Medicine By Subscription

Pay doctors like you do Netflix. The rise of doctor by subscription

By Marni Jameson

Five years ago, Dr. Ivan Castro of Winter Park was miserable with the way medicine was going.

"I was constantly running behind to see the next patient and had to focus more on paperwork than on patient care," recalls Castro, 52.

That year, Castro changed his practice to the concierge model: Patients pay a retainer fee to their primary doctor -- usually $100 to $200 a month -- in exchange for round-the-clock access, quick appointments and more attention.

Now "I really feel like a doctor and that I'm making a difference," said Castro, who went from having more than 3,000 patients with whom he spent about 10 minutes per appointment to 400 patients where he averages 30 minutes for each appointment.

Castro is one of a growing number of primary-care doctors changing the way they practice.

According to a 2012 survey of U.S. physicians by Merritt Hawkins, a national physician-recruitment company, almost 7 percent of doctors are considering the switch. The trend is especially strong in Florida, where nine out of 10 doctors are considering moving into concierge medicine.

Larry Stern, a retired attorney in West Palm Beach, switched to a concierge doctor three years ago.

"I get phenomenal care. And I'm a demanding, high-need patient," said Stern, 62. "I really feel I have a 'Marcus Welby' doctor. I'm not left alone. I have controlled high blood pressure and diabetes. I have stuff that's wrong with me, and I know I won't get dropped through the system."

Stern pays $1,675 a year so he and his 22-year-old daughter can be part of the program.

Most patients who use concierge medicine also carry some insurance to cover outside testing, fees to other consultants and hospitalization if necessary. Employees who have health savings accounts or flexible-spending plans can use those pretax dollars to pay the retainer fee.

Though good for the patients who can afford it, some predict the trend will exacerbate America's growing physician shortage. Already the nation has more patients who need doctors than primary doctors who can see them.

"A typical practitioner sees 3,000 to 4,000 patients a year," said Phil Miller, spokesman for Merritt Hawkins.

When a physician moves into a concierge practice, he or she may drop 2,500 patients.

"Where do they go?" he asks.

But doctors are already feeling the squeeze, and the pressure is driving many of them to make a change.

Michael Tetreault, editor of Concierge Medicine Today, estimates that six years ago, about 2,000 concierge-medicine doctors were practicing in the country. Today he puts the number at 5,500 and thinks that number will grow as much as 15 percent in the next few years.

"They want to provide quality care and feel they can't when they're on a treadmill," Miller said. "They'd rather give good care to few than inferior care to many."

A busy primary-care doctor with a full schedule can't allow more than 10 minutes per patient and usually closer to seven minutes. Concierge doctors can afford to spend 30 minutes or more.

"For the patient who can access a concierge doctor, the quality of care will be better," Miller said. "They will get more face time."

David Dycus of Orlando's Baldwin Park signed up for concierge medicine with Castro about four years ago because he'd had several stints in the hospital, and "I didn't have a quarterback. There was no one person to talk to about my health. Most regular doctors don't make rounds anymore."

Now he estimates he sees the doctor nine or 10 times a year, mostly for minor problems. "If I have a question, I have his personal-cellphone number. I've called at midnight on a Saturday, and he's responded."

Doctors who practice concierge medicine say it isn't about the money. Castro, whose patients pay $2,500 a year, said his income, after startup costs, has stayed about level.

That's consistent with what salary studies show. A 2012 Medscape report found that the average salary for a primary-care physician ranged from $156,000 to $315,000. Separate salary studies show a similar range for concierge doctors.

The model also lets doctors use technology more.

"Someone sends me a picture of their rash, or they text me questions, and I answer," Castro said. In a traditional practice, doctors don't get reimbursed for that time.

Consumers considering the option need to be clear about what they will get in return, said Dr. Reid Blackwelder, president of the American Association of Family Practitioners.

Not all doctors include hospital visits in their fee. Others won't help patients with insurance coverage for outside services and leave that up to the patient.

As to what the trend is doing to the physician shortage, Castro shrugs and says, "I don't have the answer to that. I can only control my own microcosm."

mjameson@tribune.com