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Botique medicine: your thoughts?

Discussion in 'Clinical Rotations' started by PimplePopperMD, Jan 15, 2002.

  1. PimplePopperMD

    PimplePopperMD Senior Member

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    This was in today's NYTimes... struck a cord, and wanted to expose the non-NYT readers to it...


    Doctors' New Practices Offer Deluxe Service for Deluxe Fee
    By PAM BELLUCK



    Jared Leeds for The New York Times
    Dr. Jordan S. Busch is one of two Boston internists who plan to open a practice that for an extra annual fee of $4,000 will provide their patients amenities and attention that no managed care practice could match.




    OSTON, Jan. 14 ? In a city full of medical innovations, this one raised some eyebrows. Two respected physicians announced plans to open a medical practice that charges patients $4,000 a year on top of the medical costs covered by their health insurance.

    Patients who pay will get amenities and attention that virtually no managed care practice can provide nowadays: round-the-clock cellphone access to doctors, same-day appointments, nutrition and exercise physiology exams at patients' homes or health clubs and doctors to accompany them to specialists.

    The move by Dr. Steven R. Flier and Dr. Jordan S. Busch, both internists leaving Beth Israel Deaconess Medical Center for the new practice, has prompted newspaper columnists and some physicians to accuse them of abandoning lower-income patients to cater to the wealthy. The doctors say they are just trying to give patients more attention at a time when managed care pressures physicians to crowd ever-more patients into ever-shorter appointments.

    "We want to be able to spend more time with patients," said Dr. Flier. "We're desperately struggling to create a system that lets us do that within the limitations of managed care."

    Nationally, a small but growing number of doctors are doing the same. While the very rich have been able to strike their own deals with individual physicians for years, now doctors across the country have begun to put such services within the grasp of the upper middle class.

    The new "concierge" or "boutique" practices include several in Florida that charge $1,500 a patient; one in Arizona charging $5,000; and several in Seattle, including one that charges families $20,000 and provides heated towel racks, marble showers and personally monogrammed robes. Several practices are franchising, planning to add doctors in New York, California, Illinois, Texas, Maryland and Virginia.

    "I couldn't stand it anymore ? the day was an absolute treadmill," said Dr. Bernard Kaminetsky, an internist in Boca Raton, Fla., who formed such a practice through a company called MDVIP. "I wanted to devote more time to patients and I wanted to enjoy practicing."

    The extra hand-holding is possible because the fees let doctors slash the number of patients they see. Dr. Flier and Dr. Busch will go from thousands of patients a year to 300 each. The rest of their patients will have to find new doctors.

    Critics, many sympathetic to the doctors' frustrations, ask whether patients who cannot or will not pay the fees are being abandoned.

    "If you had a substantial portion of America's doctors doing this, who's going to take care of everybody else?" said Dr. Richard Roberts, chairman of the American Academy of Family Physicians. "We've got 40- plus million people in this country without health insurance, another 20 million who are underinsured. What's wrong with this picture?"

    Government agencies, including the federal Centers for Medicare and Medicaid Services, are investigating whether the arrangements illegally charge patients for services also covered by insurance or Medicare. Senator Bill Nelson, a Florida Democrat, has introduced a bill to keep doctors from charging Medicare patients a separate fee.

    In Massachusetts, a private insurer, Tufts Health Plan, has questioned whether the Flier-Busch practice, which is to open in April, discriminates against patients who cannot pay. The state's insurance department is investigating.

    Nancy Achin Sullivan, executive director of the Massachusetts Board of Registration in Medicine, which licenses doctors, said the agency had found nothing illegal, but would discuss with insurers, hospitals and patient groups whether the state should allow such practices.

    "It just doesn't sit right," she said. "Is it the type of practice and the type of medicine that the board members would like to see in Massachusetts? The answer clearly is no."

    Concierge practices say they adhere to the law by ensuring that their fees pay only for services not covered by insurance or Medicare.

