Concierge Family Practice: A Minor Trend Sparks Major Ethical Questions

Less than one year ago, Dr. Richard Maffezzoli was CEO of Clinical Associates, a group of 70 doctors based in Towson, Maryland. Today, he’s waiting for word on whether his list of about 100 patients will grow enough to keep his new concierge family practice afloat.

Maffezzoli is unruffled as he sits in his third-story office on a Friday morning, explaining his decision to switch to a concierge practice in which patients pay an annual retainer fee. The 66-year-old – in a stylish black dress shirt with vertical gray and brown stripes and silver, stamp-sized, cowboyish cufflinks – is philosophical about his future.

“Will I have enough patients to pay my overhead?” Maffezzoli, an endocrinologist and onetime chief resident at Greater Baltimore Medical Center, asks rhetorically. He’ll need at least 200 on the rolls. “Beyond that I don’t really care. I’m not really doing it because I need the money.” The doctor, whose income is largely bolstered by his ownership of several care dealerships, later declared, “I don’t want to keep rushing around like a madman. It was either retire or do this.”

Under Maffezzoli’s plan, which takes effect January 1, he will charge patients an annual flat fee ranging from $500 a year for an individual over 90 years old to $2700 a year for an adult couple aged 45 or older. In return, Maffezzoli promises to spend more time on in-office visits, make himself available by phone 24/7, and serve as a more thorough steward of specialist referrals and a more vigilant watchdog over hospital stays. Also included in the fee is a comprehensive annual physical that won’t be billed to the patient’s insurance. The plan is similar to those offered by the 112 concierge primary care physicians who responded to a nationwide 2005 Government Accountability Office survey.

So why the move – from a doctor who founded and led one of his region’s most successful family practice groups – to prune his patient roster of a few thousand down to no more than 300 or 400? And how are doctors who make the switch to concierge care handling the ethical issues inherent in this elite form of care delivery?

In a letter to a his patients in October, Maffezzoli explained: “I am forced to see more patients in less time, offer shorter appointments and attend endless paperwork … By implementing a new practice structure, I will have the time and freedom to provide old-fashioned, personalized care in a technologically advanced manner.”

Maffezzoli set up his new practice under the guidance of Specialdocs, a Chicago-based consulting firm that walks doctors through the process of converting to concierge practices. Another such firm – and one that’s gotten a bit more attention nationally – is MDVIP, based in Florida. MDVIP claims to serve “more than 50,000 patients through 140 affiliated physicians located in 16 states and Washington, D.C.,” according to a May 2007 press release from the company. Former Secretary of Health and Human Services and erstwhile presidential candidate Tommy Thompson is Chairman of the MDVIP Committee on Cost Reduction through Preventive Healthcare, where he champions the consulting firm’s cause and helps “[reduce] national healthcare expenditures,” according to the same press release.

In its 2005 report, the GAO noted, “Concierge physicians are few in number and located primarily in urban areas on the East and West Coasts. Since the first Seattle practice was founded in the mid-1990s, the number of concierge physicians has been rising but remains small. We were able to locate 146 concierge physicians in the United States as of 2004 – a small number compared with the more than 470,000 physicians who regularly submitted claims to Medicare in 2003.”

And, concierge family practices don’t operate independent of insurers. The GAO found that “about three-fourths of respondents reported billing patient health insurance for covered services and, among those, almost all reported billing Medicare for covered services.” The first order of business for a doctor adopting a concierge practice is to confront legal issues, the foremost of which is ensuring that he doesn’t charge patients for services already covered by Medicare.

Concierge practices inherently favor those patients who can afford the service. In an unpublished research paper entitled, “Boutique Medicine: Future or Fad?,” Johns Hopkins University graduate student Dr. James Paskert, a member of Maffezzoli’s group, wrote that patients who can’t afford to pay could be abandoned by their longtime caregivers, an effect that doesn’t help physicians’ collective image; by seeing fewer patients, concierge doctors are throwing even more patients back on doctors with traditional practices, exasperating the shortage of family care physicians; and, the trend towards concierge service further stratifies how Americans receive health care based on social and economic factors. In a telephone interview, Paskert said he didn’t know enough about Maffezzoli’s new practice to comment on it. But in his research paper, penned in 2006, Paskert drew the conclusion that, “On the practice level, the potential loser is the patient who cannot afford to or chooses not to subscribe to the new practice. This displaced patient must begin anew with a different practitioner, at an emotional cost.”

While Maffezzoli’s decision to adopt a concierge practice came as he was considering retirement, a West Coast family doctor made the change at an earlier point in his career. Dr. David B. Baron, 45, opened a concierge practice in Malibu, California in April 2004. He did not hedge, in a recent interview, on questions of ethics, which he says he weighed heavily before adopting the unconventional style of practice. Baron’s 300-patient practice, he says, is “legitimate, legal and in my opinion, highly ethical.”

