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The doctor is in ... and on retainer

This article first appeared in the St. Louis Beacon, Feb. 11, 2009 - For physician Lewis Fischbein, the frustration kept mounting.

It began years ago when the cost of supporting a growing office staff made his practice at Barnes-Jewish Hospital difficult to sustain. Fischbein joined BJC Medical Group, a multi-specialty physicians' group that managed the practice and allowed him to get a better rate on employee health insurance and other expenses.

But he remained aggravated - not with BJC, which he said "treated us very fairly," but with a health care system that, as he wrote in a letter to patients earlier this year, "forces doctors to see more and more patients each day to cover an increasing overhead dictated by our association with Medicare and private insurance companies."

So last summer, Fischbein and colleague Mary Kiehl decided to establish a new primary care and rheumatology practice. When it opens this spring, it will be supported by annual fees for care and services paid by patients. The practice will not participate in any insurance plan.

"Basically we decided that we were done compromising how we take care of patients," Fischbein said. "We think of this as a way of reclaiming our ability to deliver quality health care without the intervention of a third party."

Fed up with limits on reimbursements and the frenetic pace of work, a growing number of physicians nationwide are breaking off from large groups and establishing practices that operate on direct payments. Called by a variety of names - retainer, boutique, concierge, direct access (the term favored by Fischbein) - the practices all emphasize convenient access to physicians.

Fischbein's University Personal Physicians, located on the north campus of the Washington University Medical Center, is in many ways typical of retainer operations. He and Kiehl will limit the number of patients they see so they can hold longer appointments. A typical primary care physician has anywhere from 2,000 to 2,500 patients at a given time, according to Jim Crane, CEO of Washington University Physicians and associate vice chancellor for clinical affairs. Many retainer practices aim to have fewer than 600 patients; Fischbein said it's too early to make size estimates.

Fischbein's patients will have access to physicians' cell phones and e-mail addresses. And his office promises that limited wait times and same- or next-day appointments will be the norm.

For primary care patients, the annual fee ($1,600 for patients over 50; $1,000 for those 30-49; $500 for people under 30) covers all office visits, the practice's portion of hospital care costs at Barnes-Jewish Hospital, as well as routine medical testing. Patients still need to maintain their health insurance to cover costs of other tests and medications, but Fischbein's office promises no co-pays or other fees from the office for covered care in the office or hospital.

While financial arrangements for retainer practices vary, proponents agree that the fees are justified because they allow patients more immediate and sustained attention, and physicians more schedule flexibility. Critics argue that such practices create a tiered system of health care that rewards wealthy patients who can afford to pay a premium for personal care.

A 'Niche Market'

Kathleen Gillespie, an associate professor in the department of health management and policy at Saint Louis University School of Public Health, said she's noticed a rise in the number of retainer practices, so much so that it's becoming "a niche market," instead of a rarity.

Just not necessarily in St. Louis. Mike Castellano, chief executive of Esse Health, the region's largest independent physicians' group, said he isn't seeing the concept catch on locally. It's slowly growing here and is still much more prevalent on the coasts, according to Elizabeth Laffey, a St. Louis family practitioner who opened a retainer practice, Gateway Physician, in 2005.

Many medical associations don't track the number of retainer practices because the concept is so new. A 2004 General Accounting Office report found 146 concierge physicians across the country. It's estimated that there are presently about 1,000 such physicians, according to the Society for Innovative Medical Practice Design, a group that tracks data on doctors nationwide.

The American Medical Association takes the position that while retainer practices can be a viable opportunity for doctors and patients, physicians merely looking for financial gain should think twice. Gillespie said that opting for a retainer practice is more often a lifestyle choice for physicians than a cost-savings option.

Fischbein said that's true in his case. His goal is for the retainer practice to be revenue neutral compared to his current one. And he's expecting to see up to 20 percent of patients in his new practice on a scholarship basis or pro bono. Laffey said she sees low-income patients for free. For most patients, though, the annual flat rate is $1,500 a person and $1,000 a head thereafter for families, which covers all contact and visits with her. Her office doesn't bill insurance or collect co-payments; patients' insurance still covers additional expenses such as X-rays.

