When Jody Fazzano developed headaches and nausea after hitting her head in a fall, she called her doctor, Lewis R. Weiner. He came to the phone immediately and advised her to go to the emergency room.

But he didn't stop there. He called the hospital, described her medical conditions, and faxed over a list of her medications. By the time Fazzano arrived, the emergency room doctors already knew who she was and what she would need.

"It was very easy," said Fazzano, 53, of East Providence, who suffered a concussion that day. "I didn't have to wait hours in the emergency room and have someone decide what they were going to do."

In fact, as Fazzano tells it, everything is easy with Weiner. He gave her his cell phone number and accepts her calls any time, day or night. He calls her the minute he gets test results. No matter what her reason, she can get an appointment the day she calls, or at the latest the next day, and never has to wait when she arrives.

What separates Fazzano from the huddled masses in waiting rooms around the state is the type of practice Weiner has set up -- and Fazzano's willingness to pay $1,500 a year on top of her copays and insurance premiums. Weiner has only 340 patients, and will allow a maximum of 600 patients (compared with 2,000 to 3,000 for the typical primary-care doctor), so he can provide lots of time, attention and access in return for the annual fee. He calls it "concierge medicine."

Although the concept is relatively new to Rhode Island -- Weiner started in June 2005, and another concierge practice opened that September -- around the country an estimated 400 to 500 doctors have chosen this path, setting up what are variously called "concierge," "boutique" or "retainer" practices. The doctors say the concierge model allows them to practice the kind of medicine they went to school for.

In his Providence office, Weiner sees only 8 to 15 patients a day (compared with 20 to 30 for a typical doctor), and books each appointment for a minimum of 30 minutes. The looser schedule gives him the leeway to discuss health and prevention with patients, to make house calls, to accommodate emergencies and to coordinate care with specialists.

Other doctors, however, raise ethical and societal concerns. They say concierge medicine deepens the divide between the haves and have-nots and threatens to worsen an expected shortage of primary-care doctors.

They also wonder how much of this "preventive care" is just idle handholding and schmoozing -- offered at an exorbitant price.

"It doesn't have to cost that much," said Dr. Michael D. Fine, a family doctor in Pawtucket and Scituate, who has studied the cost of primary care with an economist. He said it costs only $140 to $150 per person per year to pay for what a primary-care doctor does.

But even the harshest critics of concierge medicine sympathize with its appeal. They see it as a symptom of the ills in primary care today.

"It's a cry for help from the system," said Dr. Yul D. Ejnes, a Cranston internist who is chairman of the Board of Governors of the American College of Physicians. "Patients want more time with doctors. Physicians want more time with their patients. The way the system is set up today, the reimbursement system doesn't support that kind of care."

JODY FAZZANO knows exactly what he means. She has been Weiner's patient since the early 1990s, when Weiner worked with a large group of internists within the University Medicine Foundation. In those days, she says, Weiner seemed pained by his inability to give her his undivided attention.

"I always sensed that he was rushed," she says. "I never saw the man not running. Never."

Fazzano, a news producer for Channel 6 (WLNE), says it was "a big financial decision" when Weiner asked her about switching to his concierge practice. "I thought, selfishly, 'I need this.' It's worth the investment for me." Now she goes out to dinner less often, and takes only one vacation a year. The price comes to $125 a month -- as much as some people pay for hair styling or a night out with friends.

"This is the ideal way to be a patient," Fazzano says.

Weiner thinks it's the ideal way to be a doctor. "It's a joy to feel I can wrap my arms around the practice and manage it," he says.

Primary-care doctors everywhere complain that they're under extraordinary stress, chiefly because of the way they're paid. The essence of their work -- talking with patients, diagnosing them, advising them, coordinating their care with specialists -- is poorly reimbursed, if at all. Doctors get paid nothing for the hours they spend making phone calls, for example.

To pay for staff, overhead and malpractice insurance, doctors say they have to see 20 to 25 patients a day.

Weiner, who turns 46 tomorrow, found that pace grueling, and felt it prevented him from providing the best care. He struggled with it for years, before proposing to his colleagues that they try the concierge approach for at least part of the practice. But none was interested, and in June 2005, Weiner went off on his own -- becoming Rhode Island's first concierge doctor.

Now, more than a year later, Weiner has about 340 patients, well below the 600-patient cap, but enough, he says, to keep him busy and in business. He finds his new practice "liberating -- to enjoy the day, to feel good about your work, to see your patients happy about what you're doing for them."

