Clarence Fanto | The Bottom Line: Stratified medicine exacerbates shortage of primary care physicians


LENOX — Imagine having a primary care family doctor on call 24 hours a day, available to see you on a few moments' notice, easily reachable by e-mail and cellphone. No waiting weeks or months for an appointment, no long delay at the office — personalized care, and no rushing so the doctor can move on to the next patient.

It's called direct primary care, a business model that's an offshoot of "concierge medicine" and naturally, there's a catch, perhaps 22 of them.

Here's the deal, as outlined in a Boston Globe profile of one such practitioner, Dr. Jeffrey Gold of Marblehead on the North Shore.

You pay a 12-month fee, typically $1,200 more or less, that gets you up to 12 visits a year plus telephonic and e-mail consults. But you still have to pay the premium and co-payments for health insurance, as required by the Affordable Care Act, or Medicare, in order to be covered for specialists, tests, treatment in hospitals or as out-patients for serious illness or injuries and prescriptions, just to mention a few of the catches.

So, only the affluent can afford this medical equivalent of first-class plane travel and VIP membership in airport lounges. This looks like another disturbing example of income inequality that enrages many middle- and lower-income Americans, quite understandably.

In well-heeled communities, it's a boon for doctors bogged down by insurance paperwork and forced to handle a patient load into the thousands in order to make a typical physician's income, cover officer overhead and, for many younger MDs, pay back hefty medical school loads. The direct care, or concierge doctors, don't take insurance.

'All about volume'

The aforementioned Dr. Gold, who charges adults $75 to $95 a month, seniors $125 and youngsters $30, sees his new, scaled down practice of 600 patients as a way to avoid burnout. Previously, as a member of a physicians' group practice, "it was all about volume and coding and how many people a day you can see," he told the Globe. "I couldn't do it anymore. It was not aligned with how I grew up thinking about medicine."

Some high-end concierge doctors not only charge monthly fees, much higher than Dr. Gold's scale, and bill insurance as well.

But supporters of direct care compare the payment model to auto insurance — motorists pay directly for general maintenance but are covered for big-ticket charges following accidents.

As far as I know, this new gold-plated version of medical care has yet to arrive in the Berkshires. Given the low family income averages here compared to Eastern Massachusetts, few area residents would have the wherewithal to afford the monthly fees on top of insurance premiums.

Furthermore, as the medical director of Brigham and Women's Primary Care in Brookline pointed out in a letter to the editor, there's an alarming shortage of primary care doctors. Siphoning off a growing number of family physicians attracted by higher income and a less stressful work life will only intensify the challenges many patients encounter when they seek basic care.

'Shameful' practice

Citing the need for more than 40,000 new primary care doctors nationwide over the next few years as many current practitioners retire, Dr. Martin P. Solomon writes that "medical training is largely subsidized with federal taxpayer dollars, and I'm pretty sure I missed the course at Tufts Medical School, more than 40 years ago, that taught us how to take care of rich people. It is shameful that the Massachusetts Medical Society and the insurance commissioner allow the practice of shedding or denying care to patients who are not able to pay the extra fee for this so-called personalized care."

Dr. Solomon declares that "we should be demanding limitations to this egregious practice."

Egregious or not, this could be the start of a medical revolution, as you can see if you look up Direct Primary Care Journal online, which offers a directory to locate these practices, and a wealth of information and resources, including live events and guidebooks for would-be "doc-preneurs."

Organized support for doctors seeking a change to direct primary care is coming from the Massachusetts Medical Society and the Massachusetts Academy of Family Physicians, which surveyed members and found that nearly 10 percent might adopt this business model since it promises annual earnings well above the $207,000 average for family doctors, according to

Of course, there are other sides to the story — direct-care doctors say their patients save money by avoiding costly visits to urgent care centers or emergency rooms and they claim to offer access to discounted prescriptions and lab tests. They spend more time with each patient and develop a personal, professional relationship.

Berkshire County faced a primary care emergency just a few years ago, when at least 30 high-volume physicians left the area or retired, all within a few months. Many remaining practices had to be closed to new patients.

But Berkshire Medical Center opened Lenox Family Health Center, adding new primary care doctors to the area, and the parent company, Berkshire Health Systems, has taken other steps to address the shortage.

Treatment models are changing, as physicians' practices form teams of doctors aided by well-trained assistant practitioners with expertise to see patients with nonurgent needs.

The idea of stratified primary care, with expedited treatment and customized special advantages for patients who can afford an extra $1,000 a year or more, raises troubling issues that divert attention from what should be the priority — improving President Obama's health insurance reform, as candidate Hillary Clinton proposes.

Contact Clarence Fanto at


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