Flexible Practice Approach Has Something for Everyone : Hybrid form of concierge care translates into happy patients—and physicians.


Cardiologist John Levinson, M.D., has a multifaceted approach to health care.

In 2001, he established the first “concierge” practice in New England. But unlike other practices of this type, Dr. Levinson runs a “hybrid” practice that cares for retainer and regular insurance patients. Plus, he still finds time to see patients in the hospital.

This seems like an ambitious way to practice medicine, but in an interview, Dr. Levinson insisted that his hours have never been more manageable—and his patients are happier than they used to be.

Traditionally associated with high fees and a limited and wealthy patient base, concierge care—now often called “retainer care”—is morphing into a number of different types of practices, according to Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics.

Some practices are offering special programs for the indigent or providing various payment options for their patients. Or, in Dr. Levinson's case, they're providing specific types of care, such as cardiology/primary care.

The seeds of Dr. Levinson's practice evolved from the complaints of one very ill cardiac patient who had been under his care at Massachusetts General Hospital, Harvard Medical School, Boston, for several years. The patient ran a large corporation. In 2001, after an extended hospital stay, “he came into my office furious. I was sitting my desk, wondering if I'd done something wrong.” It turned out the patient was angry with the insurance company.

“He'd gotten the explanation of benefits statement which said the insurer had paid 25% of my charges.” Most doctors in Massachusetts get around 25%–30% of their charges, he said.

“But the bottom line was this patient felt he would not have made it through that hospital stay if it weren't for me, and he was worried about me working too hard. He wanted me to slow down so I wouldn't die before him, and he wanted me to be his primary care doctor, not just his cardiologist.”

While his practice initially started with this one patient in mind, it eventually turned into several practices, catering to different types of patients.

“The way my day works is, I drive to the hospital at 5 in the morning, see my inpatients until 8 a.m., then have a regular office day,” where he sees his retainer patients, along with the regular patients who are on Medicaid and other types of insurance. “That's one of my values, to accept patients into my practice regardless of whether they can pay or who's paying,” he said. At the end of the day, he goes back to the hospital to check on in his inpatients.

Overall, his practice includes approximately 7,500 patients, 40 of whom are retainer patients. There are two groups among the retainer patients. The first group uses Dr. Levinson as the primary care physician. Upon request, he later developed a cardiology-only retainer practice. “Some—about 25—use me for primary and cardiology care and the others are just cardiology patients.”

Those who want primary and cardiac care pay a higher annual fee than do the cardiac patients, he said. He would not disclose the fee, but said the retainer patients generally pay the fee annually.

“For every patient in my practice, retainer or otherwise, myself or another cardiologist is always available 24–7. That, of course, is the law in this country; it's only appropriate that patients get their doctor or some covering doctor when they need them. The difference with retainer care is there's never a covering physician between me and the patient. I'm personally available 24-7. They can arrange for a Saturday house call. When they make a routine visit, the appointments are always longer for patients in the retainer practice.”

This doesn't mean he neglects his regular patients, he said. Retainer patients know they might have to wait if they make a same-day appointment and he is busy treating an indigent patient in his regular practice. “I don't skip lines ethically.”

Dr. Levinson said he now has more time for all of his patients. “Oddly, I'm more available for everyone. I'm more relaxed in each session.” With more time for patients, it's like taking care of friends and family, he said.

Retainer practices have often been criticized for “double billing” patients—charging an access fee on top of regular services covered by insurance. According to BlueCross BlueShield of Massachusetts, “If you're an active member of our network you can't charge an access fee to patients,” Chris Murphy, spokesman for BCBS in Massachusetts, said in an interview. To charge such a fee, the physician would have to charge for services beyond the insurance company, he said.


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