Asked if concierge medicine were elitist, Weiner smiles. No doubt, he's heard that before. "It's a matter of choice, an alternative. . . . It adds a type of care. If choice is elitist, there's plenty of precedent for that." Some people pay more for private rooms in hospitals, or to send their kids to private schools, or to shop at Whole Foods.

Weiner says that roughly two-thirds of his patients have followed him from his previous practice, and they represent about the same mix of income levels. "I wasn't looking for this to be an exclusive country-club practice."

Weiner is working under a five-year contract with MDVIP, a Florida-based company that helps doctors manage their transition to concierge practice and provides office support services. When a doctor makes the change, MDVIP handles publicity, helps patients find other doctors if they decline the concierge model, and makes sure the practice abides by state and federal regulations.

MDVIP also provides a template for the practice -- such as a suggested panel of tests for the annual physical, a screening questionnaire for patients -- and a CD that each patient gets containing all his or her medical records. Each patient pays the $1,500 fee to MDVIP, and MDVIP returns $1,000 of that to the doctor. But the doctor handles his own billing with insurance companies.

The annual fee is intended to pay for services that insurance doesn't cover. Weiner accepts most insurance and Medicare as well, and will go to bat with insurers on his patients' behalf.

ONE MORNING, Sophia Meyersiek, a real estate agent, visits Weiner for a physical. Meyersiek, 56, had been a patient of Weiner's at the University Medicine Foundation. Although it was difficult to come up with the money, she decided to join his concierge practice because, she says, both her parents died of cancer after being misdiagnosed.

"I've decided that will not happen to me. . . . I want a doctor who actually cares for me and won't say, 'Go home and die.' "

Weiner typically spends 90 minutes on an annual physical. Much of that time is devoted to talk. Working from a thick folder detailing Meyersiek's previous care, Weiner consults every page, asking questions after question.

"There had been some fatigue," he asks her. "Has that abated?"

"I don't feel that any more," she replies.

"And the tennis elbow? Has that quieted down?"

He talks with her about her previous problems with heartburn, and moves on to the importance of increasing her calcium intake. Then, he gathers information about her family, inquiring about her mother's death from gastric cancer, her brother's heart attacks.

Finally, leaving no stone unturned, Weiner runs down a list of symptoms she hasn't mentioned, asking her if she has experienced, among other things, "fevers or chills, night sweats, weight loss or gain, chronic earaches, sore throats, ringing in the ears, change in hearing, hearing loss, chest pain, palpitations, loss of appetite, trouble swallowing, nausea. . . "

Weiner also performs a battery of screening tests, including testing Meyersiek's hearing, lung function and the percentage of oxygen in her blood.

These tests are not part of the typical physical, but Weiner says they are risk-free and inexpensive, and have occasionally proven crucial. A man who saw the dismal results of his lung-function test was finally motivated to quit smoking. Another patient learned of a brain tumor after Weiner detected an asymmetrical hearing loss.

"There's no downside to providing this comprehensive package," Weiner says.

Later, Meyersiek remarks: "He knows me and he knows my history. I do not have to go in and remind him who I am. . . . He cares, he takes the time to ask those secondary and tertiary questions that get to the bottom of the physical investigation of what's wrong."

Weiner says that other doctors often ask him if his patients act "entitled," taking advantage of his availability. He says it hasn't happened. People are courteous and grateful, and don't abuse their access to him. Nor do they demand inappropriate care by insisting they've paid for it. He attributes this to the trustful partnership he develops with his patients, and the time he now has to explain why, for example, a requested test or treatment isn't a good idea.

Sheila Hanley, 60, a Pawtucket teacher, takes her 94-year-old aunt, Edna Burke, to see Weiner. She has also signed on for herself, and her son joined the practice. "My husband's father was a doctor. This is the kind of practice our family was used to -- in terms of having a relationship, being able to call and speak to a person, not a machine."

For herself, and especially for her aunt, the $1,500 fee requires a sacrifice, but one she doesn't regret. "I'd rather do that than take a vacation, to be honest with you. . . . It's such a peace of mind for the patient, the family. It's worth that amount of money."

Lawrence M. Halperin, a 73-year-old financial planner from Warwick, who has survived a quadruple-bypass heart operation and an aortic aneurysm, also thinks the cost is well worth it. Halperin was flabbergasted last winter when Weiner called him from his ski vacation to see how he was feeling after a recent hospitalization.

Peter Arpin, 49, a business owner who also lives in Warwick, found Weiner through an ad in The Journal when the practice started. As a business owner, Arpin says he's impressed with the service he gets -- no waiting for a scheduled appointment, quick responses to his e-mails requesting Weiner's opinions on health issues. He was delighted when Weiner got down on the floor to demonstrate some exercises for back pain. "To me, it's very small investment. I'm big on prevention," he says.

