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BOUTIQUE DOCTORS

Customized Care

January 2006
by Jo Kaufman
Nob Hill Gazette

When Norman Stone experienced severe abdominal pain on a May evening in 2004, his wife Norah urged her normally stoic husband to call their doctor, who promptly came to their home and diagnosed acute appendicitis. Three hours later, Norman was in surgery at California Pacific Medical Center. By the next morning, he was home and resting comfortably.

A house call, immediate and personal service. Sound familiar? Probably not. But theirs is no ordinary doctor; he’s part of a small but growing number of physicians who charge an annual fee for such amenities as lengthy, comprehensive medical exams, same or next day appointments, and 24-hour access.

Called “boutique” or “concierge” doctors, a name that makes some of them bristle, these doctors typically have a patient load of 100-500 patients a year, as compared to the roughly 2,000-3,000 patients other doctors see. Boutique doctors charge $1,500-10,000 per person a year, and can go as high as $20,000, according to an American College of Physicians report, with an average annual cost of $2,000-3,000.

And while the concept of “boutique” medicine has sparked debate among lawmakers and medical ethicists for creating a system that supports a patient aristocracy, proponents see it as the inevitable next step in health care.

“May 18th — I’ll never forget that date,” Norah Stone explains. Two years earlier, while vacationing in Hawaii, she had the same symptoms as her husband. But she wasn’t as lucky in terms of diagnosis and treatment. By the time she was rushed to Honolulu from Lanai, 36 critical hours had elapsed.

“What I thought was food poisoning turned out to be appendicitis,” she says. “I spent four days in the hospital in Hawaii, and ended up with peritonitis when I came home.” Her recovery was long and slow, and something she feels could have been avoided with more timely care. Like many people frustrated with the shifts in health care since the early ’90s — the long waits for appointments, the voicemail responses — the Stones did their research and signed up with a boutique doctor in 2003.

“We’re thrilled,” says Norah, who remembers when it took three days to receive a call back from a doctor and up to several months to see a specialist.

Forty-four-year-old Jock McDonald changed to a boutique practice after a routine colonoscopy. “My father died of colon cancer when he was 63, so I thought the doctors would be concerned about my family history.” Aggravated and worried when he didn’t receive test results for over a week, Jock was fed up. “I shouldn’t have to chase my doctor,” he says of his decision to seek out alternatives. “When you’re sick, you want a doctor now, not next week.”

For Jock, however, the benefits of such service go well beyond the occasional phone call he makes when he’s ill. As a self-employed photographer and filmmaker, he confesses that he can’t afford to miss work, let alone keep track of what tests are in order and when. To that end, his doctor now oversees everything from his annual physicals and specialist visits, to the immunizations needed for his frequent business trips to Third World countries. He even provides travel kits for each patient, stocked with staples — aspirin, antibiotics, nitroglycerine, and an Epi-Pen for anaphylactic shock — and customized medications.

“I think of my doctor as a coach. The job isn’t just to see me when I’m sick but to keep me healthy.” As far as the annual fee, McDonald claims that it’s a small price to pay. “It’s like a monthly car payment, but the difference is that it’s my chassis!”

The compact and energetic Dr. Jordan Shlain, Medical Director of San Francisco On Call, and one of several concierge practitioners in the city, is a firm believer in preventive medicine. “The focus is on extremely timely care,” he explains. “It’s about being proactive, ahead of the curve, in terms of health care. It’s also about restoring the doctor-patient relationship.”

For Dr. Shlain, 38, the appeal of a small boutique practice began when he was a resident at CPMC/UCSF, where part of his training involved making house calls, which he describes as “enormously gratifying.” Unlike older, established doctors, however, for whom switching to an exclusive practice could present too great a shift in the way they do business, Dr. Shlain was in a position to decide how and where to focus his energies. And it’s clear from his exuberance that he’s made the right choice, for himself as well as his patients.

Criticism of the inequities in our health care system notwithstanding, it’s rare to see a physician so involved in the day-to-day business of pursuing wellness. How often does anyone hear their doctor say, “The only waiting room should be your living room”?

The hitch is that Dr. Shlain, along with other such practitioners, are out-of-network (not on the preferred list of most insurers, so that fees are reimbursed at a lower rate). This means that, in addition to the yearly amount paid to these doctors and to your insurance provider, you pay upfront for all services (including house calls). You may or may not be reimbursed by your insurance or Medicare, depending on whether the services are deemed reimbursable. Dr. Shlain is clear that signing up with him is not a replacement for having insurance, especially to cover catastrophic illnesses, hospitalizations, and such.

