Since April 1, Minnesota has been home to a health care experiment that has recently been popping up in cities around the country. It's called concierge care, or two-tier health care. Under concierge care, patients pay their doctors an annual fee to buy personal service and 24-hour access. Patients say they're simply choosing to pay for services the market isn't providing. And doctors say concierge care allows them to provide more intimate care they prefer, for a better price than they can fetch under managed care. But critics say concierge care is unethical and favors the elite at the expense of the less fortunate.

The notion of so-called concierge care has been around for a long time. Hospitals like the Mayo Clinic have always provided intimate, personal care for a premium.

But concierge care moved into the mainstream locally this spring. On April 1, Park Nicollet Health Services started a program called Compass Program, and a small Minneapolis clinic called Specialists in Internal Medicine started a similar program called Senior VIP.

	Dr. Frederick Goetz is a retired physician and consumer of concierge care service. (MPR Photo/Andrew Haeg)

Park Nicollet's patients pay $3,000 a year for the Compass Program. Senior VIP members pay $800 annually. In return, patients get perks like same-day appointments, around-the-clock telephone and pager access to physicians, and coordination of specialty-care referrals.

Concierge care offers patients intimate, personal attention in an environment where physicians are increasingly feeling pressure to give otherwise.

"The pressure to have a rapid turnover has at times clearly meant that care was perfunctory," says Frederick Goetz, a retired doctor and a concierge care patient. Earlier this spring, he signed up with Senior VIP at Specialists in Internal Medicine. As a patient, Goetz says concierge care helps preserve his doctor's ability to provide continuous care, from the clinic to the hospital.

Under managed care, doctors take on more patients for less money. So they hand off care to the hospital staff, rather than treat the patient continuously.

Back when Goetz practiced at the University of Minnesota, continuous, more generous care was a given. Now it's a luxury, one Goetz says he's pleased his doctors are offering.

"It's been a shame to see that many physicians have been under pressure from HMOs to accept a marginal level of reimbursement unless they increase their patient flow in a manner that's really against the grain for them," Goetz says. "I'm delighted that this model of primary care is persisting."

"The pressure to have a rapid turnover has at times clearly meant that care was perfunctory, " - Dr. Frederick Goetz, a retired doctor and a concierge care patient.

Since Specialists in Internal Medicine started its Senior VIP Program on May 1, more than 500 people have signed up. Dr. Dudley McLinn, who runs the clinic with three other doctors, says they're not turning away patients who don't sign up. McLinn says he and his colleagues chose to offer concierge care in part because patients said they wanted it.

"Benefits that people that we've found really, really value, are frequently not paid for by Medicare," McLinn says. "We feel that they have value. And patients, we think, feel they have value. And so we decided to put together a program that would allow us to continue giving these kinds of benefits."

But McLinn also says they're offering concierge care to counteract the drop-off in reimbursements from Medicare - a decline of five percent last year, and, by McLinn's estimates, 17 to 20 percent in the next three years.

"We're faced with an economic issue. And if we're going to keep providing the kind of care that we want to, the kind of care that the patients desire, then we have to put a value on the extras that we provide," McLinn said.

Likewise, Park Nicollet Health Services, which is not an HMO, came to the same conclusion.

"We knew that many of our patients were increasingly asking for the type of time, attention and flexibility from their primary care physician that this sort of program affords," says Park Nicollet CEO David Wessner.

Wessner says Park Nicollet introduced the program, in large part, to satisfy patients' demand for services they couldn't get under standard health plans. Wessner says the program will also help attract and retain experienced physicians.

	Dr. Dudley McLinn is among a growing number of physicians providing a higher level of care to patients willing to pay an annual premium for better access. (MPR Photo/Andrew Haeg)

Older doctors around the country are leaving medicine early because under managed care, every year they spend less time with more patients for fewer dollars.

"It's hard to find any other professional area where the payment to the professionals is as regulated as is payment to physicians," Wessner said. "As a result of that, it doesn't matter how much experience someone might have, it doesn't matter what sort of record they might have, they get paid exactly the same amount as the brand new physician."

Under concierge care, the Compass Program doctors can make as much or more money than they did in years past, while treating far fewer patients. Park Nicollet uses the proceeds from concierge care to support the system's free clinics in Wayzata and St. Louis Park.

Regardless of Park Nicollet's intentions, critics of concierge care say it's unethical.

"Once you start setting up these country clubs, then people start figuring out ways to manipulate the market," says Dr. John Goodson, an associate professor at Harvard Medical School, and an internist at Massachusett's General Hospital in Boston. He says health systems like Park Nicollet are just trying to make more money.

"In this situation, they're trying to portray themselves as some kind of Robin Hood practice. Which is ludicrous, it's ridiculous," Goodson said. "Let's call it what it is, which is, 'We're trying to enhance our income, and we're taking a small portion of our resources and allocating them to good deeds.' But let's not kid ourselves to think that this is not about improving their own incomes."

From another perspective, concierge care represents a perfectly rational response to a dysfunctional market.

If Medicare and managed care can't pay doctors the money they feel they deserve, then, economists and others argue, doctors should be able to charge more money for extra services. Leave it to the patients, they say, to decide whether they want it or not. And, for now at least, quite a few patients seem to want it.

Roger Feldman, professor of health insurance at the University of Minnesota, sees no problem with concierge care, unless it marks a concentration of power in the hands of doctors.

"If the doctors are getting this monopoly power, and they're charging higher prices in order to exercise it, that would be a concern," Feldman says. "On the other hand, if the trend represents serving the preferences of diverse consumers, and this is a form of satisfying the market which wants different types of care, then I see nothing wrong with it."

There are some signs that the downward spiral of Medicare and managed care payments may soon end. Congress is considering measures to increase Medicare funding, but even with new infusions reimbursements may continue to fall. If they do, expect more doctors to start offering concierge care sometime soon.

American Medical Association News Renegotiating health care (March 18, 2002)