It takes time to heal
She drives 20 minutes from downtown Charlotte to SouthPark, the city’s second downtown — high-end retailers, high-rise offices and high-dollar houses and condos clustered around the ritzy shopping center with that name. Event planner Mary Tribble walks into one of the office buildings, stopping at a reception desk of richly inlaid wood. On the walls hang paintings by local artists. Freshly cut flowers fill a vase on a table. She and a nurse disappear down a hallway into a suite evocative of a waiting room. More flowers.More local artwork. She climbs onto an exam table covered in fresh linen. Elizabeth Perry, trained in internal and emergency medicine at three of the nation’s top medical schools, takes her time. They talk, chatting about Tribble’s health but also about her business and personal life. “You’ve been fasting?” the doctor asks. The patient nods: “Since last night.” Perry laughs. “I’ll bet you’re hungry.” She goes to the kitchen, returns with an apple, then peels it.
A few years later, Tribble will sell her business, retiring at 50, then re-emerge as chief of events planning for the 2012 Democratic National Convention. Still a patient of Perry’s at Signature Healthcare, what she remembers most about that first visit was not the relaxed, hour-plus examination but a highly trained physician slicing her a piece of fruit.
Practicing medicine this way is but a sliver of North Carolina’s $60 billion-a-year health-care economy, and only about 4,400 of the nation’s 600,000 doctors — a figure that includes surgeons, psychiatrists and other specialists — do so, estimates Tom Blue, executive director of the American Academy of Private Physicians in Richmond, Va. Called direct, private or concierge care, boutique medicine and retainer-based medicine, what they all promise is meticulous attention and quick access to doctors. To get that, patients pay a premium. In North Carolina, an individual membership fee is typically $1,500 to $3,500 a year, out of pocket, on top of health-insurance coverage for visits and treatments. Tribble pays about $2,700.
In 2003, Signature Healthcare PLLC became North Carolina’s first concierge practice. Nobody keeps official count, but now more than a dozen doctors engage in retainer medicine at a handful of practices across the state. Among the latest is Perspective Health & Wellness, started this year in Charlotte by Carolinas HealthCare System, the nation’s second-largest public hospital network. Even doctors’ views of this trend vary. A recent national survey of 900 by the journal Physicians Practice found nearly half wouldn’t want to be in such a practice but don’t object to those who do. But more than one in 10 question the ethics of medical care catering to the relatively healthy wealthy — though nearly that many say they’re considering forming, joining or already working in one. Here’s one reason why.
William Lee is settling in to catch the late news when the phone rings at his Raleigh home. He turns off the TV and picks up the receiver. A woman’s voice, sobbing. “Mama died.” He listens as she recounts details. He’s an affiliate of Boca Raton, Fla.-based MDVIP Inc., a national direct-care network. She’s his patient, as her 89-year-old mother had been for 30 years, most recently in hospice care. He searches for words. “We know,” he says softly, “that she’s no longer in pain or suffering the indignities of health care.” They grieve together. In conventional practices, where primary-care physicians have as many as 3,000 patients and might see 30 a day, time is often too precious for such attention. In a boutique practice like Lee’s, a doctor’s patient load doesn’t exceed 600. Signature caps the number at 350.
Rushing through patients and appointments can result in burned-out doctors and be reflected in mistakes, missed diagnoses and even subtler ways. “Research shows that when doctors prescribe antibiotics for sore throats, it’s typically inappropriate,” says Marshall Silverman, an internal-medicine specialist who joined Signature in 2011, “but it’s because the doctor is trying to get out of the room quick and he thinks the patient is expecting a quick fix. But the patient doesn’t give a damn if he gets an antibiotic or chicken soup. What he really wants is to understand what’s going on with him, what the plan is and what the backup plan is.” That takes time, though, to explain.
This is what private practice has become for many primary-care physicians, and why, its proponents say, concierge medicine is gaining popularity. It is a weekday afternoon in the office of a 62-year-old internist in a traditional practice. Pacing in a hallway, he scans records of a patient with a racking cough, nausea and dizziness and finds he had prescribed the antibiotic cefuroxime axetil two weeks before. He opens the door to a room dominated by a worn exam table sheathed in tear-off paper, its gray walls bearing vivid posters of intestines and inner ears. “Projection of heart valves and auscultation points on anterior thorax,” one reads. Above it all hangs a faded portrait of George Washington. The doctor peers into the patient’s throat, listens to her chest. It’s possibly chronic bronchitis, he muses, but he rules out more antibiotics. The first round did no good. Pneumonia? Unlikely, but he orders an X-ray at a nearby hospital. The visit ends. His time with the patient: less than five minutes. Her diagnosis and prognosis: still uncertain.
