More personal care? It'll cost you from some doctors

Dr. Laura Heiby’s juggling of 1,700 patients last year  didn’t match her vision of how medicine should be practiced.

She could see people for their annual checkups,  but when they came in sick, she often couldn’t fit them into her schedule. So they were seen by a nurse practitioner in the same office.

“That seemed backwards to me,” Heiby said.

The family practice doctor started this year with a fraction of that caseload in her Virginia Beach office, and a goal of capping it at 400.

Now she sees her patients for every visit and has more time to go over their health problems. She coaches them on exercise and nutrition and suggests extra testing to head off disease that might be years down the road.

How does she make the bottom line work?

By charging patients an annual fee of $1,500, over and above what’s covered by health insurance.

Those who couldn’t – or wouldn’t – sign up were referred to other doctors.

Heiby’s is the latest local rendition of a style of medical practice that goes by various names: concierge care, boutique medicine, retainer-fee practice.

Basically, people pay a fee in exchange for more personalized care and better access to their doctors.

Some people see the trend as a symptom of what’s wrong with health care in America: Primary-care doctors are forced to cram schedules with patients so insurance reimbursements will cover costs. That could get worse come March, when a planned cut to Medicare payments takes effect.

Others see it as a growing gulf between people who can afford quality health care and those who can’t.

Private-pay doctors are still a very small piece of the pie – 5,000 practice across the country by one estimate – but the trend’s existence during a recession has caught the attention of some experts as health  care  overhaul efforts hang in the balance.

Will  the overhaul address any of the conundrums – insurance paperwork, inadequate reimbursements – that have led some doctors to set up these practices? Will an influx of newly insured patients lead more primary-care physicians, already in short supply, and their patients to take cover under private-pay arrangements?

Tom Blue, executive director of the Society for Innovative Medical Practice Design, a professional organization of concierge physicians, thinks the trend will grow: “It’s a combination of declining reimbursements and the uncertainty of what the future holds.”

Heiby said her shift to retainer-fee practice grew out of a desire for a more preventive approach.

“I didn’t want to just treat illness,” she said. “I wanted to focus on taking care of the whole patient by being a health coach, and that takes time. Wellness gets short shrift in a regular practice.”

Now she’s able to talk in detail with her patients about making diet and exercise changes, and parse their family health history to help them head off problems. For instance, she might recommend that a patient with a family history of heart disease get a test that measures the thickness of the carotid artery walls.

Her practice has an ultrasound machine that can do that, and while the $250 test is not covered by insurance as a preventive measure, some of her patients are willing to pay out of pocket for it.

The idea of concierge care goes back to the late 1990s, when doctors in the Seattle area switched from insurance-based care to private pay. Dr. David Grulke, a Norfolk internist, was the first to bring the model to this area in 2002.

He said his practice, which does not accept insurance and charges $90 a month for people 36 and older and $55 for patients 22 to 35, has thrived and even added a physician.

“People think concierge care is for glitzy, high-end people, when in fact it’s for ordinary people who appreciate their relationship with their doctor,” Grulke said.

Sentara began a similar practice in 2005, with guaranteed on-time appointments, on-site prescription service and a Web site where patients can call up their own records.

Heiby’s practice is a new twist on the idea. She hooked up with a company called MDVIP,  which is based in Boca Raton, Fla. Two doctors who started a concierge practice there in 2000 developed a model they now use to help doctors across the country make the same switch.

The model includes helping inform patients about the new approach; a preventive health plan with comprehensive annuals, screenings, genetic reviews, and exercise and nutritional help; and advice to keep practices from running afoul of insurance regulations.

So far, 350 doctors have joined in 28 states. They sign a five-year contract and give $500 of the $1,500 annual fee to the company.

Heiby is one of 22 MDVIPs in Virginia and the first in Hampton Roads. Unlike Grulke’s practice, Heiby accepts insurance payments. She started telling patients during the summer  so they’d have ample time to decide whether to pay the fee, switch to another provider in her office or change practices all together.

Marlyn Brown, 75, had been seeing Heiby for 20 years when she learned of the new annual fee.

“My first reaction was 'Wow,’” Brown said. “But when I thought about it, I realized I better check into it, because I really like her, and I didn’t want to lose her.”

Brown decided to pay the fee.

“It gives me a little assurance.”

Critics have decried the idea as an elitist approach that further divides the classes, but most experts say it’s not big enough to have much impact.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said he believes it’s a symptom of a broken care system, rather than a solution to it.

Insurance companies are “crushing docs with red tape,” he said in an e-mail response. And patients are exasperated with long waits, short visits and being shunted to different doctors within the practice. But he says concierge care will have limited growth because few people are willing to pay for it, and few doctors have a high enough volume of patients who can afford the fees.

Dr. Christine Matson, chairwoman of family and community medicine at Eastern Virginia Medical School, said the trend has not yet had a big impact locally. But a national movement, she said, would have the potential to siphon off primary-care doctors, already considered to be in short supply.

That crunch is expected to get worse if a health care  overhaul goes through that  increases the number of insured. And in March, Medicare reimbursements to doctors are scheduled to be reduced unless legislators reverse an already passed formula to help control the cost of the federal insurance for people 65 and older and some disabled people.

Some see the root of the problem as Medicare’s “fee for service” system that tends to reward physicians for the number of interventions ordered rather than for evaluation and management of disease. There are proposals in the heath care  bills to increase payments to primary-care doctors over time, but many fear not enough is being done to change the overall system.

Dr. Bernard Kaminetsky, medical director of MDVIP in Boca Raton, said concierge care also has been criticized as creating a two-tiered health system, but he argues that the system already is pluralistic. People get different types of care depending on whether they are covered by government insurance, HMOs, private insurers or free clinics.

“What we offer people is the opportunity to have non covered services,” Kaminetsky said. “Society can’t afford it in the aggregate, but people who can should have the option.”

Ultimately, he said, the approach saves public health dollars because more of it is private pay. The higher-access care – such as for screenings like the carotid artery test – can decrease the need for insurance-paid hospitalizations by heading off problems.

At a time when legislators are considering whether health care is a commodity or a right, though, some question whether the “haves” receive a level of care that likely includes unnecessary testing, while the “have-nots” wait for basics.

Virginia Beach resident Tina Donnigan, a 43-year-old legal assistant, hardly sees herself as elitist. She looked closely at her budget before signing on with Heiby. She said that rather than feeling rushed through an appointment, she wanted to be able to address all her concerns.

“I look at it as investing in my health,” Donnigan said. “It’s like a gift to myself.”

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com