After three years of visits, my primary care physician still didn’t know who I was. During my final appointment, as I sat on the exam table swinging my legs, she barely glanced at me. Instead, she swiveled her desk chair toward her computer monitor and began, in a robotic monotone, to read questions from the screen. I never got around to asking her about several nagging health concerns, because when she finished typing my answers on her clacking keyboard, our time together was up.
I would not have accepted this treatment from another professional—say, my accountant or lawyer. And right then I decided this was not the kind of relationship I wanted to have with my physician. I was fed up with the culture of unavailability. I yearned to put myself in the hands of a persevering detective who would get to the bottom of things, no matter how long it took, and bear witness to a menopausal body so mysterious that at times I swore it belonged to someone else. In short, I wanted a medical home.
Ten years earlier, I’d lost an internist I’d liked and trusted to retirement. Since then, I’d been riding the Blue Cross preferred-provider circuit, delivering my medical records into the hands of one local physician after another—three in quick succession. In my Northern California town, you took what you could get: Several well-established doctors no longer accepted health insurance reimbursement, and others had closed their practices to new patients.
But now I was determined to do better for myself. Opening my Facebook page, I typed a question into the “What’s on your mind?” box: “Does anyone have a terrific primary care doc?” For several days, the comment box remained empty. Then my friend Jennifer wrote back. She’d been a patient of Dr. Mei-Ling Fong’s for more than a decade. Dr. Fong, Jennifer assured me, was a great physician, as well as a true friend. There was just one catch: A few years ago, Dr. Fong had transitioned to a “concierge practice,” which meant that she now collected an annual retainer of $2,100 from each patient. This allowed her to limit the size of the practice and to provide an impressive level of personalized care.
As a self-employed person, I thought this sounded a little too rich for my pocketbook. The fact that I was already shelling out $435 per month for my own health insurance plan was irksome enough; I balked at the prospect of spending even more. Discouraged, I returned to the Blue Cross Web page.
And at first I believed my luck had changed. One doctor, a woman in her early forties, had excellent reviews on Yelp. She accepted my insurance, and although she practiced primary care, she was also board certified in rheumatology, which sounded promising. My perpetually aching joints were one of the nagging concerns I’d never had time to bring up with my previous primary care doctors.
After the receptionist ran my credit card for the $30 insurance co-pay (“get-to-know-you” appointments aren’t free), I learned several things. This doctor, every inch as youthful and attractive as she appeared in her Yelp photo, worked only three days a week. She was, in fact, an employee of the other physicians in the practice, all of whom happened to be orthopedists. This wouldn’t be of much help if I came down with the flu on her day off. At least she was young, I told myself—she’d be there for me as I grew old. But no. As we chatted, she mentioned that within the next 10 years she intended to retire and move to Kauai.
I took my charts with me when I left. It was time to call Mei-Ling Fong and investigate “concierge medicine.”
A Different Medical Model
I learned that concierge doctors are physicians (most practice internal and family medicine) who have rebelled against the pressure cooker conditions typical of primary care: seeing 20 to 25 people a day for only about 15 minutes each and carrying a roster of 2,000 or more patients. Instead, they have set up personalized practices serving far fewer patients (usually 300 to 600) who typically pay a retainer of $1,500 to $3,000 a year—although about 20 percent of concierge doctors charge a lot more, in the range of $15,000 to $25,000. (Spouses usually pay separately, though some doctors offer a family discount, and dependent children under 26 are sometimes covered for free.) Because of that annual fee and a reduction in insurance-related paperwork (fewer patients means fewer forms), doctors are able to reduce their patient load but maintain their income level. Despite the economic downturn, business for concierge doctors is booming. The number of doctors engaged in what is often referred to as “private medicine” has exploded from 146 in 2004 to 2,800 in 2010 and now is estimated, by the American Association of Private Physicians, to stand at 4,400.
The financial aspect of concierge medicine isn’t complicated. For the patient, all the usual costs stay the same; you just add on the doctor’s yearly retainer. In other words, you continue to maintain your health insurance coverage. You foot the bill for your co-pay for all visits except your extensive annual wellness physical, which is typically included in the concierge fee. You’ll be charged for such extras as pretravel vaccinations. If you’re referred to a specialist, you’ll pay the fee set by your health insurance provider. You pay separately for your prescriptions, and you rely on your health insurance to cover what happens in a hospital.
