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."