Some doctors now charge extra for "concierge level" care


Margie Derryberry has been a patient of Dr. John Chauvin for 15 years. But that’s about to change because Derryberry can’t afford to pay a new $1,500 annual fee that Chauvin plans to charge patients on top of the cost of their insurance.

The fee is part of Chauvin’s bid to trim his patient rolls to about 600 people – down from 2,500 – so he can spend more time with each one and offer what he sees as extra preventive care.

But for Derryberry, 71, of Robertson County – and for other middle-income patients – the hefty fee raises questions about equal access to medical care at a time when some national studies say 40 percent of U.S. adults are already uninsured or under-insured.

“He’s a good doctor,” said Derryberry, who is raising three grandchildren. “If I had the money, I’d do it. But I just don’t have the money.”

Chauvin, who practices at an office near Summit Medical Center in Hermitage, is among a handful of doctors in Nashville now asking patients to pay an annual fee to gain access to their examining rooms.

It’s a trend on the uptick nationally, particularly among experienced doctors frustrated by what many see as an insurance system that’s reducing doctors’ pay, coming up with new pay-for-performance rules or pushing them to see more patients to lower costs.

Chauvin defends the $1,500 fee as a cost-effective way to deliver high-quality health care to people who need it and to provide a few extras, such as in-depth physicals.

“I have older patients that require more time – they don’t have just one problem when they come in,” Chauvin said. “Patients have a choice how much they want to get involved in their health. Just as people pay a comparable amount of money for cable TV and cell phones, it’s where their preferences are.”

Other health-care analysts warn of a widening gap between the haves and have-nots. Paul Ginsburg, president of the Center for Studying Health System Change in Washington, D.C., said new business models being used by some doctors could create a class system in medicine.

“It’s not only going to be the uninsured versus the insured,” Ginsburg said. “It’s going to be differences even among the privately insured – between those who can afford a concierge practice and those who cannot afford it.”

Derryberry, who already spends $660 a year on premiums for a private Medicare plan, will soon choose among several other doctors, including two who practice at Summit Medical Center in Hermitage. She expects to make a decision next month.

That’s when Chauvin and two other Nashville doctors – both of whom work at Heritage Medical Associates, a large group practice near Baptist Hospital – start charging a $1,500 annual fee.

Dr. Edwin Anderson and Dr. John Thompson are the only physicians at the 80-doctor Heritage Medical Associates adopting the plan.

All three physicians are joining a network of 245 doctors nationwide affiliated with a company called MDVIP. It gets $500 of the annual fee for providing support such as a CD-ROM with a patient’s electronic medical records and other benefits when a patient is traveling and needs a doctor. The remaining $1,000 of the $1,500 fee goes to the patient’s doctor for a variety of services.

MDVIP has few physicians enrolled, but others in Nashville are considering the concept. Patients of Nashville Medical Group recently were polled on whether they saw value in a model that would provide better access to doctors and promote wellness for a fee.

West Meade resident Howard Tepper, 76, and his wife chose not to enter the fee arrangement with Anderson, which would have cost them a combined $3,000 a year.

Tepper said he understands the pressure that a primary care doctor faces, and he thinks Anderson is a good physician, “but that’s kind of an elitist practice.”

Some other patients were quick to sign up, in part to keep doctors they like. “It’s worth whatever I have to pay to stay with him,” said Jimmy Gallivan, a retiree from the investment business who sees Thompson at Heritage Medical Associates.

Other similar models are popping up nationally. Some require patients or families to pay a retainer up to $25,000 a year for 24/7 access to doctors who limit their practices to 50 families, and who don’t accept insurance. Other doctors have gone mobile, focusing on house calls or meeting patients somewhere more convenient than the doctor’s office with the cost paid by the patient or the patient’s insurance.

“It’s a reaction to declining compensation for primary care at a time when the need for primary care is increasing dramatically,” said Paul Keckley, executive director of the Deloitte Center for Health Solutions, a nonpartisan think tank. “You can understand why doctors would choose to take an alternative route.”

UnitedHealthcare won’t contract with doctors who charge extra fees for concierge-level care. The insurer said preventive care should already be covered under benefits that physicians agreed to provide under regular insurance.

“A physical is a physical is a physical,” said company spokesman Roger Rollman. “Charging additional amounts for what should already be paid for is what it boils down to.”

CIGNA HealthCare dropped a handful of doctors from its network when the physicians refused to accept health plan members who didn’t pay the concierge fee. Under the company’s contracts, doctors must provide equal access to every member, said Mark Slitt, a CIGNA spokesman.

Proponents, however, say concierge payment methods keep experienced doctors practicing longer and improve patient care. Dr. Edward E. Goldman, chief executive of MDVIP, points to a 2007 study that showed a 53 percent drop in hospitalizations among patients seen by an MDVIP doctor over 12 months.

The average age of the 245 doctors signed up for the program so far is 53, he said – an age at which, he added, many doctors hope to slow down from 80-hour workweeks. “We think we can keep the good doctor in practice longer,” Goldman said.

Others say there’s nothing wrong with some doctors charging for what they, and perhaps patients, see as a higher level of service.

“In almost all other marketplaces, you can pay for a better steak, finer piece of clothing or jewelry, but why shouldn’t patients be able to pay for good health care?” said Dr. Marcy Zwelling, an internist and critical-care doctor in Long Beach, Calif., who is president-elect of theSociety for Innovative Medical Practice Design.

“If a doctor says, ‘I’d be happy to work extra hours for you, Mr. Smith,’ why shouldn’t that be possible in a free market?”

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