Doctors Opt for Retainer Practices to Serve Rich - NYTimes.com

Five years ago, Steven L. Glazer, an internal medicine doctor in Norwalk, Conn., told his thousand patients that he would no longer be able to care for them because he was going to focus on only a dozen, wealthy patients who could pay his annual fee.

With that he entered the world of concierge medicine, a growing subset of medicine where patients pay doctors anywhere from $1,500 to $25,000 a year to receive personalized attention and care. (Dr. Glazer said he was paid toward the top of this range.) In most cases, patients presume that in an emergency their concierge doctor will push them to the front of the line to see a top specialist.

Even as more people are struggling to pay medical bills and being rushed through office visits with their doctors, an elite group with money has another option: exclusive medical care, around the clock and anywhere in the world, including on a yacht or private plane.

One of Dr. Glazer's clients, for instance, has had his yacht outfitted with a system from Guardian 24/7, a company in Leesburg, Va., founded by former White House doctors that advertises itself as offering "medical protection previously available only to the president of the United States." The company's "ready room" will allow a doctor trained in the system to perform basic medical care remotely if something should go wrong while the patient is on the high seas.

"There is very little that we can't do with the triage room on their yacht," he said.

The cost of Guardian 24/7's services ranges from $6,000 to $12,000 a month, plus an additional $700,000 for one of the company's top-of-the-line "ready rooms" installed in a client's home, yacht or airplane, said Jonathan Frye, chief executive.

While it is difficult to determine how many people are served by this more personalized care, the number of doctors who have moved to this new model has risen fivefold in the last five years. And that raises questions about medical care in America. For those who can afford it, what do they get for their money? Is it worth it? And for the rest of us, who cannot afford this level of care, is it fair and ethical for doctors to be doing this? Or is concierge care contributing to the growing gulf between the wealthy and everyone else?

COSTS AND BENEFITS Concierge medical care is nothing new. In places like Florida, with a high concentration of Medicare patients, some upper-middle-class retirees pay extra fees so they can see a doctor when they need to.

MDVIP, which has 450 concierge doctors in 34 states, charges patients $1,500 to $1,800 a year. Their doctors are each limited to 600 patients, whereas, the company says, most primary care physicians serve at least 2,000 patients. It says appointments with doctors "start on time and last as long as necessary" and can usually be made the same day or the next one. The company's fee is for the extended care and comprehensive annual physical and wellness plan, but its doctors still bill the patient's insurance company for procedures.

The international, around-the-clock programs take concierge medicine to a different level. Their primary goal is to offer an extra level of oversight to make sure that participants are getting the proper level of care whenever they need it.

Dr. Miles J. Varn, chief medical officer at PinnacleCare Private Health Advisory, which charges annual fees of $1,500 to $25,000, said the starting point for all patients was a complete review of all health records with an emphasis on finding gaps in care.

"We have physicians who look for omissions of care or deviations from standard care," Dr. Varn said. "That record travels with them around the world."

In promoting themselves, the plans say their doctors know each patient's health conditions intimately and are able to discuss it with another doctor anywhere in the world.

Dr. Daniel Carlin, founder and chief executive of World Clinic, which charges $20,000 to $75,000 a year on average, said he recently had to intervene and stop a patient from getting the wrong procedure. The client was at a hospital in Florida where the doctors wanted to do bypass surgery for a blocked vessel. Dr. Carlin said the proper care was putting in a stent, and the difference was months of pain and recovery for the patient and tens of thousands of dollars for the hospital.

"You're holding up a shield and saying, 'We'll weigh everything before we move forward,' " Dr. Carlin said. "With the primary care guy gone, the average patient isn't being treated."

IS IT WORTH IT? Despite reports about the decline in the number of family physicians and the increase in the hours the remaining ones work, many wealthy people are reluctant to pay extra for health care.

Dr. Varn said more than half of the company's members were in a program that costs $10,000 a year, or about $800 a month — on top of whatever private insurance members may have. "How much do you pay to have your lawn mowed every year?" he asked. "Why wouldn't you pay to get the same advice on your health? People think having great insurance means having great health care and that's not the case."

Beyond personalized primary care, the main selling point for high-end plans is access to top specialists when needed. Yet it is difficult to determine just how much shorter the wait is for the specialist.

"We regularly would engage with our clients to facilitate and get them to the appropriate specialist," said Dr. Sean O'Mara, founder and president of Guardian 24/7 and a former Army doctor who was on call when the president or top Cabinet members traveled to South Korea. "We have an extensive Rolodex of medical specialists that we're familiar with."

Mark Murrison, president of marketing and innovation at MDVIP, said: "When the doctor makes that personal call to the specialist, that has a meaningful impact on getting that patient into see the physician quicker than they would be able to on their own."

Beyond that, these companies argue that they help members locate the right doctor, something they would have more trouble doing on their own.

FAIRNESS DEBATE Unlike professions where money is a primary goal, doctors are obligated by their ethical code to provide care for people in need. This becomes an issue when their practices are confined to the wealthy, and it elicits complaints that concierge medicine caters to the elite.

"This isn't fair," said Dr. Carlin, who worked as refugee camp doctor and in an emergency room before starting World Clinic. "I'm a small solution to a vast health care problem."

The American Medical Association's policy on concierge care — or what it calls retainer practices — states that it is part of the "pluralism in the delivery and financing of health care." But the A.M.A. also says these retainer practices "raise ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care."

But some of the doctors involved in these practices argue that some variation will eventually be available to people who are not wealthy. "The solutions we're developing right now are very expensive ones, but they're going to migrate down to even the poorest people in the world," Dr. O'Mara said.

He said one of Guardian 24/7's members had underwritten a project to make a ready room mobile and put it in a free medical clinic in Northern Virginia. The company hopes that top specialists can be available remotely at the clinic.

Others were less sanguine about the shift to concierge medicine. "My response has been helpful to me and my patients, but it hasn't addressed in any meaningful way the larger policy issue," Dr. Glazer said.

And that is the bigger issue: whether these services for the wealthy can be translated to make the medical system better and more efficient.

http://www.nytimes.com/2011/04/30/your-money/30wealth.html