My doctor is going concierge, and if I want to keep seeing her, I have to pony up $1,500 a year extra. On top of insurance and copayments.

At an informational meeting, a patient asked if other physicians in town were going the same route. If they're not, my physician said, they'll be staffing up with more nurses physician extenders, she called them -- to handle the growing workload and increasing pressure to cut costs.

There's no doubt that the 32 million people expected to be covered under healthcare reform will strain the limits of primary-care practices and put pressure on physician reimbursement. My doc's answer is to join up with MDVIP, which allows her to trim her practice to 450 patients, promise same-day appointments, institute personal wellness plans, and offer a battery of tests to complement the traditional physical exam.

If it were my mother-in-law who were her patient, $1,500 would seem like a small price to pay for such ready access and someone to coordinate her care from an oncologist, cardiologist, podiatrist, dermatologist and orthopedist. But I don't think I need an Epworth Sleep Index or EKG.

Many of the 100-plus patients at my doctor's informational meeting were elderly and clearly happy with the care they get from her and her colleague (the two doctors will cover for each other under MDVIP). But $1,500 isn't chump change for someone on a fixed income. Several looked worried; one told me afterward she flat out couldn't afford the extra $3,000 for her and her husband to participate in MDVIP.

The irony here is that healthcare reform calls for a focus on wellness and better access to care, precisely what MDVIP is promising for a price. But reform also pushes for more efficient care, and for the healthy nonelderly, the concierge battery of tests does not fit that bill.

Doctors who choose concierge medicine are essentially opting out of healthcare reform. Implicit in their sell is the idea that only a primary-care doc with extra pay and lots of time can coordinate care well. The hope and promise of health reform is that health plans, physician groups and accountable care organizations with good systems and well-calibrated disease management programs can do just as well, and more affordably, for the many.

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