Gold-card healthcare: Is it boon or bane?

Doctors who offer 'concierge' service for a fee tout closer ties to their patients. Critics, though, say tiers of care raise issues of equity.

Duck inside Pratt Diagnostic Clinic in Boston and you'll find a cozy lobby with wood accents and stuffed sofas. There's coffee and pastries for those who'd like a snack, and the staff is cordial and businesslike. Can this quiet, uncrowded place really be a doctor's waiting room?

That's just what it is - though the serene ambiance comes with a price tag. For a $1,800 annual fee beyond what health insurance or Medicare pay, patients receive amenities such as 24-hour access to their physician by pager or cellphone, a promise of same- or next-day appointments, no more than a 15-minute wait to see the doctor (leaving little time to enjoy the plush waiting room), physical exams that include extra tests - and even a personal CD-ROM of their health records.

Among the hundreds of thousands of doctors in the United States, perhaps only several hundred are "concierge" or "boutique" physicians. But those in the field say interest in this sort of practice is rising - both from doctors who want to spend more time with patients and from patients who want a higher level of medical service than they feel they get under Medicare or private health insurers.

Of course, concierge practices can't claim to offer better medical care - not if they want to remain eligible to receive money from Medicare or private insurers, who expect all doctors to provide high-quality care. So rather than emphasizing basic services, they play up the extras and amenities.

If this trend picks up, some observers worry American healthcare could move toward a three-tiered system: high-quality care for those who pay extra, less-than- optimum service for those covered by ordinary private or government insurance programs, and spotty healthcare for the more than 40 million Americans without health insurance.

"It makes it look like America is becoming less equity-oriented and more market-oriented in that people with money will get more [healthcare] faster, and people without it will face more barriers," says Dr. Robert Blendon, a professor of health policy at Harvard University's School of Public Health. "It moves further from the original Medicare idea that everybody would be treated the same with a Medicare card."

The idea of those with means paying more for better healthcare is expanding around the world, Dr. Blendon says, with the exception of Canada, where that approach is illegal. In countries that provide national healthcare, about 15 percent of people opt to pay for additional insurance to receive extras like private hospital rooms or faster elective surgeries, he says.

Those setting up concierge practices in the US say they're not neglecting the poor but rather responding to patients' demands for a bit more "Marcus Welby"-style personal care in modern medicine.

"The current model of healthcare delivery, particularly in the primary-care setting, is dysfunctional, to say the least," says Dr. John Blanchard, president and cofounder of the year-old American Society of Concierge Physicians in Grand Rapids, Mich. Patients today have begun to "feel like a number," he says. "You're shuttled through offices like cattle. This is not the way healthcare was designed. The quality of healthcare is based largely on the integrity of the patient-physician relationship - and that relationship breaks down in a high-volume healthcare setting."

At Pratt, a nonprofit practice that introduced the concierge concept in December, patient fees don't line the pockets of its doctors. Instead, profits will be plowed back into the operating deficit of Tufts-New England Medical Center (NEMC), the money-losing teaching hospital that it is part of. So far, Pratt has about 250 patients and would need 400 or more to turn a profit.

Two hundred years ago, Tufts-NEMC was known as the Boston Dispensary, which treated the wealthy for a fee and used that money to subsidize care of the poor, says Dr. Deeb Salem, the hospital's chief of medicine, who hopes to use the concierge concept in the same way today. Now visitors from other teaching hospitals are coming to see how Pratt is doing it, he says.

For Pratt patient Kim Sawyer, knowing that profits will be "going back to help an academic hospital which is suffering tremendously in the current financial environment" was crucial to her decision to join, she says. As a principal at a small financial services firm, "I have an absolutely crazy, crazy work schedule," she says. Now she can easily reschedule a doctor's appointment and know that, when she arrives, she'll be seen quickly and then can get on with her day.

She fits the profile of many of Pratt's clients, says Dr. Bruce Cohen, who heads the clinic's four-doctor team. Other patients have complicated medical histories and want to make use of the extra time for consultation. Others are interested in wellness programs and learning about steps they can take to prevent illnesses.

None of the Pratt doctors has abandoned previous patients or demanded that their patients join Pratt. Dr. Cohen spends about half his time seeing his 1,200 regular patients and the other half on 85 Pratt patients (Pratt hopes that number will grow to 250 to 300 patients per doctor). He schedules 30 to 40 minutes for a physical exam for his regular Tufts-NEMC patients and an hour (or more if needed) for his Pratt patients. "It is very nice to have a little more time with the patient and occasionally you pick up something [about them] that you otherwise might not have picked up," he says.

Pratt belongs to MDVIP, a marketing service for concierge physicians. The company in Boca Raton, Fla., has about 50 member physicians and is adding three or four a month, says Wayne Lipton, MDVIP's senior vice president.

It also counsels members how to stay out of legal trouble with Medicare. In a March 31 alert, the Office of the Inspector General (OIG) of the US Department of Health and Human Services warned doctors against charging extra for services already covered under Medicare. In one case the OIG cited, a physician charged $600 per year to provide patients with "coordination of care with other providers ... a comprehensive assessment and plan for optimum health ... and extra time" with patients. He was forced to pay a settlement to OIG and discontinue the fee.

Some healthcare analysts say patients should not have to pay extra for doctors' attention. "It can rightly be argued that [doctors] should be giving us attention anyway," says Becky Derby, a policy analyst at Health Care for All, an advocacy group in Boston. Health Care for All is backing a bill now under study in the Massachusetts legislature that would prevent concierge practices from treating patients who are members of health maintenance organizations (HMOs).

But Dr. Blanchard believes more and more doctors will find concierge practices attractive. Inflation-adjusted real income for primary-care doctors dropped 6.4 percent between 1995 and 1999, according to the Center for Studying Health Care Change in Washington, and the alternatives are either to charge more or see more patients.

"The doctors out there aren't trying to line their pockets, I can tell you that," Blanchard says. "We went into [medicine] because of the physician-patient relationship we build with patients. Frankly, I think many physicians have had it [with overburdened practices]."

Instead of neglecting the poor, he says, concierge doctors are more likely to have the time and income to take on nonpaying patients. His own concierge group spends one-third of its time on pro bono work, he says.

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