March 18, 2008
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.
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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."