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Since completing his residency a year ago, Dr. Natan Schleider has been building a specialized practice centered on a forgotten service: He makes house calls.

"I'm in the office seeing patients about 10% to 20% of the time, and the rest of the time I see patients in their homes," says Dr. Schleider, a board-certified family practice physician who is based in Manhattan.

With black bag in hand, Schleider is a throwback to an era when physicians had time to get to know their clients personally and patients didn't feel rushed through their appointments.

But this doctor delivers tradition with a modern twist, for along with the classic bag, he arrives at his patients' homes armed with the latest medications and equipment, including portable X-ray and EKG machines and a laptop he uses to view radiology films.

Dr. Schleider takes customer service to an even higher level by encouraging his patients to contact him directly, 24/7, for routine and emergency care. "I treat my patients like family. They have my cell phone number and can call me anytime," he says.

Dr. Schleider is among a growing number of physicians who are turning to concierge, or boutique, medicine as a way of improving the health care experience for both their patients and themselves. "I wanted to


see 50 patients a day, be happy as a physician and make a good living, so I opted for a boutique practice," he explains.

First-Class Aid

The concierge movement, which has emerged in the past decade, aims to provide quality primary and preventive health care through the establishment of a direct financial relationship between the physician and the patient. In this system, patients pay an out-of-pocket monthly or annual fee to the doctor and become "members" of the practice -- and depending on the provider, additional charges for procedures or tests, or even coverage under a traditional insurance plan, may be required.

In exchange, concierge physicians promise to deliver high-quality medical care and a level of personal service virtually impossible to find in most health care settings today.

There are various concierge practice models. Dr. Schleider's practice,

NY House Call Physicians, represents the high end of the fee and service spectrum.

Schleider charges a minimum retainer of $1,000 a month, accepts no Medicare or third-party insurance and concentrates his efforts on a very small number of patients. He processes patients' insurance forms in the event they are entitled to reimbursement for his services as an out-of-network benefit and encourages patients to keep some form of high-deductible health insurance for hospitalization.

More common are practices that accept insurance and collect concierge fees.

MDVIP is a fast-growing example of this concierge model.

A national network of nearly 120 physicians in 15 states, MDVIP limits its physician practices to 600 patients each vs. the 2,500 patients typically served in a traditional primary care practice. Patients' membership fees are $125 to $150 per month.

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A Weakened System

In the eyes of many physicians and patients, the traditional health care model, as exemplified by Medicare and health insurers such as


, is broken.

To control their costs and stay competitive, for-profit health insurance companies continue to lower physician fees while raising the price of individuals' premiums. The Medicare picture looks equally bleak -- the federal government is expected to reduce Medicare reimbursement to physicians by nearly 5% as of January 2007 as part of a series of cuts that could total 37% over the next 9 years. And to offset costs of the increase in Part B spending, Medicare beneficiaries' monthly premiums are expected to rise at least 11%.

Ultimately, these costs and other factors all contribute to a significant decline in both physician and patient satisfaction. To keep their practices viable, physicians today must see many more patients than in the past, and this increased quantity impacts quality of care -- often allowing doctors to only address a specific condition vs. a patient's overall wellness.

Internist Garrison Bliss, MD, is board chairman of the

Society for Innovative Medical Practice Design (SIMPD), an advocacy organization that promotes concierge medicine as a solution to this troubled industry. He and his partners at

Seattle Medical Associates were among the first in the country to establish a concierge practice.

"Concierge medicine is not a situation of better care for rich people. This is an attempt to save the entire system," Dr. Bliss says. "The pure insurance-driven model is a disaster for patients and doctors. There's very little cost control, and service has little to do with it."

From the start, Dr. Bliss says he and his partners aimed to provide concierge service at the lowest possible price. Seattle Medical Associates charges a $95 monthly retainer per patient.

"The question is, how expensive is it to provide really good care? Consider your cable bill, or your cell phone bill -- compare the cost of concierge care to them, and it begins to be affordable to people, especially the disenfranchised," Bliss explains.

And despite its nonconformist approach, the concierge philosophy may be gaining support from the established medical community.

In a 2006 policy statement, the

American College of Physicians describes the nation's current physician payment system as "dysfunctional" because it rewards quantity rather than quality and undervalues primary and preventive care.

The organization, which is the nation's largest medical-specialty society, is advocating for changes in the way primary care is delivered and financed.

Among the ACP's proposals is the creation of a revised national reimbursement system for doctors that supports development of the "advanced medical home," a model of patient care that provides more personal attention to patients and some of the financial benefits to physicians that the concierge model of care offers.

By revamping reimbursement, access to quality primary and preventive medicine could be more widely available, not just to those patients who can afford to pay an additional annual fee.

"There are 40 million people with very little access to primary care in this country, so concierge medicine is not an ideal solution for the entire nation," says Lynne Kirk, MD, president of the ACP. "In our advanced medical home model, the patient has a physician practice that provides traditional care and helps coordinate care with other providers. This model is especially helpful in managing chronic diseases."

The ACP maintains that the advanced medical home will revitalize the patient-physician relationship, enhance coordination of care across the health care system and lead to macro system changes.

Priceless Service

James and Amy Rabenstine of Pittsburgh, Pa., believe the concierge fee they pay pediatrician Dr. Scott Serbin is money well spent.

When their daughter Olivia was born in May, everything appeared normal, until mom and baby were discharged from the hospital. It was a Saturday afternoon, and within a few hours the Rabenstines knew something wasn't right. "She didn't hold her food well," James Rabenstine says. "We called Dr. Serbin, and from then on he kept in constant contact."

Olivia's condition worsened, and when Dr. Serbin called early Sunday for an update, he decided to make a house call. "He walked in with his black bag and a scale, examined her and felt she needed to go to the hospital," James Rabenstine recalls.

Dr. Serbin called Children's Hospital of Pittsburgh to alert them of the infant's impending arrival. After conducting tests, physicians there determined that Olivia had intestinal malrotation, a birth defect involving a malformation of the intestinal tract. Emergency surgery was performed, and today Olivia is in good health.

"With a more traditional doctor, we never would have gotten an appointment on Saturday or Sunday," says Rabenstine. "Dr. Serbin is like a hometown doctor or dentist. We can always call him, and he'll be there."

Dr. Serbin's office,

Pinnacle Pediatrics, is the country's first concierge pediatrics practice. He converted to a concierge model last year after 20 years in a more traditional setting.

"I became disenchanted," Serbin explains. "Pediatrics is extremely high-volume work, and it is fast-paced. I wanted to do better and enjoy myself again."

He was exploring his options when he saw an article about concierge medicine in the New England Journal of Medicine. "It sounded like Nirvana," he says. He spoke to established concierge physicians and attended conferences sponsored by the SIMPD. "What struck me was how many different approaches to concierge care exist, yet the common goal is

always to offer greater care."

Before converting his practice Dr. Serbin had 2,500 patients; now he has 250. His patients' parents sign a membership agreement in which he promises to deliver amenities like house calls, immediate appointments, no waiting-room time (he schedules a full hour for each patient) and called-in prescriptions.

"The time I can spend allows me to practice preventive medicine," Dr. Serbin says. "My goal is to have the healthiest practice in the country."

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Anne McDarby is a freelance writer living in New Jersey. Her professional experience includes work as a newspaper reporter and editor in northern New Jersey and more than 15 years in health care public relations and marketing.