TOP VIEW Clients of concierge medical practices receive more convenience, comfort and personal attention from these retainer-based physicians. Proponents of this type of service argue that these patients thereby receive better care than those who use doctors who work in traditional practices. But others doubt whether concierge practices add any value to the medical services already available to affluent individuals, especially when it comes to obtaining access to the very best specialists. Skeptics dismiss concierge medicine as more style than substance.

A growing number of primary care physicians are retooling their medical practices to target patients like Rautenberg with retainer-based services. As many as 300 primary care doctors nationwide have transformed their practices with the goal of convincing patients that they can offer a quality of care that is no longer readily available, even to those patients for whom physician access and skyrocketing medical costs are typically irrelevant.

“My time and my peace of mind are my priority,” Rautenberg says. “I have no problem paying a little bit more for that to increase the odds that I’ll get a doctor who is paying enough attention to me and my concerns and my health that he’s not going to make a stupid mistake.”

Commonly referred to as concierge medicine, this burgeoning brand of health care generally requires patients to pay an annual retainer ranging anywhere from $1,500 to more than $20,000. Many affluent patients already enjoy much of the comfort and convenience promised by these concierge practices through their long-standing relationships with their family doctors. But for those who do not, or those who require specialized care, concierge physicians offer an alternative. “This model turns every patient into someone who has instant, privileged access to his doctor—into someone who has, in effect, a personal physician ready to help at a minute’s notice,” claims David Katzman, who has a list of 50 St. Louis residents waiting to sign up for his concierge medical practice. “I can’t offer my patients dramatic new technologies, but I can, and do, give them the kind of old-line service that has vanished from the rest of the health care system.”

Most concierge doctors insist that they offer much more than convenience and access. They contend that they actually provide a higher level of medical care than a traditional physician because they can operate profitably with fewer patients. Thus they can afford to spend more time with each patient. “This is the way that they are enlisting patients: by presenting them with the logical argument that more time equals better outcomes,” says John Connolly, founder of Castle Connolly Medical, a New York research firm.

Yet some critics of concierge medicine question whether increased access necessarily equates with better and improved outcomes. “You may be able to provide the appearance of better health care, but I personally believe doctors have to see a larger number of patients in order to keep their skills sharp,” says Christopher Barley, a Manhattan specialist in internal medicine who serves as primary care physician for “a few thousand” patients. “The risk is that if all you’re doing is routine physicals for a handful of generally healthy patients, you’ll lose your edge and you’ll be bored. And that’s a recipe for disaster.”

Concierge care enables patients to essentially purchase a value-added relationship with a health care provider. Unless individuals are fortunate enough to have a long-standing rapport with a family physician and the access that comes with it, Katzman explains, “they walk into a doctor’s office and, bingo, they are just like everyone else: a run-of-the-mill patient sitting in a crowded waiting room, waiting to be seen for nine minutes by the doctor who is supposed to be in charge of their health. And no one likes that feeling.”

Alternately, concierge patients are pampered. Doctors promise to work themselves around a patient’s schedule, rather than vice versa, promising on-call visits or same- or next-day appointments. Those seeking privacy and confidentiality are enamored of the idea of secure, discreet offices. Renovated waiting rooms boast juice bars and comfortable sofas on which family members can relax. Patients who have cardiac stress tests can shower in spa-like bathrooms before returning to work. Every patient receives the personal doctor’s home, office and cell phone numbers.

Howard Maron is the physician credited with creating the concept of concierge care. “The ‘Highly Attentive’ Approach” . While serving as team physician for the NBA’s Seattle Supersonics, he began to wonder how to provide the same kind of personalized care he gave to the athletes on the road and at home, at all hours of the day and night. “A team owner can’t afford for the star players to sit on the sidelines, so a team physician is trained to detect problems before they even occur,” says Jon Moses, a veteran health care administrator recruited by Maron to serve as chief executive of his new venture, Seattle-based MD2.

At practices in Washington and Oregon, MD2 physicians care for a maximum of 50 families each, or 100 families in each two-person practice. Fees run $13,200 per year for an individual, $20,000 for a couple and an additional $2,000 for each child. “These [services] are for people who say, ‘There is a price for good care, and I’m willing to pay it,’” Moses notes.

I can’t offer my patients dramatic new technologies, but I can, and do, give them the kind of old-line service that has vanished from the rest of the health care system.

Moses and Maron say their patients (clients, as Moses calls them) receive not just superlative service, but also better health care. “Our doctors have the time to devote to their patients and become their confidant, their advocate, their friend,” Moses says. “This translates into a better quality of care, by far.” He is convinced that had he and his wife been MD2 patients several years ago, physicians would have been quicker to diagnose her cancer, which is now in remission. “It’s too easy to delay or miss diagnoses if you don’t know a patient intimately,” he says.

According to Connolly, concierge practices can handle this type of preventive care and wellness service more effectively, and may be able to better identify recurring issues, ranging from strep infections to depression. “That’s the kind of detailed attention that our wealthiest citizens have sought from the health care system, but that really has become harder to find,” he says.