What your retainer does buy is a variety of services and amenities. In most concierge practices, you get a two-hour, comprehensive wellness exam, including lab tests and other screenings. Often included are high-tech medical screenings, such as advanced lipid profiling, a test that goes far beyond the ordinary good-cholesterol/bad-cholesterol measurement. In some situations, the market value of such “free” tests exceeds the cost of the retainer.
Above all, the annual retainer buys you an astounding level of access and attention. You get same-day appointments with little or no waiting. You can text, e-mail or phone your doctor whenever you want, from anywhere on the planet, and he or she is very likely to answer immediately, even if it’s the dead of night. He or she will also customize a long-term wellness plan for you and coordinate all specialist care; the office may even intervene with those evasive preauthorization people at your health plan. If you are rushed to the ER, your electronic medical records will arrive there before you do—and you may find your concierge doctor waiting there as well. Then there’s the intangible payoff: the experience of feeling that someone besides you is deeply interested in your health.
I finished my research on concierge care knowing that this was the kind of treatment I was looking for. I was ready for a road test.
Up Close and Personal
When I called the number Jennifer had given me, Dr. Fong herself answered after the first ring.
Several days later, as I walked through the front door of her freshly renovated suburban office, she greeted me as warmly as if I were entering her home. Dressed in casual cords and a nice sweater, she looked like a college girl, even though she’s 44. Within moments, we were chatting like longtime girlfriends, swapping stories of kids and career paths. Here’s what I noticed right away: There was no professional firewall between us, no “You are the patient and I am the doctor, and you will stand in awe of my white coat.”
For the next hour, we talked about every aspect of my personal and professional life, including the continual stress involved in meeting the deadline for my next book. She understood how difficult it is for us laypeople to navigate the health care system and recognized that it was her job to coordinate care. First, she’d collect all my medical records, bringing the findings of my OB-GYN, my breast surgeon, my orthopedist, my physical therapist and my endocrinologist under one roof. She would study my medical history in detail, and then we would move forward. She would select all my specialists and stay in touch with them. She’d also deal with my insurance provider on preauthorizing any scans, tests or procedures I required. If a specialist ordered a test, or a battery of them, she’d use her judgment, making certain they didn’t duplicate evaluations I’d already had. She would remind me, five times if necessary, to get my mammogram and not dare blow off my next colonoscopy when I turned 60. If I needed to see her—this wouldn’t happen often, because so many things could be handled over the phone—same-day appointments were typical and would never cost more than my $30 co-pay.
As I climbed into my car, I realized I felt cared for in a way that often eludes women in midlife, when the demand to meet the needs of other people—spouses, parents, children and bosses—is unceasing. The annual fee was starting to seem like a sound investment. I needed a partner in health care, a cheerleader who would refuse to let me put myself on the back burner. While I can’t guarantee that every concierge doctor makes patients this comfortable, with Dr. Fong I felt as if I’d planted the seeds of a special and enduring relationship.
From Practicing Medicine to Practicing Wellness
About nine weeks after I signed on with Dr. Fong, I got this article assignment and informed her I was writing about my health care experiences. I don’t believe that affected her treatment of me, but in any case, all the other new concierge patients I interviewed were similarly positive. Sherise Beale, who lives near Philadelphia, said she started having leisurely conversations with her doctor of eight years after she transitioned to a retainer practice: “I’d had migraines for the entire time she was my doctor, but after she went into concierge practice, she could adjust my meds when she needed to without my having to wait three months for an appointment.”
Other patients commented on a shift in emphasis from reactive care to preventive care. Tracey Watson, an attorney who serves as the general counsel for the Utah Education Association in Salt Lake City, went to Dr. Beth Hanlon’s traditional medical practice after it opened in 1993. “It was extremely hard to get an appointment, and when I did, my visits lasted 10 minutes,” Watson recalls. In the months since Dr. Hanlon made the transition, that has totally changed. “It went from ‘Dr. Hanlon, I’m sick, please make me better’ to an opportunity to work with me on long-term goals,” Watson says.
The opportunity for follow-up is particularly useful when it comes to changing risk factors such as smoking and being overweight. Dr. Hanlon recalls a young woman who had been her patient for years before the transition: “Every year she came back five pounds heavier, and every year we had the same discussion about her need to lose weight.” Last April, after examining the woman for the first time in the new concierge practice, Dr. Hanlon told her to come back in three months “10 pounds lighter.” To the physician’s delight, when the woman returned in June, she’d lost 23 pounds. “It was very exciting,” Dr. Hanlon recounts. “She’d quit eating fast food and drinking sweet soda. Her cholesterol had improved, and she was no longer on the brink of diabetes. What changed is that with my concierge practice, I could sit down with her and come up with a definitive plan.”
