A different approach to health care: 'Boutique' medical practices attempt to strengthen the doctor-patient relationship -- and local residents are opening up their wallets A different approach to health care: 'Boutique' medical practices attempt to strengthen the doctor-patient relationship -- and local residents are opening up their wallets (June 08, 2005)

By Monique Johnson

Special to the Almanac

Bureaucracy and paperwork. Complicated health-care plans. Hurried consultations. Both patients and doctors voice a range of frustrations with today's health-care system.

"Much of medicine these days is dictated by the business and insurance aspects of care," laments Dr. Eric Weiss of the Village Doctor in Woodside.

Physicians are squeezed between the high overhead costs of practice and the low reimbursement rates for their services set by health insurance plans and government payers (Medicare/MediCal). This imbalance, Dr. Weiss explains, translates into the need to drive practice volume up in order to stay afloat, and seeing more patients every day means less time with each patient.

Dr. Kelly Traver of the Menlo Medical Clinic sums up a sentiment echoed by all of the doctors interviewed for this article: "My favorite part of medicine is developing a relationship with the patient, but with the changing face of health care, it is harder and harder to do that."

In response, some local doctors are creating new approaches to the delivery of health care. Their new practice models are designed to allow more time to listen to and talk with patients, and to offer a more comprehensive "wellness" approach to medicine.

Patients also value time and attention from their doctor -- so much so that many of them are willing to open their wallets and pay up to thousands of dollars for the premium medical services these doctors are offering.
The 'concierge' approach

Retainer medical practices, also known as "concierge" or "boutique" practices, were pioneered in 1996 by a group of physicians in Seattle. Concierge doctors limit their practice to a very small number of patients -- typically about 10 percent of what doctors in the traditional system handle.

Patients can reach their doctor directly 24 hours a day, seven days a week via e-mail, phone, or cell phone, and can get appointments usually the same day they call. Time with the doctor is unhurried. Concierge doctors even make house calls, and will accompany patients to the emergency room if necessary, as well as personally oversee any hospital care.
Elite care?

Patients pay a retainer fee on a monthly or annual basis for this access, service, and attention. Locally, retainer fees range from $175 to $325 a month. Considering that these fees are paid on top of those for health insurance coverage, concierge medicine has been criticized as an elite substructure in health care, affordable only to those with an above-average income.

Anthony Wright, executive director of Health Access California, a statewide health care consumer advocacy coalition, acknowledges that innovative practices like these will succeed because "doctors and patients who want to make it work will find a way to make it work." But he describes concierge medicine as "a trend for the healthy and wealthy, not a model for the future of medicine because these practices do not meet the needs of the vast majority of patients and doctors."

The continuing frustrations and issues with managed care must be addressed at the policy level, he says, with the goals of working to expand access to comprehensive coverage and setting standards and regulations for health plans.

"People should not have to check their bank accounts before getting needed care," Mr. Wright states.

But for now, the demand for better access to physician services is clearly strong, and those in robust financial health can -- and do -- pay for above-average access.

The following local practices offer "concierge" care.
The Village Doctor. Dr. Eric Weiss has lived in Woodside for 12 years, and has often helped neighbors in need, putting in stitches over the kitchen table when an emergency arises, for example.

"I like being integral to the fabric of community," he says. Opening the Village Doctor last year was an attempt "to do the right thing for patients and physicians, namely to try to capture back the way medicine used to be practiced," he explains.

With pediatrician Dr. Raquel Burgos on board from the beginning, and a retainer fee that is progressively discounted for each additional family member, the Village Doctor practice has a unique family focus. There is a limit of about 200 to 300 patients per doctor. "We are offering time and access; we don't want to get back to where we are too busy for that," says Dr. Weiss.

The concierge practice model has allowed Dr. Burgos to develop new approaches to pediatric care, such as the Newborn Program, in which she visits her newest patients in the comfort of their own homes -- weekly for the first month, then monthly up to 6 months of age. These programs "build upon what most physicians would like to do, but simply don't have the time," Dr. Weiss says.

