Families Online Magazine

Marvin Ackerman, MD - Retainer fees for doctors, what's happening to the Hippocratic Oath?

Not too long ago I wrote about doctors, annoyed by too many visits from pharmaceutical company representatives, who found ways to charge for the right to spend time with them.

Now an article by Avram Goldstein in the Washington Post discussed another new program concocted by 19 doctors in an apparent attempt to get around Medicare and HMO fee restrictions. Goldstein's title for his article pretty much tells it all: "Doctors on Call-for a Hefty Retainer. 'Concierge Care' Plans Tout Access but Also Stir Medicare Debate." Think about it a moment. How would you like to be notified one day, by your internist, that you would no longer be welcome in the office unless you ante up $1,500 for an annual membership permitting you access? Incidentally, your doctor would also continue to collect all the usual fees from your health insurance plan. Before you pass judgment, let me present you with some of the more potent arguments concerning this new venture, both pro and con.

Members of Congress, as well as physicians, have criticized this membership program, originally based in Florida, and given the acronym MDVIP. As might be expected, some House Democrats who go so far as to propose that MDVIP doctors be banned from Medicare mainly opposed it. Medicare has been setting rules about how much a doctor can bill for 40 years, and these lawmakers consider this an attempt to circumvent these rules, labeling it denial of care and abandonment of poorer patients. One of them, Rep. Benjamin L. Cardin (D-Md.), plans to sponsor a bill, which would bar physicians accepting retainers from being paid by Medicare. This approach to the problem is nothing new since a similar bill was defeated in 2002. Cardin reasons, "basic health care protection for our seniors should be at an even par for everyone . . . I'm very much opposed to these boutique practices from the point of view of participating in the government insurance program. The federal taxpayers are subsidizing this type of practice."

In spite of similar objections, many patients who can afford to pay for the privilege are rather pleased by its advantages. Commentary ranges from frustration by doctor defenders such as MDVIP general counsel Darin Engelhardt who calls the lawmaker's objections an absurd "paternalistic approach" to advocates like Yet Mott who can't afford it but would gladly join if able. Calling opposition on Capital Hill unreasonable Engelhardt expresses his opinion that their ideas stem from a "belief that if everyone can't obtain care like this, no one should." According to MDVIP advocates, the retainer fee pays for services not covered by Medicare including physical exams and preventive medicine. The doctors had the Bush administration on their side with Health and Human Services Secretary Tommy G. Thompson permitting them to participate in Medicare. In any event, there is no doubt that doctors enrolled in the program are enthusiastic about it. This, to them, is a way of getting out from under a crush of patients, health plan bureaucracy, dwindling fees, and a threat to their health. They want more time to spend with their patients, an ability to see patients within minutes of scheduled time, and time to concentrate on their patient's problems. The plan allows them to drastically cut the number of patient visits yet earn an excellent income. This latter reason for approval does make one wonder when you realize that the MDVIP plan is geared to limiting practices to 600 patients instead of about 3000, collecting $600,000 per year, and, amazingly, requiring each physician to send $300,000 to MDVIP for its continuing oversight.

With doctors participating in protests by withholding services because of excessive malpractice premiums amounting to as much as $290,000 per year, retiring from practice, or switching to specialties such as cosmetic surgery, which are independent of Medicare or insurance coverage, the addition of retainer fees to the morass is rather depressing. In addition, new laws requiring drastic changes in practice management have become overwhelming burdens. The question that we all must ask ourselves is, "Are all these impositions on what has long been considered to be the finest medical care in the world a means of eliminating inherent evils in the system, or rather a destructive force fostered on the profession by well-meaning but misguided outsiders?"

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About Marvin Ackerman, MD

Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission. Copyright © 2009 by Marvin Ackerman, M.D.

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