You can almost hear some Cincinnati-area doctors gritting their teeth defensively when they hear their medical practices described as “boutique” or “concierge.”

Even among the affluent, the skyrocketing costs of health care and health insurance get people as touchy as $4-a-gallon gasoline and exit strategies for the Iraq war. So, most doctors want to avoid giving the impression they’ll deliver the best possible medical care only to anyone who can afford ... well, just about anything.

Call it concierge care or the more benign “subscription” services, the idea is the same: Pay an extra fee, out of pocket, to guarantee VIP access to a physician in person, over the phone or on the internet. Such “subscriptions” can run up to $5,000 annually or higher.

The trend is spreading beyond pockets of affluence in the U.S. All you need is the demand for the best and brightest docs to exceed the supply, coupled with enough patients who don’t fret a bit about deductibles or co-pays, and you’ll have clients willing to pay a premium for a next-day appointment instead of waiting a month or more.

Critics say this trend puts the U.S. on a slippery path toward third-world health care, where decent medical services are reserved for the rich. They fear concierge care will lead more doctors to drop out of Medicare and private health insurance programs entirely, moving to straight fee-for-service practices.

Defenders contend alternative service give them the chance to do best what they were trained to do, reducing the administrative overhead and headaches that come with trying to care for too many patients with too little time.

Several Cincinnati-area doctors dismiss the notion that only the well-off and famous can take advantage of “subscription” practices.

“I’ve been really happy to — gratified to — see the variety of demographics that have followed me into this new practice, really cutting across all kinds of racial and socio-economic types of groups,” says Dr. Michael M. McClellan. The young physician left his primary care position with Hyde Park Internists to join MDVIP, a national network of about 220 physicians that promises to get doctors “off the treadmill” of dealing with insurers and large patient caseloads, beginning with annual membership fees for patients.

“The cost has turned out to be within the grasp of the vast majority of my patients. They see value in it,” McClellan maintains.

He is one of seven Cincinnati doctors who are working with MDVIP. The network’s business model attracted the attention of Procter & Gamble, which bought a minority stake in the company late in 2006.

“This is a matter of giving people the health care they need, the way they want it for people who want it, and we have a broad cross-section of patients,” says Dr. Douglas A. Magenheim, who in 2003 established probably the first Cincinnati-area “subscription” practice, called My Doctor, in Sycamore Township.

“When you look at the cost, it’s less than a couple of Starbuck’s a day,” Magenheim remarks. “It’s a difference in values, a different choice that people have made to value their health care. A lot of people spend more time with their lawyers and tax accountants than they do with their physicians in taking care of their health.”

Dr. Lisa Larkin, an internist who heads a Madisonville practice, was so much in demand that she has had to refuse new patients. After a recent dispute with Anthem Blue Cross and Blue Shield over insurance reimbursement rates, her practice now declines Anthem coverage. Dr. Larkin is now offering patients a wide variety of services that aren’t covered by insurance, for an annual fee of $50 ($75 for the first year).

Lisa Larkin & Associates also has two categories of special care that are available to a limited number of patients. “Comprehensive care” is available to the first 300 patients who pay an extra $300 a year, while “comprehensive care plus” provides around-the-clock access for the first 40 patients who are willing to pay an additional $1,000 annually.

“Our model of care is one that requires longer appointment times and higher levels of attention,” Larkin explains. “As you might recognize, this model is not a financially sound model for a small practice like mine if relying strictly on managed care reimbursement rates.”

In general, fees for concierge care — $1,500 a year at both MDVIP and My Doctor — certainly aren’t at a Bill Gates-only level, but they typically aren’t covered by insurance. What that fee buys varies.

The cost of an annual “executive physical” and, in effect, membership in the MDVIP practice, is covered by the fee. With Magenheim and his business partner, Dr. Kellie K. Smith, the extra charge provides membership in a smaller practice in which each doctor is committed to taking no more than 700 patients. That compares to a typical patient load of about 2,500 in many traditional practices, the MDVIP doctors say.

