For $1,500 or more, some local doctors offer "concierge" services such as 24-hour direct access, comprehensive testing, home visits and wellness counseling. Dan Bryant left a meeting a few weeks ago unconvinced at first that his doctor's offer of longer appointments and more tests for a $1,750 annual fee was something he needed.

He attended the meeting with several hundred patients who had responded to the mailed invitation to hear about "a new program." By the time he got home, he'd made up his mind.

"I told my wife, if all I do is get the physical and the tests that are part of my physical, I will have felt like I have gotten my money's worth," said Bryant, 56, a local businessman.

Bryant signed on to be one of the 150 patients who will get "concierge" care from Dr. Michael Mandel, who starting this month will devote part of his practice to patients who pay more to get more.

One of the other physicians in the practice, Dr. Amy McConnell, also will provide concierge care to patients, limiting enrollment to 150 patients while continuing to provide traditional care to others.

Concierge patients will be given a cell-phone number that will give them direct access to the doctor. They will get a comprehensive annual physical; unhurried and same-day appointments; an hour with a nutritionist; and various screening tests.

The annual fee is not insurance -- the doctors will continue to bill insurance for covered services. The fee covers additional time and tests and other extras not reimbursed by insurance.

"We saw this as an opportunity to go back to practice medicine the way we really would like to if we could, yet continue to take care of our patients who choose not to do this," Mandel said.

Mandel said when he started in medicine, he might see 12 patients a day. Today, he sees about 22 daily. Other doctors say the number is higher -- closer to 25 to 30.

But a tiered system of medicine raises ethical and legal dilemmas for physicians.

The American Medical Association recognizes the right of doctors and patients to enter into retainer arrangements but says the practices "also raise ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care."

The American Academy of Family Physicians says "retainer practices are not a panacea for all" but that some doctors have "enjoyed great success and liberation from the current health-care financing albatross" with such practice models.

In 2004, the U.S. Office of Inspector General warned Medicare physicians about charging patients extra for services covered by Medicare.

Mandel said his practice, one of the few independent internal-medicine practices left in town, was recruited heavily by several companies and that it ultimately decided to go with New York-based Concierge Choice Physicians. Another national firm, MDVIP, has associated practices in more than a dozen states, including Virginia.

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It's hard to say how many doctors are choosing to offer concierge services. Organizations such as the Medical Society of Virginia and the Virginia Board of Medicine do not capture data on practice-setting models.

PartnerMD, started in Richmond in 2002 by Dr. Jim Mumper and Linda Nash, the firm's chief executive officer, is growing. The practice recently added an office in McLean.

The Richmond office has six doctors, and Mumper said PartnerMD is looking at another office in Northern Virginia and starting offices in Atlanta and Charlotte, N.C.

"We thought we would be successful if we would have two physicians here in Richmond," said Mumper, a family physician.

When Mumper went to concierge medicine, he went 100 percent. The practice's annual fee is $1,700. Each doctor is limited to 600 patients.

Mumper said he is able to spend more time with patients and focus more on preventive care.

"Part of the reason that I think we have grown so rapidly is patients see the things that we provide that a traditional practice does not," he said. Membership includes an annual physical that takes three hours.

"We ask them to wear their warm-up suit and tennis shoes. We are going to ask them to exercise and stretch and test their strength and go through a nutritional diary," Mumper said.

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If the goal is to keep people healthier, is there evidence these boutique practices are doing that?

Mumper said outcomes are measured in various ways -- for example, what percentage of members get recommended screenings, such as mammography and colonoscopy.

"Even though we have 2,800 patients, that's not a big enough number to have statistical significance yet," Mumper said. "From a personal standpoint, as I have been looking at what I have been doing here for five years, clearly I see a benefit with our patients."

Bryant, the local businessman, said he will try Concierge Choice with Mandel for a year to see how it works.

"You don't have that many chances to get things right the older you get," he said. "I think this is the kind of health care everybody needs. Unfortunately, it's not free."