Some retainer-based doctors take preventive health care much further, setting out on walks with patients, teaching Tai Chi classes in the waiting room, conducting indoor Spinning sessions in a local gym or, in the case of Shari Rosenbaum, a doctor based in Boca Raton, Florida, maintaining an active and lively Facebook page where she posts health tips for her patients and their friends.
The downsides of “on Demand”
Concierge physicians are convinced that the comprehensive two-hour annual physical is a key part of their relationship with their patients. But public health experts have serious questions about whether such microscopic inspection is necessary or even prudent. The U.S. Preventive Services Task Force, an expert panel that reviews medical evidence and delivers recommendations on preventive care, has made itself clear on this matter by advising against annual ECGs for people who do not have chest pain or diagnosed heart disease and by dismissing advanced lipid profiling in favor of a no-bells-or--whistles cholesterol check. A 2009 study from Thomson Reuters Healthcare Analytics noted that the unwarranted use of medical care—-including high-cost diagnostic procedures and lab tests, unnecessary use of brand-name drugs and surgery of unproven value—-accounted for somewhere north of $250 billion in expenditures added to the national health care tab each year.
It’s not that the screenings cost a lot. The problem is what often comes after them, usually as a result of false positives that lead to unnecessary imaging (which not only is expensive but also exposes patients to radiation), biopsies and other invasive procedures. There’s a psychological drawback to this kind of testing as well: Who among us has not anxiously awaited the result of a breast biopsy or pelvic ultrasound that turned out to be perfectly normal?
I considered these questions as I embarked on a comprehensive wellness screening with Dr. Fong. In the end, I decided that for me what happened after those tests would be a good thing rather than a bad thing. In a concierge practice, the tests and screenings don’t get shoved into the back of a file cabinet, as they might in a more rushed traditional practice. Instead, the data would be considered in the context of my lifetime wellness plan, initiating and encouraging an ongoing conversation about wellness goals. So, in addition to having tests like the advanced lipid profiling, I filled out a comprehensive questionnaire about diet, anxiety, sleep and sexual dysfunction. For me, the result of the wellness exam was not a lot of unnecessary, expensive tests; it was an action plan that would help me improve my overall health in the months that followed.
Proponents of concierge medicine argue that this kind of practice can actually save the system money. Typically, wellness exams devote most of the two hours to establishing extensive baseline measurements of how your body functions when it’s healthy. Having those baselines might eventually spare you hospitalization for, say, chest pain. If you go to an ER, this kind of symptom often leads to hospitalization, which may be unnecessary, expensive and inconvenient. Having a baseline ECG on hand can help resolve the question of whether this is indeed an emergency, sparing you an overnight stay, notes Las Vegas concierge physician Candice Tung.
Keeping people out of the hospital can save money for the federal government, which picks up the tab for Medicare-patient hospitalizations. According to a 2010 study commissioned by MDVIP, the largest of the consulting companies that help concierge doctors manage their practices, Medicare patients cared for by -MDVIP physicians were hospitalized 79 percent less frequently than Medicare patients cared for by physicians in conventional practices. And -MDVIP patients under 65 who were covered by commercial insurance were in the hospital 72 percent less often than patients in conventional practices. If these figures represent concierge practices in general, they suggest that this form of personalized medicine may actually discourage overutilization of hospital services.
A New Class System
Individualized care may feel like a huge improvement for patients who can afford it, but what about those who can’t? Many researchers and public-policy experts say doctors who limit their practices to patients who can afford an annual fee create a two-tier system, a “wealth care” some find ethically dubious.
Every doctor who transitions to a concierge practice leaves behind patients who can’t afford to come along, raising the ethical issue of “patient abandonment.” Critics note that when freshly minted physicians take the modern Hippocratic oath, they vow to “treat without exception all who seek [their] ministrations.” In other words, an ethical doctor can’t just walk away, letting the chips fall where they may. It is a transitioning physician’s duty not only to suggest other doctors for patients who do not take the concierge route but also to make certain that -patients are not unleashed on a community without enough practitioners to absorb them.