At Signature, Silverman’s day is little like that. It includes two physical exams, from an hour to an hour and a half each, followed by a consultation with a new patient for an hour, interspersed with several sick-patient visits — a sore throat entails a 30-minute examination — and several follow-up visits. Patients are guaranteed same- or next-day appointments, and if they become sick or injured after hours, their calls will be answered by him or one of the practice’s other three doctors. Recently, an executive boarding a plane for an eight-hour business flight discovered she had forgotten an important medication. “We took it from there,” practice manager Jeannette Anselmo says. The prescription was called in and delivered to her destination. “She walked into the hotel room, and her medicine was sitting on the dresser.”
In Raleigh, Lee’s day mirrors Silverman’s. Mozart and Vivaldi quietly flow through the sound system. A Morehead Scholar at UNC Chapel Hill, Lee, 65, earned his medical degree there in 1974 and is certified in family medicine. His morning begins with a young woman he’s treating for a respiratory infection, followed by a man with spinal stenosis, a narrowing of the spinal canal that is pinching nerves. Another patient has a palette of six different medical woes. Another is nearly 90, a woman “in remarkably good health.” He closes his day with a 34-year-old he had treated as a boy. They catch up, bantering about the patient’s career, exercise habits, pros and cons of Vitamin D supplements and his personal life. “A fun time,” Lee says with a grin after the visit. He’s seen seven patients today.
“This kind of practice has extended my career, improved my health, I think it has probably extended my life,” he says. If so, there’s evidence concierge medicine might be having a similar effect on patients. In 2008, an independent study of 500 MDVIP doctors — the VIP nominally stands for value in prevention, though it’s obviously a marketing double entendre — showed only 119 per 1,000 of their patients were hospitalized each year. That’s about half the rate of traditional practices, despite MDVIP patients frequently having chronic or multiple medical problems. The numbers are no fluke.
On a recent Saturday morning, Larry Carroll, 60, chooses a club and looks down the fairway of Cedarwood Country Club. Stepping onto the tee box, the Charlotte financial planner twists, and wrenching pain racks his hip. By Sunday morning, it’s unbearable. He dials Jordan Lipton, one of Signature’s founding physicians. “I’m on the way to the emergency room,” Carroll tells him. Lipton listens. “Well, Larry, if you want to, I’ll meet you there, but this is what’s going to happen. They’re going to give you some painkillers and tell you to see me Monday morning. Tell you what. I’ll call in a prescription, and you can come in tomorrow morning.” A week later, with no emergency-room visit, he is back to normal.
Carroll, who with wife Vivian has a family membership that costs them upward of $5,000 a year, considers it a bargain. “They take time to sit and talk with you and figure out what’s wrong.” The founder of Carroll Financial Inc. is mildly diabetic and slightly overweight. Before joining Signature, “I hadn’t had a physical in four or five years. I’d go to the doctor and never see him. On at least two occasions, I never talked to a doctor at all, only physician assistants. I’d wind up in waiting rooms — I hated that — sitting there thinking, ‘I have work to do.’”
His doctor almost certainly was frustrated too. A recent study by the University of California San Francisco School of Medicine concluded that primary-care physicians’ patient loads shouldn’t top 1,800. The average is 2,300, and many exceed 3,000. Another study found that in conventional practices a doctor typically interrupts the patient in the first 23 seconds of a visit and, in a quarter of the cases, never asks for the patient’s version of what’s wrong. “If you spend more time with your patient,” Silverman says, “you’ll not miss that 5% of people who come in with typical symptoms but have those one or two little things that get your antenna quivering a little. In a five-minute visit, you’re not going to get to that, and they wind up in the emergency room the next day. If you can follow up, lo and behold, you can keep that patient out of the hospital.”
If Carroll was sick of conventional medical practices, he had company. Many of the doctors who’ve switched feel the same way.
A Duke graduate who earned his medical degree at Tulane University in New Orleans, Silverman, 46, served as an Army doctor with an elite airborne division in Kentucky. A trim distance runner who sometimes wears a fleece jacket in the office, he’s neither soft nor facing burnout. That’s not what led him to leave University Medical Associates, near Lake Norman, where he had practiced since 1999. Though nearly 20 years older, Lee shared the same frustration: “Doctors aren’t being asked, but required, to see more and more patients in less time for less reimbursement, just to pay the bills.” Doctors like those in Silverman’s previous practice, pressured by absentee employers to increase productivity — theirs had been bought by Winston-Salem-based Novant Health Inc. — have seen patient visits soar. The nation’s busiest 10% of primary-care doctors averaged nearly 5,100 in 2011, about 21 per workday, according to Englewood, Colo.-based Medical Group Management Association.
Paradoxically, the stampede might be driving up costs. One reason is that primary-care providers often refer patients to specialists because they don’t have time to diagnose them. In the South, specialists averaged $384,000 in compensation in 2011, about 75% more than primary-care doctors, according to MGMA. Even those who aren’t referred to specialists get short shrift. “You find yourself passing off the bulk of your work to physician assistants or nurse practitioners,” Silverman says. “There’s nothing wrong with that, but that’s not what I signed up for.” The alternative? “You deliver shoddy medical care. Signature looked like an opportunity for me to provide medical care at a level I could sleep with at night, to get off the treadmill.”
