It’s doctors, not government, who are in the best position to reform healthcare. The single most important step that can be taken to reform healthcare is for doctors to stop accepting third party payment. If every single doctor changed their payment model to cash/credit cards, that would change patient-doctor relationship, the private insurance industry and government insurance. Everyone orders lobster because they believe the insurance industry has convinced the consumer it’s free. However, the truth is it’s not really free and in the end we all pay.

If doctors would charge reasonable rates, there is no reason why those seeking health care shouldn’t be willing to pay for it. We all pay for food, gas and many other services. We may not all be able to afford lobster, but thus far no has ever died because they can’t afford to eat lobster.

Get the third payer (insurance) out of the practice.

I have run small business all of my life and they are very difficult. I also understand your frustration with the payment system. Small businesses have no “Economy of Scale”, that is the reason there are few left in the retail space and the Walmarts of the world have taken over. Most of us don’t like it but everyone seams to want cheaper and faster. The same reason that we are buying so much junk from China.

If you have a boutique practice that cater to a richer demographic that is great. I have a friend that has the same type of practice but I cannot afford the additional $1500/yr for his service plus pay 100% out of pocket each time I visit.

Technology as I mentioned can only help you do your job more efficiently and with less errors but it like everything else is not for free. It will take your time and money to implement.

I never said EMR/technology will save you time in the encounter. Initially it will cost you time, a lot of time. The saving is on the back end, charts, prescription handing, billing, better coding… But you have to admit there are not many family practice doctors that spend 30 min with their patients as you do.

You might want to check out a lower cost alternative to EHR http://www.simplifymd.com/ It looks interesting.

Thanks for the conversation,

Jeff Brandt
motionPHR for the iPhone
MyMobileMedBox for Android

The best solution for doctors, especially primary care doctors, is to not sign any third party contracts. Just say no.

Dr. Brian Forrest of Apex, NC has and he reports an annual overhead of about $80,000 with one office assistant. He is also able to spend about 30 minutes with each patient – and his net income is higher than the average made by family docs in this country.

Of course, most docs discount this possibility out of hand. It can’t work, they say. It is working already. There are other primary care docs who have been doing direct payment for years – including me.

Jeff Brandt thinks technology can enable docs to mass produce the doctor patient encounter. No patient wants to feel like cattle and no doctor worth their salt wants to provide that kind of care or continue on their treadmill.

Kevin says the govt should reimburse for emails, phone calls. Realistically, this is not going to happen. However, it can happen once doctor and patient can negotiate reimbursement on terms acceptable to both. Then doctors can provide services that patients want including access to the doctor without the patient being there and still be fairly reimbursed for his time and expertise.

When comparing professional medical providers to other professionals or businesses, there are certain soft costs rarely acknowledged which are borne only by the medical profession.
(Of course the first most obvious is therisk of being targeted by the med mal mental anguish industry).
Instead of always being on the defensive, why not ask for parity in other professions—lobby to subject lawyers and politicians and insurance execs to the same personal risk as medicos?

Jeff Brandt motionPHR for the iPhone
MyMedBox for Android

I think many have missed the basic point of the article however: that the reimbursment rules and legal regulatory framework should be changed to incentivise whatever kind of physician behavior that we want to see as a nation.

IF we believe that 6 minutes of face time is insuffucient for a PCP visit, then change reimbursement – perhaps capitation is better than procedure based? (with appropriate safeguards!) Perhaps salary based? Perhaps bonuses for positive patient health outcomes (e.g. a poorly controlled diabetic becomes more well controlled, a obese pt loses some weight?) Difficult targets, but worthy ones! We could even pay physicians to specialize in dealing with patients who are non adherant (sounds like a fun subspeciallty!)

As for physicians avoiding sick pts to avoid bad outcomes on their records and poor payments – in the UK PCP’s are paid MORE for having sicker patients (similar to how the German wellness fund private insurers are paid more for insuring sicker patients).

The wall street journal article was laudable for pointing out some serious problems with the model of linking pay to meeting standard of care targets. That does not mean that we should automatically abandon the idea completely however – perhaps we just need to ACCNOWLEDGE the sort of excellent research that has revealed these problems and constantly MODIFY the rules appropriately. I refuse to believe that we cannot find scientific methods to roughly estimate physician performance – put some of the MIT boys on it, we put men on the moon after all? I agree that considerable latitude should be allowed for physician autonomy, all should be 100% transparent to all involved, and appeals should be allowed by physicians.

