Unwelcome Surprise - Doctors' Shift to Boutique Care

http://www.washingtonpost.com/wp-dyn/content/article/2008/03/14/AR2008031403519.html?wpisrc=newsletter

Unwelcome Surprise
Fairfax Doctors' Shift to Boutique Care Leaves Patients Weighing
Options

By Chris L. Jenkins
Washington Post Staff Writer
Tuesday, March 18, 2008; HE01

Between now and next month, Lou Bruhn, 65, of Fairfax County will have
to make an important decision about his medical care: Should he pay
$1,500 a year to stick with his primary care physician of three years
-- a doctor who he says has given him excellent care? Or should he
resign himself to finding another doctor?

Some 5,000 Northern Virginia residents are mulling the same question
after learning that their Franconia family practitioners, Brett Wohler
and Andrew Wise, are switching to what's sometimes called boutique, or
concierge, care. On April 15, the pair will join a national doctors'
network and will charge each patient an annual retainer of $1,500. In
return, the physicians say they will offer more attention, including
round-the-clock cellphone access, same-day appointments and time to
accompany their patients to specialists.

The move follows a nationwide trend that began nearly 12 years ago as
a reaction to what some doctors see as the excesses of managed care.
More than 1,000 doctors have switched to this mode of practice,
according to the Society for Innovative Medical Practice Design, a
trade group in Richmond.

Under concierge plans, doctors typically reduce the size of their
practice so they can stretch patient visits to 30 minutes, compared
with the seven to 16 minutes that various studies have found to be
average under managed care. In addition to their annual retainers,
doctors collect the usual fees for service or reimbursements from
patients' health insurance plans. The doctors also accept Medicare
patients.

Proponents say concierge care lets doctors give patients the time and
services they deserve, and allows them to focus more on preventive
care. But critics say the development exacerbates inequities in the
American health-care system by limiting access and increasing the
workload of doctors who don't join such networks.

Several years ago, only a handful of Washington area doctors listed
themselves as members of MDVIP, the nation's largest retainer health-
care company and the one Wohler and Wise are joining. By June 1, the
area will have nearly two dozen MDVIP doctors, according to company
officials, with 15 in Northern Virginia, six in Maryland and one in
the District.

"It's not really about the money; I can afford it," said Bruhn, a
retired engineer and a patient of Wise's. "I guess I'm still curious
to see if it works as well as the doctors seem to believe, and if that
would be worth the price for me."

But some other patients are less sanguine.

To convert to the new plan, Wohler and Wise plan to drop about 4,000
of their 5,000 patients. Remaining patients, up to 1,000, will be
selected on a first-come, first-served basis, they say, leaving the
rest to find a new physician they can trust.

Lisa Zuber, 51, of Springfield, is one of them. A patient of Wohler's
since 2004, she said that she initially considered following him into
his new plan. But the more she learned about concierge care, the more
it made her uncomfortable.

"I guess what bugs me so much is that even if everyone wanted to join,
they couldn't," said Zuber, an administrator for a national
professional association. "It sets up this situation where people are
competing against each other to get health care. I just didn't want to
be a part of that."

Wohler voiced regret about the situation. "There are patients that
I've seen for years that probably will not continue, and that's hard,"
he said in an interview last week. "Part of me asked myself, 'Is this
right?' But I firmly believe I'll be getting back to doing the things
that I set out to do when I first became a doctor."

MDVIP requires doctors like Wohler to help each of his patients find a
new primary care physician, and they don't stop seeing them until they
do.

Last week about 50 patients attended an information session in
Springfield hosted by Wohler and Wise, complete with a video touting
the benefits of the program. Here, too, patient views were mixed. "I'm
absolutely going to join," said Arthur Smith of Fairfax County. "There
doesn't seem to be any drawback."

Others were more cautious.

"It makes you wonder where we're going as a health-care system," said
a patient of Wise's, who identified himself only as Ray and declined
to give his last name. "I understand where these doctors are coming
from -- all the paperwork they have to fill out, no time with
patients. . . . It can make you feel like you're really not doing your
job."

Doctors and medical ethicists across the country continue to debate
the trend toward concierge medicine.

In a policy statement several years ago, the American Medical
Association said that while retainer contracts offer viable options
for care, "they also raise ethical concerns that warrant careful
attention, particularly if retainer practices become so widespread as
to threaten access to care."

Even short of that, some have expressed concern about limiting access
to care for poorer, sicker and nonwhite patients.

A 2005 survey of 144 retainer doctors in the Journal of General
Internal Medicine found that such practices had far fewer minority and
Medicaid patients than non-retainer doctors.

"This really isn't a solution to the chief problem in our health-care
system, which is maldistribution," said Jay Jacobson, chief of the
division of medical ethics and humanities at the University of Utah
School of Medicine, who wasn't involved in the survey. "By giving more
people an opportunity to opt out, they're not addressing the problem
of access to health care."

Others have questioned how much impact retainer practices are having.
The 1,000 or so retainer physicians, they say, are few compared with
the more than 280,000 primary care physicians nationwide.

"Reasonable people can disagree about the practice, and they certainly
have been a lightning rod for controversy," said G. Caleb Alexander,
an assistant professor of medicine at the University of Chicago, who
co-authored the Journal of General Internal Medicine study. "But it's
unclear to me how viable the market is right now."

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