The response from the community has been very good; Dr. Neda Pakdaman, an internist formerly with Menlo Medical Clinic, joined Dr. Weiss and Dr. Burgos on June 1 to expand the practice further.
Dr. Ami Laws. At the Stanford Medical Group, Dr. Ami Laws had a primary care and diabetes practice of more than 1,500 patients.

She is now opening a solo concierge practice because "I was totally, utterly burned out" and "had to make a change," she says, citing the frustration of having only 20 minutes to be with a patient who had come 100 miles to see her.

In addition to time and the chance to develop relationships with patients, Dr. Laws likes the flexibility in a retainer practice to offer care in many different ways -- via e-mail, phone, office, and home visits.

Her practice will continue to have a dual focus on primary care and the specialty care of patients with diabetes, high cholesterol, high blood pressure, or thyroid problems, she says.
The Encina Practice. The Palo Alto Medical Foundation incorporated concierge care into its services in May 2003, when Dr. Jeffrey Croke and Dr. Henry Jones III formed the Encina Practice. "Patients were asking for this type of care," says Jill Antonides, PAMF director of public affairs.

Traditionally, regular patient care at PAMF centers on a primary care physician, but specialty, after-hour, urgent, and hospital care is handled by other PAMF doctors. Thus, care is segmented.

In the Encina Practice, Dr. Croke and Dr. Jones follow their patients personally through all aspects of care. Each doctor will take care of about 300 patients, compared with an average of 1,000 to 1,200 patients per doctor in a conventional PAMF primary care practice, according to Ms. Antonides.

Ms. Antonides adds that "everyone gets the same level of high care at PAMF; what patients in the Encina Practice are paying for is more personalized service, and around-the-clock, direct access to their doctor."

Patients pay for this privilege -- retainer fees are $3,600 a year for an individual or $6,000 a year for a couple. A portion of the revenue from the retainer practice subsidizes other services offered at PAMF, such as community health programs and care for low-income patients, she says.

Like the Village Doctor, response to the Encina Practice has been very favorable. A third doctor, Dr. Yumi Ando, will join the practice in July.
Interactive Wellness. Menlo Park has had a concierge practice since 1996. There are four doctors in the practice; all declined to be interviewed for this article.
A "wellness" approach

If a boutique practice is not quite the right fit, but help is needed to jumpstart your health, Dr. Kelly Traver offers a different approach. She has just opened the Wellness Center, spearheading a new proactive approach to health care for the Menlo Medical Clinic, where she has practiced as an internist for 12 years.

"We see people every day who are struggling to do the right things for their health, but are tugged in so many different directions that it is often overwhelming for them to even begin a (wellness) program, let alone keep one going for life," she says.

The Wellness Center houses fitness equipment, a health library, and a bio-feedback area to target stress reduction. A cornerstone of the center will be the Health for Life program, piloted by Dr. Traver in January "to help people learn the tools to live as healthy a lifestyle as possible for the rest of their lives."

The $3,500, six-month program involves a state-of-the-art health and fitness assessment; ongoing evaluation through a daily e-mail log; alternating weekly appointments with Dr. Traver and a nutritionist; weekly sessions with a fitness trainer; and personal counseling if necessary.

Dr. Traver says she will expand the Health for Life program for seniors, adolescents, and new mothers, and will offer programs targeted at issues such as senior fitness and diabetes management.

Support from Menlo Medical's Charles Armstrong Foundation, which funds community health projects, will allow the Wellness Center to extend its programs to those who otherwise can't afford the fees.
Clear contracts needed

Though opinions on the subject may vary, it appears as if these new health-care options are here to stay.

The American Medical Association approved ethical guidelines for retainer practices in 2003, stating that "retainer contracts ... are consistent with pluralism in the delivery and financing of health care." But the policy specifies the need for a clear contract between physician and patient, and counsels doctors to continue to provide care to those in need, regardless of ability to pay.

The California Medical Association "encourages physicians to explore ways to deliver care the best they can," and supports "a variety of way for patients and physicians to interact," states Nileen Verbeten, vice president for economic services.

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