In Part I of this two-part series, Dr. Tom Lansdale, a 53-year-old internist who previously headed the Department of Medicine at Greater Baltimore Medical Center, left his post to open his own practice.

Unhappy with the insurance-driven reimbursement system, he said, "I would rather have my teeth drilled without anesthesia than practice as an internist in the current insurance-based system."

But the "retainer practice" Lansdale established, which bills patients an annual, out-of-pocket, flat $1,500 fee to retain his services, freed him from having to deal with insurance companies. In exchange for the fee, it gave his patients personalized care, 24/7 access, house calls and reduced waiting times..

It also allowed Lansdale to limit his caseload to a very manageable 250 patients. That gave him time not only to treat their illnesses but to work with them to prevent them from becoming ill -- and still draw a salary commensurate with physicians in their prime who have been forced by insurance companies to carry a typical caseload of from 1,500 to 2,500 patients.

He became what he wanted to become: "the personal family physician ... who plays a meaningful role in his patients' lives."

Is Tom Lansdale's journey just a nice little story about a man finding happiness as a doctor, or is it a cautionary tale about the state of the medical profession?

How many primary care doctors will switch to retainer practices, and what will happen to the patients they leave behind? Are you going to become one of them? Part 2 seeks answers to these questions.

Retainer medicine -- also known as concierge or boutique medicine -- is controversial.

"My main objection is the practice discriminates against patients who don't have enough money," said Dr. Sidney Wolfe, director of the Public Citizen Health Research Group. "The concept is very bad; it's a betrayal of the ethics of physicians."

Public Citizen is a national, nonprofit consumer advocacy organization that Ralph Nader co- founded in 1971 to represent consumer interests in Congress, the executive branch and the courts.

While proponents focus on how doctors and patients benefit from retainer medicine, Wolfe and other detractors cite the impact retainer medicine could have on the patients who can't afford or choose not to join a retainer practice, and on the health care system in general.

"If it's widely adopted," Wolfe said, "it is going to exacerbate the No. 1 health-care problem vexing the United States today, which is the multimillion load of Americans without medical resources of any kind except, perhaps, the dubious privilege of visiting an already crowded, publicly operated emergency room."

But Wolfe doesn't have a kind word for insurance companies either. "The entire insurance industry has to be destroyed, as it was in Canada 36 years ago," he said. "It would mean eliminating one of the biggest barriers to good care."

Meanwhile, Wolfe views "concierge medicine," as he calls it, as "a giant step backward in the quest for universal health care."

"We are the only developed country that doesn't provide health care as a fundamental right, he said."

Both Wolfe and the American Medical Association agree that retainer medicine adds another tier of medical care -- in addition to patients covered by insurance and patients with little or no insurance.

Having two tiers is bad enough, Wolfe says. But the AMA's Council on Medical Service points out that retainer medicine is not a radical departure from the way care is financed and delivered now.

A multitiered system of care already exists in the United States, the council points out, with higher levels of service for patients whose health insurance offers a wider array of benefits.

The AMA council is not getting involved in this dog fight. But it stands by physicians who make the transition, as long as they adhere to ethical principles.

"Retainer practice is consistent with longstanding AMA policy in support of the rights of physicians to freely contract with their patients, according to the council.

But Wolfe has other objections as well.

He says doctors' target incomes are too high, even as the American College of Physicians points out that the median indebtedness of medical school students graduating last year was $120,000 for public schools and $160,000 for private schools.

Wolfe also has strong words about what happens to patients whose doctors elect to make the transition to a retainer practice.

"Kicking out patients is unconscionable," he said.

On the other hand, Lansdale gave the patients in his old practice, which was owned by Greater Baltimore Medical Center, six months notice to find another internist.

MDVIP, a Boca Raton, Fla. company founded in 2000 that offers physicians in 16 markets across the country a package that assists them in establishing and maintaining a "concierge" practice goes even further.

MDVIP gives every patient who chooses not to join the doctor's retainer practice a list of other practices in the community that MDVIP feels is suitable for that patient.

Defenders of retainer medicine, including Towson resident Jim Turner, a financial manager for Johns Hopkins Health System, say it allows doctors the time to practice preventative medicine.

"There is a need to experiment in different models of health care delivery," Turner said. "Just because everyone at this time can't benefit from it doesn't mean that those who can afford it should be denied it.

"A model like this offers the potential for significant health care savings in populations that are currently underserved by preventing conditions from worsening that would end up costing the system more. It seems worthy of consideration."

The model already is working well for patients in the concierge practices that MDVIP franchises, according to its chief executive officer, Dr. Ed Goldman.

In 2005, in seven states, including Maryland, patients in MDVIP-affiliated practices experienced from 36 to 92 percent fewer hospitalizations than patients covered by top state insurers, Goldman claims.

