More doctors charging patients annual fees

More doctors charging annual fees
By BOB LAMENDOLA
South Florida Sun-Sentinel
Monterey County Herald
08/04/2007

FORT LAUDERDALE, Fla. ?- Taking a cue from lawyers, a small but growing number of doctors have started charging patients an annual fee to help make ends meet.

These are not "boutique" doctors offering exclusive attention to patients who can afford to pay thousands upfront each year for special access and attention. These are regular family doctors asking for a few hundred dollars per person, saying they are squeezed between rising costs and flat payments from insurers and Medicare.

Administrative fee|

"We don't want to do this. I wish it were not so that we were in this position. But we are," said Dr. Mary Colburn, a geriatrics specialist in West Palm Beach, Fla., who last month asked all 400 of her patients to pay a "voluntary administrative fee" of $250 per year.

She said the fee, which comes on top of the patients' normal co-payments, would be less painful than if she tried to make more money by taking on hundreds more patients ?- limiting the time she can spend with each one ?- or by becoming a "boutique" doctor.

The reception from patients has been "overwhelmingly positive," Colburn said. But not everyone likes the idea.

"This is outrageous. It's like a doctor having a tip jar in the front window," said David Ruberg, a Medicaid consultant in Wilton Manors, Fla., who advises a destitute and institutionalized Alzheimer's patient seeing Colburn.

"Doctors already make a lot of money, and these old people are hard-pressed," Ruberg said. "They're not joining an exclusive club, they're not buying any extra services. Why would anyone just turn over an annual fee to a doctor just for being who they are?"

Shrinking payments|

Across the country, family doctors and lower-paid specialists are starting to charge annual fees as their compensation stagnates, or falls. They blame shrinking payments from HMOs and federal cuts or freezes to Medicare fees at a time when medical malpractice insurance, employee benefits and other costs have jumped.

From 1995 to 2003, average incomes for doctors fell 7 percent after inflation, 10 percent for primary doctors, the Center for Studying Health System Change reported.

Last year, doctors made $330,000 on average, the Medical Group Management Association reports. But some made much less. The lowest-paid ranks of certain pediatricians made $108,000, certain orthopedists $111,000 and certain family doctors $130,000, the survey showed. Geriatricians made $165,000 on average.

No agency tracks how many physicians are asking for annual fees, but industry experts say the numbers are growing and the trend will likely continue.

"Hundreds and hundreds and hundreds of doctors are (charging annual fees) now," said Texas physician Chris Ewin, president of the Society for Innovative Medical Practice Design, which promotes the need for the fees. "It's not going away."

Some doctors bill only for a monthly fee, leaving patients to chase down their insurers to get reimbursed. Some, like Colburn, collect from both patients and insurers.


"Fees are upsetting to some patients, but some of these practices are running on razor-thin margins and these doctors can't work for free," said Liz Johnson, a spokeswoman for the Medical Group Management Association.

About 500 doctors have started boutique practices such as MDVIP in Boca Raton, Fla., the nation's first and largest, now handling 160 doctors seeing 60,000 patients in 17 states since 2000, company President Darin Engelhardt said.

MDVIP patients pay $1,500 to $1,800 per year, and in return, enjoy rarely seen services such as immediate appointments, the doctor's cell phone number, lengthy annual physicals, custom wellness plans, preventive tests and online access to medical records.

The concept is a rebellion against HMO-style medicine, in which primary doctors with large rosters topping 2,500 patients often run late and spend maybe 10 minutes per patient, Engelhardt said. Doctor-patient relations suffered and preventive medicine waned, he said. In the MDVIP model, doctors cut back to 600 patients.

Colburn said going boutique would be too costly for her patients, and taking on more patients would "compromise the quality of the way I do medicine." After agonizing for three years, she followed a few other South Florida doctors asking the voluntary $250 fee. She insisted that those who don't pay get the same quality of care as those who do.

Some patients said they were happy to pay.

"She's worth every penny," said Phyllis Ciliberti, 75, a West Palm Beach, Fla., retiree who had a two-hour exam with Colburn this month.

But health care attorneys warned that the voluntary fees may be illegal under Medicare law, which requires that each fee be attached to a specific service. It's illegal to charge extra if the services the patient receives are already covered by Medicare, said David Hilgers, a Texas attorney who follows doctor billings.

Consultant Ruberg said even a voluntary fee pressures patients to pay, in fear the doctor will give lesser care if they don't. Patients should not be made to take up the slack when Medicare and insurers cut physician pay, he said.

"It's like her asking them to pay the rest of the money that insurance won't pay," he said.