On a typical day two years ago, Steven Fugaro, M.D. ’81, saw a patient in his solo primary care practice every 10 to 15 minutes. Onerous paperwork and economic difficulties made it hard for the San Francisco-based physician to provide the quality of care he felt his 3,000 patients deserved. “I was becoming increasingly dissatisfied with what I was doing,” he said, “although I was probably too busy to be reflective of it at that point.”
Then MD², a concierge medicine group, based in Bellevue, Wash., approached him. Would he like to join them as a concierge physician and gain the time and resources to provide extraordinary care for a small number of patients? His decision to do so changed his life and made him part of a controversial trend in primary care.
Fugaro had opened a private practice after an internal medicine residency at the University of California, San Francisco, and eight years in academic medicine. Although he loved primary care, physicians in that field are under tremendous pressure to see patients in great numbers—time is tight, reimbursement rates are stagnant and preventive care must take a back seat to immediate problems. Few medical students choose the field, and many weary primary care physicians are retiring early or taking jobs in industry or administration. These doctors are in short supply.
Enter concierge medicine. In this model, introduced in 1996 by MD² founder Howard Maron, M.D., patients pay a yearly fee ranging from $15,000 for an individual to $25,000 for a family of four. In return, physicians make themselves readily available, offering prompt appointments, house calls and other extras.
Critics of the practice, also known as “boutique medicine” or “retainer-based medicine,” call it unethical. The retainer is beyond the means of many people and because concierge physicians care for fewer patients than other primary care doctors, the practice increases colleagues’ burdens and may endanger access to care. But many concierge doctors say that they would have quit practicing altogether if not for this option. Fugaro agonized for months over his decision. “I was worried about what my colleagues would think. I was worried about … leaving patients. I wondered if I would be intellectually stimulated,” he said. “On the plus side [was] being able … to have basically unlimited time with [patients], to be able to care for them in a very holistic way and to have balance back in my life.” For Fugaro that meant more time for such pursuits as mountain biking and spending time with his wife of 22 years and their son, who studies theater at Northwestern University.
In 2007, Fugaro arranged for the patients in his primary care practice to be cared for by a successor, Allan Treadwell, M.D., relinquishing the practice free of charge. Then Fugaro joined MD².
He cares for just 50 families now, and on a typical day sees or speaks to six to 10 of his patients. The office does many of its own tests, with results available on the spot. He makes regular house calls. Many of his patients have complex medical conditions and he is better able to anticipate problems before they arise. “I was juggling so many things before,” Fugaro said, “it was clearly possible for something to fall through the cracks, and that’s far less likely now.” He also accompanies patients to specialty appointments and the ER, and enjoys learning from subspecialty colleagues at such times, “as opposed to just communicating through a consult letter.” For about 5 percent of his patients, the retainer fee is waived.
Fugaro is partnered with another physician; neither leaves town unless the other can stay. Though always “on call,” Fugaro said he has more time now for nonclinical professional pursuits. In 2007, he was elected president of the San Francisco Medical Society, where he pushes for such public health measures as restrictions on secondhand smoke, and partners with the California Medical Association to battle Medicaid cuts. He also has volunteered at a clinic in Mexico.
Fugaro says his colleagues’ reactions have been mostly positive. Indeed, several are opening retainer-based practices of their own, including Treadwell, the physician who took over his old practice. Fugaro acknowledged that access to primary care is a tremendous problem in American medicine. “We need to create a better model for primary care doctors to continue doing what they’re doing and be emotionally rewarded for it, as well as deriving reasonable economic compensation. And right now our system is broken in that regard.”