MDVIP attributes the numbers to physicians having "the time to have much closer relationships with their patients."

"Most of us look at our health in terms of symptoms," Goldman said. "We wait until it hurts. But we are proving prevention really does work. We think we are in the early stages of what should be a national model."

The Internal Revenue Service -- and Congress, which writes the laws the IRS implements -- doesn't quite recognize the new medical model.

The IRS says the annual retainer fee does not qualify as a medical expense, even though it is paid to a doctor, "due to the uncertainty of medical care and timing." That is., it might turn out that the patient did not need a doctor that year.

The courts, according to the IRS, have qualified the prevention of disease as a medical expense, but only in so far as it applies to the imminent danger of contracting disease. Things you do for your general good health do not qualify.

The downside of Lansdale's happy move to a retainer practice is the number of patients who are very satisfied with their primary care physicians and their insurance who suddenly discover they are going to have to pay an additional $1,500 or more a year to continue the arrangement, improved as it might be.

That raises the question of how many primary care doctors are going to switch to retainer medicine in the future. Some imply there won't be that many.

The AMA council cites "economic realities," reasoning that the more physicians charge for their services, the smaller the demand for their services. While retainer medicine may mean higher costs for those who can afford to pay for it, it won't jack up the cost of services for those who can't afford it, and it won't adversely affect patients' access to care.

"It's a small subset of the vast majority of doctors," said Mohit Ghose, a spokesman for America's Health Insurance Plans, which bills itself as "the voice of America's health insurers" and represents nearly 1,300 member companies providing health insurance coverage to more than 200 million Americans.

"They form a niche; they do so for their own financial reasons., but nine out of 10 physicians still continue to have at least one insurance contract."

Indeed, the financial risk and the work required to establish a retainer practice prohibit retainer practices from multiplying like rabbits.

Like Lansdale, some doctors do it on their own.

But MDVIP has formalized the process with screening, researching, interviewing and demographic studies as it searches for "excellent, excellent doctors with at least 15 years experience and a lot of patients who love them," according to spokeswoman Nancy Udell.

MDVIP takes only 12 of 100 doctors who are interested in making the transition, she says.

Then again, some physicians who meet the criteria are not interested in making such a move at the time.

Dr. George Karkar, an internist with more than 2,500 patients in practices he maintains at GBMC and in Eastpoint, is one of them.

He enjoys his patients, Karkar, said, but his work day has become very demanding with fielding 25 to 30 faxes and telephone calls a day as well as examining and interviewing patients.

"For the time being, switching to a retainer practice wouldn't be practical," Karkar said, "but it's something to consider."

"It's easy to limit your number of patients if you have a well-established clientele of well-to-do people," he said, "but in my Eastpoint practice, some people don't have that much money. Some can barely make the co-pay.

"There is a financial risk to eliminating so many patients. If you did make the change, and it didn't work out, how many patients would come back to you?"

Lansdale believes he's "ahead of the curve." He knows of six doctors serving patients in north central Baltimore County who have switched to retainer practices, and at least one who is on the brink.

And MDVIP, which had 24 retainer practice franchises in 2003, now has 160 franchises with a total of 55,000 patients and is growing eight practices per month, Goldman reports.

Marty Wasserman, a former state health commissioner who is now director of the Maryland State Medical Society, thinks Lansdale is right about the curve.

"It's a small percentage now," Wasserman said. "But I think this type of practice will increase in numbers as it becomes more difficult for primary care doctors to make a living.

"The current insurance market forces doctors to see too many patients too quickly and file too many forms. It doesn't pay properly, and it changes rules. It's not a good business model."

On the other hand, he said, the poor and the lower middle class don't have the dollars to pay a retainer fee. They may find they are dealing with an eventual shortage of doctors.

A 2003 study by the American College of Physicians documents the steep decline in the willingness of physicians to enter training for primary care.

It said that only 27 percent of third-year internal medicine residents in the United States planned to pursue careers in general medicine, down from 54 percent in 1998. That figure declined to 19 percent of first-year internal medicine residents.

As Lansdale said, "They have no happy role models."

Increased life expectancy in this country will only exacerbate the problem. The number of people 85 and older, who are most likely to require chronic care services for multiple conditions, will increase 50 percent from 2000 to 2010, and it will more than double by 2030, according to the same organization.

Wasserman said he is looking forward to the results of a study generated by Senate Bill 107. By request of the O'Malley administration, it established a task force staffed by the Department of Health and Mental Hygiene to look at health care access and reimbursement.

Its interim findings and recommendations are due Dec. 1. The final report is due June 30, 2008.

For those who don't want retainer practices to proliferate, Wasserman has some advice. "Make sure the physician is adequately compensated for the work he does," he said.

E-mail Loni Ingraham at lingraham@patuxent.com