    Michael Blau, a lawyer for the Flier-Busch practice, said it is divided into two separate entities: one bills for services covered by insurance; the other applies the $4,000 fee ? $7,500 for families ? strictly to noncovered extras.

    The American Medical Association has not taken a position on concierge practices. Dr. Frank A. Riddick Jr., chairman of the association's council on ethical and judicial affairs, said the issue is complicated.

    "Physicians have an obligation to meet the needs of a community," he said. "You could do that with 10 percent of physicians in the area practicing boutique medicine, but if it gets much more than that then I think you really have to question the process."

    Many concierge doctors, including Dr. Flier and Dr. Busch, say they help patients who don't join their practice find new doctors. Still, some patients have been outraged.

    "It's pure greed," said Herbert Kleinhaut, 75, of Lake Worth, Fla., who complained to federal and state agencies when his doctor joined the MDVIP practice. The Florida insurance department determined that MDVIP was not violating state laws.

    Others, like David Heerensperger, the 65-year-old chairman of World Lighting in Seattle, have been thrilled. He and his wife pay $20,000 to MD2 , which was started by Dr. Howard Maron, a former Seattle SuperSonics team doctor.

    "We thought, `Oh, gee, that's quite a bit of money," Mr. Heerensperger said. Then his hip replacement slipped out during a trip to Hong Kong and Dr. Maron coordinated his care by cellphone. "Even if it was half again as much, it's still nice to have that service available."

    MD2, which plans clinics in New York, Los Angeles and elsewhere, considers itself the "Ritz Carlton" of concierge medicine, with a ratio of 50 patients per doctor in its luxuriously appointed offices.

    In Boston, Dr. Flier, who is 51, said he was inspired after a longtime patient developed leukemia. Dr. Flier went unannounced to the man's office to break the news, drove him to meet a team of specialists and stayed with him for hours at the hospital. Dr. Flier realized he wanted to give each patient such attention, but that none of it was billable.

    "The telephone calls, the arranging, the going to give the news, being with him ? to the insurance company that paid the bills, there was nothing in their system that registered as being of value," he said.

    The Boston practice, which is called Personal Physicians HealthCare, is signing up patients like Karen Kavet, who said she "couldn't be more grateful" for Dr. Busch's help with her father's stomach surgery.

    Pamela Cantor, a psychologist at Harvard Medical School, said that Dr. Flier's personal care convinced her. "It's not like one is a multizillionaire," she said. "I want to keep him as my doctor ? enough to make the sacrifices."

    Some who will not be joining the practice have no hard feelings.

    "He's saying `Hey, I have all these patients to take care of and I want to give them the best,' " said Mimose Breger, who cannot afford to follow Dr. Busch.

    Bennett Feinstein, 68, who also cannot afford the fee, said, "I know other people think it's immoral, but there's so many Toyotas and there's only so many Bentleys."

    Dr. Flier and Dr. Busch say they will lose money at first and then break about even. They also say they will use their lighter schedules for volunteer work and teaching.

    Critics include Dr. John D. Goodson, a Harvard Medical School professor, who wrote to The Boston Globe that "the implication that well- heeled patients have the right to something more is abhorrent."

    Other doctors have defended them, like Dr. Mitchell T. Rabkin, another Harvard Medical School professor. He wrote in another letter, "What Flier and Busch are trying to do is what most physicians want to do: Care for their patients the way patients should be cared for."
     
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  3. Goofy

    Goofy Senior Member

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    Hi PimplePopper,

    The idea of privelege medical service isn't new. There is a corporation of doctors that started another service called MDVIP or something to that affect. The idea is that for a yearly fee, you get choice access to a network of physicians who will answer your calls immediately perform procedures of any kind the next day.

    Obviously there are going to be some pretty charged views about this sort of thing. I am very much for it. There is nothing that says a physician and his family must suffer when oppressive and unbending HMO policy has been instituted. In fact, it can be argued that these physicians are putting themselves in a situation to provide much much better care, albeit to a more limited clientele.

