By Joshua Tompkins, LA TIMES
9/17/2013 11:49:00 AM – My late father, a physician like myself, began his career as a family practitioner in Texas in the 1950s, when most doctors still made house calls. He switched to radiology shortly after I was born in 1971, but I can picture him in those early years, cruising Dallas neighborhoods in his bronze ’57 T-Bird, sitting at the bedsides of pockmarked teenagers and wheezy chain-smokers, sifting through his black leather bag for a tongue depressor or a cautery needle. I can feel the thrum of our home phone ringing in the evenings and make out the T-Bird’s taillights vanishing into the night.
Back then such devotion was the standard of care, but today it epitomizes an intimate style of practice called concierge medicine, which is gaining momentum with L.A. doctors and patients. Concierge medicine, as fans of the USA Network series Royal Pains know, is not a unique medical specialty but a business model in which a consumer pays a monthly or annual fee for the same personalized care that in a perfect world every patient could still expect from any primary care physician: a comprehensive annual checkup, same-day appointment scheduling, and round-the-clock access to the doctor for questions or emergencies. The fee, which can range from $500 to more than $5,000 per year, covers only the aforementioned checkup and perks; it isn’t a substitute for health insurance, which patients are encouraged to carry for expenses such as additional office visits, outside referrals, and hospitalizations.
You could think of the fee as the medical equivalent of club dues at one of the city’s tonier gyms. At Concierge Medicine/LA, a clinic in Brentwood that’s analogous to, say, Equinox, those who sign up for the Deluxe Membership ($149 to $849 per month, depending on age) are not kept waiting for more than five minutes. Walk-ins are welcome, and face time with the doctors is “unhurried,” according to the clinic’s Web site. “Concierge medicine gives me all the time and tools I need to make medical decisions,” says cofounder Raphael Darvish, one of three physicians on staff. Indeed, Deluxe Membership patients get an annual “Presidential Physical,” which lasts up to three hours and includes elements that are part of President Obama’s annual checkup (comprehensive lab tests, an EKG) as well as procedures that even his doctors forgo, such as microdermabrasion.
For Darvish “the relationship is the most important part.” He is referring to the once-revered doctor-patient relationship, which the managed care industry has vitiated. Sir William Osler, the father of modern medicine, said a century ago that a physician should see at most four patients a day to give each the proper attention, but now, as insurance payments decline, many traditional family doctors must see 30 or more just to make a decent living and pay off their six-figure student loans. In L.A. patients spend almost as much time in the waiting room (19 minutes) as with their doctor (21 minutes), according to the health care statistics Web site Vitals.com and a study in the journal Archives of Internal Medicine. Whereas the concierge doctor can afford to limit his or her practice to about 500 patients, other physicians must maintain rosters of as many as 3,000 to generate enough revenue, and some have resorted to seeing several patients with the same chronic condition (diabetes, for example) simultaneously, much like a veterinarian might tend to a barn full of dairy cows suffering from foot rot.
Concierge doctors offer an escape from such indignities to anyone who can afford it. And their prices are stated up front—a novelty in a health care business where every new bill portends an ugly surprise. Want a house call from Concierge Medicine/LA? It will cost you $450. In true libertarian fashion concierge practitioners seek to make primary care a simple business arrangement between buyer and seller, to stand as islands of salvation in a sea of medical mediocrity—and in some cases to charge up the wazoo for it. If Ayn Rand had been a physician, she would have been a concierge doctor.
Like Rand’s fiction, concierge medicine is defined by polarizing extremes. At its worst, it not only panders to the worried well for profit, but it potentially violates physicians’ ethical duty to provide the same care to all patients, rich or poor. At its best, the approach rekindles a sense of personal responsibility that years of running on the managed care “hamster wheel,” as one physician describes the work environment, has spun out of doctors. Such responsibility is now a marketable commodity.
With its velvet-rope connotations and hoity-toity name, concierge medicine might seem like an affectation first ginned up by wealthy Manhattan or Beverly Hills narcissists a half century ago, around the same time that having a psychotherapist became a fashion statement. It could also be mistaken for a natural outgrowth of L.A.’s thriving medical spa industry, but in reality it began quietly in Seattle in 1996. The field is still inchoate, and even insiders are uncertain how many practices are operating here; estimates range from 50 to several hundred. (The best way to find a local concierge doctor is to search the directory at PrivatePhysicians.com, a Web site run by the American Academy of Private Physicians, the field’s trade association.)
Elona Dyner, a retired schoolteacher, signed up because she was tired of waiting for treatment. “It was ridiculous,” she says. “You have a urinary tract infection, and they tell you they can see you in three weeks.”
Dyner is a patient of geriatrician Thomas LaGrelius, a former chairperson of the American Academy of Private Physicians who converted his Torrance practice in 2005 after being frustrated with managed care for more than two decades. “You can’t take care of 3,000 people,” he says. “You can’t take care of 1,000 people.” LaGrelius’s clinic is located in a tidy office park near the Torrance Airport. He quickly dismisses the notion that concierge doctors minister only to affluent hypochondriacs. When he made the switch to concierge, “the 600 patients who stayed in my practice were the sickest ones,” he says. His patients who are older than 45 pay $2,100 a year for a membership; those who are younger pay half that amount. Like the young concierge doctor in Royal Pains, who does pro bono work when not tending to full-fare snobs in the Hamptons, LaGrelius treats about 100 of his patients free of charge.
He says his patients ultimately consume fewer health care dollars due to the one-stop-shopping approach of concierge medicine, which relies less on referrals to specialists and emphasizes preventive care. And the shop never closes. When a patient’s dog nipped off a chunk of her lip late one evening, LaGrelius reattached the severed piece of skin himself. “What did it cost her? Three hundred bucks,” he says. “In the emergency room it would have been thousands.”
A recent study in the American Journal of Managed Care reported similar disparities. The authors found that concierge patients were as much as 62 percent less likely to be hospitalized than regular primary care patients, saving the health care system $2,500 per patient per year.
That’s more than the annual fee LaGrelius charges, and it makes a convincing—if seemingly ironic—case for concierge medicine as a cost-cutting measure. Yet the individual affordability question lingers. Is there a way to get poor people hooked up with rich-person care? Over lunch LaGrelius and I hash out a plan like a couple of revolutionaries plotting a coup. (I’m training to be a psychiatrist, so concierge medicine isn’t professionally relevant to me, but because I did my medical training at the largest public hospital in the city, I know how desperately L.A.’s indigent residents need better primary care.)
The plan starts with concierge medicine attracting more young doctors, who further reduce Medicare costs by keeping old folks out of pricey ERs (which often segue to expensive ICUs) whenever possible. The recouped funds are used to create more residency training programs in primary care, producing even more concierge docs—and more savings.
Then comes my favorite part (LaGrelius likes it less): Flush with money, Medicare gives $2,000 annual vouchers to poor seniors who want concierge-style care, and Medicaid does the same for the low-income young and middle-aged. The U.S. health care system becomes a model of efficiency. Happiness skyrockets. Diabetes drops. And boom, we’re the new Norway.