For Dr. Shlain’s patients, it usually starts with an annual five-figure investment. But as many claim, with such low doctor-to-patient ratios, coupled with higher fees, these physicians have the luxury of lavishing time and care on patients that traditional “in network” doctors do not.

A distinguished man in his 50s, Dr. Leslie Squires has a hybrid system that allows him to have both a traditional and a concierge practice. And despite what he candidly admits is “a lot of skepticism among doctors” for working outside the mandates dictated by the current health maintenance organizations, he’s convinced that, “This is the way medicine has to go in San Francisco.”

Dr. Squires explains that his decision to enter the boutique medicine field was patient-driven and began when the adult children of his older patients sought his advice to help them care for aging parents. What he’s discovered, though, is that an increasing number of people, regardless of age or medical needs, opted to sign up for MD LTD, his concierge service.

“I’m sort of like home base,” says Dr. Squires, admitting that he knows his limits. “If I can’t solve the problem myself, I know where to send people.” And while he rarely has trouble remembering a patient’s history, he only has to go as far as his desk for the latest in computerized records. He keeps an up-to-date list of everything ranging from lab work to EKG results and medications, all of which are burned onto a miniature CD for patients to carry with them.

When a 54-year-old San Francisco attorney signed on for the service in September, she was looking for a skilled internist to replace her recently retired family physician. Concierge medicine was the closest she could come up with in terms of returning to the old fashioned, hands-on care she had grown up with. What she couldn’t possibly have known then was that less than three weeks later, she’d end up in the ER undergoing an emergency angioplasty.

“Both my parents were dead of heart disease by the time they were my age,” she says, “so I’d had every imaginable test run, and all of them came back negative.” What struck her was the seamlessness of her care. “My doctor talked to all the doctors. He knew what the cardiologist said, what the gastroenterologist said. It was a great reassurance to turn to him, to know that someone was monitoring my well-being.”

Such sentiments are echoed by a health care manager who chose a Palo Alto boutique medical practice for herself and her husband after reviewing all the options. “I see the (mainstream) system on a daily basis, and I understand its flaws,” says the Peninsula woman. “When you’re sick, you’re not in a position to think clearly. It’s absolutely critical to have someone there to serve as an advocate. Honestly, it’s the best investment you’ll ever make.”

For many, the price tag is a strong deterrent. Engineer Andrew Cowan scoffs at the idea. “Maybe I’m a typical male. I’m 41, I’m healthy, which means I only go to a doctor when I have to.” But his 79-year-old father is another story, and it was after discussing the situation with caregivers at his father’s assisted living facility that Andrew decided to enlist these special services.

“They have attendants at my dad’s place, but no doctors or registered nurses, and even though he’s a pretty alert guy, he’s not in a position to manage his own care.” And while the younger Cowan visits his father regularly and tries to keep on top of his medical needs and appointments, he can’t always be there to supervise.

By the same token, he admits that it’s an emotional and financial balancing act. “Everybody has to evaluate their own needs…nobody’s putting a gun to your head to pay this extra money. It’s something I think about all the time, especially since my dad is basically healthy and would probably be okay with the care he gets where he lives.”

Since the first concierge practices began appearing in 1996, many physicians have extolled the virtues of what would appear to be a win-win situation for all involved. Having a boutique medical practice allows them to be better doctors, they say, and to fully subscribe to the tenets set forth in the Hippocratic Oath.

Some claim they’re even saving the insurance companies time and money on what would otherwise be costly interventions and/or preventable visits to the emergency room.

The field of concierge medicine remains an unregulated industry, albeit a small one consisting of about 250 practices nationwide. Even so, it’s inspired the wrath of some lawmakers and governmental agencies who decry the injustices of any system that excludes those unable to pay for the amenities. It has also alienated patients who consider the notion of additional payment for elite services to be excessive and unnecessary. One local businessman described his experience as “a rip-off.” After paying the initial fee of $10,000, he was charged $300 for a routine house call a few months later. He promptly resigned from the service; there was no refund.

Discussing health care is a tricky business, with passions running high on both sides of the debate. In the words of a recent convert, “We’re not used to thinking of medical treatment as an investment, but that’s what it’s come down to.” For subscribers and devotees, it’s an invaluable addition to their portfolios. For detractors, it’s throwing money down the drain.

Jo Kaufman is a San Francisco writer whose work has appeared in the Santa Clara Review, The Paterson Literary Review and various local small presses. She received her M.F.A. in Creative Writing from USF, where she also taught English Composition.

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