Dr. David Grulke, a 54-year-old internist in Norfolk, saw only two choices ahead of him: quit medicine or reinvent the wheel. Continuing the way he was going — seeing close to 30 patients a day and coming back to the office until midnight to complete the paperwork — was simply not an option. “Medical care has deteriorated in the past 10 years, primarily because of managed care,” he says. So Dr. Grulke stopped accepting insurance payments. As of June, patients who want to see him pay a monthly fee and in return receive unhurried personalized care.

Dr. Grulke’s reaction was an atypical one to the increasingly common backlash against managed care. A decade ago, managed care was seen as a promising way to control costs and, to a large degree, it was successful. Health care premiums stayed fairly steady for most of the last decade. Yet these days, there’s just not a whole lot left to squeeze even while businesses are hit with double-digit premium increases, which they often pass on to employees. To cut costs, HMOs still insist that they control access to specialists, while drugs cost more and hospital labor is more expensive. Even so, physicians such as Grulke earn less money for an increasingly unsatisfying experience.

Dr. Grulke’s radical move underscores the frustration of primary care physicians, who feel they need to see more patients to keep up their incomes. Dr. Grulke doesn’t charge very much for his plan, so it is sort of the common man’s version of the “concierge care” for the well off. Yet as more people seek to get out of what they see as a broken health care system, the end game could be that the well off buy the best care or there are fewer physicians available for the rest of us — or both.

However, paying more for health care doesn’t necessarily get you better health care, says Paul Lombardo, director of a program in law and medicine at the Center for Biomedical Ethics at the University of Virginia. “Some people buy extraordinarily expensive cars even though they won’t get them home any faster.” It’s hard to say how many doctors are doing the same thing. Dr. Grulke said he got the idea from Seattle physicians, and there are several firms in the U.S. who are working to franchise similar practices. None responded, however, when asked if they’ve made headway in Virginia. “If this is a trend,” says Lombardo, “what it points up is the general disaster of our non-system of health care. We have 40 million people who have no regular health care. I’d lose sleep over that rather than the fact that a few very wealthy people will be able to buy their own care.”

So far, more than 800 patients have been willing to pony up the monthly fee — ranging from $28 to $68 depending on age — to get care from Dr. Grulke or his partner, Dr. Stuart L. Shepheard. Some have increased their insurance deductibles so their net increase in cost is slight. They still keep insurance to cover hospitalizations, lab tests or visits to specialists — which serves to protect Dr. Grulke from being financially swamped from having to care for extremely sick patients. However, Dr. Grulke insists he’s not “cherry picking” only the healthiest patients. His practice includes patients who have chronic illnesses and see him regularly. Plus, Dr. Grulke believes his way of doing things can ultimately reduce health-care costs. “We’ll order less tests and provide more thorough care. I don’t have to order each test at the first visit. I can wait until the second or third visit to see if they need it. That can save hundreds in co-pays for tests these patients might not need,” he says.

Drs. Grulke and Shepheard capped their patient base at 600 each; they used to have 2,000. If more patients want to get into the practice, they’ll consider adding more doctors. Patients who are with the practice get, in essence, a return to the old days. They have their doctor’s phone number; if they need to go to the hospital, the doctor will meet them there. When they come to the office, they’re not told to wait in a crowded reception area, but are typically ushered to an exam room. And they’re not pushed out the door seven minutes later.

Nearly everyone can point out something that is wrong with the health-care system. Physicians will say they’re being paid disproportionately well for more expensive services. For example, the fee for a Caesarean section is higher than the one for attending an all-night labor. Others say patients need to take more financial responsibility. Paul Ginsburg, president of the Center for Studying Health System Change in Washington, D.C., says businesses sharing costs with employees is “the most important trend in health care.” While it could help drive down costs, it will increase the hassle factor for physicians. “Physicians are going to have to collect these payments, and will ultimately be paid more slowly and with more difficulty,” he predicts.

Blaming all the health care problems on managed care, however, is just piling on, says Mark C. Pratt, executive director of the Virginia Association of Health Plans. “Were it not for managed care, the premium increases would be higher still. Traditional fee-for-service plans are on average 25 to 30 percent more than HMO products.” Even so, he admits that managed care “helped create the perception that health care comes with a $10 co-pay. When you buy automobile insurance, you don’t expect to get oil changes with it. But with health care, patients expect everything.”

Ron Pollack, executive director of Families USA in Washington, D.C., says the term “consumer-driven health plan” is a misnomer. “These are systems of choice, but they are created in such a way that consumers need to pay more in deductibles or co-payments.” That enables fragmentation in insurance pools. In other words, younger or healthier workers will hedge their bets with high-deductible, low-premium options, putting less money into the system. “The whole notion of an insurance system is predicated on spreading risk between those who make claims and those who don’t. The more it’s fragmented, it leaves the people with the greatest need without the ability to spread their risk.” Pollack argues for greater investment in public programs.

Whatever policy changes come about, Dr. Bill Hazel, president of the Medical Society of Virginia, empathizes with Dr. Grulke and other primary care physicians. He’s an orthopedist, so unlike primary care doctors, most of his profits come from his surgical business. Lower fees and increasing costs have put a real burden on primary care physicians, he says. For his part, Dr. Hazel’s practice in Herndon is trying to beat the system by joining it. It has grown to include about 30 medical partners and 300 employees. But it’s different strokes for different folks, he says. “I absolutely can sympathize with what these doctors are doing. Do I completely understand the ramifications or is it the right thing to do? We’ve got a lot to find out still.”

Yet as far as Dr. Grulke is concerned, there’s no doubt it was the right thing to do. “I’m so much happier. My patients say I look healthier. I’m ready to go another 20 years.”