Vt. doc using new care system, criticized by some

By Wilson Ring

Associated Press

Published: Sunday, Dec. 4 2011 10:07 a.m. MST

RUTLAND, Vt. — For the first time in years, Rutland primary care physician Dr. Seth Coombs is feeling good about his practice: He's spending time with his patients, he's helping them manage their chronic diseases, he's making house calls and he's even seeing more of his family.

Coombs is one of the first physicians in Vermont to adopt a new style of medical practice that is expanding across the country. The new system has a number of names, boutique or concierge doctors, personalized medicine, or retainer practices. For Coombs, it means patients pay him a retainer, and he still bills his them or their insurance companies for appointments and procedures.

In return, the patients get his cellphone number and email address and they're guaranteed appointments the same or the next day. Coombs says he's also providing better care than traditional practices.

But thousands of his former patients have had to find new doctors, and sometimes people who once called Coombs or his partner when they were sick are heading to the emergency room because their conditions couldn't wait for an appointment with a new physician.

Some see personalized medicine as an elitist form of medicine that caters to the rich, but Coombs sees it as the only way he can keep his practice open. Among pressures that prompted Coombs to switch were low reimbursements and high costs that had his private practice on the brink of insolvency.

Coombs came to Rutland in 1996 after he had completed his training in internal medicine. He went into private practice the next year. Over the years the pressures built, such as ever-lower reimbursements, more administrative costs and the continuing need to cut down on lengths of appointments in order to see more patients and increase revenue.

"I realized I was halfway through my career," said Coombs, 49. "I was beginning every day farther behind. I was earning less money than I was when I was fresh out of school and I was working harder than I could possibly sustain.

"Then it hit me on the head: In both my personal and my professional life, I wasn't even doing what was important for people."

He'd seen a newspaper story about personalized medicine, so he attended a seminar on the topic and decided to switch. In July, he sent his patients a letter explaining that if they wanted to continue seeing him, they would have to pay the retainer, $1,200 a year for someone under 50, or $1,600 for those over 50. Children are included in their parents' fees and there are discounts for couples.

From its beginnings in 1996 in Seattle, the number of physicians practicing personalized medicine has grown to 3,500 to 4,000 doctors, most in primary care fields, said Tom Blue, the head of the industry's trade group, the American Academy of Private Physicians in Richmond, Va.

"For doctors, private medicine is an opportunity to recapture control of their practice, their financial future, and their relationships with patients and to be reacquainted with the satisfaction of practicing thoughtful preventive medicine," Blue said. "For patients, private medicine is an opportunity to secure a lasting relationship with an easily accessible doctor who has the time and independence to deliver optimal preventive care."

But ultimately, retainer practices could worsen the problem it is trying to solve, said Dr. Robert Macauley, the medical director of clinical ethics for Vermont's largest hospital, Fletcher Allen Health Care in Burlington. Vermont was among the last states to get personalized care doctors.

"We already have a lack, relatively speaking, of primary care physicians. So the reason that people are dissatisfied is there are too many patients and not enough doctors," Macauley said.

So if doctors choose to practice boutique medicine, thus treating even fewer patients, that would worsen the problem for doctors who continue to practice traditionally, he said.

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