In a perfect medical world, patients get to see a doctor the same or next day, and they never wait once they arrive for a visit.
Consultations proceed at an unhurried pace and start with extensive executive-style annual physicals.
Doctors also do house calls and make themselves available by cell phone around the clock.
That's the world Dr. Ronald Santasiero wants to offer his patients. But it will cost them.
Santasiero, a Hamburg family physician, is joining a small but growing number of primary care doctors nationwide who are replacing their traditional practices with "concierge medicine."
They treat a much smaller number of patients who pay a fee for better access and more attention.
In August, he will limit the practice to 400 of his 3,000 patients -- about half of whom visit regularly -- who are willing to pay at least $1,650 annually for individuals and $3,000 for couples.
Some doctors in concierge medicine keep only those patients who sign up. Others, like Santasiero, hire physician assistants to see those patients who want to stay but not pay.
The growth of concierge medicine -- also known as boutique, VIP or personal care -- coincides with the increasing frustration of many physicians.
"The health system is a dysfunctional mess. You spend a ridiculous amount of time jumping through hoops for insurance companies, time that should be spent with patients. I can't change the system, but I can change the way some of my patients get their care," said Santasiero, who appears to be the first physician in the Buffalo area to convert to the cash subscription model.
The appeal of concierge medicine is obvious, yet it remains controversial.
Doctors get more time with patients and their own families, fewer hassles, and possibly more money. Patients get enhanced service.
"The executive physical alone and the counseling afterward are worth the money. I think he's going beyond what your normal doctor would do," said Madeline Brown, who signed up with her husband, Mel, after a recent presentation by Santasiero.
But the trend worries critics who see the approach as catering to the wealthy, forcing many patients to find new doctors and, if it gains in popularity, worsening a projected shortage of primary care physicians.
"It's difficult to vilify those doctors who feel for one reason or another forced into starting a concierge practice, although I have no sympathy at all for those who did so simply to make a financial killing," said Dr. Michael Stillman, a Boston, Mass., internist who took up the issue recently in the Annals of Internal Medicine.
If reaction to his article is any indication, he said, most doctors believe that the practice violates a basic tenet of the medical profession to treat without exception all who seek a doctor's services.
The concept of concierge medicine started in 1996 with MD Squared, a medical practice in Seattle, according to the American Academy of Private Physicians, a Glen Allen, Va. trade group.
Since then, the approach has been adopted by about 3,500 physicians in the United States who limit their practices to 400 to 600 patients, said Tom Blue, the academy's executive director.
"Primary care isn't a sustainable business model for doctors, and consumers are starting to realize that having an insurance card doesn't guarantee access to a physician," he said.
Santasiero, 59, trained in family medicine but also became an early adopter of acupuncture, pain management and holistic medicine. He and his wife, Cherie, in 1995 founded the Sedona Holistic Medical Centre, which combines a traditional medical practice with alternative therapies.
"Fifteen years ago, I used to reach for the prescription pad first. Now, I reach for it last. I reject the idea that health and longevity can come alone from little brown prescription bottles," he said.
Over the years, his disenchantment with the health care system has grown. He views dimly the bureaucracy of Medicare, the government health plan for the elderly, and the reimbursement policies of insurance companies, especially their reluctance to value alternative medicine.
Santasiero cited studies that show the United States spends far more than any other country on health care, yet lags far behind on such key measures as longevity and infant mortality.
He described how primary care doctors -- these include family physicians, internists and pediatricians -- today struggle with larger workloads, piles of paperwork and an income gap with specialists.
The field has become unattractive to doctors-in-training. The Association of American Medical Colleges projects that the nation will experience a shortage of about 160,000 physicians by 2025, including 46,000 primary care doctors.
All of which makes the country ill-prepared to absorb millions of newly insured patients from health reform, he said. Without changes to energize primary care, he foresees a dark future in which patients receive lesser care in brief encounters from anonymous providers.
"The era of the family doctor will fade away," he said.
After making the decision to pursue concierge medicine, Santasiero began working with SignatureMD, a Santa Monica, Calif., company that helps doctors establish and run the practices.
The company, started in 2007, tries to differentiate itself from competitors by working with physicians to retain as many nonconcierge patients as possible with the use of physician assistants or junior physicians.
"Most of the patients who choose personal care have a high affinity for their doctor and highly value their health. Most of them are well and not high utilizers," said Matt Jacobson, the company's founder.
He and others defend the concept, saying people routinely spend equivalent amounts of money on such products and services as cigarettes or cable television. They argue that concierge medicine isn't the reason primary care is failing, just a symptom of the problem.
If anything, Blue said, concierge medicine represents a "correction" back to the number of patients doctors should have to do their jobs well.
Jacobson also said he prefers not to use the phrase "concierge medicine" because it evokes an elitist image that doesn't fairly represent the business.
"We attract everyone from middle income to high income," he said.
Patients pay the fee annually -- or monthly for a slightly higher price -- in addition to their regular insurance co-payments for office visits.
The annual fee is for extra attention from a primary care doctor, the physician patients generally see most often and who handles basic medical needs. Individuals who opt for concierge medicine also need to keep health insurance to cover the cost of diagnostic tests, care from specialists, emergency room visits, surgical procedures and hospitalizations.
The Browns, both in their 60s, describe themselves as "average Joe people." They said they chose concierge care not because they are wealthy and can afford it, but because they like the idea.
"He is going to spend the time to teach us how to be healthy," said Madeline Brown, who opened Kitchen Creations of Western New York three years ago with her husband.
It's unclear whether concierge medicine will be a small niche in medicine or grow to play a larger role.
If it does become more popular, Stillman, the Boston doctor, and others worry that it will leave behind the poor, the elderly, the chronically ill and minorities.
Santasiero respects the concerns but sees concierge medicine as restoring the concept of placing the patient first.
He acknowledges that concierge medicine will divide patients by ability to pay, but counters that so does the current health system.
"This fits what I want to do," he said. "It's the only way I can provide the kind of health care that I want to deliver and that my patients deserve."