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Doctors on retainer catch on: a new model driven by doctors dissatisfied with traditional managed care catches on with the few who can afford it. Not surprisingly, the model has begun to attract closer regulatory scrutiny.

What would it be worth to you, if you never had to wait for an appointment with your doctor or sit around in the waiting room? What would it be worth if you received exhaustive preventive care year in and year out? How much would you pay if you could summon your doctor 24 hours a day, seven days a week to your house for a call? Would you pay $100 per month more for such premium care? How about $1,000 per month? Maybe even more?

These are price points in a small but now well-established niche of health care called retainer medicine. And patients buying these higher levels of personal care have been renewing on a better-than-90-percent annual basis in many practices.

Also known as concierge or boutique medicine, the approach arrived in the late '90s and has grown slowly but steadily. Just as recent years have been good for other products and services aimed at the affluent, so these years have supported the establishment or conversion of an estimated several hundred physician practices nationwide to a contractual form of old-fashioned medicine.

Internists and family practitioners in retainer practices give their patients better access and more time and personal care, offering:

* Patient-to-physician ratios that are a fraction of those in managed-care practices.

* Executive-health-type services, such as comprehensive physicals.

* In-hospital advocacy and better coordination of specialist care.

* Various types of in-office testing as part of the fee.

* In some cases, the plush surroundings of "medi-spas," incorporating alternative or cosmetic care.

* And (because the doctors know their patients better) consultations, prescriptions, and advice over the phone more readily.

In turn, doctors using this model claim that they have regained control of their lives and their practices. They say they are sick of battling health plans and tired of having to squeeze more patients into their schedule to stay financially viable.

Retainer medicine has spread beyond select markets on the east and west coasts. Boca Raton-based MDVIP has helped to set up about 60 physicians in retainer-medicine franchises in 10 states--offering the doctors expensive assistance in transitioning to, maintaining, and building such practices. Using the MDVIP identity as part of their marketing, the practices agree to a maximum of 600 patients per physician and a charge of $125 per month, per person. (Primary-care physicians in conventional practices typically have thousands of patients each.)

"Our doctors develop an individual wellness plan for each patient and work to keep them on track with it, like a wellness coach," explains Darin Engelhardt, CFO and general counsel for MDVIP.

The Lewis and John Dare Center at Virginia Mason Medical Center in Seattle was the first retainer practice created at, and by, a large hospital medical center. At three locations now, Dare physicians charge $250 per month, per person (pro-rated for additional family members) and accept no more than 300 patients each.

MDVIP assisted with another milestone recently when it helped to open a concierge, primary-care practice at Tufts-New England Medical Center, the first such practice at a major academic medical center. And, finally, at the highest end of the cost spectrum is [MD.sup.2] . (For more information on [MD.sup.2], please turn to page 23.)


Most retainer-medicine practices also charge their patients' health care insurance for office visits. Unless they've priced themselves into the platinum zone, retainer physicians do this to maintain or boost their income. But insurance companies, legislators, and especially Medicare regulators have questioned this practice over the last half-dozen years.

Retainer practices may be deemed to be charging for physician accessibility or other services considered paid for by third parties. The Centers for Medicare and Medicaid Services (CMS) continue to look at the propriety of retainer medicine and have reviewed some offices, including those of MDVIP. Members of Congress have looked at bills to prohibit retainer-based physicians from contracting with Medicare at all. Furthermore, the Government Accountability Office is currently visiting retainer practices across the country to so see if Medicare patients are disadvantaged by them in any way. (The American Society of Concierge Physicians offers a report to the GAO at http://www.concierge

"There are concierge models out there that are not legal," says Engelhardt, whose MDVIP doctors, like others, have had to be cautious about how they promote and market themselves. MDVIP's position now is that retainer charges cover only additional preventive care and not additional access to the doctor.

"That and the time to implement the results of a total physical exam are the added benefit and what differentiates MDVIP," says Engelhardt, who prefers the term "personalized preventive care" over the terms "retainer or concierge medicine."

"Access is a difficult thing to define, but if the type of availability we give to these patients gets defined as standard, covered access, and thus a requirement, you'll see the rest of the doctors in the country finding another profession," says the Dare Center's John N. Kirkpatrick.

But some practices have drawn an even safer line, advertising only better amenities. It remains to be seen whether such spin control solves the problem, because retainer patients clearly do get better access and care.

There are other practical issues:

* When a medical practice accepts money for services that may be needed in the future, is it actually selling an insurance policy--in effect setting up a small, outpatient HMO? State insurance agencies are studying the question. Will they impose a fee on retainer practices?

* Doctors transitioning from a conventional practice to a retainer-based practice must make sure that patients opting out are not abandoned.

* Hybrid practices that try to mix retainer and nonretainer patients have greater exposure to claims of inequity of care.