To date, however, the only thing that can be said with certainty is that concierge care saves time and offers more personalized care in comfortable, even luxurious, surroundings. No studies have been completed showing that a doctor spending more time with a patient, or having a smaller patient load, lengthens patient lifespan or ensures that cancers or other maladies are diagnosed earlier or treated more effectively. Behind the marketing hoopla, even the staunchest proponents of concierge care admit that no one knows whether all this cosseting and these accoutrements ultimately result in better medical care. “I don’t think my level of knowledge is any different from a good doctor at a regular practice,” Katzman says. “But while I can’t tell you that people live longer, the quality of their life is better. They know if something comes up, it will be addressed in a timely way.”

Patients assessing the value of concierge medicine must consider some risk factors associated with this model. One of the most common points highlighted by concierge critics concerns whether primary care physicians convert their practices to concierge services because they truly want to offer better care, or because they want to change their business model to focus on high-end patients while eschewing paperwork. Manhattan internal medicine specialist Christopher Barley, who contemplated and rejected the idea of transforming his practice into a retainer-based service, casts a critical eye. “With a lot of doctors who opt for retainer-based practices, you see them make this choice for lifestyle reasons,” he says.

Unearthing the motivation of a concierge doctor requires a patient to ask tough and often awkward questions. (See “Concierge Care Due Diligence,” below.) Is the doctor opting for this model of care because he is a good physician, or because he is a good businessman? Is his goal to spend as much time as possible with patients, or is he making the switch because he wants the additional leisure time that a much smaller patient load can offer? Is there a risk that some concierge practice patients could end up shortchanged? Only extensive due diligence can provide answers.

Concierge Care Due Diligence Essential questions to ask when deciding whether to use a concierge physician: 1. How many critically ill patients do you care for? 2. Is your practice independent, or is it a franchise? 3. What are your educational and professional credentials? 4. Does your firm have any specialists on staff? 5. What leading specialists do your patients have access to?  In what fields? 6. Does this practice have admitting rights to the leading  hospitals in my area? 7. Does this practice accept patients with preexisting medical conditions?  8. Can you provide references from existing patients? 9. Given the limited size of this practice, what are you doing  to keep your medical knowledge and skills up to date? 10. How do you advocate for your patients when they   require specialized or long-term care?

Like many popular specialists, Barley sets his own fees and bills patients directly, which allows him to spend more of his time getting to know patients and monitoring chronic conditions without limiting the size of his practice. “I have colleagues out there who are charging $2,000 to $25,000 a year for what I provide routinely for a lot less, most of which the patients are reimbursed by their own insurance,” he points out.

Health care consumers do not always need to spend more to get more, argues Michael Fleming, a Shreveport, La.-based physician who has practiced general medicine for 27 years and now chairs the board of the American Academy of Family Physicians. Rather, he says, they need to invest their time and energy in selecting their doctor and developing a long-term relationship with a trusted, experienced medical practice, what he calls a “personal medical home.” That may come more easily in a concierge practice. “But they don’t need to pay extra to get that. Concierge care is a triumph of style over substance,” Fleming argues.

Fleming may have rejected the fee-for-service aspect. But in practice, his services do not differ much from the concierge model. He leaves half of his daily appointments open every morning so he can see patients the same day they call, if necessary. Recently, one of his patients called Fleming at home at 5 am, saying, “I’ve got the flu again; I’m flying home in my jet. Would you meet me at the hospital?” Fleming got dressed and met the patient at the hospital. He helped the staff determine that this was not just another bout of flu; the patient had myeloma, a form of bone marrow cancer. “We had the kind of relationship where he knew he could do that,” Fleming says.

Moreover, just because a patient is willing to pay does not mean he will make the cut at premier concierge services. “There is always a face-to-face meeting between the doctor and the prospective patient to see if there’s a good fit—it’s a mutual selection,” Moses says. A doctor may decide he cannot treat someone. “If a person has complex health problems, he might need more specialist skills than our doctors can provide; no one wants to be a doctor to patients he can’t serve properly.”

Such practices lead some to worry that there is a risk of concierge practices cherry-picking their patients. Individuals with a chronic medical condition need to consider this when considering hiring a retainer-based doctor. “To make it work, they can’t have too many patients demanding lots of time with major medical issues,” Connolly observes. “That’s a potential ethical minefield.” Concierge practices can end up with a healthier-than-average population of patients because of these deliberate selection practices. This is more likely at a newly created medical practice than at one that is converting to the concierge model, Connolly says. The patients who opt to join are generally healthy 40-somethings willing to pay their doctors what they pay their personal trainers to stay healthy. Ultimately, this trend may skew the results of any research that is conducted on whether concierge care actually improves general health.

As more concierge clinics open their doors, most analysts agree that the model is unlikely to come to dominate the health care system. It is too early to determine how successful the concierge model will be in offering better medicine. Connolly explains, “Really, it’s like getting on a plane to Los Angeles,” he says. “It takes off and lands safely and on time. Some people go in economy class, some in business and some pay for first class. Everyone has the same outcome—only the price and the comfort level change. For now, that’s all we can say about concierge care.” 

Suzanne McGee is a New York-based freelance writer. suzanne.mcgee@gmail.com. Additional reporting by Marilen Cawad.

Photography by David Allen Brandt.

Additional Information
 The "Highly Attentive" Approach
 All Access?
 Concierge Medicine Resources
 Principles in Practice: The Ethics of Concierge Medicine
 A Guiding Hand