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.
The answer is to pay overworked primary care doctors more so more physicians will be attracted to the field, he said.
For his part, Coombs calls his practice a microcosm of his old one.
He wouldn't say how many patients have signed up, but 70 patients are on what he calls scholarship and don't have to pay the retainer. Among them are people on Medicaid, the government-run health care program for the poor, who now make up 10 percent of his practice.
The biggest change in his practice is that in his old practice about 20 percent of his patients used Medicare, the health insurance program for the elderly. Now the figure is 40 percent.
"I don't think I have any more wealthy people," he said. "I have a lot of people whom I was surprised decided that they were going to come up with the money."
Nan Puchalski said she had her husband made the switch after her 90-year-old mother came to live with them in Rutland. Coombs has made house calls to visit her mother and he's there when needed.
"At this point in my mother's care, I felt we had to have this kind of opportunity," she said.
But said she didn't know if she would be able to continue paying Coombs after her husband retires. They are both 62.
"This is a good solution for right now," Pulchalski said. "I know there are a lot of people who couldn't afford that."
Coombs' decision, combined with retirements or moves by other doctors, has added to the challenges for the local medical community. Now people who once had doctors are ending up in the emergency room, the most expensive form of health care.
"Efforts are made to ensure that these patients are reassigned to another physician, but there are invariably patients who are either left without a primary provider or who cannot see their new doctor in a timely enough fashion," said Rutland Regional Medical Center emergency department Director Dr. Todd Gregory. "These patients often turn to the emergency department."
There is some relief coming. Coombs' transition date was Oct. 1. His partner, Dr. Bruce Bullock, made the switch Nov. 15. Fortunately for residents, the switch coincided with an expansion by the Community Health Clinics of the Rutland Region, which has five practices throughout the county, said executive director Grant Whitmer.
A new facility is being opened in Rutland, which could help ease the problem of people getting access to doctors, he said.
"It's probably not, just because of the way things have come down, nearly as bad as it could or should have been."