I find it very difficult to believe, as a citizen, scientist, and future physician myself, that the best course of action is to continue with business as usual. Also I feel that well defined and constantly reviewed guidelines, defined by physician professioinal bodies (irrespective of links to payment) are the best way forward to ensure quality care. The model of expecting busy individual physicians to be personally on top of every new development in the vast field of medical knowledge is impractical, in part shown by the remarkable safety improvements of fields that have produced strong standard guidelines (anesthesia, obstetrics).

TO A POINT (and no further), standardization should be the goal. Where that point is, should be a goal of intensive and constant scientific research.

I hope that the Obama administration, with its professed love of science, is able to bring more science to the legal frameworks governing our society. Of course getting ANYTHING done in the US legislative minefield is virtually impossible, so all this talk is likley to fizzle out into a giant anti-climax.

-terry

The only way a business remains viable, whether for-profit or non-profit, is to generate enough reveune in to cover all expenditures out. The only real exception is that non-profits have the ability to go begging for donations should their revenue fall short of expectations, which is more often the rule than the exception.

Clearly, successful health reform depends on modifying physician behavior. Doing so requires that we change the incentives that motivate doctors.

The only reason my husband continues to practice is that he loves what he does.

That and the fact that 28 others depend on him – his 12 staff, 10 spouses of staff and 6 children of staff. Really though, make that 30 since he also feels (as expected) a strong responsibility for me and our child too.

How exactly would you tell him to modify his behavior when he works six days a week, 80+ hours a week (60 office hours, 10-15 paperwork and managment of practice, 5-10 post-ops and/or call resulting in having to go into the hospital for a patient), and is still tossing at night worried that this month’s payroll might not be met?

How would you suggest he see fewer patients – spend more time than he already does, already averaging 95-minutes for a new patient and 15 to 22-minutes per patient for office visits, depending on reason for office visit – and still meet payroll, pay his malpractice, taxes, student loans and finally, hopefully, himself?

As example, for a new patient visit, he is reimbursed $350.

Sounds like a lot until you realize, the entire visit he’s had a nurse chaperone (cost for 90-minutes of her salary & benefits = $83), has overhead for rent, utilities, supplort staff, supplies, equipment etc. (cost for overhead per 90-minutes = $192), thus his “profit” for the 90-minutes = $75…or $50 an hour.

Now if he billed 80-hours a week, and had only new patients, that might not be so bad – but his billable hours are about 50 a week, routine office visists reimburse no where near $50 an hour, and even then he and no other doctor actually gets paid for everything billed as you already know!

And I don’t know about you, but I pay more than that to our car mechanic, plumber or HVAC service techs for an hour of their time….and don’t complain, when I need them and they do a good job, I’m happy to pay them their worth!

Last year DH paid himself a salary of $140,000….working 80-hours a week average, 51-weeks last year – that’s right, he had one week vacation since his overhead doesn’t go on vacation anymore than his staff salaries go on vacation – they still have to be paid….so, basically, he averaged less than $35 an hour for what he actually worked and that was a reduction in take-home for him of $40,000 over the previous year, largely due to reimbursement changes from his private carrier contracts.

If he doesn’t watch the bottomline and the clock, it is HE who takes the hit at the end of the day, not his nurses, not his billing manager, not his receptionist – they all EXPECT a raise for a job well done….he gets what’s ever left, and each year that’s getting to be less and less and ya know what? At some point we just can’t do it anymore and our community, a rural community, will be out one more doc.

I’m just glad he’s less than 15-years to retirement, if he can manage to keep up the schedule he has that long.

Perhaps the biggest issue isn’t modifying physican behavior, but rather that we’ve divorced patients from the true cost, thus they don’t question how much something is unless they don’t have insurance?

When is the last time you’ve had a patient question you with “how is this going to change management?” for a test, procedure or medication?

I no longer received medical care at our local TransforMED clinic. What a nightmare. Open access scheduling means you can see the PA in urgent care. The last time I was shuffled off to the PA, the PA was unqualified to deal with my medical issue. Level 5-$300 bill to see a PA-no wonder they make profit. The treatment recommended was inappropriate when I called in with complications, another PA… My transforMED experience was more like a house of horrors than a medical home.