Boutique Medicine: For Your Well-Being? Or the Doctor’s?

Photo by William Duke

As patients spend more time in the waiting room and less in the examining room, primary care in the United States could be headed for serious trouble. “The system is broken,” says bioethicist Arthur Caplan,  chair of the Department of Medical Ethics at the University of Pennsylvania School of Medicine.

In response, physicians are offering an alternative system of care, but it has come at a price. They are quitting the traditional take-all-patients approach in favor of “boutique” practices, where patients pay an annual entry fee ranging from a few hundred dollars to $20,000 to get more face time with the doctor. This type of  practice is also known as concierge or retainer medicine, and its proponents say that for the cost of just a latte a day, patients in downsized boutique practices are probably going to be healthier, more satisfied and less hassled by the medical system.

Detractors insist there’s no difference in the care provided by boutique and traditional doctors, that some services duplicate those already covered by Medicare, and at worst, the approach violates medical ethics in abandoning poorer patients. Says Caplan: “There’s something unseemly about doctors saying, ‘You know what, this system is so broken, the only way I can practice is to set up a cash-based practice and exempt myself.’ We need to fix the system.”

In fact, the federal Government Accountability Office continues to keep an eye on boutique practices that serve Medicare patients to make sure they’re not double-billing or reducing access with hefty entrance fees. Since its last report on this trend, in 2005, GAO notes a steady growth of concierge practices in the United States.

Could such an approach work for low-income patients? MDVIP, a Florida-based company that provides boutique services, is willing to find out. The firm, whose 225 physicians care for 75,000 patients in 22 states and the District of Columbia, plans to open a clinic in Charlottesville, Va., in August for about 600 Medicaid patients, who will receive the same services as patients who pay annual fees for the privilege of concierge medicine.

In partnership with the University of Virginia, MDVIP hopes to prove that by providing greater access to their primary-care physicians, the company can stay profitable by keeping low-income people healthier regardless of their health status.

“We think our approach works across ethnic, racial and economic lines,” says MDVIP co-founder and CEO Edward Goldman, M.D., of this previously unannounced effort. The Medicaid patients will be picked at random, he says, and the clinic will match the ambience and amenities of other MDVIP facilities.

Amenities like those in the office of boutique practitioner Robin B. Merlino, M.D., of Fairfax, Va. The décor is a tasteful Native American style, and the kitchen is filled with snacks and drinks. There’s little or no waiting, and the doctor—who wears stylish business attire instead of the traditional white coat—is always in.

Merlino, an internist, has about 550 patients—more than 200 are on Medicare—who pay an annual fee of $1,500 for her services. That’s in addition to $75 to $125 for each office appointment (billable to insurance). There’s also the cost of Medicare premiums or other coverage for specialty care. For this outlay, patients get more time with the doctor during appointments, a comprehensive annual physical, an electronic medical record and easier access to the doctor 24/7 in an era when a routine office visit is shorter than lunch in a fast-food restaurant.

 “I was not trained to be a Wal-Mart or a McDonald’s in medicine, ” says Merlino, 52, who describes her approach as “personalized health” and lists her cellphone number on her business card. In her old practice, Merlino was seeing 25 patients a day in 10- or 15-minute increments. She fretted about the quality of service.

Now things are different. Three years ago, she joined MDVIP. While she and some other doctors take Medicare patients, fewer physicians may take them if boutique practices become more widespread.

“Most of our clients are very low-income and for them, affording the copayments under Medicare now can be a problem,” says Paul Precht, a spokesman for the Medicare Rights Center, a consumer advocacy group. “So for them to be asked to pay an additional $1,500 ... it’s just not realistic.”

Others say concierge medicine is a style of practice best suited to the rich and most advantageous to the doctor’s bank balance. “It’s kind of like flying first class, but there’s an implied threat that if you don’t, it’s going to be hell back there in coach,” says Caplan.

Ron Pollack, who heads Families USA, a nonprofit group promoting universal insurance coverage, says he’s less worried about first-class service to the few than the needs of the 46 million people with no insurance at all. “They’re just hanging onto the wings,” he says.

Merlino responds that her services aren’t only for the gentry. The patient’s monthly cost is about $125—equal to a typical cellphone bill. In addition, MDVIP lets doctors in each practice offer “scholarships,” or fee waivers, to up to 10 percent of patients, those who want the additional service but can’t afford it.

Many of Merlino’s patients, like 75-year-old Mary (not her real name), followed the doctor to her new practice. “I’m pleased with the service I get. I’ve always been pleased,” says Mary, who has diabetes, hypertension and obesity. “Do I have a little heartburn about paying extra money? Yes!”

Does lavishing extra time on patients produce better results? MDVIP says its data show members are 65 percent less likely to be hospitalized than comparable Medicare patients. Goldman says new data show that a wider cross-section of MDVIP patients is also healthier.

Even so, not everyone needs a lot of doctor time. “For the patient with complicated illnesses, it’s a good thing. For the patient who wants to be seen quickly for just life efficiency, it’s a good thing. For a lot of average patients, it would make no difference whatsoever,” says Barry Strauch, M.D., an internist who’s spent some 30 years in primary care and academic medicine.

Rep. Henry Waxman, D-Calif., among others in Congress, has suggested that boutique or retainer providers in general and MDVIP in particular may be violating Medicare law by charging extra for services already covered. “I continue to have concerns about [retainer medicine] and think Congress needs to do more in this area,” says Waxman.

Other organizations, including GAO and the American Medical Association, are watching to make sure concierge practices operate within ethical guidelines and don’t leave patients out in the cold.

Robert Hayes, president of the nonprofit Medicare Rights Center, says patients need to be sure they’re getting their money’s worth before crossing the boutique divide. As for doctors, Hayes says they need to be careful that any charges over Medicare’s normal reimbursements are strictly within the law. The Office of Inspector General for the Department of Health and Human Services has warned doctors not to bill patients for any services already covered by Medicare.

The AMA doesn’t track how many physicians have gone the boutique route—it’s estimated to be no more than a few thousand—and it’s not clear how big the phenomenon will become. But at least for some doctors and patients, it’s an attractive option. Dragan Djordjevic, M.D., a Chicago internist who went boutique last year, says, “I don’t want to become one of these surly, angry guys, when he’s 50 or 60 years old, who’s bitter at everybody.”

For Merlino patient David Orth, 51, director of voice and data communications for Gannett Co., controlling his diabetes and staying healthy for his upcoming wedding are more than worth the price of admission. “I earned the right to be able to take advantage of this type of practice. I work hard for those dollars,” Orth says. “So being able to have a practice that fits my lifestyle and my work style, that’s a benefit.”