For a little more, the doctor will see you now

'Boutique' plans enrich care for some but exclude many

October 26, 2008|By Tyeesha Dixon and Kelly Brewington | Tyeesha Dixon and Kelly Brewington, and

Diana Moore learned the news through the neighborhood grapevine. Her family's primary-care physician of seven years would no longer accept Moore, her husband and daughter as patients - unless the family paid a $4,500 annual fee.

The physicians at Charter Internal Medicine in Columbia are overhauling the practice, ditching the insurance-dependent model and instead charging a flat yearly fee in exchange for the promise of 24-hour access to doctors, unhurried appointments, home visits and state-of-the-art annual physicals.

Known as "boutique" medicine or "concierge" care, the national trend appears to be sweeping across Maryland as primary-care doctors feel the financial crush of rising costs and low insurance reimbursement rates. Physicians say the model allows them to trim their patient loads and give patients quality care without worrying whether insurance will cover it.

"Primary-care doctors are seeing 30 to 40 patients a day - that's too many," said Dr. Harry A. Oken, who has been with Charter Internal Medicine for more than 20 years. "It's not about the money. It's about having the time to spend with your patients to keep them healthy."

But critics argue that concierge care will exacerbate Maryland's primary-care doctor shortage and force thousands of patients who cannot afford the new fees to be dropped by their physicians. And they say it creates two health care systems: one for those who can pay and another for those who cannot.

"Shouldn't we redesign the care delivery system so that everyone has this kind of access, rather than just those who can afford it?" said Pegeen Townsend, a senior vice president at the Maryland Hospital Association.

Still, as patients weigh the possibility of paying higher costs, some say they understand the bind physicians are in.

"I was so incredibly disappointed, but I can see why they're doing it - the system is so broken," said Moore, 51. She received a six-page letter notifying patients of the shift, complete with a list of frequently asked questions and a "retainer fee agreement" to be returned with a check or credit card number.

An estimated 8,000 to 12,000 people could lose their primary-care doctors this year in Howard County alone, estimates Victor Broccolino, president and CEO of Howard County General Hospital. He said at least eight physicians, including the five at Charter, have told theospital of the change in their practices.

Determining how many Maryland patients are affected by the trend is difficult, since no agency keeps track of boutique practices. But the state medical society and the Maryland Hospital Association think the numbers are growing.

"Doctors have nowhere to turn but to try to find a different business model," said Dr. Ronald Sroka, president of the medical society, known as MedChi. "Some people want more than their insurance company will provide, and some people are willing to pay for this additional service."

Sroka, who practices in Crofton, said that after paying salaries and expenses, he makes about $15 to $20 an hour. He said he's not sure if he can last more than another year or so, working some 80 hours a week to keep up with his bills.

Proponents say boutique practices allow doctors to increase their income while reducing hours and giving patients higher-quality care.

Insurance reimbursement rates for primary-care doctors are lower than for other specialties, Sroka and others point out. That, coupled with Maryland's high cost of living, overhead and insurance premiums, has led many doctors to take on large patient loads to stay afloat. Some are leaving the business.

In 2007, Central Maryland was the only region in the state that had enough primary-care physicians to meet demand, according to a study by MedChi and the hospital association. The statewide shortage is expected to continue through 2015.

"I don't blame them for wanting to manage their lives," Townsend said of doctors choosing boutique practices. "They have been on the treadmill. The plus side is they are still in medicine."

Dr. Peter L. Beilenson, Howard County's health officer and former Baltimore health commissioner, said he understands the frustrations of primary-care doctors. "But I have serious qualms about this trend toward concierge medicine," he said. "It's absolutely critical that we have enough primary-care doctors, and this just compounds the problem."

Charter Internal Medicine began notifying its 9,000 patients this month that starting Jan. 1, it will no longer accept private insurance or Medicare. Rather, the doctors will charge patients $2,000 a year plus $500 for each child ages 14 to 25, a plan the practice calls the "Personalized Health Care Model."

Patients are encouraged to keep their insurance for procedures not covered by the retainer, such as hospital stays, ambulance rides and blood work.

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