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An aged medical bag, that duffle shaped style that doctors used to carry on house calls, sits proudly on display in the office of Birmingham internist Dr. James Frey. It’s a memento of his father, Sidney Shields Frey, and a tribute to a timeworn form of health care. His father, says Frey, “practiced medicine the way it should be done.”

“My Dad was a man of character and integrity. I became interested in medicine because of him, and I really wanted to practice medicine like he did. He actually did make house calls, ” Frey recalls. “That was just part of practicing medicine back during that time, but he really had a way with patients and that’s what I wanted to emulate — that care, understanding and concern.”

After more than two decades of trying to achieve that goal, Frey instead found himself suffering “burnout and despair, ” defeated by a system where he saw “the patient getting lost in the paperwork.” Citing what he recalled as a typical day in his 2, 500-patient practice, Frey says, “I was in an exam room with a patient. Three other patients were in another three exam rooms. At least three or four more were waiting in the waiting room and I had 10 to 20 return calls that needed to be made. About that time, I got a call from the emergency room where one of my patients was very, very ill and I needed to call back urgently. Now, I can’t focus on what is wrong with one patient when all those tracks are running around in my head.”

That’s why Frey, after much soul searching, decided to convert his practice to concierge medicine, an emerging trend where in exchange for an annual fee, doctors limit their practices to a set number of patients — usually five or six hundred — and provide the patient 24/7 access rights, cell phone, fax, email access and same-day appointments with little or no waiting time. In addition, the physician acts as the liaison between the patient and specialists. If a patient is referred to a specialist, then traditional insurance or private pay is still in place. Fees for concierge care are generally between $1, 500 and $3, 000 per patient, per year.

Frey chose to join MD Value in Prevention (MDVIP), one of more than a dozen national organizations, which, for a fee, exist solely to help doctors through the process of changing models. In his practice, patients pay $1, 500 annually, in addition to a co-pay per visit. In return, they get 24/7 access and a comprehensive annual physical.

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While Frey sees this medical trend as growing, Greg Carlson, UAB assistant professor of health administration, says although concierge medicine is getting a lot of attention these days he does not expect it to be “a game changer in the health care delivery system. Only a very small percentage of physicians are providing this service to a small number of patients.” He estimates that in Alabama less than 1 percent of almost 5, 000 primary care physicians in the state have converted their practices.

“The patients interested in this kind of care want assured access to their doctors. They don’t want to have to wait in their doctors’ offices, and they don’t want to wait six weeks for an appointment.” Concierge medicine is tailored to those who have access to health care without the levels of bureaucracy that exist. Carlson says while concierge practices share similarities, they vary widely in their structure, payment requirements and levels of services.

“There is no defined template for concierge care, ” he says. “It is what the contract calls for between doctor and patient, but the standard terms mean the doctor will provide exceptional service, and the patient will have full access to their physician based on the terms of their agreement. ”

Whatever the specifics, one common denominator in all concierge medicine is that it is controversial. Detractors call this kind of medical practice elitist. A pediatrician in Huntsville has even harsher criticism, calling it  unprofessional and unethical. “We already have a doctor shortage, ” says Dr. Pippa Abston. “By removing themselves, they are shirking on their share of the duty. Plus, the large part of a physician’s medical education cost is actually borne by the public, through tax money distributed to medical schools and hospitals. Our tuition doesn’t come close to covering the actual costs. To me, that means we owe a debt, not only in terms of student loans but also to our communities. Is the income a person makes really based on what she deserves, on the hours or effort expended? If this were true, public school teachers would make as much as surgeons. Their work does not end when the school bell rings, either. The truth is that our incomes are based on what people are willing to pay for our work, not on what we deserve. And as professionals, we are obliged to consider not only what people are willing to pay, but also what they are able to pay.”

Abston also takes issue with concierge doctors who limit their practices by dropping patients they have seen for a number of years. “Suddenly, these people don’t have a doctor anymore. Either they can’t pay it (the annual fee) or they didn’t get in under the cutoff. It can be very difficult to find a doctor. I wouldn’t feel right taking fewer patients. That’s not why we went into medicine. We went in to serve people. I was always raised to say if it’s not fair for everyone to do it, then it’s not fair for anyone to do it.”

But, for those critics who see Frey’s concierge practice as contradictory to the values he finds in that old doctor’s bag, he disagrees. “I couldn’t have continued practicing medicine without this change, ” he said. “Yeah, I took some heat for making the move. I took about 25 to 30 percent of my practice with me. Some couldn’t afford it.

Others thought it was wrong. It is not a perfect system, and every doctor who makes this move is going to struggle, because, as much as we hate the paperwork, we love the patients. Now, we’ve formed a process for which we let many fewer things fall between the cracks. We focus on a wellness. We can spend more time with our patients, and there’s more time to review and process problems. All that takes away that nagging feeling that I didn’t do something that should have been done at the end of the day. The work and time with MDVIP is every bit as strenuous as before, but the anxiety component is vastly relieved.”

Concierge medicine, says Frey, “is not perfect, but it does create the hope that primary care and internal medicine will have a future.”

Linda Long is a freelance contributor to Business Alabama. She lives in Birmingham.

By Linda Long

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