Faced with criticism about catering to the wealthy, many physicians - and neutral observers - have the same response: "We have a tiered system already whether we want to admit it or not," Gillespie said. "This might highlight the tiered system, and I'm not sure if it's a good or a bad thing. It's just being more up front about it."

Laffey agrees. "It's a tiered system, sure, but that's what we already have," she said. "In my opinion this is the lesser evil." Her argument: She and other retainer physicians are able to see low-income patients for no cost - something that's not possible for doctors who accept Medicare (it's considered fraud).

Still, questions about improving health care for all linger. Said James Kimmey, president and CEO of the Missouri Foundation for Health: "This is showing us that people value direct and continuing contact with primary care providers. Folks who can afford to use this are voting with their dollars that they like it. But it's important that we restructure the system so that not just people who can afford the fee can take advantage."

Systemic Problems?

Whether or not they support the idea of retainer practices, medical experts and observers interviewed agreed that the increasing interest in such offerings reflects a growing unease with the current state of primary care.

Louise Probst, president of the St. Louis Area Business Health Coalition, said that while the group doesn't have a stance on retainer practices, the real issue is that "it's unfortunate that we as a society haven't been able to make primary care satisfying for physicians."

Among Fischbein's laundry list of complaints: Overhead costs for medical offices are rising as a growing number of employees are needed just to deal with insurance companies. The criteria insurers use to evaluate doctors doesn't reflect quality of care. And when dealing with these companies, physicians have little bargaining power to negotiate reimbursement rates.

Fischbein said he tries to spend as much time with patients as he did when he began practicing 30 years ago, but that means working 12-hour days instead of nine and seeing 25 patients instead of 12. With so many appointments to schedule, he said he worries about his ability to talk to patients about preventative care. After the change in practice, Fischbein said he'll have more time to follow up with patients, including visiting them in the hospital.

Laffey said she reached her wits end with a crammed schedule. "In a 10-minute appointment, you are throwing pills at things and running out of the room," she said. "When you are able to get to know a patient better, you can talk about their lifestyle. There's a whole lot more time for communication."

Her average appointment now is 30 to 60 minutes. She offers house calls. And perhaps the biggest change: She - and not a receptionist -- answers the phone at her office.

Fischbein said that until the reimbursement system is fixed, primary care physicians will continue to face an uphill financial battle. The result: a shortage of doctors who "direct traffic" for patients trying to find appropriate care.

Castellano, the Esse executive, shares that concern about access to primary care physicians. But he said his group isn't interested in supporting retainer practices. Instead, there's an interest in exploring the idea of a "patient-centered medical home" in which the primary care provider is the first stop and is subsidized for services such as referring patients and orchestrating care.

Crane, the Washington University Physicians chief executive, said he agrees that the current reimbursement structure needs fixing, and that reimbursement rates for Medicaid don't come close to covering the actual cost of providing service.

Fischbein acknowledges that retainer practices aren't the silver bullet for an ailing system. "Many doctors couldn't or wouldn't want to do it," he said. "Certainly many patients can't do it." But he said it's an option that older patients and people with chronic illnesses might find appealing.

With the move, Fischbein and his partner are resigning from BJC Medical Group and joining Washington University Clinical Associates, a university-based physician network for primary care. Theirs will be the only retainer practice on the campus of the Washington University Medical Center and Barnes-Jewish Hospital.

Crane said the university is helping Fischbein and Kiehl organize the transition because it is interested in keeping two "outstanding" and long-tenured physicians at the medical center. He said there's no clear right or wrong when it comes to evaluating retainer practices.

"It's not something we're necessarily proactively advocating or recruiting people for," Crane said. "We'll look at this on a case-by-case basis."

Elia Powers is a freelance writer.