The last straw for April Burnette-Dubose of Pembroke Pines, Fla., came one morning when she was 30 weeks pregnant. She had a prenatal doctor's appointment scheduled for 9:20 a.m., but wasn't seen until 11. The obstetrician had just left to deliver a baby, they told her. Which would have been understandable, had the same thing not happened at her three previous appointments. Her own doctor was never available at that practice, says Burnette-Dubose, 33, an attorney, and no one ever apologized for making her wait. Worse, her appointments rarely lasted longer than 5 minutes. She sensed indifference from the doctors and their staff: "I felt like I was in a pregnancy mill."
Burnette-Dubose's experience is extreme, but many American patients feel the same way like they're just a number in line at the butcher's shop. Some patients have had enough, and those who can afford it are choosing to pay hefty premiums out-of-pocket to get more personalized, more polite service. There are now more than 1,000 doctors in the U.S. who have opened concierge, or boutique, practices, according to the Society for Innovative Medical Practice Design. They limit the number of patients they see so they can devote more time to each; accept insurance for routine treatment and tests; and charge patients an additional flat fee for extras like no waiting, longer office visits and Ĺround-the-clock availability via e-mail or cell phone. Though it seems like a recipe for more work, boutique docs say their style affords them more control over their lives and careers, and is more fulfilling. Most are primary care physicians, but OB/GYNs are entering the field too, as Burnette-Dubose discovered when an acquaintance suggested she bring her business and her baby to Elite Obstetrics and Gynecology, a Ft. Lauderdale practice owned by Dr. Lanalee Araba Sam.
Sam founded Elite in 2004, frustrated and disillusioned by how little time she was able to devote to her patients. After her residency Sam had joined a large private practice at which, in one 54-hour period, she delivered 12 babies. At one point, she recalls, "I introduced myself to a couple and they looked at me like I was crazy. I had just delivered them but I didn't remember." Sam struck out on her own soon after and opened Elite, and now charges patients $15,000 on top of insurance for VIP prenatal care that includes add-ons like a fetal ultrasound photo at every visit, private birthing classes, one massage per trimester, optional home doctor visits, her private home and cell phone numbers and e-mail address, and the guarantee that she will be at the hospital for her patients' full active labor and delivery. In order to fulfill that last promise, Sam, who also has a regular gynecological practice, accepts obstetric patients by due date no more than four women due per month. That kind of attention, even for the most mundane concerns, goes a long way toward comforting patients during pregnancy, when every health concern is heightened. Burnette-Dubose says that Sam sent her periodic text messages just to check in.
Most physicians who offer concierge health care recognize the absurdity in paying so much to get the same kind of treatment the non-medical perks aside that used to be standard. But the model of the amiable country doctor who knows your kids and treated your grandparents has been replaced by a bureaucratic insurance behemoth that rewards physicians for seeing more patients in less time. "Thirty years ago, a family doctor could have had a panel of 1,500 patients and seen them each for enough time, given them personal care and met all their needs," says Dr. Robert Brooks, associate dean for health affairs and professor of family medicine at Florida State University College of Medicine. That model fell by the wayside as people moved around, farther from their extended families. "There was the ability for doctors to make a nuanced diagnosis that's not possible in a more fragmented, mobile society," Brooks says. Today, people who really want their doctors to get to know them have to pay for that investment of time.
Critics argue that concierge medicine enriches its practitioners and facilitates care for wealthy patients, at the expense of those who can't afford it. The fundamental question is: Should health care be provided equally for everyone, or is it fair to pay more for better health care? "Obviously there needs to be a standard of care we should try to obtain at a certain level for everyone in the country, and we're not there yet," says Dr. Raphael Darvish, founder and medical director of Concierge Medicine in Brentwood, Calif. "Beyond that, there are things people should be able to pay extra for." Given the insurance companies' strict rulebook, says Darvish, neither patients nor doctors have much choice. "I think the incentives are all wrong," Darvish says. "They don't pay for you to make a phone call. They don't pay for you to send an e-mail. They don't pay for you to find an interesting article about a problem the patient is having and discuss it with them."
The number of American physicians offering boutique medical services remains low in a 2005 survey of 4,200 primary care doctors led by Brooks, only 16.5% of respondents said they had ever even used e-mail with their patients, and only 2.9% used it frequently. The shift to personalized health care has been slow and gradual, but it's led by a young generation of doctors who are accustomed to having easy access to information, and are betting that their patients want to be able to contact their physicians as easily and immediately as they contact their bank. Still, it's not clear that an uber-personal relationship with a doctor is any guarantee of better care or better health. And not every patient feels that more face time with a primary care physician is worth paying a premium for. "Even very wealthy people have a hard time understanding the value," says Darvish, 32, whose practice, despite its location in a tony part of Los Angeles, doesn't see many millionaires come through the door. "Most of our patients are normal people who just care a lot about their health." Sam, who is 39, agrees that it's tough for some to quantify the added value of her VIP obstetric services. "Women seem to spend more time picking a hairdresser than picking who's going to take care of them for nine months and be responsible for the baby," she says ruefully.
That's why when Sam meets an expectant mother deeply interested in her own health but who cannot afford the fee, she sometimes offers her services at a discounted rate or for free. "I wish could give this service to everyone," she says, but "I have a family to look after, business to run and life to live while enjoying my work." A relaxed, unflappable doctor is important for jittery moms-to-be. Even more important is a doctor who remembers that her patients even exist. In the months since she canceled her appointment at her last doctor's office, says Burnette-Dubose, whose daughter Chloe was born in February, "no one ever called to find out why." Seems she got out just in time.