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Doc's in, at a cost

'Concierge' practice hints at the future of doctor-patient relations
by: JIM CLARK, Dr. Charles Kilo of GreenField Health examines patient Don Hoffman. GreenField’s “concierge” practice offers same-day office visits and e-mail and phone contact with the doctors for a $300 annual retainer fee.

Mary Davis, who runs a software consulting business, values her time. And she hates waiting, especially in doctors' offices, which she says she used to do a lot.

'I was becoming stunned at how poorly medical scheduling was being done,' says Davis, 56. 'I'd go to the doctor; he'd say, 'Be here at 11.' He'd see you at 12:15 and then sometimes they'd put you in their little waiting room and the doctor still didn't come in for 20 more minutes.'

Davis doesn't wait for her physician anymore. Now, as long as she calls early in the morning, she gets same-day appointments that allow her to spend as long as she wants with her primary care doctor.

She pays for the privilege - a $600 combined annual retainer to GreenField Health in Southwest Portland for Davis and her husband, Steve. That's $600 in addition to their health insurance premiums.

But Davis says it's worth it, even though most of her appointments last only about 30 minutes.

'The time I spend sitting in a waiting room in a doctor's office is time I'm not spending building my practice,' Davis says.

Davis is willing to pay the extra money for what she perceives as better health care and better service. So are a lot of other people, at what are called 'concierge' medical practices, springing up to provide satisfaction to people who are fed up with long waits and short physician visits.

Concierge practices, at least one of which charges a reported $13,000 for an annual retainer in Oregon, are not new. They began appearing about 10 years ago in reaction to the long waits and short physician visits that were becoming common in an era of managed care.

Currently there are about a half-dozen in Oregon.

When concierge practices first arrived, health care advocates decried the advent of practices that promised better health care for the rich. But that criticism is more muted now.

Maribeth Healey, a vocal proponent of affordable health care as executive director of Oregonians for Health Security, says people paying more for better health care is no longer news.

'It doesn't matter what we do, wealthy people will always be able to access health care in a different way than those of modest means,' she says.

State Rep. Mitch Greenlick, D-Portland, longtime director of the Kaiser Permanente Center for Healthcare Research, says the GreenField model should serve as a warning for other practices.

'The rest of the medical care system has to learn how to respond to needs being expressed by patients who aren't willing to pay $1,200 (for a family of four),' he says.

Here's a pioneering practice

But internist Charles Kilo, who founded GreenField, says his practice was never intended to serve only the wealthy.

What he has tried to produce is an alternative model for a primary care practice that focuses on technology to help the practice run more efficiently and deliver better preventive care. And, he says, that model is finding ways to make high-quality care accessible to a wide range of patients. A number of experts agree.

As far as Davis is concerned, that $300 fee, for many, is more about choice than the ability to pay.

'Somebody else might spend that $300 to go to the beach for the weekend,' she says.

Jody Stahancyk runs Stahancyk, Kent, Johnson and Hook, a divorce law firm in Portland. Stahancyk not only provides her 50 staff members with health insurance, she also pays their retainer fees for GreenField Health (or another concierge practice if they choose).

Guaranteed same-day appointments and e-mail and phone contact with doctors for Stahancyk and her staff add up to savings in the long run, the attorney says. 'If a person can get into a doctor immediately, they will take care of a problem sooner and they lose less work,' she says.

But the real savings, Stahancyk says, comes in the form of physician appointments that don't happen. GreenField offers its customers telephone and e-mail access to their doctors around the clock - at no charge, all as part of the retainer service.

Stahancyk says that's how the GreenField contract really saves her money, despite the retainer fee. 'I charge $400 an hour, and I save more than an hour of my time by being part of this group,' Stahancyk says.

Focus on preventive care

Kilo says GreenField's goal in large part is to find a way for physicians to practice preventive medicine and feel good about it.

The financial model at most primary care offices emphasizes volume, Kilo says. And a volume practice means limited time with each patient. 'It is not a pleasant experience trying to see 25 patients day after day,' he says.

But the solution - a practice in which the six GreenField physicians have about 800 patients each instead of the more common 2,000 to 3,000 - was not easy to set up. Fewer patients means lower revenues.

To balance that, GreenField instituted the retainer fees. But the fees themselves weren't enough; GreenField needed to keep operating costs down. What has made that possible, Kilo says, is more reliance on technology, specifically electronic medical records that better track patients and their needs.

