Garrison Bliss, M.D., doesn't believe that so-called concierge care has to involve a $4,000 yearly fee.
The Seattle internist charged patients only $65 a month when he opened his practice in Washington state in 1997—one of the first practices in the country to adopt the concierge care model. His current monthly fee is $85. Patients who receive medical services don't get a bill and neither do their insurance companies, he said.
Traditionally associated with high fees and a limited and wealthy patient base, concierge care—now often called “retainer care”—is morphing into a number of different types of practices, according to Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics. So many different types of retainer care have emerged that the trade association for concierge care practices changed its name to “the Society for Innovative Medical Practice Design,” he said.
There is a misconception that retainer care is elitist, that patients don't want to pay for it, and that it's something they can't afford, said Marcy Zwelling-Aamot, M.D., an internist who runs a retainer practice in Long Beach, Calif. The 460 patients who belong to her “choice care” program pay a $1,500 yearly fee—but can pay it in monthly installments. “That's less than what they pay for car insurance, a little more than $100 a month,” she said in an interview.
For patients who cannot afford the retainer, she provides free care in exchange for volunteer work at a 501(c)3 organization such as a cancer foundation. “It really is a nice exchange. Some of my patients have gotten really involved in the volunteer work—one who was volunteering at the hospital called me and said she wanted to work there.”
About 10% of her patients take part in the program.
Dr. Bliss also cares for indigent patients. Those who can't pay the monthly fee fill out a form indicating what fee they can afford. “Whatever their answer is, that's the price they pay,” he said.
From the start, he assumed that 10%–15% of his patients would be indigent, he said.
“If every doctor had 10%–15% of their practices with people who couldn't afford it, that would go a very long way toward solving the problem” of the poor getting health care, he said. Plus, there would be no government programs to supervise the practice, no insurance costs, and no billing involved.
Some retainer practices cater to specific segments of the population. John Levinson, M.D., a cardiologist at Massachusetts General Hospital in Boston, runs a “hybrid” hospital/office-based practice that includes both retainer and nonretainer patients.
“The way my day works is I drive to the hospital at 5 in the morning, see my inpatients until 8 a.m., then have a regular office day,” where he sees patients that are on Medicaid and other types of insurance, and his retainer patients. At the end of the day, he goes back to the hospital to check on in his inpatients.
There are two groups of patients within the small group of 40 retainer patients he sees. Most see Dr. Levinson as their primary care physician. However, a smaller group sees him for cardiac care only. “Some—about 25—use me for primary and cardiology care, and the others are just cardiology patients.”
Those who want comprehensive care pay a higher retainer fee than the cardiology only patients, he said. He would not disclose the fee.
Pediatrician Scott Serbin, M.D., who established a retainer practice for children in December 2004, decided to “tier” his fees based on the age of the child.
Some physicians who spoke with this newspaper said they doubted that any type of retainer medicine would become a major trend.
“It doesn't bode well for medicine, and it smacks of elitism, but in its defense, it is what America has pushed some doctors into doing,” Charles Scott, M.D., a pediatrician in Medford, N.J., said in an interview.
“Without a doubt [retainer] physicians know that there are ethical dilemmas associated with their practices, that colleagues are really scrutinizing them for their ethics,” Dr. Wynia said.
In a recent survey of 83 retainer practices, he found that retainer physicians reported better quality of care and fewer hassles, but they also saw fewer minorities and Medicaid patients, and fewer patients with chronic illnesses than regular practices.
The physician's role “is to provide 24/7 access for our patients—all patients, whether they're on Medicaid, have special health care needs, etc. That's what the medical home is all about,” said Garry Gardner, M.D., a pediatrician in Darien, Ill.