Sept. 14, 2007 -- Although most of us balk at the idea of paying even higher rates for health care, a growing number of people choose to shell out hundreds more -- and actually like the idea.
Retainer practices, also referred to as "concierge medicine" or "boutique health care," offer patients a wide range of services, including longer appointments, no wait time and 24/7 access to their physician.
All this comes attached to a hefty price tag -- a yearly fee of up to $1,500 or more.
Despite a report this week in the journal Health Affairs that insurance premiums are rising faster than inflation and wages, many are willing to pay these extra fees. This testifies to how far those who can afford such services are willing to go to avoid frustrating waits and receive first-class care.
But therein lies the controversy.
"This is clearly an example of two-tiered medical practice -- one tier for the wealthy and another for the less financially able," says Dr. Curtis Stine, professor and associate chair of family medicine at the Florida State University College of Medicine in Tallahassee.
Dr. David A. Goldstein, co-director of the Pacific Center for Health Policy and Ethics at the University of Southern California, says that this type of practice "further marginalizes the care that is given to patients who cannot afford it; it risks reducing the available pool of physicians to care for the populace."
However, others say that this model of care allows them to devote more time to their patients.
Dr. Stephen Glasser, an internist in Baltimore, is affiliated with MDVIP, a company that specializes in personalized preventive care. He switched to this model when his former practice became overwhelming.
"We [started] to be in a mode of seeing more and more patients to keep up with the overhead and demands of the practice," he says. "I would see 30 patients a day. I was unable to carry out what I consider to be appropriate care for every patient."
Dr. David DeAtkine Jr., an MDVIP-affiliated internist and endocrinologist in Birmingham, Ala., has also seen an easing of his patient burden in his new practice.
"I see, on average, 10 patients instead of 40," he says. "The national average for an internist [appointment] is seven minutes. My office appointment is 90 minutes.
"I still work hard, but the difference is instead of spending five minutes with 50 people, I've spent an hour with eight people."
Enough Docs to Go Around?
However, in an age when the primary care doctor is already a rare commodity, some worry that concierge practices may further jeopardize the availability of care, since these physicians treat a fraction of the number of patients ordinarily seen by a mainstream physician.
"For every patient in a physician's concierge practice, there may be a few others that needed and did not receive medical care, even though it might have been more rushed or less convenient," says Dr. Greg Anderson, a family medicine physician at the Mayo Clinic in Rochester, Minn.
The thought that health care is just another commodity that consumers can buy more or less depending on their financial ability also concerns some physicians.
"The objection I have is that it is exclusionary," says Dr. John Messmer, associate professor of family and community medicine at Penn State College of Medicine in Hershey, Pa. "It's a model available only to those with the means to pay. Of course, most of life is that way, but health care is different than a house, food or a car."
Physicians in these practices are quick to point to the benefits, however.
"I can't become the kind of doctor that just skims the surface, walks in one door and walks out the other, and that's the limit of my contact with patients," DeAtkine says. "I like taking care of sick people.
"Even though these people are paying for this service out of pocket, I get a lot more love and gratitude from my patients," he says. "The idea that time doesn't translate into benefits amounts to denial."
And even those opposed to the idea can't deny their frustration with their current model of practice.
"The idea of limiting the number of patients managed so as to allow enough time to really be able to spend quality time with them is very appealing," says Messmer. "I would be happy to take time to handle e-mails and long phone calls if I could get paid for my time. That's one thing concierge medicine covers.
"Now, I spend up to four hours a day with messages. I get zero dollars for that. It's free work."
Dr. Mimi Ghosh at Ohio State University Medical Center in Columbus says "many doctors are burning out doing traditional medical care and do not wish to spend countless hours [doing] paperwork."
Do Patients Get What They Pay for?
Despite the extra attention that physicians in concierge practices provide, physicians debate whether this necessarily equals better care.
"When you are able to spend more time with patients, you should be able to better answer questions and address their needs more thoroughly," Anderson says. "Whether that translates into better health is unclear.
"I have never seen any studies comparing, for example, diabetes or hypertension control rates for those practices as opposed to usual medical practices."
DeAtkine, however, believes these practices do offer better care.
"Fifty to 75 percent of known preventive measures don't get done. This boils down to one thing -- time."
And although some doctors maintain that healthier patients may be more inclined to enroll in these boutique practices, DeAtkine says he has found otherwise.
"Some of the sickest people are attracted to this because they know they need the help," he says. "A lot of people join the practice because they know in a regular practice they are a liability."
Patching an Ailing System
Some doctors feel that boutique health care is, simply put, a sign of the times -- one that has emerged to patch the holes inherent in the current health care system.
"It's a shame everyone can't practice this way and all patients can get this type of care, but it's clearly the way medicine should be practiced," Glasser says.
Others hope that this type of attention may one day be extended to all.
"With millions of people not able to afford health care at all and millions more not having enough health care coverage, I think we should have a system that is affordable for all and allows us to practice personal care that covers all that is needed with plenty of time for the patient," says Messmer.