Just what the doctor ordered

If there is one area of unanimity in this sharply divided nation of more than 300 million people, it may be this: America's health care system is a mess.

COURTESY PHOTOS "I have very strong bonds with my patients." — Dr. David Scott Madwar, Naples No one is happy with the course we are on. Doctors and other health care providers practice assembly-line medicine that is as impersonal as it is perfunctory. The time a patient actually spends in the presence of a physician during an office visit is down to an average of seven minutes. These seven precious minutes, of course, do not include the hours patients spend filling out forms and cooling heels in waiting rooms and emergency-care facilities that often possess the charm of a big-city bus terminal.

Doctors say that constraints imposed by Medicare, Medicaid and private insurers make it difficult to turn a fair profit, thereby leading to the "line-'em-up and get-'em-out" style of medicine that is commonplace. Physicians uniformly insist that this is not how they wish to practice medicine, but it is how they must if they are to survive.

Dr. Wayne Burr Beleaguered patients, on the other hand, have scant sympathy for the "plight" of the physician, since spiraling medical costs not only stretch budgets but actually drive increasing numbers of Americans into financial ruin. According

to the most recent issue of the American

Journal of Medicine, 60 percent of personal bankruptcies in the United States during 2007 arose from medical debt.

Amid this chaos and confusion, a phenomenon known as "concierge medicine" runs counter to many of the medical stereotypes to which we have become accustomed; at the same time, however, it reinforcing others.

Concierge medicine is not new; it's been around since the mid 1990s, but it is limited to an estimated 5,000 or so practitioners scattered across the United States. It first breathed life in Seattle, and like that city's other gifts to the nation —Microsoft, Starbucks and grunge music — it appears here to stay. It has existed in Florida since 1998, when Dr. Gary Price opened his concierge practice (which still flourishes) in Fort Myers.

Dr. Gary Price You get what you pay for

In the world of concierge medicine, physicians generally practice internal medicine and are primary-care providers. The major benefits of this practice are:

• Patients are given their doctors' office, home and cell phone numbers and have access to their physicians 24/7.

• The doctors make house calls.

• Office visits are unhurried and consultations exhaustive.

• Waiting rooms are sanctuaries free from crowds and endless paperwork.

• Preventive medicine is not just discussed, it is practiced.

• And according to its proponents, the quality of concierge care is superior because of the highly personalized attention patients receive.

There is, of course, a catch. It costs a good bit of money, and that money comes out of the patient's pocket, for concierge doctors do not accept insurance. Instead, they charge an annual fee that is paid directly to the doctor. There is no third-party billing to Medicare, Medicaid or private insurers.

Dr. David West Fees vary wildly. One physician in Seattle asks for and receives up to $25,000 from his patients annually, many of whom are Microsoft millionaires. In Lee and Collier counties, annual fees are mostly in the $2,500 to $5,000 range. For the extras — such as lab charges and tests, visits to specialists, hospital fees and the like, all of which can involve staggering sums of money — the patient still needs health insurance to pay the freight, unless he is Warren Buffett, Bill Gates or a member of Congress.

Concierge practices treat a limited number of patients. Whereas a traditional, third-party-billing internal medicine physician might see 3,000 or more patients a year, concierge doctors often limit their practices to a few hundred, at most.

Concierge physicians — many of whom do not like that term and prefer the less grand designation of "direct care" — say the perception that their practices are "elitist" is unfair and untrue.

"Not every one of my patients is tremendously wealthy," says Dr. Wayne Burr, who has had a concierge practice in Fort Myers for more than three years and recently opened a satellite office in Bonita Springs. Dr. Burr treats about 100 patients who pay $2,500 a year. "I have single moms (as patients) and people who work in the food-service industry," he says about his patients, adding they range in age from 17 to 86.

"We're adding new patients every month," he says, "but I still see probably only five to six patients during a typical day. Some days it might be just two. Eight to 10 patients would be a really busy day."

Most doctors of internal medicine, as is Dr. Burr, attend 25 to 45 patients a day.

Dr. David Scott Madwar, a concierge physician in Naples, says many of his patients are "people who feel the medical profession has let them down." He describes his patients as generally intelligent, keenly interested in preventive medicine and looking for a personalized approach to health care.

"I have very strong bonds with my patients," says Dr. Madwar, who was formerly hospital chief of staff at The Cleveland Clinic in Naples. His patient roster numbers about 150, and he charges $5,000 annually for an individual and $8,000 for a couple.

One patient's reasoning

Wally Labermeier and his wife, Lil, were among the first patients to sign on with Dr. Madwar when he opened his practice on Jan. 1, 2007. Mr. Labermeier, a blunt-speaking, hardnosed entrepreneur who walked away from a successful career at Procter & Gamble many years back to build a string of successful businesses in his hometown of Cincinnati before retiring to Naples, says he and his wife turned to Dr. Madwar after they became displeased with their doctor of 25 years.

"A number of my golfing buddies at Quail West were going to concierge doctors," Mr. Labermeier, 77, recalls. "They had good things to say, so I started looking around and interviewed several before we decided on (Dr. Madwar). We have been nothing but pleased. He has exceeded our expectations."

