Gold-card healthcare: Is it boon or bane?

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.

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