Much of the debate currently raging in Congress over health care focuses on insurance: who should have it, how much it should cost, what it should cover.

But, as of 2008, about 10 percent of primary care physicians didn't take insurance at all. In that minority, there are a small number of doctors starting membership-based practices, similar to better-known “concierge care” but with smaller price tags.

‘Old-school village doctor’

Dr. Bruce Hopper's new practice near Rittenhouse Square is one of them.  His three-room office looks more like a chic studio apartment than a doctor's office. The waiting room has a sleek black couch and minimalist desk, and there are no nurses or medical files in sight. It's small, he says, because there’s not actually any waiting in his waiting room.

Hopper doesn't take insurance. Instead, he charges a $35 per month membership fee, which buys patients a physical and unlimited consultations with him via cell phone and personal e-mail. He gives members a discounted rate for office visits, and guarantees no waiting and next-day appointments. It is his attempt at carving a niche where he can be an “old school village doctor.”

“I feel like if I can peel away all the distractions, I can restore that bond between patients and doctors,” Hopper says.

Hopper says not dealing with insurance companies, or letting patients bill their insurance themselves, cuts down on his practice's overhead, which means he doesn't have to cram as many patient visits into a day to make ends meet. Good for his patients, and good for him.

"I don't want a hamster-wheel type practice where I'm running from room to room. What makes me happy is happy patients,” Hopper says.  “Rushing through office visits all day long exhausts me, (and) it makes patients unhappy because, ultimately, they have to wait long periods of time."

So-called concierge-care practices have patients pay a yearly fee in the thousands of dollars to keep a doctor on retainer. But the idea of membership care at a more affordable price is newer. The most well-known of these practices, which charges a higher membership fee but includes office visits in that fee, opened in Seattle in 2006.

Hopper launched his business last spring and says he does not know of any other doctors in Philadelphia with similar setups. Still trying to build his practice, he is currently working night shifts in a hospital ER until he can attract more patients.

He left a large sports medicine practice to try to do primary care as he thinks it should be done.

"I think morale among doctors is low,” Hopper says. “Instead of working in a broken design, why don't we say ‘Let's redesign this’?”

Doctoring in the 21st century

J.T. Christensen is one of Hopper's patients. When he left his old job to start his own interior design business, he lost his insurance and decided to become a member at  Hopper's practice.

"Previously when I had a doctor, it was just a pain in the butt to go see them,” Christensen says. “Bruce, I can just e-mail. It's just easy."

Christensen hasn't actually seen Hopper since his introductory physical. He’s e-mailed and texted, he estimates, about a hundred times in the first four months of membership. He asks about affordable ways to treat his persistent headaches or deal with anxiety.

"He probably gets annoyed,” Christensen laughs.

Christensen carries catastrophic insurance to supplement his membership, as Hopper recommends. He says if it weren't for this plan, he wouldn't have a doctor at all because he can't afford traditional insurance.

Gaps in coverage

An arrangement like this is better than nothing, says Dr. Marjorie Bowman, but it’s still not as good as comprehensive insurance. Bowman is head of the department of family medicine and community health at the University of Pennsylvania. She says a membership like this is most attractive for young, healthy people who don't anticipate needing a lot of specialist care.

The model makes sense in some ways: a membership fee can help cover costs of phone calls and e-mails that can't be billed under traditional fee-for-service insurance. But Bowman says for many people, opting for a membership plan and forgoing traditional insurance leaves serious gaps in coverage.

"One of the disadvantages for patients with these models is it often does not cover any lab work or any drugs, both of which can be incredibly expensive,” Bowman says.

That means the model does not make sense for a lot of people. And unless doctors can offer this care to everyone, Bowman says she thinks relatively few will move their practices to this kind of model.

"Family physicians actually want to take care of everyone, not just people who can really afford to pay for the best,” Bowman says. “We really care about what happens to our community and people across the socioeconomic spectrum."

A 2008 study found that only 3 percent of physicians in Philadelphia worked on retainer, a percentage that would include “concierge” practices and lower-cost membership-based practices. Bowman says she thinks that's partly because all patients expect to be able to call their doctors and schedule appointments whenever they want, so there's little incentive to pay extra.