When Dennis Howard came down with bronchitis on the Friday afternoon before Labor Day, he figured it would be a challenge to get a prescription for antibiotics before Tuesday.

A Eugene resident, Howard was with his wife, Linda, in Florida visiting their grandchildren. The family doctor was 3,000 miles away.

But he put in the call to her office anyway. Dr. Lisa Quillin had come through for him in unusual circumstances before, agreeing to see him at 8 p.m. the night before a business trip to China. Within an hour, she had faxed in a prescription to a Florida pharmacy.

It’s the kind of availability and attention the Howards are willing to pay extra for.

Quillin is part of a growing national trend of physicians breaking away from high-volume practices characterized by short office visits. Tired of seeing more than 20 patients a day and staying on top of the well-being of 2,500 people every year, they are paring down their practices to a few hundred patients, who get a lot more of their time.

But in the primary care field, where office overhead has skyrocketed and insurance reimbursements have flattened or dropped, seeing fewer patients is a tricky financial operation.

Some physicians have simply stopped handling health insurance, cutting office expenses by requiring their patients to seek reimbursement from insurance companies.

Others have stripped down their practices – and their lifestyles – so they can survive on less money. Still others are charging patients for an array of services they couldn’t otherwise provide.

In Eugene, Lisa Quillin and Pamela Wible – family practice doctors working in area clinics since the mid ’90s – each opened solo practices this year, promising longer visits, same-day or next-day appointments, email and phone access and a host of other services.

Their business models are different. Quillin charges her clients an annual enrollment fee, $400 per patient and $75 per additional family member.

Wible – who works part time – has stripped the overhead from her practice and expects a smaller paycheck than her full-time peers.

In both cases, patients are singing their praises.

Dennis and Linda Howard had been with Quillin before she went solo and decided to continue seeing her.

It was an easy choice, Linda Howard said.

“If she had moved to the North Pole, I probably would have followed,” she said.

Quillin has a way of listening, of remembering previous conversations and even reading between the lines. She has helped Howard stay ahead of the migraine headaches that trouble her and on top of the threat of ovarian cancer that killed Howard’s mother at a young age.

Like the Howards, Kelli Wiley sought out Pamela Wible because she had been Wible’s patient at another clinic.

“I instantly liked the rapport with her,” Wiley said. “I felt like she really listens to me. A lot of doctors feel like they’re rushing you through. I didn’t feel rushed.”

Wiley and the Howards also wanted to make it clear that it’s not a matter of skilled vs. unskilled doctors, but of a health care system gone awry

Nationally, primary care doctors are spending between 10 and 15 minutes with their patients these days, said Dan Stech, who oversees doctor surveys for the Medical Group Management Association. The trade association represents more than 11,000 organizations and 240,000 physicians.

Doctors blame the short office visits on a financial bind of increasing overhead and decreasing reimbursements. The only way they can stay afloat is by seeing more patients.

The federal government has reduced reimbursements to doctors from Medicare and Medicaid insurance for the elderly, disabled and poor in recent years. There is also some anecdotal evidence that reimbursement from private insurers is decreasing, Stech said.

At the same time, office costs have increased for doctors. Medical and surgical supplies, computer equipment, wages and benefits for employees have all gone up, Stech said. Multi-doctor practices have extensive support staff, between four and five clinical and administrative employees for each doctor, he said.

In the past 10 years, doctors have had to hire more people to respond to increased oversight as insurers tried to manage care more effectively. The current financial drain on doctors comes from a push to do electronic billing and electronic record-keeping, which require new computer systems, he said.

Because primary care physicians don’t get paid as much as specialists for their services, their profit margins are smaller, he said, and they feel the squeeze more.

The numbers bear him out, said Alwyn Cassil, spokeswoman for the Center for Studying Health System Change. The Wastington, D.C., nonprofit organization tracks health care trends.

“Primary care physicians took a pounding in the late ’90s,” Cassil said.

