By David Lazarus
San Francisco Chronicle
Sunday, January 8, 2006
David Ogden, a doctor in Marin County’s affluent Greenbrae, says he wants more time to spend with his nearly 3,000 patients, and he knows his patients want more face time with him.
Ogden’s solution: a $2,400 annual retainer to be paid by “several hundred” patients who want round-the-clock access to his expertise, no waiting for appointments, plus more leisurely visits with him in the examining room.
Everyone else — in other words, at least 2,000 current patients — will no longer see Ogden during routine checkups or for most ailments. Instead, they’ll have to make do with a nurse practitioner.
This is the latest trend in health care — variously called “concierge medicine” or “boutique medicine.” For an additional fee, patients receive more access to, and attention from, their physician, on top of the normal cost of treatment.
For those who can’t (or won’t) pay the extra charge, health care can be less convenient, less comprehensive and possibly less skillful. And that’s if the concierge doctor will still accommodate patients who aren’t paying retainers.
Most of the estimated 200 concierge doctors nationwide are making such people look elsewhere for primary care. Ogden is one of a relative few attempting to maintain a full practice through expanded use of nurse practitioners.
“This is about spending more time with patients,” he told me. “It’s what I want, and it’s what my patients want.”
Perhaps, but most apparently don’t want to pay thousands more each year for the privilege.
Ogden said he notified most of his patients shortly after Thanksgiving about the switch to what he prefers to call a “retainer practice.” As of last week, only about 1 percent had signed up for the new service.
“I’m very encouraged by the response so far,” Ogden said.
Gordon Schiff, a founder of Physicians for a National Health Program and a doctor at Chicago’s Cook County Hospital, responded that there’s little encouraging about concierge medicine. At least from a patient’s point of view.
“They should resent this,” he said. “Many of the things that doctors are saying they’ll do under concierge medicine should already be expected by patients. It shouldn’t be a privilege that you have to pay extra for.”
In-depth meetings with physicians, personal calls with test results, ready access to treatment — these should be staples of all medical practices, Schiff said.
“Concierge medicine is inherently discriminatory,” he observed. “Poor people will be treated differently from rich people, probably worse.”
But Schiff acknowledged that the U.S. health care system is so dysfunctional that most doctors are prevented from providing concierge-level service to all patients. It’s impossible when a physician is churning through 20 patients a day so he or she can reap sufficient returns from insurers.
This was Ogden’s situation. He said most visits with patients had to be limited to just 15 minutes so he could squeeze in as many as possible during an eight-hour shift.
“It’s not how I want to practice medicine,” Ogden said.
On the other hand, being restricted for the most part to seeing a nurse practitioner, and not their primary-care physician, is probably not what most of his non-retainer patients want either.
Worse, it might violate guidelines laid out by the American Medical Association, which determined in 2003 that concierge medicine raises “ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care.
“Physicians who engage in mixed practices, in which some patients have contracted for special services and amenities and others have not, must be particularly diligent to offer the same standard of diagnostic and therapeutic services to both categories of patients,” the association concluded.
“All patients are entitled to courtesy, respect, dignity, responsiveness and timely attention to their needs.”
This is why a Florida company called MDVIP, the leading force in concierge medicine, requires participating doctors to shift all non-retainer patients to other physicians.
“The hybrid approach with nurse practitioners is questionable,” said Darin Engelhardt, MDVIP’s chief financial officer. “If you’re providing priority to some patients, that could be detrimental to others.”
MDVIP accounts for about half of all doctors now practicing concierge medicine nationwide. The company essentially helps a physician get a concierge practice up and running. In return, it gets $500 of the doctor’s annual retainer, which typically runs $1,500.
Tommy Thompson, who until January 2005 served as President Bush’s secretary of health and human services, is on MDVIP’s payroll. He’s chairing a committee on preventive medicine.
Engelhardt confirmed that Thompson is being compensated for his role with MDVIP but declined to specify how much he’s being paid.
In 2002, Thompson was asked by members of Congress to clarify the government’s position on concierge medicine in general, especially as it relates to Medicare patients, and on MDVIP’s operations in particular.
Thompson responded that “it is not clear that such annual retainer agreements necessarily violate the law” and that “physicians may proceed with agreements of this type,” thus providing concierge doctors with the administration’s legal blessing.
Thompson didn’t address the lawmakers’ specific questions about MDVIP.
Engelhardt disputed critics’ charges that concierge medicine is responsible for a tiered health care system. He said managed care has already created different levels of service for patients.
“In a perfect world, the services provided by MDVIP physicians would be available to everyone,” he said. “The market reality precludes that.”
At Chicago’s Cook County Hospital, Schiff said, he can sympathize with doctors wanting to spend more time with patients. But he questions the ethics of any physician who demands more money for preferential treatment.
“If medicine is a public service and we’re here to take care of everyone, you don’t limit yourself to people who have money,” Schiff said. “Most people expect to be treated based on need, not on how much money they have.”
In Greenbrae, Ogden said, he feels comfortable that all his patients — retainer-paying and otherwise — will receive appropriate care.
“If someone needs me, I’m here,” he said. “I’m still a doctor.”
And, increasingly, a businessman.
David Lazarus’ column appears Wednesdays, Fridays and Sundays. Send tips or feedback to dlazarus@sfchronicle.com.
