Despite a far cry from consensus around the country regarding the health care reform debate, the discussion has heightened awareness of the nations current system and the prospect of its future for everyone involved: Patients of all ages, primary care and specialized physicians, insurance companies and federal, state and local governments. As part of that discussion, this series examines the issues surrounding health care on a local level its current standing and what reform could mean here. 

The series begins this week with a rendering of a phenomenon in medical practices that is known as, but not necessarily representative of, the term concierge medicine and its role in the local health care scene.

By David Sachs

Some people refer to them as boutique medical practices, others call them direct care doctors. The reality is that there is no umbrella phrase that accurately describes this unique form of health care, because there is an array of nuances distinguishing otherwise comparable practices from one another. 

But the basic premise of what these terms have come to represent for many is this: An extremely close-knit doctor-patient relationship founded on preventive, individualized care accompanied by an upfront fee, allowing physicians the ability to care for patients in a more customized fashion without having to worry about low reimbursement rates from insurance companies. The fee covers an extensive preliminary exam, which doctors say allows them to better understand a patients distinct physical and social state, leading to enhanced primary care, less return visits and decreased likelihood of emergency medical attention theoretically a boon for the entire health care system in the long run.

The quality of care at some practices seems exceptional; around the clock access to doctors, scheduled appointments longer than the national average and same or next day appointments portray patients as part of a relationship as opposed to a statistic. 

It has been my personal experience that at least once a week Im able to talk to someone on the phone, or have them come in and see them in person, whereas under the traditional practice I would have had to have my secretary tell them to go to the emergency room or go to a specialist, which are much more expensive and usually are not as effective a way of dealing with most problems, said Dr. Patrick Tokarz, whose Northern Virginia Family Practice Associates here in the city charges a $1,500 annual fee to practice medicine with a preventive attitude. Additional health care is handled with insurance, as with traditional practices.

But detractors of this medical approach cite quantity (or lack thereof), not quality, as a problem, because the customized approach comes with a price. 

Tokarz has practiced primary care in the city for about 30 years and has always strived to maintain a personalized approach to his patients but over the last 20 years, he said, providing truly individualized care became impossible because of increased operating expenses and decreased reimbursements from insurance providers. So his practice transitioned to its current system and he limited his patient count from several thousand to less than 500.

Physicians consider primary care as the first line of defense against poor health. Without it, patients maladies become increasingly worse, trickling down into emergency room visits for those with and without insurance that put pressure on the health care system. The more people who have access to it with or without insurance the more likely the assurance of long-term health and less pressure on the health care system.

But the overwhelming majority of Americas medical practices are comprised of specialists, not general care physicians. Alexandria is no different.

Theres a much more limited group of people that [direct care offices] provide care for, said Alexandria Health Director Dr. Lisa Kaplowitz. We already have a gap in primary care. We know that. And this will exacerbate the whole issue of access to primary care. We need increased access to primary care.

Kaplowitz believes direct care practices negatively affect the populations health because, while they may reduce the number of emergency room visits over time, their patient limits put a cap on health care availability. The taxpayer-funded Health Department continues to experience significant budget cuts and caters to residents that for the most part dont have the resources for direct care, even if they have the need.

Im just concerned about the whole bigger picture of access to primary care, she said. We cant produce primary care providers fast enough and as we limit the patients cared for by them, where else are people going to go?

I mean, if people think community health centers can fill the gap, they have limitations themselves in terms of staff and space.

Hospital emergency rooms around the country experience the runoff from the uninsured and those without access to primary care, increasing pressure on the entire system. The not-for-profit Inova Alexandria Hospital, for instance, cares for anyone who walks through its doors no matter their income level or whether they were referred its the hospitals function, 

Inova Alexandria saw an increase of more than 7,000 emergency room visitors between 2004 and 2008, according to hospital statistics. Proponents of direct care say their operations relieve hospitals by nipping maladies in the bud.

Not only is it much more cost-effective as a practice, but its dramatically more cost effective for the community as well, Tokarz said. In other words, my patients, whether they have Medicare or other insurance across the board end up costing the health care system about a third less than other patients because the visits to emergency rooms are cut down by 50 percent, and the number of days in the hospital are cut down by 30 or 40 percent. And thats where the real expense is.

There does seem to be a consensus on the crucial value primary care plays in the city and in the country. The question is how to structure reform that will do it justice for patients while compensating physicians fairly. Also, after going through medical school, most students cannot afford the overhead of the primary care field the most crucial field for health care.

I am certainly in favor of any improvement in reimbursement for primary care and greater numbers of primary providers, which I think will be a big improvement for our health care system, Tokarz siad. And the only way to get them is to reverse the fact that people going to medical school cant afford to practice primary care under the current insurance reimbursement system. So if that gets changed, that would be wonderful.

The pending health care reform may, I hope, help in terms of peoples ability to have health care insurance, Kaplowitz said. And there will be and there is interest in increasing the training of medical students more to go into primary care. But that takes time and its not going to happen in the short term.