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Is concierge the new ‘it’ word in medical care?

Frustration brought Dr. Christopher Dowd and Mary Hunter Hardison together.

As a general practitioner and then a hospitalist in Suffolk County, Dowd found himself, unhappily, spending less and less time with his patients.

Hardison, a 2nd grade teacher at Nansemond Suffolk Academy, had resorted to traveling to Chicago frequently to see a specialist in hopes of curing her chronic headaches—migraines that could last up to three days.

In 2011, Dowd made his move. He left his position at Chesapeake General Hospital and embraced the concierge-medicine model, creating Cornerstone Private Practice. Dowd traded less time with thousands of patients for more time with a few hundred patients, all of whom pay him an annual fee in exchange for better access to him and a higher level of care.

Hardison took the leap as well. She wanted a doctor who would maintain her medical records, communicate with her specialists and coordinate her overall care. When a mother at Nansemond Suffolk recommended Dowd, Hardison made up her mind and left her primary care physician for him.

“It’s the best medical decision I’ve ever made,” says Hardison, 30. “It’s not for everyone. I’m married, and my husband doesn’t see him. But I need more consistent, routine medical care than my husband does.”

Hardison’s story is becoming increasingly common in Virginia and nationwide as doctors and patients meet at the intersection of convergent trends in health care. General practitioners are looking to dramatically reduce their patient load—typically between 2,000 and 3,000 people at a traditional practice—without sacrificing income. Consumers, meanwhile, are drawn to the more personal doctor-patient relationship of 50 years ago. They want to reach a real person on the phone and make an appointment inside of a month. They want a doctor who has the time to listen, and who knows them as a person beyond their symptoms.

The result is concierge medicine, sometimes referred to as membership, retainer-based or boutique medicine. Though some have decried it as “healthcare for the wealthy” and suggest that it will contribute to a two-tiered American healthcare system, this small but fast-growing approach to primary care has made true believers out of converts on both sides of the stethoscope.

Each concierge practice offers a different set of services, but common examples of their enhanced care include longer office visits, fast (even same-day) appointments, preventative screenings, 24/7 access to doctors by phone or email and a greater focus on fitness and nutrition. Concierge physicians can continue to oversee medical care in the event of hospitalization.

While it’s possible to pay tens of thousands of dollars per year for high-end care in the concierge stratosphere—think doctors who vacation with you—the average per person annual retainer is $1,600, or $135 a month, and that yearly fee is generally discounted for spouses and children.

Based on a model that originated in Seattle in the mid-1990s, the number of concierge physicians grew by 25 percent between 2011 and 2012, according to the American Academy of Private Physicians. The sector now comprises more than 5,000 physicians nationwide—including dozens of practices in Virginia, clustered mainly in populous Northern Virginia, Hampton Roads and metro Richmond. In 2012, trade publication Concierge Medicine Today named Washington, D.C., the sixth-fastest-growing city for retainer-based care, just behind Baltimore.

Physicians in retainer-based practices remain but a tiny portion of the nation’s 900,000 licensed physicians of whom a third are primary care physicians (i.e., generalists in geriatrics, pediatrics, internal medicine and disease prevention). But one in 10 doctors is thinking about switching to a concierge model in the next three years, according to a 2013 study conducted for the nonprofit Physicians Foundation. While some primary care physicians convert entirely to the concierge model, others take a hybrid approach with a small number of retainer-paying patients helping to subsidize the traditional portion of the practice.

“There’s no question that concierge medicine is still on the rise,” says Jeffrey Carr, corporate and consumer services growth officer at Inova Health System which, in 2012, hired a third concierge physician for its Inova VIP 360 branch at Inova Fairfax Hospital.

The nearly 500 patient members of Inova VIP 360 pay an annual retainer of $1,800 as well as any co-pays charged by their insurer. Through Epic software, Inova VIP 360 patients can access their own medical records online at any time.

House calls, when necessary, are among the concierge services offered by Richmond-based PartnerMD, where individual retainers range from $1,700 to $1,900. PartnerMD was the second concierge practice in Virginia when it opened 10 years ago and has since expanded to Maryland, South Carolina and the state of Washington. The vast majority of the network’s 23 physicians and 5,500 members are in Virginia. In fact, the network’s flagship Richmond office is now the largest individual concierge medical practice in the nation, according to Linda Nash, PartnerMD founder and executive director.

As for house calls, Nash explains: “If your whole family is sick with the flu, that might be a case where the doctor will visit your home and give shots. And sometimes when there’s a really important decision, like who to go to for a difficult back surgery or whether to have chemotherapy or not,” PartnerMD doctors will go with patients to specialist appointments to take notes, ask questions and guide the decision process.

