By Liz Kowalczyk
Tired of rushing through 25 to 30 appointments a day,
Dr. Rick Versace thought he'd found the perfect solution: In October
2002, he opened a ''concierge" medical practice, spending $100,000
on radio ads, brochures, and other start-up costs and promising a smaller
number of patients more time and attention in return for an annual
fee.
But Versace's leap into a new kind of medical service didn't work
out. Patient enrollment was stagnant and the patients he did have needed
his attention at all hours and on weekends, so in February, he shuttered
his Cape Cod practice. Now, Versace is employed working a regular shift
treating hospital patients.
When two Harvard Medical School-affiliated internists quit their jobs
at Beth Israel Deaconess Medical Center three years ago to open the
state's first concierge practice, a dozen Massachusetts doctors frustrated
with what one called ''turnstile medicine" followed and many more
considered doing so. But patients have not lined up to pay the $1,500
to $4,000 a year such practices cost. In return for the fee, doctors
typically offer 24-hour cellphone access to their patients, hourlong
same-day appointments, detailed research into patients' medical conditions,
and other extras.
Two practices have closed, and most of the roughly 10 practices in
the Boston area are not full. Even the Harvard pioneers, who run one
of the few concierge practices that have reached capacity, said they
will not expand and that patient demand is lower than doctors predicted.
''We're not getting calls saying 'Will you open a satellite practice?' " said
Dr. Jordan Busch, who left Beth Israel Deaconess to help create Personal
Physicians HealthCare. ''It's kind of a surprise given how dissatisfied
people say they are with health care."
Nationally, results also are mixed, according to health care lawyers
and consultants. Most concierge practices have met intermediate targets
but many are having difficulty reaching capacity, generally considered
300 to 600 patients per doctor. Most doctors have patient loads of
2,500 to 3,500.
Managed care, under which insurance companies stopped paying physicians
the large fee increases they were accustomed to, forced many doctors
to increase productivity and squeeze more patients into their day.
Some doctors have complained that their schedules are unbearable, leaving
them just minutes with each patient, no matter how complex the illness.
Some have looked to concierge medicine as a solution.
The idea is to charge patients an extra annual fee on top of health
insurance payments, allowing the doctor to cut back the number of patients,
spend more time with each patient, and improve care -- while at the
same time make a healthy living. The benefit to patients, doctors said,
is more time spent on preventive care and on coordinating treatment
among different specialists and hospitals.
Critics have called concierge medicine elitist and, at least at the
outset, worried it could transform the landscape of health care by
creating two levels, one for the well-off and another for the working
class.
But it has yet to attract a widespread following. Even though Versace
hired a marketing specialist to evaluate patient demand on Cape Cod,
develop a marketing strategy, and book speaking engagements at senior
citizen centers, in the end about 150 patients were willing to pay
the $3,000 annual enrollment fee. He had hoped to reach 300 patients
in the first couple of years.
Even though many of the patients in his original practice had complex
medical problems -- the exact group doctors think can benefit from
the extra attention a concierge practice promises -- many also were
on fixed incomes and couldn't afford to join his concierge practice.
Versace gave a number of patients discounts or let others join for
free.
Another physician, Dr. Richard Goldman, who opened a concierge practice
in Wellesley two years ago, has enrolled 235 patients but needs 350
to 400 to make his practice financially sustainable.
''Before, I was seeing 30 patients a day; I was in the office until
8 p.m.; I'd take work home with me; and my family said I was cranky
and short-tempered," he said. ''This is absolutely a better quality
of life. There's no question I am happier professionally than I ever
have been since I started practice. But people are not beating down
the door."
Doctors and health care researchers aren't sure why more patients
aren't joining faster. With insurance premiums skyrocketing, working-class
and middle-class people may not want to pay more for medical care.
And, even for those who can afford the fees, people may not be as unhappy
with medical care as doctors believed, especially if they're healthy,
as are most patients of primary care doctors.
''Things are not as bad in terms of quality as these doctors made
them out to be," said Uwe Reinhardt, an economist at Princeton
University. ''With all the whining doctors have been doing about having
to pump through patients faster, being professionals they never really
cut corners."
Surveys done by the Center for Studying Health System Change, a nonprofit
research organization in Washington, D.C., suggest that patient satisfaction
actually is increasing. In 2003, for example, 69 percent of patients
surveyed said they trust their doctor, up from 66 percent six years
prior.
Concierge practices also address only one aspect of the health care
system: primary care. While patients' concierge doctors refer them
to specialists, the annual fee doesn't give patients faster access
to specialists or to hospitals.
Allison McCarthy, a consultant with the Corporate Health Group based
in Rhode Island who has advised physicians who have opened concierge
practices, said the most successful practices were those that opened
first in a market.
McCarthy said the Boston market is saturated, and ''probably can't
take any more practices."
Darin Engelhardt, chief financial officer for MDVIP, a Florida company
that helps run 72 concierge practices across the United States with
22,000 patients, disagrees. The company has four practices in the Boston
area, although only the original one, started by Dr. Harold Solomon
after he left Beth Israel Deaconess, is full at 600 patients. But Engelhardt
said doctors in the other three practices are either new or want to
remain smaller. He said the company still is negotiating with doctors
to open other practices here. MDVIP doctors collect a $1,500 annual
fee from patients. The doctors split the fee with company, which does
all the research and marketing.
Engelhardt said the company is collecting data on the advantages of
their practices that may persuade more patients to join.
Many doctors who've opened such practices said they're very satisfied
-- and so are their patients.
Busch said that 98 percent of patients re-enroll annually in his practice
with Dr. Steven Flier and Dr. Nancy Corliss, which has 900 patients,
or 300 patients each.
Versace, 44, said he got his patients admitted to the hospital faster,
was able to spend an hour on the phone at a stretch reviewing medications
and test results, and helped patients in other ways during his short
time as a concierge physician. But he said being on call on his cellphone
''24/7 got overwhelming for me personally." His older patients
required a lot of hospital visits and house calls.
''I wanted to spend more time with patients, which I achieved," he
said. ''At the same time I wanted to have better quality of life outside
the office; that's the part I didn't achieve."
