After steadfastly seeing one doctor for 20 years, Deems and Elizabeth Disney now find themselves searching for a new primary care physician for the second time since last December.

Unable to afford an extra yearly fee of $3,000, the Ellicott City couple will split from their current primary care doctor next week when the doctor heads down the same path blazed by their former longtime physician and converts his practice to "boutique medicine."

Boutique medicine -- also called concierge care or personalized care -- involves primary care physicians assessing their patients an annual fee in exchange for upgraded medical services with a personalized approach.

With those fees in their coffers, doctors are able to cut loose low-paying health insurance plans and reduce bulging patient rosters by as much as 80 percent.

Physicians' schedules are then freed up for longer appointments, quick access by phone or e-mail, in-depth annual physicals and even house calls -- a cluster of luxury services previously unheard of in typically overbooked primary care practices.

The problem, patients and health care experts agree, is what happens to the patients who can't afford the care.

Eight doctors have instituted concierge care in Howard County this year and a second group practice is monitoring the concept's results with tentative plans to convert in January 2010, said Victor Broccolino, president and chief executive officer of Howard County General Hospital.

Between 8,000 and 12,000 county residents have decided to find new doctors this year as a result of the changes, he estimated.

"I understand these physicians' motivation -- they all want to provide better patient care," Broccolino said. "But I am concerned about this trend and its long-term consequences for the general public."

Dr. Peter Beilenson, county health officer, echoed those concerns. He said he knows most of the physicians involved in these conversions and was confident financial gain is not their motivation.

"But I really have a problem with concierge medicine," he said. "It will stratify health care and then only the real 'haves' can continue to get the best care."

Broccolino also said he anticipates an increase in the volume of emergency room visits over the next six months, as temporarily dislocated patients use the ER as a substitute for primary care.

With annual costs ranging between $1,500 and $2,000 per person, concierge care is out of reach for many patients who are unable to pay sizable fees in addition to their regular health insurance premiums.

Patients must retain their health insurance to cover diagnostic testing, hospitalization and other specialty procedures.

The move toward boutique medicine gained momentum recently when the five physicians of Columbia-based Charter Internal Medicine announced plans to retain only about a third of their 9,000 patients beginning Jan. 1 and to charge adult patients an annual fee of $2,000, plus $500 for dependents ages 14 to 25.

Calling their plan "personalized health care," the doctors joined three other county physicians in separate practices in choosing this business model, Broccolino said. Each arrangement supplies its own services and rules, he pointed out.

Dr. Jonathan Fish, who joined Charter Internal Medicine 11 years ago, said the group's decision to move into concierge care may exacerbate access to primary care in the short term.

In the long term, he said, it will prove beneficial to patients by providing a successful model that, in the future, will draw more physicians to primary care medicine.

"We feel it is important for the community to realize that primary care physicians are going to cease to exist (as we know them) because they have the largest administrative burden and the lowest reimbursements," Fish said.

"We also had to respond to our ethical obligation to take care of our patients well," he said. "What are the ethics behind seeing patients for seven minutes apiece?"

Charter patient Martin Kirchhausen, of Ellicott City, said he can afford to pay the annual fee but added he is "flat-out against it." He said he and his wife, Barbara, are looking for new primary care. Both are retirees from the Social Security Administration in Woodlawn.

"Their plan creates a sense of elitism and goes against the grain of what the county is trying to do with the Healthy Howard Plan," he said, referring to the recently launched county program to provide access to health care for uninsured county residents.

"I urge a public discussion of this issue," said Kirchhausen, 76, who added he has sent e-mails to County Executive Kenneth Ulman and to Beilenson. "I want to hear how our elected officials view this trend."

Ulman was one of the patients left with an important decision to make when Charter Internal Medicine went boutique. Ulman and his family are Charter patients.

"I'm trying to make some tough decisions between a doctor I adore and what I can afford," he said recently. "I completely sympathize with the primary care physicians who work incredible hours and don't have enough time with patients, and aren't making as much money as doctors in other fields.

"But it's a troubling trend. You have ... a real class system of quality care."

Not all patients are unhappy with the new trend.

The decision by Dr. James Otto, who practices in Columbia, to switch to boutique medicine pleased patient Donna Goodman.

"I am willing to pay to maintain the privilege of being Jim's patient," said Goodman, a Columbia resident and former pharmacist.

"I look at this as an opportunity for complete care and additional communication -- not as a way for him to make money," added Goodman, who is blind and has diabetes.

As for the Disneys, they haven't yet been successful in their quest to sign up with a new primary care doctor.

"So far, we have only put our names on two waiting lists" at practices that are closed to new patients, said Elizabeth Disney, an English teacher at Burleigh Manor Middle School.

"We are a bit frustrated," she said, not only at having to repeat the search but at having to leave a second doctor whom they liked and respected.

Broccolino said he believes 75 to 80 percent of patients who have no primary care physician as of Jan. 1 will have found one by March 31. He called that "the best-case scenario."

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