Concierge medicine an "affordable option"

For years, doctors who started so-called "concierge" medical practices, offering personalized care in return for fixed retainer fees, have existed in legal limbo.

State regulators have argued that the arrangement is essentially medical insurance and should be subject to the same rules. Doctors and patients insist it's the antithesis of insurance: middleman-free deals between patients and doctors.

State lawmakers are now on the verge of finally ending the confusion and opening the door to more such practices. But the controversy is far from over.

A bill poised to land on the governor's desk this week proclaims concierge medicine an "innovative, affordable option," and directs the state insurance commissioner to keep track of the plans but not regulate them.

"We want to liberate primary care to do what it's really meant to do," Seattle physician Erika Bliss urged a state Senate committee in February.

But opponents, including some of the state's largest insurers, called the measure a "wolf in sheep's clothing" that would send the best medicine to wealthier, healthier patients while making it even harder for average families to get decent primary care.

"If you are concerned about the sickest and most vulnerable people in our state ... this isn't going to help that," said Dr. Steve Tarnoff, an associate medical director at Group Health Cooperative.

Fewer patients, more profit

Concierge practices have proliferated nationwide since being pioneered in Seattle more than 10 years ago.

The idea is relatively simple. Doctors don't bill insurance for services. Instead, patients pay a retainer, typically $50 to $250 or more a month. In return, doctors provide primary care — but not specialty or hospital services or prescription drugs — and they limit their patient load to perhaps 600 or 800.

Because the retainers allow doctors to carry many fewer patients and still remain profitable, they can provide around-the-clock access by phone and e-mail, same-day appointments, and can personally coordinate specialty care and give bedside attention in the hospital.

The first such practice in the country was Seattle's MD². It charges $1,300 a month for what it calls "high-touch" care. Doctors there have no more than 50 patients.

The arrangements appeal both to primary-care doctors — who have felt underpaid and overworked, with a typical patient load of 2,000 to 3,000 — and to many patients fed up with impersonal medicine.

From the beginning, though, the trend has drawn aggressive objections from health-care ethicists and economists who warn it could widen the gap in access between the rich and poor.

Four years ago, state Insurance Commissioner Mike Kreidler threatened to shut down the practices unless legislation was passed to allow them.

Terms of the bill

In Washington, Senate Bill 5958 passed the House last week, 90-5, after passing the Senate in slightly different form. It has been sent back to the Senate for concurrence and is expected to go to Gov. Christine Gregoire for her signature.

Under the bill, doctors offering concierge care would have to inform patients what services they provide and that they don't take insurance. They would have to refund fees if they stop seeing a patient.

The doctors would be barred from raising prices more than once a year, but there would be no limit on how high they could raise them. The bill also warns doctors not to cherry-pick healthier patients, but only by saying that doctors can't reject patients "solely" because of health status.

The bill specifies no penalties for violating its provisions. Instead, that would be addressed by the state Medical Quality Assurance Commission under existing "unprofessional conduct" codes.

The insurance commissioner's office would be directed to analyze the effects of concierge practices on overall patient access, health-insurance premiums and patient demographics, and report back to lawmakers in five years.

The legislation does not cover practices that bill insurance but also charge monthly fees for "extras" such as newsletters, cellphone access or other personalized services.

Affordable care?

Supporters argue that direct-fee practices put doctors and patients back in control of their health care.

Bliss, the Seattle doctor, says she wants her family practice to become a place where she can listen, advise and do what's best for her patients without worrying about whether insurance covers it.

Her cousin, Garrison Bliss, a family practitioner who runs Seattle Medical Associates, one of the first concierge practices, has long been lobbying for law changes. The two plan to open another retainer-fee clinic that charges about $55 or $60 a month, which they say would be affordable for uninsured patients.

Garrison Bliss also argues that concierge medicine would encourage more doctors to enter primary care, an area now facing a doctor shortage.

Small-business lobbyists side with the Blisses, saying direct-fee medical care offers an alternative to group-insurance plans.

But others scoff at the notion that such practices would be "affordable" or accessible to seriously sick patients.

"There are an awful lot of people who aren't going to be served under this program, people who really need care," said Bruce Reeves, president of the Washington State Senior Citizens' Lobby. "It seems to us they can cherry-pick whoever they want, and come up with reasons."

Group Health's Tarnoff warned lawmakers in February not to endorse a "wolf in sheep's clothing," saying they were glossing over "real ethical issues" raised by the current legislation.

He said the bill would allow large, for-profit companies to offer essentially a "primary-care insurance product" without any of the regulations or costs imposed on traditional insurers. Those regulations include consumer protection and mandates to contribute to state programs for high-risk or low-income patients.

Fundamentally, Tarnoff argues, it takes a "giant step backward," creating a two-tier health-care system.

As for Kreidler, the state insurance commissioner, the current measure is a far cry from the original intent to regulate the practices under insurance codes.

Even so, Kreidler is satisfied, said Beth Berendt, one of his deputies. Kreidler doesn't want to stifle innovation — just protect patients, she said.

"We just want a bill so we can get our arms around the practices," Berendt said, and be able to monitor and evaluate the impact.

"If there are problems, consumers will know they can come to us for assistance."

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com