A survey taken from 1995 to 1999 revealed that primary care physician salaries decreased by 6.4 percent. During those years, other professionals and high-tech workers saw a 3.5 percent increase in wages and salaries in numbers adjusted for inflation.

In 1999, primary care doctors’ average income was $138,000, compared with $219,000 for specialists, according to data compiled by the center.

“We pay doctors fairly well to do procedures on people. We don’t pay particularly well for consultation and managing,” Cassil said. “Then we’re surprised that doctors don’t spend a lot of time with patients.”

New tools, old style

Quillin, who is 39, knew she wanted to be a doctor from the time she was in grade school, but her vision of the job wasn’t the current reality – running from appointment to appointment, with three patients in exam rooms all waiting for her.

“It’s like trying to keep all the holes in the dam plugged,” she said.

She didn’t mind the hard work. What she missed was a sense of connection with her patients.

“Where you look at somebody. You look in their eyes. You get to know them in a physical, social, psychological and behavioral sense. You can’t do that when it’s limited to a few minutes,” she said.

So Quillin did some research and decided to open her own office in a cozy bungalow on Lawrence Street. She hired a receptionist and business manager who is trained as a paramedic, alleviating the need for a nurse.

The small house has a single waiting area and one exam room. Patients get in to see Quillin the same day they call or the next day. She has a secure Internet connection, so she can consult with patients via email. If they call her with questions, she calls them back, often on the same day.

Instead of a hurried 15-minute visit, her patients get an hour of her time on their first consultation and a half hour on subsequent visits. If all they need is a prescription for a condition she’s familiar with, they don’t even need to come into her office. She takes care of it over the phone.

The fee allows her to keep the number of patients she sees low enough so that each of them receives more of her attention.

Known nationally as a concierge or boutique practice, it’s a business model that emerged in 1996, when a couple of Seattle doctors began charging patients an additional $1,000 a month beyond the regular cost of office visits. While different doctors offer different services, from spalike settings to the promise of 24-hour, seven-day-a-week cell phone access to home visits, the premise is the same.

Since the late ’90s, hundreds of doctors nationwide have adopted the model with annual fees that range from $60 to $15,000, according a 2004 Government Accountability Office report. According to that report, about half charge between $1,500 and $1,900 annually.

Like Quillin, about three-quarters of the doctors surveyed for the GAO report said they billed both private insurers and Medicare.

Quillin says she’s happy with how things are working.

“I can keep my practice size small enough to guarantee my availability to each and every patient,” she said. Currently she sees 300 patients, but says she’ll cap the practice at 500.

Quillin said she has not yet achieved her previous income, but that she hopes to come out even in the next several years.

She declined to give specific figures, but the American Academy of Family Physcians reports family practitioners receive an average income of $134,000.

Her patients say her enrollment fee is worth every penny.

“It’s an experience like you’ve never had. It harkens back to the very old days when doctors were there for the patients,” said KathrynKoelling, another Quillin fan.

“When you walk into her office, she’s right there to greet you. I’ve never waited as much as five minutes.”

Koelling began seeing Quillin for help with sinus infections that have bothered her for 20 years.

Quillin impressed Koelling by taking time, listening to her and developing a plan that included consultation with an ear, nose and throat specialist. When there was confusion over the referral to the specialist, Quillin dropped the paperwork off at the other physician’s office herself, Koelling said.

“When I got there, the nurse said, `I can’t believe your doctor. She hand-delivered it on her day off,’ ” Koelling said. “Whatever it takes is what she gives.”

Critics of enrollment practices say the fees create a tiered health care system where those with money get the best care. They worry that more doctors will opt for such practices, reducing the number serving the neediest people.

But that ship has already sailed, said Cassil, the Health System Change spokeswoman.

“If you are uninsured, you have far less access to health care,” she said.

The GAO study was prompted over concern for the impact such practices could have on Medicare patients. Because so few doctors have adopted the model, the federal report found little impact.