The latter is a major issue, notes Dr. Jay Jacobson, an internist and professor emeritus at the University of Utah School of Medicine. “If an individual who is responsible for 2,000 patients quits a practice, taking only 300 of those patients along, that leaves 1,700 patients for the partners who remain in the practice to divide among them,” he says. “Unless those doctors weren’t very busy, which would be unusual, some—or many—of those patients will have a prolonged search for a new physician and in the meantime may wind up in the ER for routine problems.” For this reason, many concierge doctors dedicate 10 percent or more of their practice to “scholarship patients,” the sickest and most dependent people from their traditional practice. But no one believes that people are never left behind.
Public health experts also worry that concierge medicine limits the general public’s access to primary care physicians, which inarguably it does. Primary care doctors, underpaid and overworked relative to specialists, are already in short supply. More than a quarter of today’s primary care physicians are 56 or older and will probably retire within a decade. There are not nearly enough primary care doctors in the pipeline to replace them. One medical group estimates that in 2015 the country will have 62,900 fewer doctors (in all specialties) than needed.
And if it’s hard to find a new primary care doctor now, expect things to get worse. While I was writing this article, the U.S. Supreme Court announced its decision to uphold most provisions of the Patient Protection and Affordable Health Care Act. Assuming the law is fully implemented by the federal and state governments, it will open the door for health insurance to 30 million patients who are currently not covered.
The Bottom Line
I asked my go-to ethics guy—Arthur Caplan, head of the division of medical ethics at NYU Langone Medical -Center—for his take on concierge medicine. From a public-policy standpoint, he doesn’t like it. “Concierge medicine is a symptom of not having enough primary care doctors,” he states. “Our standard of care has just collapsed. Now you’re being asked to pay for what you once expected as routine, like having the doctor return your call or not keep you waiting an hour in the office.”
But the medical system doesn’tfunction the way it should. So for many of us, the $1,500-to-$2,100 annual retainer makes sense, even if we have to sacrifice some other purchases to pay for it. Sylvia Sanchez Lindsey, a patient of Dr. Tung’s who recently retired after many years in human resource development in Las Vegas, has made that calculation.
When Lindsey experienced a violent allergic reaction to a sulfa drug prescribed after cosmetic surgery, her husband got on the phone with Dr. Tung shortly before midnight. By the time Lindsey, now in a coma, reached the hospital by ambulance, Dr. Tung had already had her records delivered there, which was hugely helpful to the attending physician. Lindsey feels that this kind of possibly lifesaving assistance is worth the cost. “If you break down the fee,” she told me after her recovery, “it comes to about $125 a month. We all have choices about how we spend money, and this is mine.” Choices, of course, assumes discretionary income, a luxury not every American enjoys.
My first visit with Dr. Fong occurred on March 15, barely half a year ago. To get a sense of how the relationship has unfolded, I counted the e-mails we’d exchanged. There were 75. After a few months with her, I realized I was solving problems without racking up extra doctors’ bills. I was no longer racing to the acupuncturist out of frustration over not being able to get to see my primary care doctor about my bronchitis. I did not need to visit the allergist for hay fever or the dermatologist for a rash, because these are things that a primary care physician is perfectly capable of handling. (See “How Much Does It Really Cost?,” for my conclusion about the net effect of concierge medicine on my bank balance.)
When I had a problem, I e-mailed Dr. Fong—actually, Mei-Ling and I were on a first-name basis—and she’d tell me what to do. For example, I was concerned about what seemed like a never-ending menstrual cycle. At one point, Dr. Fong sent me several well-crafted paragraphs describing how a deeply confused menopausal uterus and ovaries might behave and what she thought we might do about mine. After a very expensive pelvic ultrasound that showed nothing worrisome, she referred me to a gynecologist in San Francisco who focuses on menopause management and also takes my Blue Cross PPO. Dr. Fong made the appointment for me and sent the specialist a detailed chronology of my reproductive issues.
He suggested I try a CombiPatch, a transdermal hormone-therapy patch that contains both estrogen and progestin, which are continually released into the skin and the bloodstream. The next day, Dr. Fong and I talked it over. Because I had no risk factors—no breast cancer or heart disease—she thought I should give it a try.
Two days later, Dr. Fong texted me to see how I was faring. I was happy to tell her that at least for the moment, my female troubles were entirely resolved.
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CATHRYN JAKOBSON RAMIN’s next book, out in 2013, is The Fragile Column: How to Beat the Back Pain Industry at Its Own Game.