More doctors gravitate toward boutique practice

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More doctors gravitate toward boutique practice

Fed up with long hours and limits on fees, they aim to offer a more personal

approach — at a price

By Liz Kowalczyk Globe Staff / April 17, 2011

Concierge medicine is expanding as more doctors — and patients — tire of

assembly-line primary care, opting for something more personal, and pricey.

The numbers are still very small — a survey commissioned by a congressional

agency last year identified 756 concierge medical doctors in the United States,

up from 146 in 2005. And Florida-based MDVIP, a company that helps physicians

set up these practices, said it will add six new MDVIP doctors in the Boston

area this year, increasing its physicians statewide to 16.

But even a tiny number of doctors leaving traditional offices for boutique

practices — out of thousands of primary care physicians — is enough to make some

health care industry leaders nervous. They worry that more doctors will follow

as insurers and government payers cut fees and hem in providers with

regulations. And when even one doctor makes the switch, there are substantial

side effects, leaving hundreds of patients to scramble for a new physician.

Concierge doctors care for a small number of patients who agree to pay an annual

fee on top of insurance — $1,500 to $1,800 in MDVIP's case — in return for fast,

unlimited access to the physician and to extra services like a comprehensive

wellness plan. Patients also enjoy more leisurely appointments than the

15-minute visits that are now standard for most primary care doctors.

MDVIP's expansion has upset leaders at Newton-Wellesley Hospital, after two

extremely popular internists affiliated with the hospital told their patients

this month that they are joining MDVIP and closing their traditional practices,

in which they each care for 3,000 patients.

Under the plan, Dr. Holgerson and Dr. Legare will dramatically

shrink their workloads, each caring for about 600 patients who are willing to

pay the $1,800 fee — which compensates for their lost income from seeing fewer

patients. The large doctors' group to which they still will belong,

Newton-Wellesley Primary Care, is hiring two new doctors for the patients

Holgerson and Legare leave behind.

Holgerson, who turned 62 yesterday, said he couldn't imagine practicing into his

70s with the existing pressures; most weekdays he arrives at the office at 6

a.m. and goes home after 7:30 p.m., not to mention the numerous weekend hours

spent completing paperwork.

" I could provide the kind of care I've always wanted to provide with more

time,'' he said in an interview last week to explain his decision. " I want to

emphasize patients' health and not just deal with acute issues.''

Legare, 48, was not available for an interview.

Many of their colleagues, however, have been critical of concierge medicine,

saying doctors who open these practices strand thousands of patients in a system

where primary care access already is tight and foster a two-tiered medical

system, one for the well-off and another for everyone else.

" I understand it might be the answer for them,'' said Dr. Lee, president

of Partners Community HealthCare, a large physician organization that includes

doctors affiliated with Newton-Wellesley Hospital, " but it's not an answer for

the health care system. If too many of our physicians do this, it's just going

to make primary care access that much more challenging.''

While Lee said the number of concierge practices " is ramping up,'' he does not

believe it will become a widespread trend among doctors, largely because most

patients cannot afford the fees. But others are not so sure.

Newton-Wellesley Hospital surveyed about 170 of its primary care doctors last

year, and half said they had considered becoming concierge physicians. The

hospital has started a " master clinician'' program, which pays some doctors to

mentor younger ones and provide longer appointments for challenging patients.

The pressures on doctors have only intensified. The state's mandatory health

insurance law means even more people with coverage are seeking doctors. Insurers

are squeezing payments to doctors, and regulators and insurers are pressing

providers to make care less expensive.

" It's hitting home here at Newton-Wellesley,'' said Dr. Selbovitz, chief

medical officer. " As health care reform matures, doctors are questioning whether

they want to be part of the new world order.''

The decision by Holgerson and Legare hit especially hard because they both have

leadership roles at the hospital — Holgerson is medical director of a joint

physician-hospital organization and Legare is a trustee — positions hospital

officials will now review.

MedPac, the Medicare Payment Advisory Commission, which advises Congress on

Medicare issues, paid for a study last year on " retainer-based physicians''

because of concerns that Medicare patients could be left without doctors.

The study identified 25 concierge doctors in Massachusetts, out of thousands of

primary care physicians. Researchers interviewed doctors who said they were

" mentally and physically drained at the end of their day'' and that becoming

concierge physicians relieved that stress. Some said they were making more

money, too.

If 600 patients pay a $1,800 fee, that comes to $1,080,000. MDVIP keeps

one-third of the total for helping the doctors run their practices, leaving

$720,000 for the doctor to pay salaries and other expenses — on top of

reimbursements from insurers for standard office visits and exams, which

generates more revenue.

Lee said that the doctors who end up becoming concierge doctors " are physicians

so liked and respected that their patient panel grew to a number that was not

consistent with a life with family and friends.'' He said he himself was guilty

of asking Holgerson and Legare to take on new patients, even though their

practices were full.

Holgerson said he knew of no good way to cut back on his patients without making

a dramatic change.

There are no data on the growth of patients in concierge practices, but one

person who recently made the switch, Luigi Schena, says he is pleased.

A chief financial officer for an environmental clean-up company, he had been a

patient in a very busy practice for 15 years, but he said he did not feel he was

" getting the attention I wanted from my primary care doctor. They were just

trying to bang out as many patients as possible,'' he said. A co-worker

suggested Dr. Harold , one of the first MDVIP doctors in the Boston area.

Schena joined his practice three months ago.

Greg Goostray, 45, a financial services executive, joined 's practice two

years ago. called him with test results from his Florida vacation,

checked in on him every day when Goostray was home sick for a week, and talks to

him a length about putting his high-stress job, which has caused anxiety

attacks, in perspective.

" He's not like a psychiatrist but he's damn close,'' Goostray said.

Dan Hecht, chief executive of MDVIP, said that patients are very satisfied with

the extra service, with about 92 percent of patients renewing their memberships

last year.

During a MedPac meeting on the issue in September, however, one commission

member, Dr. Castellanos, a urologist in Florida, said he sees concierge

patients referred by their doctors, and many have unrealistic expectations of

the rest of the medical system. " As soon as the come in the room, they want my

cellphone number,'' he said.

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