After completing his residency at the Santa Monica Hospital Center in 1991, Baron joined Malibu Family Physicians, a small, single-specialty family care practice. In 1996, the practice joined the University of California, Los Angeles outpatient network.

“The draw was they were gonna handle the yucky part that doctors hate to do,” Baron said, noting that the move was sold as a means to free the doctors from paperwork and administrative duties. But with management of the practice out of his hands, Baron faced increasing pressure to see more patients per day.

“Between ‘97 and ‘04 I just got more and more frustrated with the aggressive management of the practice,” Baron said, noting that he rarely saw as many patients in a day as UCLA demanded. “I was having to apologize to my patients too often for not having enough time.”

Baron said 20 percent of his current patients have their concierge fee either partially or completely waived, an indicator of his reluctance to abandon patients who can’t afford his standard $4,800 annual fee (families end up paying less per person, he says). And, Baron has declined to categorize his patients according to how much they pay.

“I refuse to have two classes or two tiers of patients,” Baron said. “I have a woman who’s been bordering on homeless for a while, and she’s one of those people who’s just not going to get her life together…so she comes into my office and my assistant makes her a cappuccino.”

Baron made about $200,000 at one point in his time with the UCLA practice, but his salary dropped several years in a row as UCLA penalized him for not seeing enough patients. Three-and-a-half years into his concierge practice, Baron is back up to $200,000. The New York native and his wife rent a townhouse in Malibu; he can’t afford to own a home in the town where he practices.

Baron doesn’t believe doctors should feel guilty about trying to make a decent living, particularly in the field of family practice, where the salary averages are in the basement when compared to the rest of the profession.

“This isn’t some way for me to be able to have more afternoons a week to play golf,” Baron said, noting that he works at least as hard now as he ever has, attending consultations with his patients, monitoring their hospital stays, and making house calls. “Philosophically I felt that I needed to get into a situation where the value of my services was determined by the people who are using the service,” Baron said. As he sees it, Baron is attempting to wrest some control over patient care back from insurance companies.

Twenty years older and less of a firebrand than Baron, Maffezzoli has a different solution for his patients who can’t afford his new fees; he’s helping them chose from any of the dozens of doctors who practice under the umbrella of Clinical Associates, the group he founded in 1972. Their offices, whose floor plans Maffezzoli designed, are in the same professional building on Fairmount Avenue in Towson.

“They can pick one of the docs here. It’s been fairly easy for them,” Maffezzoli said. After pausing, he added with a touch of irony, “Maybe too easy.” The few thousand patients on his rolls have until December 15 to decide whether to stay on with the practice, and Maffezzoli has received positive responses from just 100 so far.

For a 66-year-old man who has had a full career in medicine, and for whom the change will serve as an alternative to retirement, concierge practice may prove a good fit. But for one younger family physician who has put down roots in his community, the call to serve a larger population, and the verve to tussle with insurance companies on a daily (almost hourly) basis, outweigh the benefits of a switch to concierge practice.

My primary care physician, Dr. Bradford Ebright, a 40-year-old internist, nets $110,000 a year in personal income from a practice that serves upwards of 15,000 patients in Perry Hall, Maryland. Like Maffezzoli, Ebright is a businessman. After serving his residency at Franklin Square Hospital, the young doctor took advantage of a community grant that encouraged young doctors to stay in the suburbs northeast of Baltimore, and opened his own practice in 1994. In more recent years, he bought the two-story professional building he started out in, and has expanded his offices. Ebright shares the patient load with another full-time doctor, a part-time doctor and a physician’s assistant. He recently managed, in a testament to the increasing size of his practice, to secure a face-to-face meeting with BlueCross BlueShield to negotiate rates.

Ebright’s $110,000 a year pales in comparison to the yearly earnings of most of his University of Pennsylvania School of Medicine classmates. He is quick to point out he’s comfortable in life, and has no complaints. He doesn’t shy away, however, from noting that his neighbor, who runs a demolition company, makes $400,000 a year. Another guy on his block, an electrician, brings in $300,000. And they didn’t spend $100,000 on their education, Ebright said. But while he understands that salary levels have contributed to the shortage of young primary physicians, Ebright said he felt called to family medicine.

Asked if he’d ever consider switching to a concierge practice, Ebright said he’s too young to give up his full practice; he also said he feels a sense of duty to the larger community. But he has, like Maffezzoli and Baron, been grappling with issues of spending more time with patients.

