Some doctors are charging $1,500 to $1,900 a year, to give patients telephone access at all times, same-day appointments and, in some cases, house calls. Concierge practices typically limit the number of patients to no more than 600. That contrasts with as many as 3,000 in a traditional internal medicine practice.

Patients in these practices generally fall into two categories. One is busy, successful executives who want personalized care around their schedule. The other is retirees with multiple medical problems who are frustrated with the Medicare system.

For patients who can afford the service, having a doctor readily available offers peace of mind. It is comforting to know that a doctor who knows you best is just a quick phone call away.

MDVIP, an association of doctors who have this type of practice, maintains an online provider directory.

A big push is on to convert medical records from paper and film to digital records. (See New York Times article, "Smart Care Via a Mouse, but What Will It Cost?" The obvious benefit for us as consumers of healthcare is based on instant access to our medical records by doctors who may be faced with saving our lives, perhaps away from home. The obvious concern is about privacy and security.

What the enthusiasm is really about: not computers and software, but health information in the form of electronic records, stripped of personal identifiers, that can be easily shared, searched, measured and analyzed to determine what treatments and drugs are most effective, and at what cost.

Michael O. Leavitt, the Secretary of Health and Human Services, recently said the rollout of electronic health records was “the most important thing happening in health care.”

I had a routine physical a couple of weeks ago, something I do every 3 years, and I was back at home before I realized I hadn't asked my doctor several questions that had been on my mind for months. Apparently, I'm not alone. Research shows that although most people claim to want as much information about their medical conditions and treatments as they can get, even the most confident are struck dumb (even with their clothes on) when talking to doctors.

Virginia Teas Gill, a medical sociologist at Illinois State University, said, "Some patients show up to a scheduled appointment with a fistful of questions, and that’s fine. But, to get them answered, write the questions down beforehand, and say at the outset of the office visit: ‘I’ve got some questions. When would be the best time for me to ask them?’ That alerts the doctor — who has to keep an eye on the time — to what the patient’s agenda is, so that the two can prioritize what to cover and decide whether they’ll need a follow-up meeting".

The internet is already transforming many medical encounters. Some patients now come armed with journal articles and printouts, and demand specific treatment. Doctors may give in to a patient’s request, if it is made in an assertive manner. (They don't like confrontation any more than the rest of us.) But the patient may lose the advantages of the physician’s experience. You may end up getting what you want, not what you need.

I recommend a book, You: The Smart Patient: An Insider’s Handbook for Getting the Best Treatment,” published this year. Written by two physicians — Michael F. Roizen and Mehmet C. Oz — the book helps patients cut through medical jargon, find a good surgeon or hospital, get a second opinion and navigate health insurance problems.

I have been buying my wife's prescription drugs at CanadaDrugs.com for a couple of years now and have been very satisfied with the price, quality, and service.

Buyers must beware, though, because not all prescription drug web sites using the name Canada are selling genuine drugs. Some are not even in Canada. The FDA just released (Aug. 31, 2006 ) the following list of companies selling fake drugs and recommends that people who have bought drugs from these web sites not use them because they may be unsafe.

www.RxNorth.com
www.Canadiandrugstore.com
www.Rxbyfax.com
www.Northcountryrx.com
www.Canada-pharmacy.com
www.My-canada-pharmacy.com
www.NLRX.com
www.Canampharmacy.com
www.Canada-Meds-For-Less.net
www.Canadian-safe.com

These web sites are owned by or have orders filled by Mediplan Prescription Plus Pharmacy or Mediplan Global Health in Manitoba, Canada.

Young adults are dropped from their parents health plans between age 19 and 24. Most people this age know practically nothing about health insurance and many could care less. Unless their parents lead them by the nose or purchase individual plans for them, they are at a loss.

Sponsored by Aetna and the Financial Planning Association, the interactive website, AllAboutTheBenefits.com, guides young workers through typical experiences with information and real world examples - - graduating from high school or college, interviewing and starting a new job and budgeting for new expenses. AllAboutTheBenefits.com focuses on topics such as:

* Bridging from their parents' or college's health plan to their own
* Asking questions about health benefits during a job interview
* Making sense of health benefits options
* Translating insurance lingo
* Budgeting for health expenses

Brace yourselves, according to a recent Los Angeles Times article doctors are billing for things like prescription refill requests, copies of medical records, phone consultations, family medical leave forms, medical disability forms, waivers of insurance premiums, waivers for handicapped plates. Other physicians, notably pediatricians, charge patients for after-hours calls, passing on the $15 or $20 per call that they're billed by the answering service.
Almost unheard of five years ago, the practice has disgruntled some.

The article quotes, Arthur Levin, director of the New York City-based Center for Medical Consumers, "It shows that healthcare is like any other enterprise: It is revenue-driven”. Duh! Where has he been? Of course, healthcare is revenue driven. "In the old days, we just did it, it was part of doing business and doctors would absorb the cost," says Dr. Richard Lander, a New Jersey pediatrician who currently charges $5 for school, camp or athletic participation forms. "But in today's climate with so much paperwork involved, doctors feel they can no longer give services for free." Lander recalls the reaction when he first started asking for the fee five years ago. "People were astonished. They were incensed. I had a few patients who left my practice," he says.

