`Boutique' medicine offers luxury care, draws criticism


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 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; Lipson was rushed to the Beijing hospital on landing. And second, 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 exacerbates 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," said Rep. Pete Stark, a California Democrat, 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 Lipson, who pays $1,650 a year, the niceties enabled by concierge medicine can make all the difference.

Kaminetsky was in daily touch with her doctors in Beijing. E-mail messages, X-ray reports and digitized images flew back and forth. When the bleeding was stabilized and Lipson returned home, 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.

Lipson's long convalescence was seamless, with no long hours in waiting rooms, no lost reports, no contradictory pronouncements. Kaminetsky's office coordinated all her appointments, tests and treatments. He personally telephoned her with all results.

Now, still on medication more than 18 months later, 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 such as cruises or late-model cars. "I highly recommend it," she said. "It's well worth the money."

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 concierge corporations to date, according to the professional society of concierge physicians, the Society for Innovative Medical Practice Design, established in 2003.

These doctors charge fees as high as $10,000 a year, depending on the services promised. Most 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 that the doctor will make home visits, deliver medications and accompany patients on visits to other doctors.

In Kaminetsky's practice of three doctors, all the patients are concierge patients. About 10 percent of the patients are seen free of charge, "scholarship patients" who the doctors decided were in real need of the extra services.

Before 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.

Despite the drastic decrease in patient load, Kaminetsky's personal compensation and the salaries of his office staff members increased by about 60 percent.

This seeming contradiction results from the low per-visit reimbursement rates set by Medicare for primary care office practices. 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.

Charges that concierge practices violate professional ethics 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."

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