Some doctors seem to have embraced the airlines' model for doing business -- you know, the one where they now charge fees for things they used to just do for free.

I'll leave it to the experts to figure out if this is born of physician greed or physician frustration, but there is no doubt that an increasing number of doctors are jumping on board the concierge medicine train.

Michael Tetreault, editor in chief of Concierge Medicine Today, a trade journal covering the industry, said that there are about 12,000 physicians in the U.S. who now run concierge medical practices -- offices that charge annual fees, generally in the $1,200 to $2,500 range, for providing "enhanced" care. The total is up from just 4,000 physicians doing it in 2007, according to Tetreault. Some of them still work in-network for insurance companies, and others won't take insurance at all -- leaving it to their patients to file claims and wait for reimbursement.

And then there are those docs who don't have concierge-designated offices per se, and who nobody is counting, who have begun to charge extra fees for services that were previously part of the care they provided.

Here are a few examples of what is going on:

Fees for talking to you outside the office.

During a recent visit to a specialist, I was handed a notice suggesting that instead of coming to the office next time, I should consider asking the doctor my questions on the phone -- for a $50 fee. If that's too rich for my blood, a less expensive conversation could be conducted via email. (I'm thinking that a tweet, with just 140 characters, might eventually be the real medical bargain in the future. "Hey @drjones -- I think my blood pressure is up.")

The notice said that much of what patients generally want to talk about with the doctor could actually be handled quite effectively by phone or email, thus saving both time and money if we didn't need to see each other face-to-face.

Fair enough -- the part where he asks me how his daughter can blog for The Huffington Post can certainly be handled by email. But I think we are missing the larger point here: Wasn't answering an email or spending three minutes with me on the phone part of what he did because he was my doctor? What the notice was really saying is that he's going to start billing me for this time instead of letting me have it for "free" -- just like the airlines now charge me for checking my luggage or the crappy meals they offer. What was once considered part of the ticket price is now splintered off separately and has a dollar sign in front of it.

Fees for same-day or next-day appointments.

My husband's cardiologist sent him a letter that began by asking how he felt about the service and care he had received during his most recent visit. And then it asked if he'd be willing to pay between $150 and $250 a month out of pocket for a "Concierge Care" system that would ensure next-day appointments and give him the doctor's cell phone number. It's a program "for patients who want the doctor to act in an enhanced capacity," the letter noted, and would be available "to only a limited number of patients." The letter explained how "each day, special hours would be set aside for members of the program."

Nothing like the appeal of exclusivity, right? But putting that aside, are we to assume that this doctor has not been giving my husband the best care possible up until now and that "enhanced" care could be ours for an extra $3,000 a year? And just to be clear: If someone else pays $3,000 a year and we don't, will the doctor see that other patient first even when we are the ones with the greater medical emergency and need?

Fees for new patients and an annual fee to "join" the practice.

If those two personal examples weren't enough, I hit the audacity jackpot with a Los Angeles pediatrician in my Cigna network. Her office told me that in order to see my son as a "transfer" patient, I would have to pay a $500 one-time fee, and that the practice charged everyone a $200 annual fee every Jan. 1. I asked what was covered by the $500 "transfer" fee; would the new doctor's office run and fetch my son's records from the old practice? No, the patient must do that still. So what is covered? Well, nothing. (Roy DeLaMar, manager for Cigna's business communications office, declined to comment.)

So for the annual fee of $200, you basically get the right to make an appointment with this practice. You still pay your copays, your deductibles, and any other costs that your policy doesn't.

I was upfront in my shock. "This is all just extra money you want to collect, even though you are a network provider and are supposed to take what the insurance company pays you, right?" Righto. And if I don't like it and don't want to sign the papers that commit me to paying it, I can just go find some other doctor, even though -- and this bears repeating -- this doctor is an in-network provider of my insurance company.

