1 2 next Diana Moore learned the news through the neighborhood grapevine. Her family's primary-care physician of seven years would no longer accept Moore, her husband and daughter as patients - unless the family paid a $4,500 annual fee.

The physicians at Charter Internal Medicine in Columbia are overhauling the practice, ditching the insurance-dependent model and instead charging a flat yearlyfee in exchange for the promise of 24-hour access to doctors, unhurried appointments, home visits and state-of-the-art annual physicals.

Known as "boutique" medicine or "concierge" care, the national trend appears to be sweeping across Maryland as primary-care doctors feel the financial crush of rising costs and low insurance reimbursement rates. Physicians say the model allows them to trim their patient loads and give patients quality care without worrying whether insurance will cover it.

"Primary-care doctors are seeing 30 to 40 patients a day - that's too many," said Dr. Harry A. Oken, who has been with Charter Internal Medicine for more than 20 years. "It's not about the money. It's about having the time to spend with your patients to keep them healthy."



But critics argue that concierge care will exacerbate Maryland's primary-care doctor shortage and force thousands of patients who cannot afford the new fees to be dropped by their physicians. And they say it creates two health care systems: one for those who can pay and another for those who cannot.

"Shouldn't we redesign the care delivery system so that everyone has this kind of access, rather than just those who can afford it?" said Pegeen Townsend, a senior vice president at the Maryland Hospital Association.

Still, as patients weigh the possibility of paying higher costs, some say they understand the bind physicians are in.

"I was so incredibly disappointed, but I can see why they're doing it - the system is so broken," said Moore, 51. She received a six-page letter notifying patients of the shift, complete with a list of frequently asked questions and a "retainer fee agreement" to be returned with a check or credit card number.

An estimated 8,000 to 12,000 people could lose their primary-care doctors this year in Howard County alone, estimates Victor Broccolino, president and CEO of Howard County General Hospital. He said at least eight physicians, including the five at Charter, have told theospital of the change in their practices.

Determining how many Maryland patients are affected by the trend is difficult, since no agency keeps track of boutique practices. But the state medical society and the Maryland Hospital Association think the numbers are growing.

"Doctors have nowhere to turn but to try to find a different business model," said Dr. Ronald Sroka, president of the medical society, known as MedChi. "Some people want more than their insurance company will provide, and some people are willing to pay for this additional service."

Sroka, who practices in Crofton, said that after paying salaries and expenses, he makes about $15 to $20 an hour. He said he's not sure if he can last more than another year or so, working some 80 hours a week to keep up with his bills.

Proponents say boutique practices allow doctors to increase their income while reducing hours and giving patients higher-quality care.

Insurance reimbursement rates for primary-care doctors are lower than for other specialties, Sroka and others point out. That, coupled with Maryland's high cost of living, overhead and insurance premiums, has led many doctors to take on large patient loads to stay afloat. Some are leaving the business.

In 2007, Central Maryland was the only region in the state that had enough primary-care physicians to meet demand, according to a study by MedChi and the hospital association. The statewide shortage is expected to continue through 2015.

"I don't blame them for wanting to manage their lives," Townsend said of doctors choosing boutique practices. "They have been on the treadmill. The plus side is they are still in medicine."

Dr. Peter L. Beilenson, Howard County's health officer and former Baltimore health commissioner, said he understands the frustrations of primary-care doctors. "But I have serious qualms about this trend toward concierge medicine," he said. "It's absolutely critical that we have enough primary-care doctors, and this just compounds the problem."

Charter Internal Medicine began notifying its 9,000 patients this month that starting Jan. 1, it will no longer accept private insurance or Medicare. Rather, the doctors will charge patients $2,000 a year plus $500 for each child ages 14 to 25, a plan the practice calls the "Personalized Health Care Model."

Patients are encouraged to keep their insurance for procedures not covered by the retainer, such as hospital stays, ambulance rides and blood work.

Oken, who has been with the practice since 1985, said the group struggled with the decision for years. The doctors finally decided this summer when Medicare announced a cut in reimbursement rates.Advocates of boutique medicine say the premise harks back to the days when family doctors made house calls and had bonds with generations of patients. That level of personalization allows doctors to focus on prevention and early detection of disease, said Dr. Edward E. Goldman, founder of MDVIP, a Florida-based company formed nine years ago that has become a leader in organizing
Nationwide, there were 146 doctors in 2005 with concierge practices, according to a report by the Government Accountability Office. While current national figures are not available, MDVIP alone says it has 260 doctors in 24 states and Washington, D.C., serving roughly 90,000 patients. In Maryland, 24 doctors are affiliated with the company.

Patients pay $1,500 a year and receive a wellness plan, a wallet-sized CD of their medical history and an hourlong physical with EKG and lab tests.

While some critics question the ethics of high cost of such care, Goldman argues that the current health care system does a disservice to patients.

"Traditional practice right now is totally geared toward the treatment of illness," he said. "For those patients who want what the system does not offer, shouldn't they be given the choice? When I know I am not managing your Type 2 diabetes because I only have 10 minutes and God forbid you end up blind or amputated as a result, something is wrong with the morality of that approach and the ethics."



He said the nation's health care already has multiple tiers, comprising the uninsured and those covered by HMOs, Medicare and other options. "We think this is the system that the U.S. should have for primary care, period," he said.

Dr. Joseph Zebley, a member of MDVIP, switched his Baltimore practice to the boutique model three years ago. He said he reduced his patients from 2,500 to 600 and limits the number he sees to 15 a day.

"I have more time to practice medicine, and therefore my workload is much less and my income is more," he said. "When I depended on third-party payers for revenue, I never knew if I was going to be able to make payroll."

Zebley said he can now spend as much time with a patient as required, without worrying whether the insurance company will cover the visit. "You need time to get to know people as people," he said. "You can't do that in 7 1/2 minutes."

Longtime patients Honor and Bill Branch were determined to continue seeing Zebley. "The health care system in this country is an abominable mess," said Honor Branch, 67. "We certainly are not wealthy, but I feel that we are choosing to spend our money to have the best health care that we can."

She said always found Zebley attentive, but when he adopted a boutique practice, there was even more time during appointments to pepper him with questions. She has called him on his cell phone during emergencies and made same-day appointments. And when she was diagnosed with breast cancer last year, Zebley, who was out of town at a conference, called her at home to discuss the results and the course of action.

"I thank God that I have the doctor that I have," Branch said.

But patients like Kathy Andersonof Ellicott City are outraged at the thought of their doctors switching to a boutique model

"I just think it's morally wrong," said Anderson, a data clerk at Mount View Middle School in Marriottsville. She said her daughter and son-in-law also see the same doctor. "If I went in, I would be condoning this type of practice," Anderson said, noting that her daughter, who is in her 20s, would not be able to afford the extra expense. "I would be giving myself access at the cost of my daughter not having access."

As for Moore, she says she would prefer the new system, but doesn't know if her family can afford it.

"We have to sit down and talk about it," she said.

previous
[Edited 10/26/08 12:26pm]