The treadmill can hamper care quality in unexpected ways. Physicians say patients in conventional settings are surprisingly considerate, reluctant to ask important questions if doctors seem harried. “Just about every patient that comes to see me has a relationship with a great doctor they think the world of,” Silverman says. “But he’s been slowly crushed over the last 10 years. They say, ‘Look, he’s getting killed, and I’m going to get killed.’”
Switching to retainer-based medicine is not, however, without financial, ethical and professional challenges. Lee, “frustrated with a high-volume practice” in which he treated as many as 30 patients a day, joined MDVIP in June 2009. “I couldn’t bring myself to run out of the room when patients needed to talk more. And many times they’ll reserve their most important questions until last.” Though he describes his compensation now as 2½ times what it was in his previous practice — MGMA says the median pay for a primary-care internist in the South was $213,732 in 2011 — switching wasn’t easy. Doctors usually have to rebuild their patient rolls, essentially starting from zero, forcing them to market themselves, an unfamiliar and even odious chore for many.
Lipton, Perry and Bryan Woodward, all certified in emergency medicine, had hardly any patients to bring with them when they started Signature. They appeared at civic clubs, business groups and retirement communities, selling their then-new model. “You have to have more of an entrepreneurial approach than many doctors,” says Anselmo, the practice manager, who has an MBA from Queens University of Charlotte. “It took about four years of dinners, open houses and wine-and-cheese events before they didn’t have to keep beating the streets so hard.” The practice recently enrolled its 1,000th member.
Overhead costs at a retainer-based practice might be double or more those of bare-bones clinics. Signature patients, for example, get freshly laundered, blue terry-cloth robes and gowns, snacks and beverages — when they don’t interfere with treatment — and other pampering. Each of the four doctors has a nurse, the practice has its own radiology technician for in-house X-rays and labs for routine tests, and there’s a referral coordinator for specialists and procedures such as mammographies and colonoscopies, plus positions unknown in conventional practices, such as a patient-relations specialist who does tours for prospective members.
About 75% of revenue comes from membership fees, and though practice officials decline to discuss details, that could top $3 million a year. The average fee is about $3,000. Patients typically are slightly older than in conventional practices and cover a variety of demographics. “Maybe a third are Medicare age or a little older, some are retired, some have a variety of medical issues or are aware of their mortality and want to be at the top of their health,” Silverman says. In Asheville, Blue Ridge Premier Medicine offers discounts to members who reside in North Carolina fewer than six months a year, targeting Floridians and other second-home owners.
As a trend, though, retainer medicine is less than tranquil. The nation’s second-largest physicians’ group behind the American Medical Association, the 133,000-member Philadelphia-based American College of Physicians, which represents internists, has debated its ethics, and some members of Congress have unsuccessfully attempted to block concierge practices from accepting Medicare patients. They can but are not allowed to bill Medicare for the membership fee.
Its practitioners, however, say its elitist image is undeserved, and criticism that it’s a step in the wrong direction, limiting access when patient numbers are soaring and there’s a shortage of doctors, is a misdiagnosis. Same for accusations that it creates a two-tier health-care system, one for the rich and another for those who aren’t. “People who say that obviously aren’t paying attention to what’s going on in medicine right now,” Silverman says. “We live in a four-tier system, even without talking about concierge medicine. At the bottom you’ve got Medicaid, then Medicare, then insurance HMOs and PPOs — health-maintenance organizations and preferred-provider organizations — and then more-traditional insurance plans. Yes, concierge adds another tier, but so far as creating elite care only for those who can afford it, I’ve got bus drivers and teachers in addition to business executives.”
Lee says the impact of private medicine on health-care access is exaggerated, overlooking the fact that humane schedules entice more like him to postpone retirement and attracts more medical students into primary-care medicine. “They’re smart,” he says. “They know they don’t want to work as hard, the long hours. Only 3-to-4% at Chapel Hill plan to go into primary care, but I have students rotate through here and, after, they all say they’d consider it.” Concierge medicine, though, will ultimately stand on the strength of its consumers.
Miserable and shaky, Mary Tribble walks into into Signature Healthcare. She suspects she has the flu. Wrapped in a warm, blue terrycloth gown bearing the Signature monogram — “no, it doesn’t open up the back”— she’s treated by her doctor, then escorted into a quiet room. “They cut the lights off and said, ‘OK, just stay here as long as you want, and we’ll keep an eye on you.’”
If concierge medicine is the future of health care, Tribble says, it might be because it’s a throwback to the past. “What they’re doing is practicing the kind of medicine we knew in the ’50s and ’60s.”