Mr. Labermeier says Dr. Madwar's age (which is 40) was among the many attributes he found appealing. "I sure didn't want a doctor who was going to die before I did," he points out.

Mr. Labermeier says he had become increasingly frustrated with the way medicine is practiced in the traditional model. And he believes the heavy patient loads carried by many doctors adversely affect their ability to provide acceptable care.

"I got tired of sitting in the office, waiting to see a doctor," he says. "They scheduled all the appointments at the same time, and we just sat out there and waited. I was fed up. I told (the doctor): 'I make more money than you do. My time is more valuable than yours. I'm going to start billing you for all the time I waste sitting in your office just waiting.' "

But it's not just the patients who find modern medical practice exasperating. Many physicians yearn for the days when a doctor was intimately involved with the lives of those he treated. Dr. Madwar counts himself among this group. He says his great-grandfather and grandfather, doctors in a small English village, came to know their patients on a personal level, something that a doctor who sees upwards of 3,000 patients a year simply cannot do.

"Caring for the whole individual is something that requires a tremendous amount of time," he says. "It is the way medicine is meant to be practiced."

Quality and quantity: 'mutually exclusive'

Dr. Gary Price is the dean of concierge physicians not only in Southwest Florida but in the entire state as well. He says he was the first concierge physician in Florida when he started his practice 11 years ago.

"Back in the '90s, medicine for me had become extremely difficult because the insurance companies had taken over," he says on a recent day after completing a 60-minute consultation with a patient. It was the era of HMOs, which repackaged doctors' services, sold them for less and kept the difference in profit, he says. "They pushed the fees to a point where doctors had to see more and more patients just to make a living. It became obvious to me that this was not going to work. You can't provide high quality and quantity at the same time. In medicine, (quality and quantity) are mutually exclusive."

Like many of his counterparts, Dr. Price, an assured and persuasive man of 55, enjoyed a successful practice before embracing the concierge model. But the hassles of dealing with insurers, the need to herd patients in and out of the office and the associated red tape often drained any satisfaction he had previously derived from his profession.

"I don't accept money from insurance companies," he says. "I don't take money from Medicare. I don't take money from hospitals. I only accept payments from my patients. That's the core of the whole philosophy; I work for my patients. They're my boss. … It is so enjoyable to practice medicine at the highest level you can. I have no limitations. I have some people who can't afford me. For some of those people, I don't charge at all. That's my prerogative. I answer to me, not to an insurance company."

Dr. Price's has about 330 patients, who pay a flat fee of $3,000 a year. His partner, Dr. David West, charges a fee of $2,800 a year, but also allows patients to pay on a per-visit basis, something Dr. Price does not do. Dr. West's per-visit rate is $250.

"We don't make a ton of money," Dr. Price says. After a pause, he elaborates: "We do OK. Very well, in fact. The work is hard, though. Being available 24/7 for intelligent (patients) is not easy, because they will call, as well they should." His patients, he adds, "are very considerate. They don't call after hours unless it is an emergency."

Dr. Price says he now enjoys his practice so much that, "I will never retire."

"This is not cookie-cutter medicine," says 54-year-old Howard Baum of Fort Myers, who has been a patient of Dr. Price for five years. "It is more direct and personal. Dr. Price has a greater knowledge of the individual."

Mr. Baum, who is a commercial developer and says he enjoys good health, sees Dr. Price four to six times a year, on average. He says the easy accessibility pays dividends when a problem develops. "I had a kidney stone two to three months ago, and I got in immediately and Dr. Price took care of it, no problem," he says. "It never got to the point where I even had bad pain."

"If my patients have a minor problem, I tell them to come in now," Dr. Price says. "There's no three-week delay. We emphasize prevention."

What the critics say

Despite the testimonials of patients, and the anecdotal evidence offered by its practitioners, concierge medicine's critics say there is no hard proof that the model is significantly superior — in a true medical sense — to traditional practices.

The most persistent criticism remains that concierge medicine promotes a separate, elitist class of medical care. Some critics say that by limiting their practices to a handful of affluent patients, concierge doctors are increasing the burden on traditional practices to assume more responsibility for poorer patients.

The American Medical Association has looked at ethical questions raised by concierge medicine. The AMA has endorsed the concept, but it has cautioned that concierge physicians must be upfront about their fees with patients and they should not say their style of practice guarantees better medical outcomes.

The AMA also advises those patients contemplating concierge medicine to check with their insurance companies to see if it will affect their coverages in any way. Generally, it does not, but no one should assume that.

At the core, criticisms of concierge medicine are not new to the profession as a whole and actually validate what has long been apparent: Those who can afford better medical most likely will receive better medical care. And if concierge medicine simply died on the vine — which it shows no signs of doing — the inequities inherent in the current system would remain.

What remains to be seen, however, is if concierge medicine actually improves patients' health and extends their lives. That will be hard to quantify. But it could be the ultimate selling point, if it proves true.

Wally Labermeier, the steely-eyed businessman, knows that for every patient the bottom line in selecting a doctor is the same: "You want someone who will keep you on the right side of the grass for as long as possible."