My opinion? This practice does not bother me. First of all we're not talking about a lot of money and secondly, I'd rather pay for the administrative services I request than being overbilled for medical services to pay for someone else's paperwork.

How do you feel about it?

I've talked about medical cost transparency (clearly stating the cost of medical services) by hospitals and doctors previously. While doctors and hospitals continue to drag their feet, the federal government and some insurers have begun to respond. Last week, President Bush signed an executive order requiring four federal agencies to compile and release information about the quality and price of health care provided to people they cover. Medicare now posts on its website how much it pays for 30 medical procedures in each of the nation's counties, along with data on how many of the treatments each hospital performed last year. In general, the more experience a facility has with a procedure, the better the outcome for the patient, studies show. Aetna, which covers 30 million beneficiaries, will make physician-specific information on fees, clinical quality and efficiency available to its members in seven states.

Consumers wouldn't think of buying a new car without knowing the sticker price and gathering some information about reliability, yet they'll go ahead with a knee replacement with little thought of the actual cost of treatment, and with virtually no information about their hospital's track record with that procedure. Patients who try to ask about price are unlikely to get a straight answer. "It depends" is how most hospitals will reply because they have sliding scales of fees based on a patient's insurance, discounts negotiated by health plans, and potential complications in treatment. Bills are incomprehensible.

Are you aware of other instance of medical cost transparency that you'd like to share?

Health Savings Accounts (HSAs) are going to be the most prominent health plan option for the individual buying his or her own health insurance within a year or two. In five to ten years. I think, it will be the only option for many Americans on employer paid health plans. Why? Because the premiums for traditional health insurance keep going up, and by using HSA-linked plans, employers can more precisely budget what their health tabs will be. “With traditional insurance plans, employers are basically giving employees credit cards and paying the bill for them at the end of the month”, said Kate Kohn-Parrott, director of integrated health care and disability for the Chrysler Group.

Critics say the plans are just another tax-sheltering tool for the healthy and wealthy and I agree. If you are “wealthy” enough to save some of the money you earn and are healthy enough to qualify for health insurance, there is no better option for you than the high-deductible health plan with a health savings account.

What’s new is that big companies like Chrysler are offering high-deductible health plans and health savings accounts. In most cases, the employee is responsible for building up savings in the tax-free HSA. But at Chrysler and some other companies, the employers also are contributing to the accounts. In 2006, Chrysler contributed $500 to each individual's HSA and $1,000 to each family's HSA. Chrysler also offers paid coverage for health screenings and annual physicals.

Nationwide, 3.2 million Americans -- from corporate employees to the self-employed -- have enrolled in the high-deductible health plans, up from 1 million just a year ago, reports America's Health Insurance Plans. The U.S. Department of Treasury projects that between 7 million and 21 million Americans will have HSAs in four years.

Young adults make up the fastest growing portion of the uninsured population. Insurance companies refer to them as “Young Invincibles”, probably because people at this age think that they will last forever. Many colleges have begun to require students to purchase health insurance - either private insurance on their own or a university policy.

College students are already more likely to be insured than others their age. Most state laws let parents keep college students on their policies until age 23. Those that don't attend college, leave their parents' policies by age 19, under most state laws. Most young workers don't have health insurance where they work or think the price is too high. Some young workers just decide to go without. Young people do not perceive health insurance as a good deal, paying the cell phone bill is much more immediate.

Assurant Health Insurance Company aggressively sells short-term policies for young people. Wellpoint Insurance company markets health insurance plans targeting this market called Tonik Plans in California or Sound Plans in Texas and Illinois. Wellpoint’s tactics of blending hip marketing materials, quick online applications, and comprehensive coverage at competitive prices have worked well.

Now that I'm paying a bigger share of my healthcare costs. (I have a high-deductible PPO plan and a Health Savings Account), I am more careful about reviewing bills from doctors and hospitals than I was back in the day when my employers health plan paid for everything. Even though I'm in the healthcare business, it's very difficult to for me know if there is a mistake in a bill. That's because everything is coded, making it practically incomprehensible for the lay person.

If you're faced with a huge hospital or doctor's bill, it may be worth getting an advocate to help you. There are a growing number of medical billing advocates to help people deal with healthcare billing issues. Fees for services can run from less than $50 an hour to more than $200. In some cases, advocates take a percentage of the amount they recover. Here is a good place to start: Medical Billing Advocates of America, 540-387-5870 Online Advocates Directory

I am Phil Daigle and I author the Healthcare Shopper Blog. I am the founder and CEO of HealthcareShopper.com, LLC. - a national health insurance agency based in Laguna Beach California. I pioneered the marketing of health insurance via the internet in 1996. Today, HealthcareShopper.com provides health insurance to individuals and families throughout the United States. Currently, we have over 2,000 customers.

