In the cattle-call of modern medicine, a doctor may have to take responsibility for 4,000 patients. With health maintenance organizations controlling the purse strings, doctors must squeeze in as many patients as possible. Visits with patients seem more like speed dates than real medical exams.

Those common complaints from doctors and patients alike have spawned a niche market challenging the HMO model. Called concierge or boutique medicine, it gives faster service in exchange for an up-front fee, typically in the low thousands of dollars a year. Some doctors accept HMO patients; others get out of the business entirely.

Making concierge medicine work has proved hard in practice. Many people find the prepaid fees too expensive, doctors say. Some of the most costly aspects of health care aren't covered. So while there's been a lot of talk about the concept, it has remained a niche. Yet the allure is so strong that doctors aren't giving up on it.

"It's attractive in that it brings back the old 'Marcus Welby' doctor," said cardiologist Anthony N. DeMaria, director of the cardiovascular center at UC San Diego. The iconic 1970s television Dr. Welby had seemingly unlimited time for his patients, representing a fusion of competence and compassion that today's hasty visits don't have time to cultivate.

DeMaria wrote about the practice in the July 19, 2005, issue of the Journal of the American College of Cardiology. He said in a phone interview that the surge of enthusiasm for the concept that existed when he wrote that article had slowed down. However, DeMaria said that if concierge medicine ever caught on in a big way, it would strain the medical system.

"If a significant segment of physicians gets drawn away to take care of a very small number of wealthy and generally healthier population, that could make things even worse for the patients and physicians who remain," DeMaria said.

Focus on patients

Julie Aspiras, an internal medicine doctor, signed up a year ago with one of the top concierge medicine firms, MDVIP of Boca Raton, Fla. Aspiras, one of three doctors listed on the company's Web site as practicing in North County, said she's happy with the results. She's trimmed her patient load from more than 3,800 to 600, which she said is exactly the right number.

For $1,800 a year, patients get faster access, along with other services, such as preventive care, that are not always offered by health insurance companies, Aspiras said. Patients use their health insurance to get care as usual, Aspiras said.

"What this offers is, we will guarantee you that if and when you need a physician, the same day or next you will see the physician," Aspiras said. She's able to do that because instead of seeing 20-25 patients a day, she's seeing just five to seven a day.

"We are able to coordinate their care," she said. "I have time to pick up the phone and talk to specialists, for example. I have time to go over the results with them (patients). Each visit is at least 30 minutes, minimum.

"The benefits include a mini-CD the size of a business card that contains the patient's medical information, to be carried by patients if care is needed while traveling. And if patients need treatment for a serious illness, MDVIP will help them find the top specialists, even if they're across the country, and take care of their travel arrangements."

Because the company is nationwide, patients traveling can see a MDVIP physician in that area under the same terms as if they were at home, Aspiras said.

Quick access

Marty Schulman adopted the concierge doctor model in 2005. He is a family medicine doctor in Encinitas and an associate clinical professor in the family medicine division of UC San Diego Medical Center. Schulman described himself as burned out from not having the time to give his patients the care they deserved,

"I know doctors who have patient panels of 3,000 and 4,000," Schulman said. "They'll typically have what we call mid-level providers -- physicians' assistants and nurse practitioners -- helping to take care of them."

Schulman said he would typically see three or four patients an hour. He often had to cut visits short with some patient problems left unaddressed. The patients would then have to make another visit for the less-urgent issues. That was inefficient and frustrating for everyone.

Unlike Aspiras, Schulman is not affiliated with a concierge medicine firm; he practices independently. Schulman said his goals are to see patients within a day of when they call for an appointment; to see them on time; and to give them enough time to address all their medical needs.

For this care, patients pay $600 a year for membership. It's paid in $150 quarterly sums, through automated payments, plus a preset fee for each visit, depending on the complexity. Schulman charges $50 for a visit to evaluate and manage a simple medical problem, and $120 for a visit for a complicated problem or many single problems. An annual physical exam costs from $110 to $145.

Schulman's practice takes only cash, checks and credit cards. There's no need for a billing and collections service, because the fees are collected upfront. That simplifies finances, he said. In addition, relying on cash alone avoids contracts with insurance companies.

Patients with health insurance may be able to get reimbursement. However, since Schulman is not part of any HMO, the reimbursement would be for an out-of-network doctor, which pays less than for a doctor in the network.

"It's not profitable for me yet because I don't have the patients yet," said Schulman, who said he has about 260 patients.

He estimates he needs between 400 and 500 patients to achieve his former income. He's got about 170 patients now. That compares with a patient load of 2,000 for doctors whose practice is mainly managed care, he said.

Schulman said one of his major problems is "getting the word out."

"Marketing is not something that doctors are used to doing, at least a primary care doctor," Schulman said. He does not accept health insurance, so his name doesn't appear on any of the HMO rosters of approved doctors.

Patients find Schulman either through his Web site, http://www.martyschulmanmd.com, or through word of mouth.

Taking control

Robert Ashley, a patient of Schulman's, said he met the doctor while he was director of nutrition services at the medical center.

"He had such a loving and caring sense of patient care that he could not fit into the box that was UC San Diego Medical Center," said Ashley, who is being treated for a rare form of lymphoma, a blood cancer. "He was the most popular person at UCSD family medicine. Marty is the kind of guy who felt he had to sit and talk to you and find out what's going on."

With the concierge model, doctors regain control of how many patients they see, Ashley said. This gives them the time to make difficult diagnoses.

Ashley said he saw this in action when he arrived early to meet a North County Times photographer who was going to take his photo with Schulman.

Arriving well ahead of schedule, Ashley said he observed Schulman conferring with a patient.

"He spent 90 minutes with a lady while I was there, to find out exactly what was going on with this woman," Ashley said. "This had nothing to do with the article. This was early in the morning, way before anything was scheduled. It wasn't for show or anything like that. I was just going to spend some time talking with him."

Ashley said he pays nothing for Schulman's care. He has been a longtime patient of Schulman's and his complicated condition, which has required several surgeries, demands careful monitoring.

"He has been supervising my health care through all of the crises I've been through, and he feels a personal responsibility, and he won't even let me pay the annual fee."

Contact staff writer Bradley J. Fikes at (760) 739-6641 or bfikes@nctimes.com.