    There is a big move towards this sort of thing. More and more physicians are realizing the problems of fighting the HMOs so they are opting to abandom them altogether. I wish the medical establishment had enough organization to refuse HMOS tomorrow. They have failed miserably to do everthing and anything they were established for. More people are uninsured, receiving lousier care. Both physicians and patients hate the system (as a whole). In short, it is an experiment gone bad, very very bad. Patients, physicians and their families are paying the price. It's about time some set an example and went out on a limb to better their practice and lives. I wish them much success.
     
  4. Spang

    Spang SDN Angel

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    Is it really necessary to quote the WHOLE thing, TWICE, in order to make a reply?
     
  5. i don't understand how this is an issue... i mean, it is crazy to me that people expect a group of well educated people to completly ignore the call of building a better life. many of us do not enter medicine for money, but it is absurd to me to hear people basically say, "hey you are a doctor, you cannot serve who you want and charge what you want".

    there is a health care problem out there, and many do not have access to health care. it is fortunate that many doctors see it as their responsibility to care for patients regardless of ability to pay, but we live in a capitalist society. if you want to go charge $1,000,000 per patient and you can get them to pay, then that is your right.

    i guess what really riled me up was the man who said it was just greed...well that "greed" is what america was built on. he is saying, hey you are a doctor, so you cannot try to become rich if it will cost me anything additional. give me a break. does he have a problem with non-practicing md's getting rich in other professions? are they also duty-bound to use their MD to alleviate suffering at a reasonable cost?

    bottom line is, keep medicine a business, privately run by doctors. some will be too expensive, some just right. if you can't afford what you want, i am sorry, but that is life. i don't have a ferrari...but i don't think that nobody deserves one!
     
  6. theD.O.C.

    theD.O.C. Member

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    Hey there;

    I agree with the article and the response. It seems the these docs just want to have a practice where the Dr-patient relationship is more personal, like it was in the "good old days" where docs knew their instead of the current method of practice where patients have 15 minutes slots for any kind of problem. Considering insurance doesn't pay for this extra time taken to comfort, console, and converse with patients; it would be necessary to charge a premium to help cover the cost of having a smaller population of patients.

    I don't think of it as unethical or profiteering. After all, even doctors have bills to pay. Isn't it better to meet those expenses by providing proper and patient satisfying care to a few patients who really care for their health (after all they _did_ pay a premium to see these docs) than to try to cram in more 15 minute patient visits where you spend less than 3 of those minutes actually talking to the patient?


    I kind of expected insurance companies to come up with any reason to cry foul, but I find it interesting that the AMA and the AAFP are raising objections though.
     
  7. Goofy

    Goofy Senior Member

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    I apologize for quoting the entire article. The moderators have my permission to edit my post so as to delete the bolded article.
     
  8. tBw

    tBw totally deluded

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    I don't think 'boutique medicine' would appeal to me, but that doesn't mean I don't think it should be allowed.

    How is this different from people choosing to spend their money on other elective medical treatment (eg rhinoplasty, laser hair removal, tattoo removal, liposuction, stomach stapling). It's not preventing people unable to pay from getting medical treatment. It just means they have to go to a doctor that uses their insurance plan. That's nothing new. Doctor's education may be subsidized and so people feel they 'owe' society but as we don't force MD graduates to even practice medicine how can we demand that the ones that DO practice medicine only do it "this way". It seems to me the doctors featured in this article, (who are in their 50s and have already served a long time as PCPs anyway!) have every right to define their practice any way they want. We don't make lawyers practice in particular ways.

    Obviously not *every* doctor can do this. If they did medical care would become for the rich only. But I don't really think that a couple of doctors choosing one form of patient care over another is going to make a huge difference.

    My work currently offers three health-insurance plans. Two are entirely covered. The third requires a small extra fee each month. I elect to pay the extra because I like that service better. Why should it be okay when health-insurance companies do it (define fee by service level), but not doctors?
     
