Back to the Weekly Home Page

Classifieds

Palo Alto Online

Guest Opinion: 'Boutique medicine' -- symptom of a system in disarray

by Spyros Andreopoulos

The Weekly's cover story on boutique medicine this month (Weekly, March 5) sketched out a problem that is a symptom of a health-care system in disarray, economically and ethically.

As a longtime observer of health care in the United States, I would say the problem is even more serious than the article described. Now we have a system faltering not only for the uninsured and underinsured but for the fully insured, too.

Recently, a fully-insured friend went for a consultation in one of the busy private medical practices in Palo Alto. When he arrived, he was told the doctor he had an appointment with would see him for one last time because the practice had launched a new plan -- "boutique medicine."

For an annual fee, however, my friend was advised he could subscribe and be entitled to fast-track appointments and annual checkups. This particular plan, he was told, is considered an adjunct to his regular medical insurance. If he needed to be hospitalized, his boutique doctor would coordinate patient care and Medicare, or his private insurance would cover it. Some boutique plans do not accept insurance. They charge patients a fee per visit.

This Bay Area scenario is not an exception. From retirement villages in Florida to high-tech campuses in Seattle and San Diego, gold-plated care for $3,000 to $20,000 annually (depending on the range of services) is catching on.

People in Canada or Europe with more egalitarian systems would find such a class-based human-services system appalling on ethical grounds. The new trend, in fact, has prompted newspaper columnists and many physicians to accuse boutique doctors of abandoning lower-income patients to cater to the wealthy.

Boutique doctors say they are just trying to give patients more attention at a time when HMOs and other insurers force physicians to crowd ever-more patients into ever-shorter appointments. And they may be right. Spending more time with fewer patients is a much more satisfying way to practice, with all the things that a patient should have.

But the critics, even those sympathetic to the doctors' frustrations with managed care, ask whether patients who cannot pay the fees are being abandoned. If a substantial portion of America's doctors focus on a select clientele, the rest of the public would face longer waits, higher fees and fewer preventive services.

Some physicians have attacked boutique medicine because a change toward elitism in the delivery of health care undermines the most fundamental commitments of the medical profession. When two physicians recently left a famous Harvard-affiliated hospital in Boston to form a boutique-medicine practice, their colleagues characterized it as "a moral earthquake."

In Massachusetts, a private medical insurer, the Tufts Health Plan, has questioned whether such practices discriminate against patients who cannot pay. The state's insurance department is investigating. The federal Medicare and Medicaid services are looking into whether these arrangements illegally charge patients for services also covered by Medicare.

The annual fees charged by most boutique practices may constitute illegal additional billing, according to Reps. Henry Waxman (D., Calif.), Fortney "Pete" Stark (D., Calif.) and other members of Congress.

In California, boutique medicine is regulated by the Knox Keene (Health Care Service Plan) Act. The law prohibits doctors from providing health-care services to subscribers in return for a periodic charge unless the physician group has an HMO license.

But boutique practices, if they take hold, also raise serious health manpower concerns because they remove experienced primary-care doctors from the mainstream at a time when their numbers are in short supply. In 1931 primary-care physicians constituted 83 percent of doctors in private practice. Just 62 years later, during which the U.S. population has more than tripled, their numbers have fallen to 55 percent.

Boutique medicine means that more doctors can skim the cream from the top, picking those who are able to pay the most. It is a sad reflection of a politically powerful, unregulated health system, while we have millions of uninsured families, that it is more profitable to the supply side than a world with universal coverage and heavier government involvement in controlling costs.

Boutique medicine is unlikely to be a genuine attempt to provide patients with health care of higher quality, as its proponents claim. If quality of care was the doctors' main concern there is much they could do.

Spyros Andreopoulos is director emeritus of the Office of Communication and Public Affairs at Stanford University Medical Center. He can be e-mailed at masga@Stanford.EDU.