DALLAS Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, "the number of Medicaid patients in retainer practices is much smaller6% vs. 15% in traditional practice," Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practicesalso known as concierge or boutique medicine practicesand received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

"We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered," Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent said working fewer hours was one benefit of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people "look down their noses at you," Dr. Wynia said. In a surprising statistic, "5% of people in retainer practices thought they should be discouraged" from this approach, he added.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. "Only 25%30% of nonretainer physicians thought they should be discouraged or illegal," Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patientsabout 88%didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are considered, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, Dr. Wynia said. In addition, physicians on average would continue to see 140 patients who did not pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care averaged 9.14 hours per months vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were common services provided by the retainer physicians.

The survey did not ask about salary or fees charged to patients, but Dr. Wynia estimated retainer fees ranged from "several hundred to thousands of dollars per year."

He clarified that his presentation reflected the results of a research project and did not represent a policy statement of the AMA. The data are still unpublished and have been in review the past 6 months.

Retainer Practices Are Reporting Better Care