Jack sat down on his lounge chair and shook his head. "Have you ever run across someone, and you are sure they are someone you know?"

"A few times," Laurie said, taking a sip of her drink. "Why do you ask?"

"Because it just happened to me," Jack said. "Can you see that man talking with that buxom woman in red on the other side of the bar?" Jack pointed toward the couple.

Laurie pulled her feet around, sat up, and looked. "Yeah, I can see them."

"I was sure that was Craig Bowman," Jack said with a short laugh. "He looks enough like him to be his twin."

"I thought you said Craig Bowman had sandy-colored hair similar to yours. That fellow has dark hair."

"Well, except for the hair," Jack said. "It's incredible. It makes me question my impressions."

Laurie turned back to Jack. "Why is it so incredible? Cuba would be a good place for someone like Craig to go. There is certainly no extradition treaty with the United States. Maybe it is Craig Bowman."

"No, it's not," Jack said. "I had the nerve to ask him and watch his response."

"Well, don't let it worry you," Laurie said. She regained her reclining position, drink in hand.

"It's not going to worry me," Jack said. He, too, lay back on his chair. But he couldn't get the coincidence out of his mind. All at once, he had an idea. Sitting up, he fumbled in the pocket of his robe and pulled out his cell phone.

Laurie had sensed his sudden motion and opened one eye. "Who are you calling?"

"Alexis," Jack said. She answered but told Jack she couldn't talk and that she was between sessions.

"I just have a quick question," Jack said. "Do you by any chance know a Ralph Landrum from Boston?"

"I did," Alexis said. "Listen, Jack, I really have to go. I'll call you in a couple of hours."

"Why did you put it in the past tense?" Jack asked.

"Because he died," Alexis said. "He was one of Craig's patients who died of a lymphoma about a year ago."

Author's Note

Concierge medicine (also known as retainer medicine or boutique medicine or luxury primary care) is a relatively new phenomenon that first appeared in Seattle. As described in Crisis, it is a style of primary-care medical practice that requires an annual membership fee that varies from hundreds to many thousands of dollars per person (the median being about $1,500 and the maximum about $20,000). In order for this fee not to be construed as a health-insurance premium, which would be against regulations, the patient is offered a laundry list of specified medical attention or services not covered by health insurance, for example, elaborate yearly physicals, preventive care, nutrition counseling, and individually tailored wellness programs to name a few. But the real perk stems from the physician's guarantee to limit enrollment in the practice to a number far less than usual, making possible special amenities and special access to standard medical services (but not payment, which remains the responsibility of the patient either through health insurance or out of pocket).

The amenities might include: a very personal doctor-patient relationship, unhurried appointments that are as long as needed, nicer and uncrowded reception areas (not called waiting rooms since as an amenity waiting is to be avoided), house calls or patient office visits if appropriate and desirable, facilitation of appointments to needed specialists and immediate consultation, and even possible travel by the doctor to distant locales if the patient becomes ill or injured on a trip. Special access includes same-day appointments if needed or certainly within just a day or so, and twenty-four-hour doctor accessibility with the doctor's cell phone, home phone, and e-mail address.

There have been a few articles about concierge medicine in professional journals as well as in The New York Times and other mass media publications, but, for the most part, the slowly burgeoning practice style has gone unnoticed by the vast majority of the public. I believe this will and should change, because concierge medicine is yet another subtle but significant symptom of a healthcare system that is out of whack since good, patient-oriented medicine used to be available, and should be available, without a considerable up-front fee. More important it is common knowledge there are already significant inequities involving healthcare access worldwide, and one doesn't have to be the proverbial "rocket scientist" to understand that concierge medicine will make a bad situation only that much worse: Those doctors practicing in this style will, by definition, see far fewer patients, and all those patients who do not come up with the retainer fee for whatever reason will face less choice in a further constrained system. Indeed, a handful of U.S. senators officially complained to the Department of Health and Human Services about the phenomenon's potential impact on limiting the ability of Medicare recipients to find a primary-care physician. In response, the Government Accountability Office issued a report in August of 2005 suggesting that concierge medicine was not yet a problem, but that the trend would be monitored. The implication was that there will be a problem as the practice style mushrooms. Unfortunately, I can personally attest that it has already reached this situation in Naples, Florida, where concierge medicine has taken root. Currently in Naples, it is difficult for a new Medicare patient to find a physician without anteing up the requisite concierge retainer, or paying an exorbitant, out-of-pocket yearly physical fee, or opting out of Medicare altogether. Although Naples is admittedly a unique community economically, I believe it is a harbinger of what is to come in other communities both in the U.S. and internationally as well.

Although there have been articles about concierge medicine, none that I have read have truly addressed the question of why this phenomenon has emerged at this particular time. What is usually offered are economic explanations revolving around the idea that concierge medicine makes sense from a marketing perspective. After all, provided he or she can afford it, who wouldn't want the promised amenities, considering what the experience of going to the doctor is like all too often in today's world, and what physician wouldn't prefer to have financial security right out of the starting gate and to be able to practice the unhurried medicine they learned in medical school? Unfortunately, this superficial answer doesn't explain why the phenomenon makes sense now and didn't, say, twenty years ago. It is my belief that the real answer is that concierge medicine is a direct result of the dire, unprecedented state of disarray in current healthcare on a worldwide basis. In fact, there are those who evoke the metaphor of the perfect storm to describe the current situation, particularly in the United States.

There have been a number of problems plaguing medical practice over the last quarter-century or so, but never have there been so many all converging at the same time. Concurrently, we are seeing aggressive medical cost containment; personnel and equipment shortages; expanding technology; strenuous and appropriate efforts at medical error reduction; soaring litigiousness and settlement awards; rising ancillary costs; a bewildering multiplication of health-insurance products, including managed care with its associated intrusion into medical decision-making; and even the changing role of hospitals. All of these forces have contributed to making the bedrock of medicine – the practice of primary care – a night-mare, if not impossible. For a primary-care physician to stay in business, meaning earning enough to keep the doors open and the lights on (or staying employed in a managed-care environment), he or she must see patients at an extraordinary rate with an entirely predictable result: dissatisfaction on the part of both the doctor and the patient, and, ironically enough, increased utilization and cost and rising litigation.