SOME 40,000 people are patients of MDVIP doctors such as Weiner, and the company expects to have 50,000 by year's end. Of these patients, 70 percent are over 55 and half are Medicare beneficiaries. MDVIP now has contracts with 111 doctors; Weiner is the only one in Rhode Island, but MDVIP is recruiting other physicians here.

In all, there are about 400 to 500 concierge doctors around the country, according to Roberta Greenspan, a board member of the Society for Innovative Medical Practice Design. Concierge doctors are especially popular on the East and West coasts, and in major metropolitan areas, she says. The yearly fee averages $1,500 to $2,500, although some rural doctors charge as little as $600 while others catering to executives have gone as high as $13,000.

The American Medical Association does not object to concierge practices, but has ethical guidelines that require, for example, that when changing to a concierge practice, the doctor make sure every patient finds another doctor if they choose not to participate. The federal Medicare program also does not object, provided that beneficiaries who enroll in concierge practices are paying only for services that Medicare doesn't cover.

In East Greenwich, a married couple have taken a different approach to the concierge practice. Dr. David Candow, 35, and Dr. Beth Rocchio, 36, left their jobs at a clinic in Connecticut and last fall opened an independent practice, called Yestermorrow Family Medicine -- starting from scratch with the concierge model.

They are not affiliated with MDVIP or any similar company, and Candow and Rocchio do not accept Medicare or any insurance. (They provide patients with statements that patients can submit to insurers.) Patients pay them $150 a month for the first family member to sign up, $125 for the second family member and $100 for all others. In return, patients get a comprehensive physical, unlimited office visits and phone and e-mail consultations, access to their doctor by cell phone at any time -- and niceties such as cloth bedding on the examining tables.

WHILE PATIENTS rave about concierge medicine, some doctors are shaking their heads in dismay. Ejnes, the Cranston internist, says the state is already facing an impending shortage of primary-care doctors. If some physicians choose to see a quarter or a fifth of the typical number of patients, the burden on other doctors will only increase.

"To the extent that we're able to satisfy one segment of the population, that may be good for those folks, but it doesn't help the rest," Ejnes says. "It takes away from the rest." He'd rather see reform of the reimbursement system for everyone -- which he says would cost far less per doctor than what patients are paying concierge doctors.

"It's clear to me that a system redesign is absolutely necessary," agrees Dr. Mark D. Jacobs, president and chief executive officer of Coastal Medical, a large group practice. "We have to start by placing value on almost any kind of doctor-patient interaction."

(Last month, the U.S. Centers for Medicare & Medicaid Services announced that it planned to revise its physician fee schedule to provide more money for time spent evaluating and advising patients. Changes in Medicare payments often lead to changes in the private insurance reimbursements.)

Jacobs is highly critical of doctors who duck out, leaving behind four-fifths of their patients -- based on their ability to pay. At the same time, Jacobs acknowledges that he, too, draws a line based on money, although in a different place: he does not accept Medicaid patients because the state program for the poor pays too little.

"The economics of concierge medicine is very compelling," Jacobs points out. He grabs his calculator, punches in some numbers, and displays the results: a doctor with 500 patients paying $1,500 each has a gross income of $750,000. "The average internist probably makes $150,000, some a lot less," Jacobs said.

(Weiner says he's earning about the same as in the past; although he gets $1,000 from each of his roughly 340 patients, start-up costs and overhead have consumed much of that money.)

Dr. Arthur A. Frazzano, associate dean of medicine at Brown Medical School, says concierge medicine is potentially unethical because it limits access to care based on income, "and puts a class issue back in the practice of medicine."

"A physician is supposed to support access to medical care for all people," he said. "That's the bottom-line issue."

But Frazzano, a family doctor, acknowledges that he, too, burned out from practicing primary care, and now devotes only 20 percent of his time to patient care.

"It's a very difficult system to be working in for long periods of time."

ffreyer@projo.com / (401) 277-7397

About this series

When you're sick or hurt, you don't want to wait for care. You want to talk with your doctor, find out how serious it is, and get appropriate tests done -- now. But doctors can't always meet those expectations. This three-part series examines three approaches -- each controversial -- to providing quick access to medical care.

Today: Concierge medicine -- 24/7 access to your doctor, for a price.

Tomorrow: Open access -- getting to see your doctor on the very day you call.

Tuesday: The MinuteClinic -- no-wait treatment for minor ailments, at your neighborhood drugstore.

Your turn: Do you think concierge medicine is worth the price?