The effort to reform the American healthcare system could go in any one of a number of directions.
A growing number of primary care doctors are choosing their own path. These doctors have abandoned traditional ways of practicing medicine, and have turned to what's called concierge care.
When you walk into Dr. Marty Schulman's office in Encinitas, you notice there are a few things missing.
Back in one of the examination rooms, the visit begins.
Dr. Schulman: "So, how are things going now?"
Ellen Garner: "Things are going pretty good. I'm really, really happy with my job…."
Dr. Schulman and his patient Ellen Garner have time to schmooze a little bit before getting down to business.
"Now when you were here there last time we continued you on one medication, we added a different one," Dr. Shulman says. "How are things doin' with that?"
Schulman used to work in a typical managed care practice, with about 15 minutes to deal with each patient.
Schulman says it was like being on an assembly line.
"Hi how are you, what's your problem today?" says Schulman. "Oh, you got other problems? Sorry, I got someone in the next room. Come back and make another appointment. Oh, my next appointment isn't available for six weeks. Can it wait until then?"
These days Schulman gives his patients all the time they need. In fact, they can access him 24/7. Same day appointments? No problem.
For all this, Schulman's patients pay him $600 a year, plus a fee every time they come in. He doesn't accept insurance.
"So, you're paying for access, you're paying for time in the office," Schulman points out. "They can talk to me any time, refills are handled in a timely manner. For the most part I'm able to take care of things pretty quickly."
The concept is called concierge medicine. It started in Seattle in the mid-90s. Today, there are an estimated five thousand concierge practices nationwide.
Like Dr. Schulman, Dr. Joseph Scherger used to work in the UCSD health care system.
He's just been hired by Eisenhower Medical Center in Rancho Mirage. He's working on setting up an affordable system of primary care doctors on the concierge model.
"For $365 a year, we will be immediately available to our patients, we will do online communication with our patients, we'll be on the phone with patients, and we'll only see the patients whenever they want, but really as needed," says Dr. Scherger. "So the visit becomes a secondary activity rather than the only way you see your doctor or get care from your doctor."
Scherger says it's all about delivering better care. He says technology like electronic medical records and email are essential. Those tools allow doctors to help patients better manage their chronic conditions. That reduces the number of hospitalizations.
Keeping people out of the hospital is one of the keys to reducing health care costs.
Some criticize concierge care as being only for the rich. But supporters say yearly fees and visit charges don't have to be prohibitive. And they say nobody should have to wait for weeks to get a 15-minute appointment with their doctor.
Ellen Garner says the money she pays to see Dr. Schulman is well worth it.
"It's so valuable what I'm buying, the personalized health care", says Garner. "I wouldn't trade it for anything."
Dr. Scherger says the only catch to the concierge system is getting more doctors to embrace a different way of doing business.
"Changing how you work is not easy, even when it's for the better," Scherger says. "But this horse is well out of the barn, and you're gonna see it sweeping here. So, it's really a revolution that is spreading."
Kaiser Permanente has adopted part of the concierge model.
It's spent billions of dollars creating a platform where patients can go online and communicate with their doctors. Since Kaiser started the effort, it's reduced office visits by more than 25 percent.
