Concierge Medicine Growing in L.A., Orange Counties

LOS ANGELES — Concierge medicine — in which patients pay an annual fee to keep a physician on retainer — brings greater peace of mind to both doctors and patients, according to proponents. However, critics contend it widens the gap between haves and have-nots.

Only a small percentage of Californians can afford concierge medicine, also known as boutique, personalized or direct-practice medicine. A much larger percentage can’t afford health insurance, period. Despite the expense, concierge medicine is growing nationally and especially in Los Angeles and Orange counties. Exact numbers aren’t readily available, but national and local physicians, as well as concierge management organization officials said they see growing interest among physicians and patients in Southern California.

“When I converted my practice in 2005, there might have been 500 of us across the country, and now there are maybe 10,000,” said Thomas LaGrelius, a Torrance-based specialist in family and geriatric medicine. He chairs the board of the not-for-profit American Academy of Private Physicians, a professional association with approximately 300 members. Considering the estimated number of concierge physicians, the trade group’s membership is relatively low, but doctors are generally not “great joiners of anything,” said LaGrelius.

AAPP’s members provide concierge services, direct, fee-for-service and other forms of health care characterized by a direct financial relationship with patients, according to the website. The direct financial relationship reduces piles of paper and costly employees needed to push them, according to proponents.

Under the typical concierge physician business model, patients pay an annual fee for a specific “menu” of services, such as unlimited office visits, either same day or next day, and round-the-clock access to the doctor. According to many concierge physicians, the model makes it easier to coordinate care across a sometimes confusing range of conditions and specialists. Like most health providers, concierge physicians say nipping long-term, chronic illnesses in the bud keeps patients healthier and costs lower. Concierge doctors say early intervention is easier in their style of practice.

‘Not a Replacement for Insurance’

Concierge medicine is not health insurance. Doctors accept patients who pay their annual membership fee, regardless if those patients have health insurance. Most physicians submit claims to insurers for members whose treatments go beyond the annual concierge fee.

“Concierge medicine should not be a replacement for insurance coverage, which should involve protection for a range of services,” said Anthony Wright, executive director of Health Access California. “Plus, if you have any condition whatsoever, you need more than one relationship with one doctor.”

The concierge category puts a financial barrier between doctors and patients, according to Wright. “Apart from the morality and ethics of it, it’s not a sustainable business decision for most. It may be an option for the healthy and wealthy, but it doesn’t really work for the rest of us,” he said.

Still, the concierge medicine wave can’t be ignored. Rosanna Westmoreland, a spokesperson for the California Medical Association, said CMA’s policy acknowledges “concierge care” as an option for providing medical care to patients in an ethically sound, patient-centered environment. CMA continues to support direct contracting between physicians and patients.

Some experts — such as Gerald Kominski, associate director of the UCLA Center for Health Policy Research — worry that growth of the concierge model could skew California’s health care system even more toward those who can afford care and away from those who cannot.

“Because of the lure of earning more revenue, the concern is that doctors who are now practicing across a broad range of patients may start shifting their practice to more exclusively focus on people who can afford it,” said Kominski, who also is a professor at UCLA’s School of Public Health.

“In economic terms, it is a type of price discrimination. Concierge medicine does take us in the direction of introducing greater disparity within access based upon the ability to pay, despite efforts over the last couple of decades to reduce disparity and equalize access to care,” Kominski said.

Yet, no one disputes that in the current economic environment, physicians must worry about more than medicine.

“As doctors try to be more efficient and effective in managing their practices and identifying and capturing their target market, concierge medicine is indeed a unique proposition,” said Bill Bergstrom — partner at EMARC Medical Network in Los Angeles, a physician business development firm.

Docs ‘Thriving, Not Just Surviving’

For some doctors, concierge medicine is the key “to thriving, not just surviving,” said LaGrelius, whose total patient load is 600. He sees fewer than 20 patients a day. His patients who are older than 40 pay an annual fee of $1,900. Patients ages 40 and younger pay $950 a year. LaGrelius said the mean age of his patients is 65, mature adults “who really need care, often with a list of 20 to 25 problems, and lots of prescription medicines.” He added, “Patients have my home phone, cell, pager and satellite phone.”

LaGrelius said a decade ago he worked 100 hours a week in a solo private practice caring for a total of 2,500 to 3,000 patients. He had 200 office days a year and his patient visits were eight minutes each — conditions he says are the current norm under what he calls “population-based medicine.” Back then, he generated less income than now, he said. “I still work 80-hour weeks that include volunteering, but only about 50 or 60 are for the practice,” he said.

The concierge model may attract more physicians to primary care, say its supporters. A June 2009 report from the Medical Board of California revealed that 34% of active physicians in the state were in primary care, an insufficient number that “could pose a significant threat to health care access in the state,” the report stated. In addition, a fall 2010 study from UC-Davis School of Medicine showed primary care physicians’ wages are less than half that of some of the highest-paid specialists.

Encouraging Competition

Proponents say the concierge model encourages competition among physicians.

“We doctors can be better than each other with concierge medicine,” said AAPP President Marcy Zwelling-Aamot, who specializes in internal medicine and emergency and critical care in her Los Alamitos practice. She anticipates “more really interesting paradigms” occurring, she said, if doctors become competitive without a fixed pricing system.

She and other concierge doctors have a renewed commitment to the Hippocratic Oath, she said. “My patients are my friends, my focus, and I’m their advocate. Most people want to take care of themselves if they’re taught how. Humans pay for what they think has value,” Zwelling-Aamot said.

Solo family doctor Gary Seto of South Pasadena has been charging $120 per family annually since 2007 — considerably less than other concierge physicians. Seto — a member of the California Academy of Family Physicians who carries a patient load of 500 — said the annual fee has another purpose beyond raising revenue.

“I’m not looking to get rich here, but I do want people to make a commitment to me,” he said. “The fee screens out those who want a doctor today, but don’t care if they see him again.”

Retreating From Battle

“After 20-plus years of battling insurance and Medicare while trying to provide high quality care, I was frustrated and somewhat despairing,” said internist Donald Barber of Glendale. He is now a member of MDVIP, which stands for Medical Doctor and “Value in Prevention,” but also has the elite connotation of Very Important Person. “MDVIP allows us to practice the kind of medicine we were actually trained to do,” he said.

That’s the whole idea, said Mark Murrison, president of marketing and innovation at the decade-old MDVIP, a wholly-owned subsidiary of Procter & Gamble. MDVIP has 450 member physicians and 150,000 patients in 32 states and the District of Columbia and is expanding rapidly, according to Murrison.

Doctors shouldn’t just treat patients when they’re sick, he said. MDVIP’s patients tend to prioritize their health at all times, Murrison said, versus disinterested, unengaged patient categories he called “not healthy, not trying” and “young and immortal.” “We’re probably not right for them,” he said.

School teachers and bus drivers join MDVIP, along with top corporate executives, Murrison said. “Demographics aren’t the differentiator, but attitude,” he said.

MDVIP contracts with physicians in network to provide predetermined services to members. Those patients pay MDVIP physicians a nationwide average of between $1,500 and $1,800 annually. The cost of practice is higher in California because of cost of living and overhead, Murrison said. The cost is “the equivalent of drinking a Starbucks every day,” he said. Doctors retain two-thirds of the fee, while one-third goes to the company, which takes in no additional revenues. “We don’t own, manage or control the practice,” said Murrison.

The system is working for Barber, the internist in Glendale.

“I’m very happy,” Barber said. “I’ve been given the gift of time to listen, address concerns and get off the high-speed treadmill. I go home thinking I’ve done a good job.”


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