  9. penelope

    penelope Member

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    I agree with oldernotwiser, what's the difference between these "botique" doctors and plastic surgeons in Beverley Hills? That's how our capitalist, service-based economy works. Somehow people expect doctors to be inherently more noble and altruistic than everyone else, when most of them probably went into the field for the intellectual challenge, the variety, the fun of interacting with patients and colleagues, the prestige, the lifestyle, etc.

    When a doctor shows the same desire for a lucrative living as, say, an investment banker, people are bothered because they expect more from doctors. But until the medical profession starts recruiting significant numbers of people with a passion for addressing the vast inequality in health care, those standards are unreasonable.
     
  10. bustinbooty

    bustinbooty Senior Member

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    All I have to say is that I worked hard to get in and am working hard to get through med school. I will never make near as much money as a professional athlete. I suppose that we should all hate baseball players and call them greedy because they don't live a life of paitey and poverty? Doctors have special skills that they have worked hard to obtain. WE have an obligation to serve humanity, but that doesn't mean we have to ignore our needs and desires for prosperity. At least that's not what I signed up for.....
     
  11. Wifty

    Wifty Eccentrically Silly
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    Here in Washington state, the insurance companies have gone crazy and there are few rules that they have to live with.

    There are many docs here that are having to PAY to see their patients, or only get a few dollars per person...so essentially making at best 30 or 40k.
    This is an impossible salary for someone with potentially 200,000 in loans to payback!

    It can be about being greedy, but more often then not these days, it is just about making enough to have a middle class life after the taxes and loans payments are taken out of your salary.
    Anyone who goes to college for so many years, deserves at least that.

    Anyways, I live in the capital of WA and the area is quickly becoming doc deficient because of the lack of insurance regulations.

    If people have a problem with docs finding ways to survive and to be good docs, then they need to get the insurance companies to be better. People pay alot for insurance thinking it goes towards the doctors when actually, the insurance companies are making the money.

    Wifty
     
  12. LR6SO4

    LR6SO4 Senior Member

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    I agree with all responses, this is fine. To those who don't agree (AMA, etc.), it is obvious that this is a VERY limited field. The demand can't be too high with fees like that, so the supply will rise to meet the current demand of wealthy patients and maybe recruit a few more willing people. After that patient base is used up, the docs that do open up businesses like this won't stay in for long. That's the beauty of capitalism.
     
  13. Hopkins2010

    Hopkins2010 Banned
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  14. Goofy

    Goofy Senior Member

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  15. Wifty

    Wifty Eccentrically Silly
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  17. simpleton

    simpleton Senior Member

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    I think everyone has very valid points of view
     
  18. droliver

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    Wifty,

    I think the fee talked about with these personal physicians is on top of your HMO/insurance rates you already pay which would definately not make this a viable option for the overwhelming majority. On 60 Minutes they portrayed the system as a kind of "supplemental" insurance for personal care, while your major charges are against your regular policy.
     
  19. Kimya

    Kimya Senior Member

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    I found it especially interesting that they are trying to demonize the physicians for providing a higher standard of care... doesn't this say something about how insurance agencies are treating patients? It's only OK to treat patients badly if you're not a doctor? It's only OK to be a businessperson if you're not a doctor? An odd double-standard at work..

    Wifty had a good point too. If people who don't get health insurance through their work are paying premiums that are similar (especially if you are older and have a chronic illness, it starts getting REALLY expensive), for working people who have their basic coverage covered by employers it might not be as much of a stretch as we think.

    This might be a really good niche for older people with more chronic complicated illnesses. It's a lot but I could see people budgeting for it, I really could.
     
  20. Goofy

    Goofy Senior Member

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  21. lilycat

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    I'd like to move this over to the "Everyone" forum, because I think this is a topic most of the readers of the entire board would be interested in.

    Also, no offense Simpleton, but I'm going to edit out your quotes of every previous post -- humorous though it might have been, it's also annoying to scroll through. ;)
     

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