In addition, GreenField saves money because physicians don't need to see patients as often.

GreenField has found that offering the e-mail and phone service cuts in half the number of office visits that patients request; patients would rather take care of their primary care questions from a distance.

The result is a more efficient and less costly office to run.

Other efficiencies abound

Spending more time with patients when they do come in will lead to even fewer visits in the long run because more thorough preventive care will decrease the rate of chronic diseases, according to Jill Arena, GreenField's chief operating officer.

Additional savings come from the same-day scheduling practice, Arena says.

Arena says GreenField also saves money by having its staff spend more time analyzing patient habits so that they can predict how many of them will call for appointments most days. They schedule support staff accordingly.

But the greatest efficiency, and the piece of the puzzle that helps GreenField practice better preventive care, according to Kilo, is the practice's investment in electronic medical records that alert physicians when patients need tests and create a more efficient way for doctors to review patient histories.

The result of all this efficiency, according to Arena, is that the total cost of care for GreenField patients is 20 percent less than for similar patients at traditional primary care practices.

Internist David Shute is the latest physician to join GreenField's staff. Previously he worked at a traditional primary care practice in North Portland. 'It was wonderful on one level in that it was doing meaningful work for really needy people,' Shute says. 'On the other hand it was infuriating we couldn't really meet the patients' needs in the ways we wanted to.'

Shute says frustration set in when he would see patients with complex health care issues. 'There simply wasn't the time available to address all those issues,' he says.

That type of practice took a toll on Shute. 'You could say I was burned out,' he says. At GreenField, Shute says, his fulfillment comes not only from being able to take more time with each patient, but also because he and Kilo believe they will develop better, more efficient models for primary care.

Model's already being copied

Not all GreenField patients are wealthy. The practice reserves 10 percent of its load for Oregon Health Plan enrollees, for whom it waives the retainer fee.

'Part of that is a community service,' Shute says. 'Part of that is that we want to do our research and development work with all different types of patients because we want to develop models that will work in other places.'

One of those places is the new Center for Women's Health at Oregon Health and Science University. Anne Nedrow, the medical director there, hired Kilo as a consultant when deciding how to put that practice together. The center's model takes the idea of levels of care into new territory.

The center offers two tiers for patients, who choose either 'Primary Choice' care, which does not include a retainer fee, or 'Life Choice,' which does. According to Nedrow, patients with more health problems tend to choose the Life Choice option. The retainer fees are comparable to GreenField's.

Nedrow calls Kilo a visionary and says the difference between GreenField and other concierge practices is GreenField's focus on prevention.

'Some fancy places have heated exam tables and robes,' she says. 'Chuck's real vision is using technology with electronic medical records to highlight that patients aren't getting what they need, that they are skipping tests, and having the time to be attentive to that.'

GreenField is set to open a second clinic on Northeast Broadway in October and already, Arena says, there is discussion of lower retainer fees, especially for families that would have to pay one for each family member.

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Quick care's available, for a price

Phillip Unsworth makes about $50,000 a year as a roofing contractor. He's 49, a single parent with a college-age daughter, and he's gone through much of his adult life without health insurance.

None of which makes Unsworth, who now carries health insurance, a likely candidate for the retainer fee practice at GreenField Health.

But Unsworth is paying the $300 GreenField fee - for his 20-year-old daughter.

Last year Unsworth's daughter returned from Europe with health problems. The two of them started a search for a physician. But Unsworth's daughter was leaving for college in California, and finding a primary-care physician who would see her before she left proved fruitless, until they happened upon GreenField.

Once signed up with GreenField, Unsworth's daughter was able to make a next-day appointment to see internist David Shute.

'She got in within 24 hours, and the doctor not only spent enough time to address her issues but she still remains in contact,' Shute says. Using GreenField's e-mail service, Unsworth's daughter has kept in contact with Shute while at college.

The $300 is significant cash for Unsworth, but he thinks it's money well-invested. 'They work hard at having a doctor really spending an hour with a patient,' Unsworth says. 'Out of all this she'll have a health-care provider she can work with on a long-term basis.'

Ironically, though, Unsworth hasn't signed up for GreenField himself. He says he rarely needs a doctor for anything but a yearly physical - so he'll hold on to the extra $300.

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