Imagine a doctor who takes time to ask you about your family or chat about a movie. Who guarantees that you won't have to wait long for an appointment and even makes house calls. A doctor, in short, who provides the same VIP service you'd receive flying first class.
You'd have to pay first-class prices, of course.
One of the latest signs of the continuing backlash against managed-care medicine is so-called boutique doctors who promise red-carpet service to patients for a fixed fee, usually from $1,000 to $4,000 a year. These doctors, working individually or in groups, promise round-the-clock access, comprehensive annual exams and longer appointments, as well as other niceties.
For the doctors, these arrangements allow them to see fewer patients while preserving -- or enhancing -- their incomes. While a typical primary care doctor may have 2,000 to 3,000 patients under his or her care, boutique doctors aim to trim their patient load to fewer than 600.
"It's the difference between night and day," said Dr. Bernard Kaminetsky, who set up a boutique, or "retainer," practice in Florida a year ago through a company called MDVIP. He used to see up to 35 patients a day; now he sees no more than 10. Patients tell him they're happier, and so is Kaminetsky: He gets home in time to eat dinner with his family.
The concept, which originated in Seattle in the mid-1990s, has since spread to Arizona, California, Massachusetts and Florida. Con-sumer interest in such service reflects widespread frustration with the confusion and anonymity of modern medicine, in which patients often are bounced among doctors and health plans, straining the doctor-patient relationship.
The "boutique" solution is especially appealing to more affluent middle-age and older people who have continuing health concerns, and little patience for the hassles and rules of managed care. The yearly premiums are not covered by insurance, and many of the services, including office visits, may be only partly covered, if at all.
Nationwide, the number of doctors charging retainer fees is small -- probably no more than 200, according to Dr. F. Maxton Mauney, who investigated the practices for the American Medical Association -- and it's still too early to say whether the practices will be a cornerstone of medicine or a curiosity, he said. Nonetheless, they already have captured the attention of some members of Congress.
"If every doctor started doing this, it would be the end of Medicare," said Sen. Bill Nelson, D-Fla., who recently introduced a bill that would prevent Medicare and Medicaid from reimbursing doctors who charge a retainer.
Doctors themselves are divided on the ethics of retainer medicine. Said Dr. Richard Roberts, chairman of the American Academy of Family Physicians, "I feel I'm already available to my patients 24-7, and so are most family physicians. We don't need to do a wallet check first."
The American Medical Association has no objection to retainer contracts, however.
"Our position is that citizens have the right to strike a contract with their doctor, just like they do with their lawyer or any other professional," said Dr. Yank Coble, president of the AMA.
Last month, Edward L. Smith of Laguna Niguel, Calif., began enrolling members at $1,500 a year, which includes comprehensive physical exams, same-day appointments, and around-the-clock access, among other things. He plans to limit the practice to 300 patients.
On a much larger scale, practices such as Palo Alto Medical Founda-tion, a multi-specialty group with more than 450 doctors, also have investigated retainer services.
'Felt like family'
The issues are different for doctors in solo practice. "You just become a rat on a treadmill working in the HMO system, taking 30 to 35 patients a day," said Smith, who quit practicing for a year after almost a decade working at a large group practice in Laguna Beach. "In starting this service, all I wanted was to practice medicine again, to return to an old-fashioned family practice where the patients felt like family."
No one can say for certain whether this red-carpet service actually makes a person healthier than an average HMO plan.
On the one hand, researchers find that simply having a regular primary-care doctor is a strong predictor of long life. On the other hand, it's not clear that spending more time with a doctor measurably improves a person's health.
"The more time spent around the doctor, the more medical tests are likely to be done, and sometimes that makes patients anxious about things they don't need to be worried about," said Roberts. "There's the risk that this becomes a diversion, that you're medicalizing their life too much.
"Then the question is, 'Have you done them any good?' "
Benedict Carey is a reporter for the Los Angeles Times, a Tribune Publishing newspaper.