Friday, April 13, 2007

On call – for a fee

Frustrated by insurance companies, many doctors turning to retainer practices

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Chris Rossi⁄The Gazette
Dr. Norman Balog takes the blood pressure of patient Johnny Smith at Smith’s house in Silver Spring. Balog is among the growing number of physicians who have retainer practices.
Marvin Reitz of Derwood didn’t feel well and wanted to see his doctor right away.

Perhaps more than most people, Reitz, a senior HIV⁄AIDS scientist with the Institute of Human Virology in Baltimore, appreciated the need to be examined quickly. And thanks to a recent trend to help personalize physician care, he got an appointment the same day — but not because of his professional status.

Reitz, like any patient of Dr. Philip Henjum, can get a same-day appointment because Henjum and his partner, Dr. Robert Fields, practice retainer medicine in their Olney office.

Their patients pay a $1,500 annual retainer fee to see them as soon and as many times as they need to. They also make house calls.

As it turned out, Henjum diagnosed Reitz with Lyme disease, an infection from a tick bite, and prescribed antibiotics. If not diagnosed and treated early, Lyme disease can lead to severe headaches, muscle pain and serious heart problems.

Fields and Henjum are two of about a dozen doctors in Maryland and an estimated 600 nationally who won’t take insurance coverage. Instead, they charge a yearly or monthly retainer. Some work out of comfortable medical office such as Fields and Henjum, next to Montgomery General Hospital.

Others, such as Norm Balog, an osteopath, work out of their homes. Balog is a family doctor in Silver Spring whose entire retainer practice, called Doc at Your Door, is based on making house calls.

After retiring from the Army, Balog grew tired of working as a civilian doctor in a Fort Meade clinic. He now calls himself an old country doctor.

‘‘I am the guy who gets into the horse and carriage to see people in their home, the environment they are comfortable in,” he said.

AMA: It started in Seattle

Retainer practices — also called concierge, boutique or just plain old-fashioned medicine — began in Seattle in 1996, according to the American Medical Association. Physicians who convert to retainer practices say it solves many problems of primary care.

‘‘The relationship has changed in medicine between the physician and patient,” Balog said. ‘‘It is no longer between the patient and the physician. It is between the patient and the insurance company or third-party payer.”

He said he began Doc at Your Door because ‘‘there was no longer continuity in patient care.”

Martin Wasserman, director of the Maryland State Medical Society of 6,500 physicians, said low insurance payments are driving doctors to seek alternatives.

‘‘Physicians are not getting adequate reimbursements, so retainer medicine is a decision by the doctor and is a new business model,” Wasserman said. Doctors in Maryland receive some of the nation’s lowest insurance reimbursements.

He called retainer practices in Maryland ‘‘a relatively new trend. I think it is probably still in an upsweep, gaining momentum as established physicians with a set clientele would go for it first.”

Critics of retainer medicine say it provides better care for people who can afford it, but does not help those who can afford the fee, plus additional costs for diagnostics or surgeries.

Most retainer physicians charge less than $2,000 a year, which includes one full physical exam. At the high end, physicians in the MD2 network in Seattle charge $13,200 per adult and $20,000 per couple for services in spa-like settings, complete with monogrammed robes, slippers and sweat suits.

But other retainer practices are less opulent.

‘‘I loathe the terms concierge or boutique practices because it sounds elitist,” Fields said. ‘‘I feel this is about being an old-fashioned doctor.”

Fields said he makes about 100 house calls a year.

‘‘I charge $1,500 a year,” he said. ‘‘It is the price of a pack of cigarettes a day, or a Starbucks coffee. I set this up to serve the mailman, the grocery checker or the housekeeper. It should help the middle class.”

‘A primary care problem’

Most family doctors will convert to a retainer-type practice within the next 15 or 20 years, said Dr. Christopher Ewin, president of the nonprofit Society for Innovative Medical Practice Design in Fort Worth, Texas.

‘‘We believe that there is a primary care problem in this country,” said Ewin, a primary care physician. ‘‘We have been working for the wrong employer for way too long — the insurance companies and the government.”

Ewin’s retainer practice, he said, reduces the cost of an MRI from about $1,500 to $500. Laboratory blood analysis that would normally cost $300 through insurance costs $33.

Despite the benefits of retainer practices, Walter J. Cherniak Jr. a spokesman for Aetna, the nation’s third-largest health insurer, downplayed the magnitude of the trend.

‘‘We don’t take a position on it,” Cherniak said. ‘‘But, in the larger context, we have 774,000 health care providers with the great majority of them as doctors. We also have 4,400 hospitals as members.”

Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a national association of nearly 1,300 insurers, said physicians refusing insurance usually is not a concern to insurers.

However, it does become an issue if a ‘‘boutique doctor” still wants to accept insurance, she said. The physicians must ensure they adhere to the rules of the insurer’s agreement.

The AMA has no problem with retainer medicine.

‘‘Retainer practice is consistent with longstanding AMA policy in support of pluralism in the delivery and financing of health care, as well as with policy in support of the right of physicians to freely enter into private contracts with their patients,” the association said in a 2002 study.

The association asks for physicians converting to retainer practices not to abandon any of their patients and to try to transfer their non-participating patients, particularly their sickest and most vulnerable ones, to other physicians.

Doing medicine his way

Dr. Joseph Zebley of Baltimore, former president of the Maryland Academy of Family Physicians, is one of 11 doctors in the state who are members of the MDVIP network of 148 family practice physicians and 50,000 patients.

MDVIP doctors charge patients an average annual fee of $1,500 and pay one-third of that to MDVIP. The group provides a Web site for patient messaging and education, plus billing and marketing services and legal counseling for physicians.

The group ‘‘helps you stay out of court,” Zebley said.

‘‘Patients have to pony up a little more money to keep their doctors going,” Zebley said. ‘‘Doctors cannot depend on the insurance companies anymore.”

After a lot of research and setup time, Zebley launched his new practice in October. His income is about the same, $130,000 to $140,000 a year.

‘‘I am happy with this,” he said. ‘‘We had to change after looking after every nickel and dime — we could not afford to be generous. Now there is money on a regular basis.‘‘

Balog visits patients in mostly Howard and Montgomery counties for a retainer fee of $500 a year. It covers six visits, including ‘‘a complete and thorough history,” he said.

He sees about five patients a day, but not with the legendary little black bag. Instead, Balog totes a large, rifle-range bag full of diagnostic equipment, IV fluids, drugs tucked into little pockets meant for bullets and a special compartment for dried chicken soup. That’s a favorite of his patients.

‘‘I am not out to change the way medicine is done. I am out to change the way I do medicine,” he said.

Retainer practices

Percentage of physicians with retainer practices who offer these services versus other physicians.

Retainer Other

Accompanies patient
to specialists: 30% 0.5%

House calls: 63% 26%

24-hour access: 91% 40%

Same day appointments: 96% 83%

Coordinated hospital care: 86% 59%

Private waiting room: 31% 3%

Source: Survey of Physicians in Retainer (‘‘Concierge”) Practice, Journal of Internal Medicine, Dec. 20, 2005