Frustrations with the health care system drove me to a big change

After 18 years in private practice, many good, some not, I am making a very big change.  I am leaving my practice.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job.  The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve.  The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk.  I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

I must confess that there are still a lot of details I need to work out, and plan on sharing the process of working these details with colleagues, consultants, and most importantly, my future patients.

Here are my main frustrations with the health care system that drove me to this big change:

  1. I don’t feel like I can offer the level of care I want for my patients.  I am far too busy during the day to slow down and give people the time they deserve.  I have over 3000 patients in my practice, and most of them only come to me when there are problems, which bothers me because I’d rather work with them to prevent the problems in the first place.
  2. There’s a disconnect between my business and my mission.  I want to be a good doctor, but I also want to pay for my kids’ college tuition (and maybe get the windshield on the car fixed).  But the only way to make enough money is to see more patients in my office, making it hard to spend time with people in the office, or to handle problems on the phone.  I have done my best to walk the line between good care and good business, but I’ve grown weary under the burden of having to make this choice patient after patient.  Why is it that I would make more money if I was a bad doctor?  Why am I penalized for caring?
  3. The increased burden of non-patient issues added to the already difficult situation.  I have to comply with E/M coding for all of my notes.  I have to comply with “Meaningful Use” criteria for my EMR.  I have to practice defensive medicine to avoid lawsuits.  I have more and more paperwork, more drug formulary problems, more patients frustrated with consultants, and less time to do it all.  My previous post about burnout was a prelude to this one; it was time to do something about my burn out: to drop out.

Here are some things that are not reasons for my big change:

  1. I am not angry with my partners.  I have been frustrated that they didn’t see things as I did, but I realize that they are not restless for change like I am.  They do believe in me (and are doing their best to help me on this new venture), but they don’t want to ride shotgun while I drive to a location yet undisclosed.
  2. I am not upset about the ACA (Obamacare).  In truth, the changes primary care has seen have been more positive than negative.  The ACA also favors the type of practice I am planning on building, allowing businesses to contract directly with direct care practices along with a high-deductible insurance to meet the requirement to provide insurance.  Now, if I did think the government could fix healthcare I would probably not be making the changes I am.  But it’s the overall dysfunctional nature of Washington that quenches my hope for significant change, not the ACA.

What will my practice look like?  Here are the cornerstones on which I hope to build a new kind of practice.

  1. I want the cost to be reasonable.  Direct Care practices generally charge between $50 and $100 per patient per month for full access.  I don’t want to limit my care to the wealthy.  I want my practice to be part of a solution that will be able to expand around the country (as it has been doing).
  2. I want to keep my patient volume manageable.  I will limit the number of patients I have (1000 being the maximum, at the present time).  I want to go home each day feeling that I’ve done what I can to help all of my patients to be healthy.
  3. I want to keep people away from health care.  As strange as this may sound, the goal of most people is to spend less time dealing with their health, not more. I don’t want to make people wait in my office, I don’t want them to go to the ER when they don’t need to.  I also don’t want them going to specialists who don’t know why they were sent, getting duplicate tests they don’t need, being put on medications that don’t help, or getting sick from illnesses they were afraid to address.  I will use phones, online forms, text messages, house calls, or whatever other means I can use to keep people as people, not health care consumers.
  4. People need access to me.  I want them to be able to call me, text me, or send an email when they have questions, not afraid that I will withhold an answer and force them to come in to see me.  If someone is thinking about going to the ER, they should be able to see what I think.  Preventing a single ER visit will save thousands of dollars, and many unnecessary tests.
  5. Patients should own their medical records.  It is ridiculous (and horrible) how we treat patient records as the property of doctors and hospitals.  It’s like a bank saying they own your money, and will give you access to it for a fee.  I should be asking my patients for access to their records, not the reverse!  This means that patients will be maintaining these records, and I am working on a way to give incentive to do so.  Why should I always have to ask for people information to update my records, when I could just look at theirs?
  6. I want this to be a project built as a cooperative between me and my patients.  Do they have better ideas on how to do things?  They should tell me what works and what does not.  Perhaps I can meet my diabetics at a grocery store and have a dietician talk about buying food.  Perhaps I can bring a child psychologist in to talk about parenting.  I don’t know, and I don’t want to answer those questions until I hear from my patients.

This is the first of a whole bunch of posts on this subject.  My hope is that the dialog started by my big change (and those of other doctors) will have bigger effects on the whole health care scene.  Even if it doesn’t, however, I plan on having a practice where I can take better care of my patients while not getting burned out in the process.

Is this scary?  Heck yeah, it’s terrifying in many ways.  But the relief to be changing from being a nail, constantly pounded by an unreasonable system, to a hammer is enormous.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • http://twitter.com/Cascadia Sherry Reynolds

    This is simply a reflection of a financial model that is broken not the health care system itself and although you will clearly increase your income and the few patients you will treat will appreciate it (many direct pay practices are able to treat those with no insurance or high deductible plans so there is a very clear benefit to those patients who get in) but at a systems level this isn’t a sustainable or scalable solution and reflects what almost any one individual would do when there is a systemic problem. Where are the other patients you used to treat who can’t afford the small monthly fee go to? The average primary care salary is $160,000 a year so it is also hard to fathom how someone can’t make a living and send their kids to college on that when the average worker salary is 40k.. Medical school debt? I have friends who are social workers who also went to grad school (3years vs 4) who work for $15 an hour.

