Dr. Jack Padour was burning out.
The Ventura, Calif., internal medicine doctor faced falling reimbursement rates and rising overhead. The only way to maintain his earnings was to see more patients.
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"I knew I was being compromised by seeing patients every eight to 10 minutes just to keep the doors open," he said.
Two years ago, Padour changed his practice to a model attracting doctors and debate across the nation.
Patients now pay him an $1,800 membership fee that allows him to see fewer people and spend more time with each of them. A roster that once hovered at 2,000 patients is now at 300.
The annual fee guarantees an extensive physical, including tests on lung function, vision, heart, anxiety, diet and other aspects of wellness. Patients get Padour's cellphone number. They are guaranteed immediate access and, perhaps most importantly, more time with the doctor.
If they end up in the hospital or a nursing home, he follows them there for treatment.
Some doctors call it a concierge practice. Others, frustrated over what they say is a misperception that the service attracts only wealthy patients, prefer "direct primary care" or "personalized care."
The forms vary. But in most cases, doctors charge membership fees to provide certain services and specialized care. Many of the doctors, including Padour, continue to accept insurance payment for care not covered by the membership, although some doctors accept only direct payment.
A leader of the American Academy of Private Physicians estimates as many as 5,000 doctors nationwide have direct primary care practices, charging fees of $600 to several thousand dollars. A leader of MDVIP, a Florida-based company that runs a national network of membership fee practices, suggested the national number is closer to 2,500 doctors but increasing.
No patients are abandoned when doctors join MDVIP, said Dan Hecht, CEO of the 12-year-old company that is a division of Procter & Gamble. Before doctors join, they must find a new home for patients who choose not to pay membership fees.
Hecht says MDVIP helps combat the primary care doctor shortage by extending the career of physicians so frustrated with traditional practice that they leave medicine.
Dr. Paul Block of Thousand Oaks, Calif., joined MDVIP in 2004. He said the membership-fee format allows him to better avoid what he sees as the problems created by the power of insurance companies, pressure to see more patients and federal health care overhaul.
"I became aware I couldn't change the system but I could dramatically change it for myself and a few people," Block said.
Bristling at the notion of upper-crust care for an affluent few, Block said his $1,800 annual fee is less than some people spend on cable and Internet services.
MDVIP officials say their practices have brought a 79 percent reduction in hospitalizations for Medicare patients.
Tony Plaia is a 79-year-old retired insurance agent who had knee replacement surgery. A spine injury means he has 10 screws, two bars and four wires in his neck.
He comes to Block because he doesn't have to wait for appointments and the care is focused on keeping him going to the gym, healthy and out of the hospital. He receives a comprehensive physical, a wellness plan and a copy of his health record.
"It boils down to $5 a day," he said. "I could spend that on a super latte or spend it on MDVIP."
If patients need care outside the wellness program covered by the membership fee, Block bills the insurance company or Medicare.
All but a few of Block's patients carry insurance. Outside observers say people need a high-deductible plan because the membership fees don't cover all health care needs.
That means patients pay insurance premiums and membership fees. If they're not insured, they will face fines of at least $95 next year, said Dylan Roby, a UCLA health policy professor. The penalty is part of the federal health care overhaul's mandate that people obtain insurance coverage.
The law guarantees that insurance companies provide free coverage of care labeled "preventive." But doctors in concierge practices say many of the wellness tests and treatments covered by membership fees are not covered by the law.