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A Visit With Dr. Deluxe

Red-carpet treatment can be had for a price. But is 'boutique' worth it?


Imagine a doctor who takes time to ask you about your family or chat about a movie. Who guarantees that you won't have to wait long for an appointment and even makes house calls. A doctor, in short, who provides the same VIP service you'd receive flying first class.

You'd have to pay first-class prices, of course.

One of the latest signs of the continuing backlash against managed-care medicine is so-called boutique doctors who promise red-carpet service to patients for a fixed fee, usually from $1,000 to $4,000 a year. These doctors, working individually or in groups, promise round-the-clock access, comprehensive annual exams and longer appointments, as well as other niceties.

For the doctors, these arrangements allow them to see fewer patients while preserving--or enhancing--their incomes. While a typical primary care doctor may have 2,000 to 3,000 patients under his or her care, boutique doctors aim to trim their patient load to fewer than 600.

"It's the difference between night and day," said Dr. Bernard Kaminetsky, who set up a boutique, or "retainer," practice in Florida a year ago through a company called MDVIP . He used to see up to 35 patients a day; now he sees no more than 10. Patients tell him they're happier, and so is Kaminetsky: He gets home in time to eat dinner with his family.

The concept, which originated in Seattle in the mid-1990s, has since spread to Arizona, California, Massachusetts and Florida. Consumer interest in such first-class service reflects widespread frustration with the confusion and anonymity of modern medicine, in which patients often are bounced among doctors and health plans, straining the doctor-patient relationship. The "boutique" solution is especially appealing to more affluent middle-age and older people who have ongoing health concerns, and little patience for the hassles and rules of managed care. The yearly premiums are not covered by insurance, and many of the medical services, including office visits, may be only partly covered, if at all.

"We have business executives, professional people, older couples who want more time with their doctor," said Amin Neghabat, director of the Lewis and John Dare Center retainer program at Virginia Mason Medical Center in Seattle. The Dare Center has more than 1,000 members, with an average age of 62, who each pay $3,000 a year for the deluxe services.

Nationwide, the number of doctors charging retainer fees is small--probably no more than 200, according to Dr. F. Maxton Mauney, who investigated the practices for the American Medical Assn.--and it's still too early to say whether the practices will be a cornerstone of medicine or a curiosity, he said. Nonetheless, they already have captured the attention of some members of Congress.

"If every doctor started doing this, it'd be the end of Medicare," said U.S. Sen. Bill Nelson (D-Fla.), who recently introduced a bill that would prevent Medicare and Medicaid from reimbursing doctors who charge a retainer fee. "We believe it's wrong, and we're going to try to stop it." In March, five Democratic congressmen signed a letter calling on the Bush administration to review retainer practices to make sure they don't already violate Medicare laws.

Doctors themselves are divided on the ethics of retainer medicine. Said Dr. Richard Roberts, chairman of the American Academy of Family Physicians, "I feel I'm already available to my patients 24-7, and so are most family physicians. We don't need to do a wallet check first." The American Medical Assn. has no objection to retainer contracts, however. A report delivered to the AMA board by Mauney last month raised concerns about doctors dropping patients to go boutique, but otherwise it found that the practices present no threat to patient care. "Our position is that citizens have the right to strike a contract with their doctor, just like they do with their lawyer or any other professional," said Dr. Yank Coble, president of the AMA.

In California, health-care regulations do not specifically address the arrangements. Any business that charges up front for medical services is considered a health maintenance organization, and is subject to licensing fees, financial disclosure and a host of other regulations, said Daniel Zingale, director of the Department of Managed Health Care, which regulates health plans. But it's an open question whether doctors who charge retainer fees are in fact providing medical care in return--or simply more time and better service, he said. "It's very new, and we're still sorting through it," Zingale said.

If the practices are regarded as HMOs, the licensing fees and other requirements could stop them before they get off the ground, said Daniel Yakoubian, a California attorney who specializes in representing medical groups and hospitals.

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