It's an exasperating experience for all concerned, and a small but growing number of doctors and patients are choosing to bypass or minimize the role of insurance in health care through an approach to medicine that is known by a variety of names -- platinum practices, retainer medicine or concierge medicine.
Consumers can pay a fixed annual retainer directly to a medical practice in return for a package of medical services that can include same-day or next-day appointments at an office with a spa-like atmosphere, house calls, 24/7 access to a physician via phone or e-mail, preventative care and programs, free checkups and a comprehensive physical once a year. For a fixed price, a growing number of physicians are adding or exclusively providing these and other personal touches.
Annual fees for a concierge practice vary from less than $100 to $20,000, with most practices charging an average of about $1,500. The fixed fee covers all related expenses and allows the physicians to limit the number of patients they see, which supporters say allows them to devote more time to each patient. But detractors of the practice, which includes the American Medical Association (AMA), say its proliferation could eventually limit access to care for those unwilling or unable to pay a retainer fee.
Beverly Hills-based Dr. Albert Fuchs, 39, opened a traditional internal medicine practice in 2000 but switched to a concierge practice more than two years ago. He says without the constant pressures associated with a traditional practice he's able to spend more time with his patients and follow through with treatments he deems necessary, rather than having to check with an insurance company first.
"I get to actually practice medicine that I was trained in," he said. "I can be much more comprehensive and it kicks the insurance company out of the examining room because I no longer have to worry about what's covered, what's not covered."
On a typical day Fuchs sees six to eight patients without any real time limits, compared with a doctor in a traditional office who sees mostly double that amount, spending as little as 15 to 20 minutes with each.
Fuchs charges patients an annual fee of $2,400 for his services, a price he believes is within reach for many people.
"It requires a realization that your health is valuable, that it deserves extra spending," Fuchs said.
By eliminating the third party of insurance companies, concierge doctors say they save money by not having to hire a staff to handle the insurance billing, co-payments and extensive paperwork. For most of these practices the retainer covers the costs for services, so there is no need for billing.
While concierge doctors save money by not relying on insurance for payments, patients don't necessarily reap similar rewards, since most concierge patients still have and are encouraged to retain some level of medical insurance to cover hospitalization, drug prescriptions and outside lab work. Fuchs' patients use health insurance for lab tests from Cedars-Sinai, where the doctor has hospital privileges.
And while such practices typically don't feature specialists, concierge internists and general practitioners will frequently accompany patients on visits to specialists to consult and make recommendations.
Glen Melnick, the Blue Cross Professor of Health Care Finance at USC and a health economist at the Rand Corporation, views concierge medicine as a successful small niche market. It's something he likes to see.
"In the sense that people are willing to pay for something and the market is providing," he said.
However, Melnick believes that concierge medicine is far from being a part of the mainstream health care, let alone a cure for the problems plaguing the current health care system. A reason for that is the cost, which he says makes sense only for those whose time is so valuable that paying upfront for quick access isn't an issue.
"It doesn't make sense for the average person to pay a couple of thousand bucks extra a year just to get a guaranteed quick appointment," Melnick said.
Doctors who convert their existing practices to include a concierge service often create a two-tier system whereby patients who pay more get direct access to a doctor while all other existing patients are passed on to a nurse practitioner who will likely be less convenient and possibly less skilled.
And while critics acknowledge that a shift to concierge-level care isn't possible for most doctors in the highly dysfunctional U.S. health system, they say the trend is still inherently discriminatory and that the public at large will suffer as a dwindling number of general practitioners and internists opt to make themselves available to a small, privileged group of patients.
Gordon Schiff, founder of Physicians for a National Health Program, finds little encouraging about concierge medicine from a patient's point of view.
"Many of the things that doctors are saying they'll do under concierge medicine should already be expected by patients. It shouldn't be a privilege that you have to pay extra for," he said in an interview with The San Francisco Chronicle.
"If medicine is a public service and we're here to take care of everyone, you don't limit yourself to people who have money. Most people expect to be treated based on need, not on how much money they have," Schiff said.