Dr. Patricia Chambliss, a full-time doctor who joined Ebright’s Chapel View Family Care practice a few months ago, had been working at a practice near Washington, D.C., where she saw 30 to 40 patients a day. Many of her new patients have complained to Ebright that Chambliss is too brisk with them. Ebright is working with Chambliss to help her shed her old habits of blasting through examinations without necessarily spending time talking to patients. At the same time, he’s fighting with insurance companies who want him to spend less time with each patient.

“You can only see so many people, and then you’re burnt out,” Ebright said, noting he tries to see about 20 patients a day.

With the increasing overhead costs associated with primary care (many of which stem from doctors and their staff having to spend more time dealing with insurers) more patients are getting their care from mid-level medical professionals that cost less to staff, such as physician’s assistants, Ebright said.

“They make mistakes, and I catch them generally, but that’s where a lot of people are getting their medical care,” Ebright said of his own staff.

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Patients weighing the option of concierge family care must first determine if they can afford the cost, and then decide whether it’s worth it. My grandmother, a longtime patient of Maffezzoli’s, recently received the letter explaining his transition to concierge practice. At 92 years old, my grandmother, Trudy, didn’t bat an eye when asked for her opinion of Maffezzoli’s move. “I thought he was in it for the money,” she said.

Dr. Charles M. Wiener, Director of the Osler Residency Training Program at The Johns Hopkins University School of Medicine, had a different take on the plan. After hearing a brief description of Maffezzoli’s proposal, he concluded, “Sounds like a good deal for grandma.” The higher level of care would be worth it for an elderly person with complex medical needs, he said.

My grandmother switched doctors just before receiving the letter from Maffezzoli because of transportation issues. But Maffezzoli’s proposal nonetheless elicited a response from my parents, who are overseeing her care at an assisted living facility.

“That’s a lot of money for her,” my mother said. “She’s already paying for health care. She can’t afford to pay anymore for health care and live where she’s living.”

My grandmother takes in about $1500 a month from a retirement pension and Social Security, and spends all of it plus an additional $2000 a month from her savings to cover the bill at the assisted living facility. And the savings are getting low; after they’re gone, it will be up to the family to cover the costs.

According to Maffezzoli’s letter, my grandmother would have fallen into a category of patients charged $1200 a year to join the practice. In my interview with him, Maffezzoli said he’d changed the plan so that anyone over 90 years old would pay just $500 – still out of range for my grandmother. My parents’ reaction to the doctor’s letter weren’t that far removed from my grandmother’s. “There’s no way we’re paying that,” was the prevailing sentiment. At this point in her life my grandmother’s her care has become less complex and more about keeping her comfortable. However, my mother conceded that, were Grandmother 72 rather than 92, the extra cost to stay with a doctor who knows her well might be worth it.

For one of David Baron’s patients, his annual fee – and a 45 –minute drive to get to his office from her home – is definitely worth it. Marz Gordon, a 41-year-old clothing designer and paralegal living in Burbank, California, swears by her doctor.

“It’s been great … he takes all of the worry about your health off of you,” Gordon said. “It’s a million times better. It’s not even a comparison.”

Gordon said her experience with Baron has been the antithesis of a two-year stretch during which she shuffled between numerous doctors seeking treatment for an ailment.

“Two years of uncertainty, of trying doctors, and them taking me through the same routine, and getting the same treatment,” Gordon said. “I would never go through that [again].”

Gordon pulled up short of an unconditional endorsement of concierge medicine, noting that she’s always put her relationship with the individual doctor first. “It’s the best you can get if you like and trust your doctor,” she said.

So has Dr. Baron driven the 45 minutes from his office in Malibu to Gordon’s Burbank home? “If I needed him to he would. Absolutely,” she said. “He actually encourages us to call him more than we do”

In addition to the ethical questions, the minor trend toward concierge practices opens up some compelling clinical issues. In his article on luxury primary care, Dr. Martin Donohoe, under the heading “Erosion of Science,” postulated that concierge-style care could lead to over-treatment.

“There are little data to support the clinical or cost effectiveness of many tests offered to asymptomatic VIP clients,” Donohoe wrote. “False-positive results may lead to further unnecessary investigations, costs, and anxiety, and increased profits.”

And, perhaps hitting closest to home for the clinician, is the possibility that by limiting his pool of patients, a doctor could ultimately dull his own diagnostic skills. But, after 35 years in private practice, Maffezzoli alluded to the physician’s adage that, “If you hear hoof beats in Texas, think horses, not zebras.”

“It’s kind of exciting on occasion to see a zebra, but it’s not essential in my life right now. I’ll deal with the horses,” Maffezzoli said, noting that he hopes the new practice will keep him out of retirement for at least a few years. “Medicine is what I want to do, and I’m getting tired of doing it faster than I want to…most of the docs who are doing this are just throwing their hands up. They’re tired of the rat race.”