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Inside SF's Exclusive, High-Cost Concierge Health Clinics 

Wednesday, Jul 22 2015
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Sean Knox's first encounter with concierge health care was 10 years ago. "My doctor at UCSF let me know he was leaving and entering concierge practice," but the doctor said Knox could continue as a patient if he paid a new yearly fee.

"Right out-of-pocket it was like a $30,000 retainer fee. It just sounded insane to me," Knox says. "I worked in engineering in San Francisco, so I definitely had a decent income, but he was charging astronomical rates I couldn't afford."

Charging a yearly retainer for supposedly exceptional levels of care is known as concierge, boutique, or direct-pay medicine. According to Consumer Reports, the usual retainer is between $1,500 and $5,000 annually. Concierge practices vary in whether or not they accept insurance, but they all promise greater access to doctors and fewer patients than traditional primary care doctors. Same-day appointments and personal communication from doctors are the norm.

Such exclusive, on-demand doctoring has a ready market in San Francisco, where there are more than 50 concierge physicians (more than 180 if you include the doctors of the One Medical Group, which charges a more affordable $149 yearly fee and does not consider itself a concierge practice.)

As a patient with a pre-existing medical condition and a high standard for care, Knox says finding a new primary care provider was difficult. "I was desperate," he tells me. Although concierge medicine had left a bad taste in his mouth, he contacted the Dolhun Clinic in Pacific Heights on the recommendation of his previous doctor.

Knox says he was blown away. Dr. Eduardo Dolhun is a Mayo Clinic-educated doctor who teaches at Stanford, hires premed students for his staff, and does humanitarian work in Third World countries. Dolhun even invented a fruit-flavored hydrating drink that raised $5.6 million in equity financing from investors, including the owners of the 49ers and Bob Weir of the Grateful Dead.

But what impressed Knox most was Dolhun's accessibility and attentiveness. "We scheduled a lot of my first appointments with him over email, which I had never done before," Knox says. When Knox came in for a routine physical, Dolhun took pictures of moles he wanted to keep an eye on — just in case — and put the images directly into Knox's electronic record.

"I was kind of astounded," Knox says. "Like, wow, this is so much better care than I've ever received.'"

Despite his initial aversion to concierge medicine, Knox signed on. Dolhun's yearly fee ranges from the basic tier at $2,500 to the premier tier at $15,000. Knox says he worked with Dolhun to negotiate an acceptable rate. "Most interactions with clinicians feels very black box — unknowable and frustrating. Dolhun was the first doctor where I felt I am a partner in this," Knox says.

Dolhun says the concierge model provides him the flexibility to run the type of practice he wants. He notes that his patients not only include the rich, but also a homeless client who receives free care, as well as insured teamsters and longshoremen from Oakland. Dolhun explains that concierge practice is a return to what medicine used to be, back when you could spend time getting to know patients, provide timely care, and treat diverse communities.

"We're doing it the way medicine has been practiced for centuries," he says. "The doctor treated both the prince and the paupers."

That's what the medical system is supposed to do, but the history of concierge practice tells a different story. Many point to MD2 as the first concierge health service. It was launched by a former Seattle Supersonics doctor and his partner who marketed their highly personalized care to wealthy families. Today, each MD2 physician is limited to 50 families who each pay upwards of $18,000 a year. (The Bay Area is home to two: one in San Francisco and one in Menlo Park.) Since MD2' 's founding in 1996, the number of doctors adopting the concierge model has ballooned. According to the 2014 Physician's Foundation report, 7 percent of physicians now practice some form of concierge medicine, and almost one in five physicians age 45 or younger say they will transition to a concierge practice at some point.

One reason for the transition is low reimbursements for primary care doctors, which forces them to take on thousands of patients to make an insurance-based practice affordable. The average primary care doctor sees 2,500 patients a year, while many concierge doctors see fewer than 600. And in the current doctor shortage, every physician who drops thousands of patients to focus on the remaining few adds incrementally to the problem.

"There's nothing new or different about them, they just charge a high fee for access," Dr. Tom Lee says about concierge models. Lee is the CEO and cofounder of One Medical Group, which he says provides the same level of service as a concierge practice while still seeing a similar number of patients as traditional primary care models.

"It is against the spirit of what it means to be a physician. Most physicians want to care for everybody in an affordable manner," Lee says. "We call it not a very effective use of a physician's time, and it will contribute to the physician shortage."

Lee adds that he doubts concierge medicine can gain traction because of its prohibitive costs. Nonetheless, people like Knox, who put a lot of effort into choosing his doctor, face a tough choice between long wait times for an appointment or shouldering a flat annual fee.

Mike (who declined to share his last name) left his physician when she switched to a concierge practice after 23 years in the primary care model. He said she was a great doctor, but her new $1,800 fee didn't make sense for him.

"I typically only see my doctor two times a year," he says. As an immigrant from India, he recalls his family doctor there who worked until 10:30 every night and treated as many patients as possible.

"He treated my entire family," Mike says. "Now he is 72 and says he remembers when I was a baby. It's almost like a family relationship. That's the way medicine used to be, even in the United States. Now it's all about the money."

R.A. Schuetz has written for The Bold Italic, 7x7, and The Potrero View.

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