It's been called retainer medicine, premium care, VIP care and concierge care.
It's also been derided as "wealthy health" and called unfair, unethical and possibly even illegal, though its advocates like to think of it as just a greater level of service in an already multitiered healthcare system.
The practice of charging upfront access or membership fees for more personalized physician service is catching on in a few areas. And some expansion--minded medical groups want to take the concept to other major cities.
"Why is this occurring?" asks Jim Wiehl, who heads the Health Care Practice Group at the St. Louis law firm of Sonnenschein Nath & Rosenthal. "I think that it is very fair to say that the increasing trends of downward reimbursement and increased patient load are pushing more doctors to work more hours for less compensation. Everybody is looking, some more aggressively than others, how do you get off the treadmill?"
One of the oldest and most exclusive concierge practices is MD2, founded in Seattle five years ago to cater to business executives willing to pay $10,000 to $20,000 per year for the privilege of having personal physicians on call at any time. Seattle has since become a hotbed of retainer medicine, as at least two other practices, including Virginia Mason Medical Center, have started similar--though decidedly less costly--programs (see June, p. 26).
To date, retainer medicine still is largely confined to the Pacific Northwest, Northern California and south Florida.
Some physicians see their involvement in this sort of care as a lifestyle or professional choice.
"I'm having to find creative ways to fund the level of service that I wish to provide and that I have always provided," says Robert Cava, M.D., a family practitioner and gerontologist in Miami. His two-physician practice, Miami Medical Consultants, opened up a second office in Boca Raton last year so Cava could offer what he calls Premier Choice service "for patients who desire a more comfortable and convenient service to subscribe to."
Cava now spends just a day and a half per week at the original location so he can see a limited number of longtime patients.
Cava says he will meet Premier Choice patients in emergency rooms, see them at home, give same-day and next-day appointments and make sure that patients do not have to wait once they arrive at his office.
"We don't pretend to get better outcomes here," just better comfort and convenience, Cava says. The retainer fee that he charges is purely to reserve time, he says.
A Boca Raton, Fla., company makes its mission clear with its name: MDVIP, which was incorporated in November 2000. It signs up independent physicians to adopt its business model of charging patients $125 per month on top of any treatment fees and limiting each practitioner to 600 patients.
Physicians do not have to pay an affiliation fee to MDVIP, but they must agree to leave their former practices, work with the company to start up a new practice and provide an annual physical to all MDVIP patients. The physicians get to keep the majority of each patient's membership payment.
South Florida internists Bernard Kaminetsky, M.D., and Robert Colton, M.D., last spring became the first two physicians to open an MDVIP-affiliated practice.
Kaminetsky was able to cut his patient load from 2,800 to about 400 and no longer has to see 26 or 27 patients a day as he previously did. He now treats less than half that number each day.
"I felt very dissatisfied with the practice of medicine," Kaminetsky says. "I started in the days of indemnity insurance, when it was doctor-patient, not doctor-insurance company. I had reached the point when I was seriously considering getting out of the practice."
Now, Kaminetsky says, "I'm almost embarrassed to gush. It sounds almost saccharine-sweet to say this, but I've discovered the joy of being a doctor again."
Andrew Ripps, COO of MDVIP, says those feelings will help the company grow. By early fall, the company had affiliations with five South Florida practices.
Ripps says the company is looking to expand in Florida, the Northeast and Southern California.
Wiehl cautions against over-aggressive expansion, however. "I would not be surprised if it doesn't grow in some of the large cities around the country, but I don't think there's going to be a huge wave of this," Wiehl says. "A market where HMOs are your main choice and there is pressure on HMOs for access, that's going to create a ripe atmosphere" for these kinds of practices.
A vocal critic of retainer medicine, Paul Ginsburg, president of the Washington-based Center for Studying Health System Change, calls the phenomenon just another example of provider pushback, a backlash against managed care.
"There are going to be other changes in managed care that will be more profound than this," Ginsburg says.
"Pushback (and) tiered co-payments will be more significant."