As part of their increased focus on disease prevention, concierge physicians may provide more in-depth screenings than patients are used to receiving.

“For most of my patients now, I do advanced lipid panels,” says Dr. Laura Balda, the physician most recently hired by Inova VIP 360. “Traditionally, you’re looking for four numbers” indicating the amount of lipids in the bloodstream—total cholesterol, HDL (good) cholesterol, LDL (bad) cholesterol and triglycerides. “With an advanced panel,” she continues, “you’re looking for particle sizes, metabolic markers and genetic markers as well.”

Most concierge patients have insurance, and most of the practices accept it. In some cases, however, insurance is needed only for specialist co-pays and diagnostics performed elsewhere. For example, Virginia Beach Premier Medical (VBPM) doesn’t charge co-pays or any fees beyond its yearly retainer, which is $1,500 for patients between 18 and 35 years old and $2,400 for those older than 35. Things like X-rays and CT scans are handled by off-site providers and paid for by insurance.

In addition to chronically ill patients, VBPM founder Dr. Barbara Parks says she also has young, healthy concierge patients who meet with her just once or twice a year.

“I think they just want the security—knowing that there’s someone they can see who knows them,” Parks says. “They also want to do things at the last minute, like schedule a same-day appointment or have an exam just before their vacation. It’s more of a convenience as well as a security blanket.”

Both were factors for Dawn Siegel of Richmond when she and her husband, Stuart (son of the founder of S&K Menswear and VCU benefactor), joined PartnerMD about seven years ago.

“I was starting to reach a certain age and realizing I’d feel much better with a doctor who actually knew me and had a better grasp of my physical health in general,” Dawn Siegel says. With her previous doctor, “You’d have to wait so long to get an appointment. I had pneumonia once, and being told you can get an appointment in seven to 10 days doesn’t do you any good.”

More recently, when she had an allergic reaction while traveling overseas, Siegel called her concierge physician directly: “She called me back and found pharmacies for me. That’s very unusual to me.”

Unusual, yes .… but is it also financially out of reach for most Americans? PartnerMD’s Nash says no. Her members have an average combined family income of $75,000 a year, “which I was surprised by,” she explains, “because I thought it would be much higher.”

With income disparities in mind, her company gives each of its newly hired physicians 10 “scholarships” to help their former patients switch to concierge care.

Two big questions remain, however: Will the Affordable Care Act, as some predict, exacerbate America’s shortage of general practitioners, making it harder for those with lower incomes to find primary care physicians? And will the rise of concierge medicine contribute to a two-tier system of health care in America?

Carolyn Engelhard, who oversees the University of Virginia’s Health Policy Program, believes the answer to both questions is yes.

“I think it’s one of the dirty little secrets of American medicine, that somehow everybody gets the same amount of care and the same quality of care,” she says, “and that couldn’t possibly be true. We have 48 million people without health insurance. Many come to emergency rooms for their care. They come in sicker, they die earlier, and there’s even literature that suggests the quality of care they receive isn’t as good.”

Engelhard will be glad to see more people gain access to health insurance under the ACA. But as the demand for primary care physicians rises, she worries that the growth of niche medical markets, including concierge care, will continue to fragment the American health care system.

“I think we need more transparency,” she says. “We need to be better connected through information-management systems. We need better continuum so patients are cared for after hospitalization or proactive screenings. When we have entrepreneurial units that segregate themselves outside of that, I don’t think that’s good for the evolution of our health care system.”

Nash agrees that the availability of quality medical care is a valid concern. “Everybody has the right to decent health care,” she says, adding that they also deserve the right to upgrade their service level. “I’m a big proponent of really good quality public schools, too. And we need to put a lot of resources into them. But if you have a child with a learning disability and you want to send your child to a [private] school, and you have the resources [to do so], why not?”

Others consider the criticism of retainer-based medicine unfounded simply because the sector today is such a small slice of the giant health care pie.

“It won’t have a bad effect,” says Dr. Russell Libby, a pediatrician and president of the Richmond-based Medical Society of Virginia. “Some people will say it’s unethical, but it won’t affect enough of the marketplace to make a difference.”

For Suffolk teacher Hardison, even though money is always a consideration, concierge care is a worthwhile expense. She swears by Dr. Dowd’s attentiveness and calm demeanor and says she’ll stick with him even if her migraines continue.

To Dowd, the definitive allure of retainer-based care is the extra face time that he calls “an essential ingredient to a good doctor-patient relationship: Human beings aren’t robots that we can just treat by following a number on a chart.”

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