Besides the additional charge, the common threads that run through MDVIP, My Doctor and other so-called “boutique” practices are quick access to doctors — often over the phone, around the clock — and smaller patient loads, which allow each doctor to spend more time with each person, with more attention paid to wellness and preventive medicine.

As Magenheim explains it, people tend to say “When I’m really sick I’ll go call the doctor,” instead of “I’m going to go in there and make sure I have all my prevention work done, and make sure my wellness stuff is up to date, and I know there’s someone there looking out for what I need.

“That was part of why I did this (set up the practice),” Magenheim adds, “because in a 10-minute visit I couldn’t always go looking for when their last colonoscopy was and whether their tetanus vaccination was up to date.”

Darin S. Engelhardt, president of MDVIP, headquartered in Boca Raton, Fla., claims MDVIP preventive care has led to “a dramatic reduction in hospitalization rates,” in the range of 60 to 70 percent.

He says lower hospitalization frequency reduces healthcare costs overall because there are fewer and lower medical insurance and Medicare claims. “And that’s something we only could have dreamed about when we started eight years ago,” adds Engelhardt, whose company now has about 80,000 U.S. patients.

Engelhardt says Procter & Gamble became interested in MDVIP in 2006 because its patients are considered “early adopters” — consumers who are ahead of the curve, a group that the P&G market researchers want to dissect.

Any doctor who joins MDVIP must agree to withdraw from his or her existing practice so that there’s no suggestion that there are two levels of care inside a single office, Engelhardt notes.

“It’s, in our assessment, violative of both federal and state laws for physicians to have different tiers of care within their practices, violating anti-discrimination provisions,” Engelhardt comments. “We wanted to have one uniform level of care with all patients receiving the exact same type of care.”

The American Medical Association also has made it clear that doctors have to be cautious about violating ethics guidelines when involved in what the AMA calls a “retainer” practice. The AMA stresses that physicians who have a mixed practice — a blend of “retainer” patients as well as those who do not pay the additional fee — must be “particularly diligent” to guarantee that all patients receive the same level of diagnostic and therapeutic services.

Stu Scheller, a principal in the Scheller Bradford Group, a healthcare consulting firm in Anderson Township, says many patients are sophisticated about health care and frustrated that they often get no more than five minutes face time with their physicians.

“They want more time with their doctors and they’re willing to pay for it,” Scheller says. “Those who can buy a Lexus buy it because they know they are going to be catered to when they need service. But everyone can’t afford it.”

Scheller says “boutique” practices are going to continue to appeal to more affluent patients. “With an 80 percent Medicare base, it’s not going to work,” he says. “Some of the patients are going to say ‘If you can give me what I need, when I need it, it’s worth another $5,000 a year.’ ”

The inevitable question is whether the subscription practices help drive yet another wedge between the affluent and those who aren’t, for a service that some people consider a fundamental right.

“It’s our society in general,” he answers. “You see it in housing, durable goods, clothes, cars, vacations, and trips and who can afford the gas.”

John Sinclair is a market business leader for Mercer, a human resources consulting firm with offices in Cincinnati and 179 other cities worldwide. “Patients are becoming more demanding, and the trend is for providers of all types to build a closer relationship with the patients,” he observes.

Like Scheller, Sinclair says there’s no guarantee that the patient in a “concierge setting” is getting better medical care than what’s provided to patients who endure three hours in a waiting room.

McClellan, who plans to have about 550 patients in his new practice with MDVIP, says the most common patient complaint is that doctors just don’t have the time to spend time with them.

“I can tell you from the standpoint of a primary care doctor, nothing makes your heart sink (more) when you’re in a busy traditional practice than having someone come in with a laundry list of things they want to talk to you about,” McClellan says. “Five to 10 minutes is scheduled to see them. I don’t mean that to sound pejorative, because (the patients) just want the care. They just want their questions answered but, boy, you know the whole rest of the day you’re going to be trying to dig out from that and then the next person walks in, and they have a list too, and you just know you’re never going to catch up.”