomes.

George Nemcosky, 64, a recently retired Montgomery County art teacher, says he was confused when Dr. Sheff, his longtime physician, said he was going to the retainer practice.

“I thought maybe I couldn’t afford it,” said Mr. Nemcosky. “But it is really worth it. I feel I have a better relationship with my doctor. He truly knows me.”

Kevin Kelleher, a Reston primary care doctor, says the doctor-patient relationship also was one of his reasons for switching to a retainer practice in 2004. When Dr. Kelleher had a traditional practice, more than 3,000 patients were affiliated with his office. At Executive Healthcare Services, his current practice, he and his partner see about 700. Executive Healthcare Services has two levels of membership, a $2,800 individual plan that includes a comprehensive wellness exam or a family plan that has an annual fee of $1,500 a year, plus $220 a month.

Dr. Kelleher says his patient retention rate is 98 percent. He is more satisfied as a doctor, and his patients are getting better care, he adds. “Medicine needs to be about quality, not quantity, and value, not codes,” he says.

Thomas W. LaGrelius, immediate past president of the Society for Innovative Practice Management, says membership fees are not elitist.

Mr. Caplan does not agree. Retainer medicine has always been a perk of top-level executives, he says, but the current trend is aimed at the middle class.

“Sadly, medicine is following the example being set by the overstressed American airline industry,” Mr. Caplan says. “They charge extra for the bottle of water and the right to take a bag on the plane. The businessmen pushing concierge medicine are following right in their quality-degrading footsteps.”

Michael Cannon, director of health policy studies at the laissez-faire Cato Institute, says retainer practices do not create a system of haves and have-nots, but, rather, reflect our society of have and have-nots.

“People who opt for this system are not paying for better health care,” says Mr. Cannon. “They are paying for better access and more convenience. If a doctor has more time because he has to see fewer patients, he might even be able to see more patients on a charity basis.”

Dr. LaGrelius traces the evolution of the current overloaded system to the early 1990s, when Medicare cut payments to doctors and the private insurance companies followed suit. To make up the difference, doctors had to get more patients - and do much more work for less money.

“I want everyone to get health care,” Dr. LaGrelius says. “But what [many patients get] is sham health care: Wait an hour in the waiting room, have a rushed exam where the doctor has one hand on the doorknob and writes you a prescription. If you have another problem, you need to make another appointment.”

The trend of primary care doctors converting to this model “really does reflect the problems with the current health care system,” says Lori Heim, president of the American Academy of Family Physicians.

The AAFP and the American Medical Association issued retainer practice guidelines in 2003. In them, the organizations outlined ethical standards and what doctors fees should cover.

The Government Accountability Office examined retainer medicine in 2005. It found the number of retainer physicians in the United States was too small to limit Medicare patients’ access to health care but said the government would continue to monitor the trend.

“Unfortunately, this type of practice does not work for the vast majority of doctors or patients,” Dr. Heim says. “But it has kept some doctors in medicine. That’s why I don’t criticize any doctor who has chosen it. They are trying to respond to patients’ needs and their own needs.”

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