Retainer model slowly spreading to specialties

Like other physicians who have become disenchanted with the current health care system, Scott Serbin, MD, decided to start a retainer practice, where patients are charged a set fee for certain extra services.

Patients in his practice, however, will be from a different age range than a typical concierge constituency.

Dr. Serbin, a Pittsburgh pediatrician, will officially change his practice into a retainer model Dec. 1, when he will start offering longer appointment times, more same-day appointments and guaranteed return phone calls to concerned parents within 15 minutes. He realizes that it's a risk to expect parents with health insurance to add another line item to their discretionary spending budget, but "if it works, it can be a spectacular way to practice medicine."

"It's funny. Parents have said I'm going to work harder, but I don't think people realize how hard pediatricians work now," Dr. Serbin said. "Most parents are appreciative of your time, and some don't want to call to bother you. With these service enhancements, we want people to feel empowered to call."

Dr. Serbin is one of a small handful of physicians across the country who are designing models different from the standard adult, primary care retainer practice. Other specialists, such as cardiologists, dermatologists and obstetrician-gynecologists, also are making attempts to practice boutique medicine, said John Blanchard, MD, a family physician who is part of a retainer practice in Clarkston, Mich., and president of the American Society of Concierge Physicians.

"I don't think it's at all surprising that pediatricians or other specialists would try this model," Dr. Blanchard said. "Really, it's the way health care should be delivered. It restores the physician-patient relationship."

Policy passed last year by the AMA House of Delegates says retainer practices are "consistent with pluralism in the delivery and financing of health care."

But the policy also states that physicians and patients must have a clear understanding of the arrangement and agree to it, and that physicians must facilitate the transfer of their patients to other doctors if those patients choose not to accept the retainer model. Also, AMA policy states that physicians must offer the same diagnostic and therapeutic services to retainer and non-retainer patients alike, and also find opportunities to treat patients in need who don't have the ability to pay.

Some specialties are more suited for retainer models, especially considering the continuing patient relationship that forms the foundation for concierge physicians. Because they rely on referrals and have a lot of short-term patients, many specialists would have a more difficult time charging extra for services or maintaining enough of a patient base to keep the practice afloat, doctors said.

Cardiologists and ob-gyns, on the other hand, are specialties that allow for more long-term relationships with patients. Recognizing the need to maintain a flow of patients through referrals, however, many establish a hybrid model, said Michael Blau, a Boston-based health care attorney and co-head of the health practice for the law firm McDermott, Will & Emery.

"It would be a two-tier practice," said Blau, who has helped some specialists around the country establish retainer practices. "They seek to maintain a consultative practice from a primary care physician or another specialist. They're not going to charge a membership fee to those patients, but if the follow-up care will require an ongoing relationship, they may transition them."

John Levinson, MD, PhD, a cardiologist in Boston who practices at Massachusetts General Hospital and is on the faculty at Harvard Medical School, runs a hybrid practice, though the retainer portion makes up only a tiny part of his overall patient base. Retainer patients see Dr. Levinson for both cardiology and primary care needs, and can reach him at all hours, whether he's on call or not. He did not disclose his retainer fees, but he said revenue from the concierge contingent allows him to see cardiology patients with any type of insurance -- including Medicare and Medicaid.

"I don't advertise or market [the retainer model]," Dr. Levinson said. "As a cardiologist, a lot of your patients are new consults, in hospitals, who are very sick and have issues. You just don't talk about money and fees with them."

With many well visits and regular checkups, pediatricians can apply a retainer style and establish fees up front the way a family physician would, doctors said. Dr. Serbin, for example, sent a letter to patients explaining the pending change, explained the benefits of the concierge style and offered them an opportunity to join the new practice. He plans to limit his patient base to between 500 and 600, far fewer than the 2,200 he currently sees.

Dr. Serbin will charge families $100 per month for children between birth and 6 years old, and $50 per month for children ages 7 to 18. If a family has more than two children who are patients, the charge for every additional child will be $20 per month, he said.

With the extra time available to spend with each patient, Dr. Serbin said he plans to emphasize fitness and nutrition. Children will receive prescriptions for exercise, and a nutritionist will be available to consult with them as well, he said.

"I would like to say later that we had the fittest practice in the area," Dr. Serbin said. "We'll also have a Web site and a regular newsletter. This just holds such promise."