Physician Dragan Djordjevic used to see up to 30 patients a day in a busy internal medicine practice in Chicago. Visits lasted as little as 15 minutes, not long enough, he felt, to provide the best possible care to his patients. Five years ago, Djordjevic got what he says was a wake-up call: A longtime patient phoned to say she was changing doctors."She told me 'the last time that I saw you, even though it was for something relatively minor, it didn't appear that you were all there,'" Djordjevic (pictured) says. "That left a bad taste in my mouth. She was right."
So Djordjevic decided to follow in the footsteps of a growing number of family practitioners who are fed up with shrinking insurance reimbursements -- a situation they say requires them to squeeze more patients into their practices just to stay afloat. In July 2007, he went "boutique," opening a new practice where patients pay an annual fee -- $1,500 -- in return for much more personalized care.
24/7 Access to a Doctor
Today, Djordjevic's boutique medicine practice limits itself to 600 patients, just one-fifth the number seen at his old practice. In a typical day, he'll see no more than nine patients who he'll meet with for at least a half-hour, ample time to find out what's really going on, he says.
Same-day appointments and no wait are all part of the package, as is the ability to reach Djordjevic 24 hours a day, seven days a week by email or on his cell-phone. Not included, though, are services like hospitalizations and specialist care, for which patients still need regular health insurance. "Our system works wonderfully well," says Djordjevic, whose practice is affiliated with MDVIP, the nation's largest network of fee-based physicians with 351 doctors. "It focuses on prevention and wellness."
The ability to spend more time with patients may have already saved one life, Djordjevic says. One day, a female patient called complaining of symptoms that included fatigue and belching. At his former practice, where he rarely made it to the phone, someone with such non-specific symptoms would probably have been asked to make an appointment, he says. Instead, he suggested she come in. It was a good move. Turns out, the patient was having a heart attack. Djordjevic immediately gave her an aspirin and rushed her to a cardiologist.
"We were able to intervene in probably 10 or 15 minutes," says Djordjevic who is in practice with another doctor, William Kehoe. "I don't think you can do much better than that."
'Marcus Welby Health Care'
While boutique medicine is nothing new -- it has been around for more than a decade -- it has recently gained popularity. There are now an estimated 5,000 doctors practicing "concierge medicine" or "direct care" nationally, 1,000 of which opened their practices in the last year alone, says Thomas LaGrelius, who heads the Society for Innovative Medical Practice Design, a professional association based in Glen Ellen, Va.
"Patients love Marcus Welby health care," says LaGrelius, referring to the TV show that aired in the 1960s and 1970s about a doctor with a kindly bedside manner. "We are getting back to how medicine should be practiced."
LaGrelius, who runs SkyPark Preferred Family Care in Torrance, Calif., makes house calls, picks up his phone at all hours and serves gourmet coffee in his waiting room. The price tag for this high-end care? An annual fee of $1,900, or $950 for patients ages 18 to 39.
What's particularly striking is that the increase in concierge medicine has come during a severe economic downturn when consumers are trying to cut expenses. But Darin Engelhardt, president of Boca Raton, Fla.-based MDVIP, says last year's renewal rate among the 122,000 patients seen by his network's doctors was 92%, just shy of its all-time high of 93%.
Patients seem to like having their doctor's ear at all times, even if it means paying for it. "My doctor is available basically 24 hours a day," says a 73-year-old LaGrelius patient, who declined to give his name. "I'm at an age where it's nice to have that peace of mind."
Concierge doctors dispute charges that boutique medicine is elitist, saying the annual fee at many practices works out to roughly $4 to $5 a day -- about the amount some people spend on cigarettes or a coffee at Starbucks. "For that, you could get outstanding care," says LaGrelius, who switched to a fee-based practice in 2005. "What we are doing is mainstream and affordable."
Boutique practices will typically bill Medicare or commercial insurers for "sick visits" -- when patients come in with the flu, say, or a sprain -- while the preventive consultations focused on improving health and wellness are covered by the annual fee. Fees can range from $150 per year to as high a $25,000 annually per family, depending on the practice.
Is Boutique Medicine Contributing to a Shortage in Primary-Care Doctors?
Not everyone is a fan of fee-based health care. One critic has been John Goodson, an associate professor at Harvard Medical School. In an interview with CNN Money, Goodson called boutique practices "country club medicine," saying it sends the wrong message. "You still have this concept that you have to be a member of a club to get the health care you deserve," he said.
Another concern is that boutique medicine is contributing to a shortage of doctors in traditional primary-care practices. A 2008 study in the New England Journal of Medicine found that family medicine, which offers an average salary of $185,740, had just 42.1% of its residency positions filled by U.S. graduates of medical schools, the lowest percentage of any specialty.
Part of the reason residency fill rates in family medicine are so low is that med-school grads are increasingly seeking out careers in the specialties, such as radiology or orthopedic surgery, which can pay at least twice as much. Boutique medicine can offer salaries approaching those in specialty care, luring doctors away from traditional doctors offices, critics say.
"It's really sapping the workplace dry," Goodson told CNN Money. "What that means is that everyone else who decides to remain in mainstream practice shoulders the burden."
But proponents of fee-based medicine counter that their practices allow doctors who are considering leaving primary care to remain in family practice. "We actually provide a vehicle that allows them to extend their careers," says Engelhardt.
Saving Money Through Preventive Medicine
Concierge medicine got its start in Seattle in 1996 when former doctors for the Seattle Supersonics built a family practice that provided the same kind of highly personalized care they offered to athletes. MD2 remains boutique medicine's gold standard, with each of its physicians limited to treating just 50 families. The annual fee for this kind of exclusivity is an eye-popping $25,000 per family. But patients are reportedly pampered with marble bathrooms and monogrammed robes, in addition to round-the-clock access to their physicians.
As concierge medicine has spread across the country, advocates say it is allowing doctors to spend more time with patients and focus more on preventive care aimed at stopping health problems from developing in the first place. As the argument goes, doctors in traditional primary-care practices are too busy putting out medical fires, leaving them with little time to do detailed screenings for nutrition, fitness, mental health and other assessments.
At MDVIP and many other concierge practices, patients undergo a comprehensive yearly exam that goes well beyond the typical physical, with chest x-rays, extensive blood work, and electrocardiograms, among other tests. With the information gathered from these extensive checkups, each patient gets a unique "wellness plan." And the rest of the year, the "physician can serve as a coach, not just a treater of illnesses," says Engelhardt.
Thanks to this closer attention, MDVIP patients are up to 40% less likely to end up in a hospital than those with regular insurance, and up to 74% less likely to be hospitalized than Medicare beneficiaries, the company says. Doctors "can intervene early before a problem becomes so significant that it requires hospitalization," Engelhardt says.
Of course, boutique medicine isn't for everyone. With an estimated 45 million Americans already lacking health insurance, boutique practices that require people to pay cash to receive care will likely be out of reach for many -- and continue to draw criticism. That said, by removing doctors' concerns about getting reimbursed by insurance companies, boutique medicine can redirect the focus back to where doctors can often be the most effective: Helping patients prevent disease altogether.
"A lot of preventive stuff has fallen by the wayside," says Djordjevic. "If you don't have the time to listen to your patients, you are going to order an expensive test when a physical exam would have told you what you need to know. But if you can give patients the time, you can save the system money."
Here's a crazy idea: If the government and insurers began reimbursing doctors more for the time they spent talking to their patients, perhaps doctors in traditional practices could offer more boutique-like service without the boutique prices.
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