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. Last Updated: 07/27/2016

'Boutique Doctors' Grant Lavish Care

BOCA RATON, Florida -- It was on the plane from Shanghai to Beijing last year that Dorothy Lipson of Delray Beach, Florida suddenly began to cough up blood: first in streaks, then in frightening, tissue-soaking spoonfuls.

But Lipson, who was in China visiting an expatriate daughter, was lucky on two counts. First, her daughter happens to run a corporation that builds gleaming Western-style hospitals in China. And second, Lipson's internist back home in Florida is Dr. Bernard Kaminetsky, one of a new breed of "concierge" or "boutique" doctors who, in exchange for a yearly cash retainer, lavish time, phone calls and attention on patients, using the latest in electronic communications to streamline their care.

Since its debut in 1996, concierge medicine has evoked criticism from many corners. Some ethicists say it is exacerbating the inequities in U.S. health care. Insurance regulators have raised concerns about fraud.

"Concierge care is like a new country club for the rich," U.S. Representative Pete Stark, a Democrat, said at a hearing in Congress last year.

"The danger is that if a large number of doctors choose to open up these types of practices, the health care system will become even more inequitable than it is today," he said.

But for Lipson, who pays $1,650 per year, the niceties enabled by concierge medicine can make all the difference. "I highly recommend it," she said. "It's well worth the money."

Kaminetsky was in daily touch with Lipson's doctors in Beijing. E-mail messages, X-ray reports and digitalized images flew back and forth. When Lipson returned home, Kaminetsky connected her with infectious disease experts for treatment of the unusual infection that was found.

Anyone searching the country for a group of patients who are perfectly happy with their medical care, need look no farther than Kaminetsky's waiting room in Boca Raton.

Not that the waiting room usually has anyone in it. One promise made to patients paying for concierge service is that waiting will not be a part of their health care experience. Patients are guaranteed that phone calls will be returned promptly and appointment times will be honored.

Kaminetsky's practice is affiliated with a corporation called MDVIP, which he helped found. It processes the retainer fees, oversees the office's electronic capabilities and runs quality control. Nationwide, about 250 medical practices and 100,000 patients have signed up with MDVIP and similar corporations, according to the professional society of concierge physicians, the Society for Innovative Medical Practice Design, founded in 2003.

These doctors charge fees as high as $10,000 a year, depending on the services promised. The majority charge $1,500 to $2,000.

Before Kaminetsky became a concierge doctor five years ago he had 2,500 patients in his practice -- a standard number for most primary care internists. His list now numbers 600. Despite the drastic decrease in patient load, Kaminetsky's personal compensation and the salaries of his office staff members increased by about 60 percent.

The arithmetic behind this seeming contradiction results from the low per-visit reimbursement rates set by the U.S. government's Medicare health insurance program for primary care office practices. Medicare now pays an internist like Kaminetsky slightly over $50 for an average office visit. Thus, a regular internist might earn about $200 a year from Medicare for caring for the average older patient with high blood pressure or elevated cholesterol but no other major health problems.

Other medical insurers follow Medicare fees closely, which is why office-based primary care doctors who accept insurance say they must see dozens of patients a day just to break even.

A concierge doctor charging the $1,650 MDVIP fee, though, makes at least $1,150 per year per patient (MDVIP retains $500 for its services). This huge increase in per-patient reimbursement allows the patient loads to be kept low.

Primary care doctors also occasionally lower their patient loads by participating in only a few insurance plans, or, sometimes, in none at all.

Some concierge practices operate exclusively on a cash basis. Others --generally those with lower annual fees, like Kaminetsky's -- still participate in Medicare or other insurance plans.

Critics maintain that concierge services violate the spirit, if not the letter, of federal Medicare law, which aspires to regulate doctors' fees to a uniform standard and streamline access to medical care for the old and infirm.

After five senators wrote a letter of complaint to the Department of Health and Human Services in 2002, a formal examination was begun. Tommy Thompson, who headed the department at that time, concluded that as long as the retainer fee was clearly for services not covered by Medicare, collecting the fees did not violate the law.

Charges that concierge practices violate not financial ethics, but professional ethics, also abound.

"Philosophically, I think it's appalling," said David Barton Smith, professor of health services administration at Temple University in Philadelphia. "It's creating a two-class system of medicine."

Critics have accused doctors who make the transition to a concierge practice from a regular one of abandoning patients who cannot afford to join up.

Kaminetsky counters with his own story. A detail-oriented perfectionist, he had been tormented in his previous practice by the impossibility of meeting his own standards.

Now on his busiest days he sees perhaps half the number of patients he used to, spends twice as long with each one.

"I'm really helping a lot of people," Kaminetsky said. "I feel good about what I do. Does everybody deserve this kind of care? Yes, they do. And I don't purport to know the solution."