I share what I know about the health care business with my customers. potential customers, and friends to help them become informed consumers of healthcare.

Psychology Today has a Find a Therapist Website that's worth visiting. I put in my ZIP code and instantly viewed 22 psychotherapists. You get a picture and profile of each therapist.

Just yesterday I wrote abouth the need for medical cost transparancy to help us become smarter consumers of healthcare. Today I spotted this article in the PalmBeachPost.com.

Quote, "The information helps consumers doctor shop because rates can vary. For example, Aetna pays West Palm Beach orthopedic surgeon Pierre Girars $1,713 for a hip replacement. But it pays another West Palm Beach orthopedic surgeon, Milan DiGiulio, $1,456 for the same procedure. Doctors get paid differently because they negotiate with insurers separately."

Kudos to Aetna, the first to break the veil of secrecy. "Insurers have closely guarded payment data in the past, citing competitive pressures...Aetna tested its new doctor-pricing data in Cincinnati last year. In that market, about 1,000 consumers each month looked at the database, Aetna officials said. In addition to South Florida, the program is being rolled out in other markets, including Ohio, Connecticut and the Washington, D.C., area." The information is available to Aetna members in the markets mentioned above at AetnaNavigator.com

Health insurance companies who offer private health insurance to individuals and families get to pick whom they want to insure (notable exceptions NY and NJ). They will decline us for coverage if they think they might loose money by insuring us. Also, a lot of us just can't afford decent coverage. It's not fair. It is what is.

I refer my friends and clients who are unfortunate enough to fall into this category to the Healthcare Options Matrix, a state by state matrix of options for individuals unable to obtain health insurance due to medical conditions or financial need.

I'd like to thank Phil Lebherz, Executive Director, of the Foundation for Health Coverage Education’s (FHCE) for putting this information together. The FHCE’s original mission was to focus on the uninsured population in California; however, news about the Matrix and Help Line traveled fast and many states began asking the FHCE for versions based on their state’s options. In response to the demand, the FHCE developed a customized Matrix for every state in the nation.

You may have heard the term "consumer directed healthcare" recently. The idea behind the term is this: smart consumers can decide how and where to get the best medical and financial outcomes for ourselves within the guidelines of our health insurance plans.

In the days of employer provided health insurance, plans covered everything with only nominal costs to the consumer, there was no need for smart shopping. Today, it's more likely that we have a high-deductible health insurance plan, meaning less insurance cost to us and our employer, but more out-of-pocket expenses for us. Now it's our money that we're spending and it's time to pay more attention to costs.

Unfortunatley, we are just beginning to get access to the kind of information we need to make informed decisions. Our health insurance carriers need to give us access to their negotiated rates with providers. For instance, my insurance company will pay 80% of the negotiated rate for an MRI. But there is no way to know what the negotiated rate for Provider A is versus Provider B. So how would I know which diagnostic provider is going to be cheaper for me. The difference can be huge. I had an MRI on my knee a couple of years ago and the hospital bill (retail price) was $1700. My insurance company had negotiated a discounted rate of $800. Great deal right? But what if I could have shopped other providers of MRI services in the area? I probably would have saved money.

Some data is now available for comparing hospital costs, so that we can compare the retail price range for comon proceedured between hospitals - check out Healthia (free), or My Healthcare Advisor ($24/yr) as examples of hopeful signs for the future. This kind of comparing lends itself to the internet and no doubt there'll be tools available to make us smarter consumers of healthcare.

How do you go about choosing a doctor? Most people rely on the recommendations of non-medical friends and acquaintances. If someone asked me, I'd recommend my doctor. I've been seeing her for about 10 years and I think she's a good doctor. But I'd also have to say, she's a lousy manager because her office staff sucks. You can't get through on the phone. They loose stuff. So if you asked me, I'd tell you about the good and the bad.

There's a website called RateMDs.com, that let's you rate your doctor for all to see. It's still relatively new, so you may not find much information about docs in your area yet. This type to website depends on community involvement. That's one of the reasons I want you to check it out because I want it to succeed. I really need a place like this to recommend to my clients and friends who are looking for help in choosing a doctor. Oh by the way, it's FREE.

Let's say you need back surgery (Discectomy and Laminectomy). How would you go about picking the hospital that would give you the best chance for a satisfactory outcome. If you're like most, you'd probably select a hospital close to home with a good reputation. You might not be making the best choice.

You might find as I did that the local big-name hospital, 10 miles from your home, does only half as many of these procedures as a lesser known hospital 45 miles away. The lesser known hospital also had fewer patients with complications from this procedure. You can even compare charges - prices range from $10,400 to $213,300. Quite a range.

I recommend My Healthcare Advisor.
For an annual subscription of $24, you can sign up for your own personal access to My Healthcare Advisor. Well worth it.