In 2003, the AMA stated that doctors who engage in a two-tier system "in which some patients have contracted for special services and amenities and others have not, must be particularly diligent to offer the same standard of diagnostic and therapeutic services to both categories of patients."
And in 2004, California Rep. Pete Stark (D-Fremont) described concierge care as a new country club for the rich. During a joint economic committee hearing in Congress, he said, "The danger is that if a large number of doctors choose to open up these types of practices, the health care system will become even more inequitable than it is today."The first modern concierge practice was established in 1996 by Dr. Howard Maron, a former team doctor for the Seattle Supersonics, who prefers the term "highly attentive medicine" to describe the services first offered by his company MD2 (or MDSquared), which has gone nationwide with franchises in Chicago, Portland and San Francisco.
The difference in cost between practices typically depends on the number of patients seen, with higher rates being charged by offices that have a smaller clientele. Whereas the average practice sees between 3,000 to 4,000 patients, the number at a concierge practice varies from 100 to 1,000.
In a 2005 report, the Government Accountability Office listed 146 concierge practices in the United States. In 2007, Newsweek reported that there are about 250 concierge physicians nationwide.
The concept is so new that the AMA has yet to begin tracking how many practitioners have adopted this approach. And The Society for Innovative Medical Practice Design, a nonprofit organization that encourages a direct financial association between health care providers and patients, lists 10 concierge doctors in Southern California on its simpd.org Web site.
The average patient who visits a concierge doctor is typically the head of a large company who doesn't have time to sit in a waiting room or doesn't want to be seen visiting with a doctor. And most patients who can avail themselves of a concierge physician are typically delighted with the service they get.
Daniel Khani, a 65-year-old former radiologist who currently works in real estate and has health insurance, says he opts for concierge medicine because he likes the full attention of his doctor, Raphael Darvish.
"I have a doctor that is personally involved with my case, somebody that I can trust ... somebody that when I go there I don't have to wait two hours to see," Khani said.
Darvish, a 30-year-old internist, founded his Brentwood-based Concierge Medicine/LA (CMLA) in 2004. The fourth-generation doctor with an master's in business from UCLA says that traditional practices have become like factories, with dreary offices of empty correction-fluid-colored walls and bland furniture, long wait times to see a doctor, not enough time between the patient and doctor during the visit, and issues with insurance.
At CMLA, patients enter a day-spa atmosphere, with an expected short wait in a room that features organic hues of grass and wheat, floral artwork and chocolate furniture followed by a promised unhurried visit with Darvish or a colleague in a similarly decorated room. The office has a five-person support staff whose duties include taking care of appointments, helping patients with prescriptions and refills, coordinating care outside of Los Angeles and scheduling preventative tasks.
Darvish says that he is trying to get rid of the negative associations people have with visiting doctors by devoting time to listening to his patients.
"I'm able to cater their treatment and cater their care more toward them ... more sensitive to what problems they are having," he said.
Concierge doctors like Darvish say these types of visits and physicals allow them to have a real understanding of the patient and their background. With this knowledge, the doctors feel they can find illnesses early on and take preventative steps.
And while there are ethical question about concierge physicians not reaching as many patients, both Darvish and Fuchs say they devote time saved by their practice to giving back to the community. Darvish volunteers at the Venice Family Clinic weekly, and Fuchs teaches UCLA residents and treats indigent patients at the clinic's Simms/Mann Health and Wellness Center twice a month.
Ultimately, concierge medicine is centered on the individual, according to 39-year-old Dr. Benjamin Ansell, who serves as director of UCLA's Comprehensive Health Program -- a concierge-style daylong physical exam program not covered by insurance and similar to Minnesota-based Mayo Clinic model for business executives.
"It's built on putting the individual's need at the forefront rather than falling somewhere where they can get lost," Ansell said.
And while a patient like Khani would rather not have to pay a fee for the more personal attention, he feels he's getting his money's worth.
"Anytime I have any questions or have to have a consult or if I need to go see a specialist, my doctor is there for me," he said.
For more information:
UCLA Comprehensive Health Program
Society for Innovative Medical Practice Design
AMA on Retainer Practices
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