For the uninitiated in the ways of the health insurance world, by agreeing to be an in-network provider, the doctor agrees to accept what the insurance company pays and not charge the patient any additional administrative fees.

But before we envision going postal on doctors, let's take a breath and figure out who we should really be mad at. I nominate the insurance companies -- who know this is going on and are turning a blind eye.

Consumers pick a health care plan based on the representation that certain doctors will accept what is paid to them, and that if you go to that doctor, according to the rules, you shouldn't have to pay a little something extra to just get in the door.

Jerry Flanagan, lead staff attorney with Consumer Watchdog, an advocacy agency based in Santa Monica, California that's been hounding the insurance industry for nearly 30 years, said the reason insurers play dumb about what's going on is that these direct-to-patient fees discourage people from seeking medical care. And if patients just ignore what ails them, the insurance company winds up paying out less. It makes perfect sense. The same disincentive occurs when there are higher co-insurance and co-payment costs. Even insurers know this to be true: A Kaiser Family Foundation report from 2006 found that "[O]nce patients bear some of the economic costs of receiving medical care, they are more likely to use only those health care services that are worth the additional cost that they must pay." The sad part, of course, is that when coinsurance amounts are too steep, people avoid getting the medical care that is actually necessary to their health, the report notes.

In other words, it's good for the insurer -- unless you get, well, really sick.

Flanagan doesn't mince words. You paid your premiums based on the promise that you wouldn't have to pay more to the doctor out of pocket. So your insurer is violating the agreement you made with the company when they don't enforce the in-network rules, Flanagan said.

It's fraud, he said, and one reason that nobody is doing anything about it is that it's really hard to sue your health insurance company. If you get insurance through your employer or a government entity, you are barred from suing the insurer, Flanagan said. Change will come when someone who is insured as an individual sues their insurance company for letting a doctor get away with charging extra. (Flanagan said to call him if you'd like to discuss.)

Now, not to be one-sided here: If your doctor doesn't want to talk to you on the phone at 10 p.m. because your kid's fever is up to 104 or the medicine he prescribed caused hives, I suppose no one can hold a gun to his temple and make him. But medicine isn't a 9-to-5 job. And yes, I understand that it's a pain for doctors to deal with insurance companies and try to wrangle money out of them. Doctors have grown increasingly frustrated, and some medical practices have had to hire full-time staff just to handle paperwork. I get it; what a drag.

But, from where I sit, what doctors are doing now is all kinds of gawd-awful. They are creating a multi-tier medical services delivery system where those who can afford to pay them more will get better care.

For what it's worth, Dr. Marcy Zwelling, an internist and critical care doctor in Los Alamitos California, thinks I've got it all wrong. She charges patients $2,000 a year and takes no insurance. Insurance is for catastrophic illness, she said, and in many cases patients should carry just that and pay for smaller services out of pocket. "They'll save money if they do," she said. Mammograms can be had for $75, and an MRI costs $200 cash -- tops, she said. According to Zwelling, if you have a copay and deductible on top of a high monthly insurance premium, chances are it is less expensive for you to just pay out of pocket for these and other tests. I wrote about how this was certainly the case with filling prescriptions: It's often cheaper to not put it through your insurance company but just pay out of pocket.

In the case of concierge medicine, Zwelling said, it's not about better care for the rich or a case of doctors being greedy. It's doctors who want to provide an enhanced level of care -- spend time with patients, not keep them waiting for hours, coordinate their care with specialists, do research and stay abreast of new treatment options. And that doesn't happen in a 15-minute office visit, she said. Concierge medicine "allows me to concentrate on the patients, not the paperwork," she said. The fees she charges go to hiring additional staff.

And doctors aren't the rich dudes we all think they are, she said. "This is about doctors trying to stay in business. When their bottom line gets near zero, they can't continue."

So consider me schooled, Dr. Z. But I just keep coming back to the airlines, which want to charge me $35 to bring my clothes along on vacation with me. Is taking my call for a simple question really that big a deal?

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