Doctors on retainer catch on: a new model driven by doctors dissatisfied with traditional managed care catches on with the few who can afford it. Not surprisingly, the model has begun to attract closer regulatory scrutiny

Risk & Insurance, March, 2005 by Russ Allen

What would it be worth to you, if you never had to wait for an appointment with your doctor or sit around in the waiting room? What would it be worth if you received exhaustive preventive care year in and year out? How much would you pay if you could summon your doctor 24 hours a day, seven days a week to your house for a call? Would you pay $100 per month more for such premium care? How about $1,000 per month? Maybe even more?

These are price points in a small but now well-established niche of health care called retainer medicine. And patients buying these higher levels of personal care have been renewing on a better-than-90-percent annual basis in many practices.

Also known as concierge or boutique medicine, the approach arrived in the late '90s and has grown slowly but steadily. Just as recent years have been good for other products and services aimed at the affluent, so these years have supported the establishment or conversion of an estimated several hundred physician practices nationwide to a contractual form of old-fashioned medicine.

Internists and family practitioners in retainer practices give their patients better access and more time and personal care, offering:

* Patient-to-physician ratios that are a fraction of those in managed-care practices.

* Executive-health-type services, such as comprehensive physicals.

* In-hospital advocacy and better coordination of specialist care.

* Various types of in-office testing as part of the fee.

* In some cases, the plush surroundings of "medi-spas," incorporating alternative or cosmetic care.

* And (because the doctors know their patients better) consultations, prescriptions, and advice over the phone more readily.

In turn, doctors using this model claim that they have regained control of their lives and their practices. They say they are sick of battling health plans and tired of having to squeeze more patients into their schedule to stay financially viable.

Retainer medicine has spread beyond select markets on the east and west coasts. Boca Raton-based MDVIP has helped to set up about 60 physicians in retainer-medicine franchises in 10 states--offering the doctors expensive assistance in transitioning to, maintaining, and building such practices. Using the MDVIP identity as part of their marketing, the practices agree to a maximum of 600 patients per physician and a charge of $125 per month, per person. (Primary-care physicians in conventional practices typically have thousands of patients each.)

"Our doctors develop an individual wellness plan for each patient and work to keep them on track with it, like a wellness coach," explains Darin Engelhardt, CFO and general counsel for MDVIP.

The Lewis and John Dare Center at Virginia Mason Medical Center in Seattle was the first retainer practice created at, and by, a large hospital medical center. At three locations now, Dare physicians charge $250 per month, per person (pro-rated for additional family members) and accept no more than 300 patients each.

MDVIP assisted with another milestone recently when it helped to open a concierge, primary-care practice at Tufts-New England Medical Center, the first such practice at a major academic medical center. And, finally, at the highest end of the cost spectrum is [MD.sup.2] . (For more information on [MD.sup.2], please turn to page 23.)

REGULATORS RAISE THEIR EYEBROWS

Most retainer-medicine practices also charge their patients' health care insurance for office visits. Unless they've priced themselves into the platinum zone, retainer physicians do this to maintain or boost their income. But insurance companies, legislators, and especially Medicare regulators have questioned this practice over the last half-dozen years.

Retainer practices may be deemed to be charging for physician accessibility or other services considered paid for by third parties. The Centers for Medicare and Medicaid Services (CMS) continue to look at the propriety of retainer medicine and have reviewed some offices, including those of MDVIP. Members of Congress have looked at bills to prohibit retainer-based physicians from contracting with Medicare at all. Furthermore, the Government Accountability Office is currently visiting retainer practices across the country to so see if Medicare patients are disadvantaged by them in any way. (The American Society of Concierge Physicians offers a report to the GAO at http://www.concierge physicians.com/.)

"There are concierge models out there that are not legal," says Engelhardt, whose MDVIP doctors, like others, have had to be cautious about how they promote and market themselves. MDVIP's position now is that retainer charges cover only additional preventive care and not additional access to the doctor.

"That and the time to implement the results of a total physical exam are the added benefit and what differentiates MDVIP," says Engelhardt, who prefers the term "personalized preventive care" over the terms "retainer or concierge medicine."

"Access is a difficult thing to define, but if the type of availability we give to these patients gets defined as standard, covered access, and thus a requirement, you'll see the rest of the doctors in the country finding another profession," says the Dare Center's John N. Kirkpatrick.