The American Medical Association also has weighed in on enrollment practices, finding them ethical as long as doctors don’t claim that they are providing better care than their colleagues or double billing for services already reimbursed by insurance.

“I know there are people who object to a subscription fee,” Linda Howard said. “But it’s less than a latte a day for the best health care you’re ever going to get.”

And Quillin points out that her annual $400 fee is still less than the cost of a comprehensive health plan for those who don’t have health insurance. Insurers often charge as much as $400 a month for comprehensive coverage, she said.

Grass-roots changes

Other doctors are trying to improve their relationships with patients by making do with less. Wible says she’s part of a small but growing group stripping down their overhead in order to devote more time to fewer people.

Wible worked in several clinics in Eugene and in Washington state before opening her own part-time practice in April.

Her biggest complaint about working in established clinics was similar to Quillin’s: not enough face time with patients.

“I like to talk and my patients like to talk. They want to get to know me, and I want to get to know them. You can’t do that in 15 minutes,” she said.

When she decided to go solo, she conducted several community meetings that attracted about 100 people. She asked them what they wanted from their primary care physician and three consistent themes emerged.

People wanted more time with their doctors. They wanted to be listened to and they wanted to play a role in their own health care.

Wible knew she wanted more time with her patients, the opportunity to help transform the health care system, and more personal time to explore other activities.

To get there, she stripped down the overhead. She employs no one, and does all the accounting and business work in her home office. She sees clients three days a week in an office she rents at the Tamarack Wellness Center in south Eugene.

Because she carries no debt and lives simply, Wible says she doesn’t need the typical physician’s salary. But she believes that her low overhead will allow her to exceed her previous full-time salary.

Like Quillin, she offers her patients same-day or next-day appointments. She returns phone calls the same day. She also works afternoons and early evenings so her patients can see her after work.

Her flexibility works both ways. In the aftermath of Hurricane Katrina, Wible decided to fly to Houston to help with evacuees who had fled into Texas.

One of her patients, Josie Nelson, agreed to move her appointment to Sunday, so she could see Wible before her trip.

Nelson, who had seen Wible once before for reproductive concerns, was having stress-related problems. Wible suggested that a massage therapist be present for their appointment and the visit proved to be therapeutic, Nelson said.

It’s everything Nelson had sought in a doctor and not found in other settings – someone concerned with her needs, willing to explore alternative techniques, but fully grounded in Western medicine.

“She doesn’t know me from a bar of soap. I’ve met the woman twice now. She just cares,” Nelson said.

Wible, like Quillin accepts insurance, but offers patients who lack insurance a sliding scale.

That’s why Sura Cox, a University of Oregon student, sought her out. But the sliding scale didn’t mean short shrift from the doctor. Wible spent more than two hours with her on her first visit, she said.

Wible will even barter with patients, and has accepted artwork in lieu of payment.

Once she agreed to a $10 payment from someone who needed reassurance that a skin lesion wasn’t cancerous. It took all of 30 seconds, she said.

Wible believes she’s practicing the kind of medicine many of her colleagues wish they could do.

“You can give your all to your patients without being sucked dry,” she said.

More doctors are taking an interest in her approach, she said. She gets calls from all over the country, in response to articles about her practice that have appeared recently in a physicians’ journals. And a group of doctors in New York has invited her to visit in April to describe how her “ultra-light” practice works.

It won’t work for everyone, Wible acknowledges. Medical schools don’t teach much about owning your own business and some people prefer to let others manage the risk of ownership.

But it’s working for her. Wible said she expects to cap her practice at about 300.

Patients such as Nelson say they’re glad to be on her roster.

“She pays attention,” Nelson said. “She’s actively listening and it’s so refreshing because it doesn’t happen in our society today.”

Pamela L. Wible, MD is a board-certified family physician in Eugene, Oregon.
She opened the Family & Community Medical Clinic on April 1, 2005.