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As more doctors charge up-front fees, patients find better care comes at a cost

When Judy Taggart's doctor told her she'd have to start paying an annual fee for care, she decided to give it a try.

In 2013, the 69-year-old Severn resident, who was overweight and on medication for diabetes, cholesterol and high blood pressure, began paying $1,650 a year to Dr. Peter Ramirez's Glen Burnie primary care practice. In return, she received a two-hour annual exam that included mental health and sleep dysfunction screenings, body composition analysis and in-depth lab, EKG, vision, hearing and lung function tests.


She also gained around-the-clock access to Ramirez via email and cellphone and joined his weekly preventive health walks on the Baltimore and Annapolis Trail.

"The biggest difference is when he comes in and sits down to talk, I don't feel like he's in a rush," she said. "I feel like he definitely takes that extra step now."


Taggart has lost more than 65 pounds and no longer takes medications. She attributes much of her improved health to more face time with — and care from — Ramirez, thanks to his retainer-based, "concierge"-style practice.

Ramirez is among a growing number of doctors converting to a retainer-based medical practice, a model in which patients pay a flat fee directly to physicians. Since 2012, the number of retainer-based practices in the U.S. has grown about 25 percent a year, reaching about 6,500 doctors in 2016, said Tom Blue, board member and chief strategic officer for the American Academy of Private Physicians.

In a time when most primary care physicians see 25 to 35 patients a day, the fee-based system allows doctors to shorten patient rosters and spend more time with each person. In some cases, the model cuts out insurance, reducing the paperwork burden on staff.

It's a change that some say reinvigorates doctors and gives patients more personalized, comprehensive and preventive care. Yet others raise concerns that it could limit health care access to those who are wealthy and health-conscious enough to pay for it.

In Maryland, retainer-based medicine initially appeared in wealthier areas like Annapolis and Bethesda, according to Gene Ransom, chief executive officer at MedChi, the state's medical society. But in recent years, he says, more practices in middle-class neighborhoods are switching to the model, and MedChi gets frequent calls from doctors interested in doing so.

At "concierge" practices like Ramirez's, annual fees average about $1,600. Practices generally set limits of 200 to 600 patients, rather than the 2,000 to 2,500 at traditional practices. They offer same-day or next-day appointments for primary care as well as after-hours and weekend availability for urgent medical needs.

"If you get sick on a weekend or after hours, you don't go to an urgent care center or an emergency room," said Dr. Michael Downing, who shares office space with Ramirez. "You go to us."

Models vary, but most concierge practices take insurance for regular visits, and patients still have co-pays. The retainer usually covers the extra testing.


Dr. Joel Meshulam, a SignatureMD doctor in Baltimore with 110 concierge patients, made the switch in 2014. A nurse practitioner sees patients who didn't join the concierge program, and Meshulam consults as needed.

When Meshulam went concierge, patient Hannelore Schanne, 81, said she was hesitant to embrace the new model — and the $1,650 cost.

"At first, I wasn't too crazy about it," the Glen Burnie resident said. "But I liked him."

Since she joined the concierge practice, Schanne said, Meshulam has been more relaxed and available during her visits.

"I like it because I can call him anytime, and he's never in a rush," she said. "It's worth it."

Experts say most patients at concierge practices are in their 50s, 60s and 70s. And some patients will benefit more than others, said Guy David, an associate professor of health care management at the Wharton School at the University of Pennsylvania. He compared it to an airline: If you fly once a year, there's no value to becoming a platinum club member, but if you fly once a week, you'll reap the benefits.


"Some patients see physicians two times a week versus one time a year," David said. "It's the segmentation that we accept in almost every other service industry."

Patients who don't need as much face time might opt for direct primary care, another form of retainer-based medicine. Like concierge doctors, direct primary care doctors offer a range of services for a flat, recurring monthly or annual fee, but most do not bill insurance. Direct primary care patients typically have a high-deductible insurance plan to cover emergencies.

These practices, which typically have between 600 and 800 patients, enjoy low operating costs because they don't need staff dedicated to insurance paperwork, according to the American Academy of Family Physicians. David estimates that the typical direct primary care monthly retainer is between $50 and $150.

Dr. Orsolya Polgar, a direct primary care doctor in Columbia, charges $650 for patients wanting a physical and two additional office visits per year, or $1,650 for patients wanting a physical and up to 10 additional visits a year. Direct access to the doctor via email and cellphone is part of each plan.

"Direct primary care doctors don't benefit from the patient being sick or coming to the office often," Polgar said. "They are motivated to keep you healthy so you don't have to come back for the same issue over and over again."

Patients and doctors promote extra availability as one of the biggest perks of retainer-based medicine. Though research is limited, studies conducted by Florida-based concierge network MDVIP show concierge patients are more satisfied than others with their ability to reach their physicians.


Before Downing and Ramirez made the switch, they were seeing patients every 10 to 15 minutes, Downing said. Now they spend hours with each patient, analyzing test results and, for patients like Judy Taggart, drafting nutrition and exercise plans.

"Now we sit down with them and go through their diets," said Ramirez, who is part of the MDVIP network. "Before, we might say, 'You need to cut out sugars.' Now we get into the nitty-gritty."

That extra time and detail leads to better overall health, he said.

A December 2012 study published in the American Journal of Managed Care and conducted by MDVIP found that MDVIP members in five states were significantly less likely to be hospitalized than other patients, saving the health care systems $2,551 per patient between 2006 and 2010.

Still, some are uncertain about retainer-based medicine's long-term success.

"The number of people with enough liquidity and income and desire who are willing to pay … a concierge physician is relatively limited in the United States," said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School.


People willing to spend $1,500 to $2,000 a year on concierge medicine are often more conscientious about their health, Mehrotra said.

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"Probably at baseline, they were doing pretty gosh darn well," he said. "The people who would most benefit are the people who wouldn't be able to invest in it."

It wasn't a price Florence Hackerman was willing to pay. The Reisterstown resident left her primary care practice after it switched to a retainer-based model.

"I understand a primary care physician doesn't want to see a patient every seven minutes," she said. "But for the country as a whole, I think concierge medicine is more destructive to the health care system because it creates these tiers: Those who can get what they want, and those who can't."

That could be compounded by a national primary care shortage. Since the passage of the Affordable Care Act, newly and previously insured patients are struggling to see doctors because of long wait times, Mehrotra said. A March 2015 report issued by the Association of American Medical Colleges estimates a shortage of 12,500 to 31,100 primary care doctors by 2025.

"What we need is to improve the efficiency of the model so primary care doctors can manage more patients on their own, or we have new primary care providers who can provide care," Mehrotra said.


Until then, retainer-based medicine is a viable solution for patients and doctors, Ramirez said.

"The system is broken," he said. "This is one fix."