It was well past 7 p.m. on a recent weekday evening, and Dr. Marcy Zwelling-Aamot was explaining to a group of female patients how high blood pressure can damage kidney function.

As she lectured, the women relaxed in the ornate office, sipping wine, munching on crackers and Brie and smiling when the doctor let slip an occasional expletive. Later, they asked questions about medications and other medical problems.

It was an unusual gathering, to say the least. In a world of packed waiting rooms and insurance company paperwork, doctors hardly have time for patients’ office visits, let alone leisurely discussions over cocktails.

“She is one of a kind,” remarked one patient, Carol Peet. “How many doctors would have lectures? She is more concerned about her patients than any doctor I have been to and I am 63 years old.”

A year ago, Zwelling-Aamot was as overworked as many doctors. She had a patient load that topped 2,000 and kept her up well past midnight handling paperwork. But what really got to her was borrowing $50,000 from her father when insurance company payments were ratcheted down. “You realized you were in trouble,” she said.

Fed up, she opened a “concierge” medical practice, joining a budding movement of doctors who are opting out of the traditional insurance system.

Zwelling-Aamot no longer bills for individual office visits, and instead charges patients an annual $1,500 retainer for the right to see her as many times as they want. She also offers same-day appointments, her cell phone number for 24-hour consultations, and extras like the lectures. Traditional health insurance still pays for hospital visits, lab work and services like MRIs.

For Zwelling-Aamot, formerly president of the Los Angeles County Medical Association, the new regime has allowed her to cut her practice down to a maximum of 500 patients, a load that she says has helped bring some sanity back to her life.

“I couldn’t do the eight-minute physical. I was working longer and longer and things were getting tighter and tighter,” said Zwelling-Aamot, 51, who lives in Long Beach with her husband.

Making the decision

Zwelling-Aamot decided to make the switch after attending a convention in Denver last May of doctors who had opened similar practices.

“Every doctor there was happy, and they liked going to work,” she said. “They talked about their patients as if they were family. I said this was the kind of thing I want to be associated with.”

She began the transition last July and as of Jan. 1 no longer accepted patients who are not part of her concierge practice. There are an estimated 500 such practices nationwide, with the first opening up in the late 1990s.

Zwelling-Aamot decided on the $1,500 annual retainer and a target of 500 patients so she could generate about $750,000 in revenue. That should allow her to net about $150,000 once her startup costs have been paid off and costs for staff, rent, equipment, medical malpractice insurance and other expenses are subtracted.

She wound up spending “tens of thousands of dollars” to make her office look more like a home than a doctor’s office (an amount that would have been higher if her husband, a contractor, had not done most of the work himself).

But she considers it a key selling point of her practice. The flooring is expensive faux marble tile. The stuffed chairs are a kaleidoscope of colors and patterns. There are hand-drawn visages of Hippocrates and other historical medical figures on the walls.

She also hired a marketing specialist and conducted 17 “Evenings with Marcy” trying to sell the practice to her patients. “I know it’s worth it, but it’s trial and error this year,” said patient LeDean Lewis, 78, who acknowledges the extra $1,500 expense has made it difficult for her to “balance her budget.”

Reaching her target

So far, more than 400 patients have signed up, and she is still trying to reach her target. She sees just eight to 12 patients a day. Patients no longer wait for hours, and the visits themselves are longer. She also takes Tuesday off, though she’s still available in emergencies. “I fill my time,” she said. “My physicals are an hour-and-a-half long, and if a patient needs other time I give it.”

Unlike other concierge doctors, Zwelling-Aamot has not dropped out of the medical establishment. (She is still a trustee of the California Medical Association and a delegate to the American Medical Association.)

And while some concierge doctors only take cash for services, including the X-rays and other diagnostic procedures that typically are not included in an office visit, many of Zwelling-Aamot’s patients have traditional insurance or Medicare, so her staff is still on the phone with insurance companies.

In altering her practice, Zwelling-Aamot has also become part of a growing debate about the ethics of concierge medicine.

The Centers for Medicare & Medicaid Services says that these practices do not violate Medicare law as long as they are properly structured. But the Government Accounting Office is conducting a review, spurred by criticism over the phenomenon’s effects on poor patients.

“The problem is that it’s not a model for a health care system. It’s useful for those patients who can afford to put up $1,500 on top of the health care costs they already pay,” said Anthony Wright, executive director Health Access, a state patient advocacy group.

Dr. Jack Lewin, chief executive of the California Medical Association, said he agrees that concierge practices only make sense for certain patients and doctors. “We are supportive of what Dr. Zwelling and others like her are doing, because if she wasn’t doing it she probably would have dropped out of practice altogether,” he said.

Nevertheless, he’s concerned that concierge medicine is another example of a growing “two-tier medical system.” In a decade, he fears, many middle-class or lower middle-class families could end up without a family doctor.

The American Medical Association reviewed concierge medical practices last year and decided to endorse the practice, as long as doctors make sure that patients who do not participate are placed with other doctors.

In addition, doctors are supposed to continue caring for patients who can’t find another physician, and should make efforts to provide pro bono care.

Zwelling-Aamot offers free care to about 40 patients, though she requires they do some community service in exchange. “I didn’t feel it was right to say to a healthy person, ‘I will take care of you for free,'” she said.

Peet is among the patients receiving pro bono care. She admits she was “devastated” when she found out Zwelling-Aamot was changing her practice, since she wasn’t working at the time. “I knew I would have to go to a different doctor, but she said, ‘No, you are not going anywhere,'” said Peet, who suffers from a variety of ailments.

Other doctors in the Los Alamitos and Long Beach area are watching Zwelling-Aamot’s practice to see how it turns out. Dr. Joe Chen, a gastroenterologist who works with Zwelling-Aamot’s patients, said he doesn’t think many doctors can make such a practice work or really would want to open one.

“You have to have a very good physician-patient relationship to make it happen. Marcy is unusual,” he said. “And once you set it up you have to be available all the time. Not all physicians want to be available all the time.”