"A lot of medical practices contact us about going to a retainer setup, but most of them end up backing off," says Vasilios (Bill) Kalogredis, president of Kalogredis, Sansweet, Dearden and Burke Ltd., a boutique, health care law firm in Wayne, Pa.


A broader question is whether retainer medicine, especially if it gained much greater penetration or became a model for changes in the wider system, simply adds more costs to health care.

Proponents respond thusly:

* Retainer medicine can be seen as an expansion of supply, with more primary-care doctors distributed among the same number of patients. National goals for quality in medicine depend in part on the amount of time patients spend with primary physicians, which in turn can control costs. MDVIP cites data indicating that its hospitalization rates are significantly lower, and its compliance rates for guidelines on disease management are significantly higher than national averages.

* Thus, the model shifts more cost into prevention, which is what many experts have been recommending for the system.

* Retainer physicians cannot give carte blanche to clients' use of medical services, as those are still managed by the third-party insurer.

"Insurers had some philosophical objections, but some have turned around after seeing our HEDIS scoring and our hospitalization rates," says Engelhardt, who notes that some employers are now funding retainer care as a benefit or approving it as expenditure from flexible spending accounts.

And what about clinical skills? Physicians stay sharp partly as a result of seeing patients with a variety of conditions. Will they remain so if they are seeing fewer patients? Some retainer doctors say that only now do they finally have time to keep up with new medical developments.

Retainer doctors must also still satisfy their ethical duty to provide some indigent care. Those at hospitals and medical centers may do so by simply providing a profitable revenue stream to an institution that gives away substantial unpaid care each year.


Retainer medicine, which after all affects a very small portion of people who have access to health care, casts an important light on critical issues in health care, not the least of which is physician dissatisfaction.

Although an AMA study group referred to retainer practices as offering "nonmedical or medically non-necessary services," the association does not oppose the model, citing its long-standing support of pluralism in the financing and delivery of health care-and the right of physicians to contract privately without government interference. In a report, the AMA group also considered growth of the model to be inherently self-limiting due to its economics.

"We don't feel that most practices could do this," says Engelhardt. "Most patients feel they are already paying for what they need, and a lot of doctors aren't interested in making themselves available to patients to this extent. It's for a smaller group that wants this relationship."

Is retainer medicine just another phenomenon reflecting the top-heavy stratification of our society? After all, most business sectors catering to the wealthy have done well in recent years. "The economic status of patients is far less of a factor on who will join our practices than we believed," says Engelhardt. Most retainer physicians operate out of small group practices so each physician doesn't have to give up the gains that he or she has made on time demands by personally being available 24/7. "The does who switch to this model and are successful are motivated out of a desire for professional satisfaction. They are less likely to do well if going after it for the money," says Engelhardt. And clearly, retainer medicine has met a demand that practices with fees set by third parties cannot. Poponents say the notion that it creates two tiers of coverage misses the point that there have always been tiers of quality in the system, offering people the option to pay for more.

"This is the kind of medicine that I thought I'd be practicing when I went to medical school," says Kirkpatrick. "I like not having to apologize to patients for not having enough time. And I love making house calls and visiting people in their own environment, where they are often very surprised to meet a happy doctor."

RELATED ARTICLE: Delivering services fair and squared.

Jon Moses believes that being in a conventional medical practice almost cost his wife her life, when her care was rushed, and her doctors overlooked cancer that had progressed. As CEO of [MD.sup.2] International LLC., Moses needs only to recall that as a reminder of why he goes to work each day.

Initially established in Seattle in 1996, [MD.sup.2] is most often cited as the first and most exclusive retainer practice. Now operating out of three locations, [MD.sup.2] bucks the usual definition of a "busy" (and therefore successful) practice, with each of its physicians restricting themselves to no more than 60 clients or families.

[MD.sup.2] promotes itself as providing care of "the highest quality and the greatest availability for the most discerning and limited number of patients." The average retainer paid per patient is about $10,000 per year, and the group does not charge third-party payers. "We don't do any billing," says Moses.

Experts agree that this is the safest approach, in terms of legalities and regulations, for retainer practices.

"I have a similar client who has the drawing power to create this kind of carriage trade--a breast surgeon who lost half his practice when he went retainer but has the same income as before," says Vasilios (Bill) Kalogredis, president of the boutique health care law firm of Kalogredis, Sansweet, Dearden and Burke Ltd.

[MD.sup.2] says its doctors serve as private advisors who stand between the patient and the complex and intimidating medical world. "Our physicians are more able to be physicians--to exercise their skills and intellect on behalf of their patients," says Moses. "We are not in any way motivated by the insurance industry or what its executives think or dictate. We don't work with insurers and we don't care what they think."

--Russ Allen

RUSS ALLEN, a Pennsylvania-based freelance writer, is a frequent contributor of health care-related stories to Risk & Insurance[R]. He can be reached at
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Title Annotation:Benefits
Author:Allen, Russ
Publication:Risk & Insurance
Date:Mar 1, 2005
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