    Direct pay doctors don’t for example take any Medicare or Medicaid and although we often hear the “meme” that health care providers lose money on them what we as a society often forget is that CMS (Medicare and Medicaid) paid for 95% of all of the medical doctors training (residency and internship) in the US to the tune of 9 billion a year and about 100k per intern a year (400k to 1.1 million per doctor)..

    This grant is an investment in a small pool of people (there are far more qualified people who want to be doctors than there are residency and internship slots) who are then expected to “pay back” that investment (think of a mortgage of 700,000 how much would you pay a month for 30 year? – about 5,000) by being compensated less for treating those patients.

    Your individual solution makes total sense on a financial and personal level and in no way do I judge that but when we have systemic problems we need systemic solutions so that this doesn’t continue to happen. Tens of thousands of people die every year in this country because of a lack of access to basic health care (and 80% of primary care visits are unnecessary and the result of minor self limiting conditions) so I hope that you also continue to work to change the system and don’t forget about the 2,000 patients who just lost a doctor.

    • http://doctor-rob.org/ Dr. Rob

      Good points. I’ve written elsewhere that my intent of the business is not to comfortably stop at 1000 patients, but to add other team members (nurses, PA/NP’s, dietitians, counselors) to help me manage a larger population and do it in a better way. My hope would be to increase the total number of patients I can manage and (honest) lower the price of the care if possible so it is accessible to more people. If I can show this model effective in offering better care at a lower cost, it will be hard to imagine it not becoming more common. I did not go to a “concierge” practice (higher cost) because I didn’t like adopting a model that couldn’t be generalized. I truly believe this is a better mousetrap if done right. That’s a very, very big if.

      Regarding CMS paying for my education, I do point to the 18 years I accepted the lower rates of Medicare and Medicaid reimbursement when it was honestly a bad business decision. I feel it is my duty to care for the poor and the elderly (not to pay back CMS, just because it’s what is right), and so never bolted that ship. It is interesting to note that of the 120+ people who have “officially” signed up (I haven’t opened registration yet, but people have let me know their plans), the majority of these are Medicare patients. I hope to continue “paying” CMS by keeping these folks out of the ER, out of the hospital, and on as few medications as possible.

      Finally, I am very sad about the 2000+ who will lose their doctor. I was very concerned about their reaction to the announcement. Amazingly, I didn’t get a lot of angry words, or even frustration from them; the thing I heard most from my patients was “I am happy for you, doc. I know why you are doing this.”

      • http://twitter.com/Cascadia Sherry Reynolds

        It sounds like a great model Bob expecially by moving to the use of Physican extenders within the same practice (vs the new stand alone PA practices in Oregon for example).. In no way do I question your decision or ethics. There is also no question that the current low pay for short visits one clearly isn’t working.. Lifestyle issues matter to everyone and the life of a family practice physican is one of the most challenging (regardless of compension) and is partly responsible for more then 40% of US residency slots going unfilled with graduates of US Medical schools. We only spend a tiny % of our health care dollars on primary care.

        FYI – I actually try to walk the talk and even though I pay $740 a month for an individual policy it has a $1000 deductible so I have gotten my primary care from both Qliance a direct pay model ($110 a month) in Seattle (although they seemed to practice traditional health care without physican extenders) as well as at the Swedish Residency clinic (direct pay using family practice residents $55 a month) I don’t however have enough of a need for health care to really know how it works for patients with a chronic or complex conditions but the one thing that is a huge satisfier is my ability to get questions answered over the phone usually on the first call.

        The real challenge seems to be during the transition. If even 10% of primary care docs (35,000 out of 350,000) switch to this model and each one drops their panel size by 1,000 that would leave another 3.5 million people without primary care.

        My question or comment is how do we systemically roll this out at the same time we have enough primary care providers to duplicate the model? Should we carve out primary care from the insurance system? I think your model of using more PA’s and/or NP and and shifting providers up stream as the knowledge experts is one solution that I haven’t seen yet. Keep us posted.

        • southerndoc1

          You acknowledge that there’s a shortage of primary care docs on the one hand, but on the other you say they should be satisfied with an income of 160 k.
          Med students are not choosing between becoming a doctor and being an “average worker” at 40k. They’re choosing between becoming a primary care doc or a dermatologist, radiologist, etc. We’re just wasting our time until we make the first option more appealing.
          ‘small pool of people (there are far more qualified people who want to be doctors than there are residency and internship slots) who are then expected to “pay back” that investment’
          Should primary care docs be expected, as they are now, to pay back that investment over their careers at 400% the rate of anesthesiologists?

        • http://doctor-rob.org/ Dr. Rob

          I actually appreciated the tone of your comment. Some folks make it seem like I am being incredibly selfish to make this choice, even saying that I am reneging on my “duty” to CMS. I didn’t get that tone in your comment, and understand what you were driving at. I think southerndoc’s point about PCP’s not being well-reimbursed is important, as it will drive the market and availability of PCPs. It would be ironic if medical subspecialists were drawn to primary care because it paid better and because we were doing a better job managing patients and making them expendable. That is a LONG way away, but for the ration of PCP to specialists to change this may be the way things go.

          I looked at Qliance and MedLion as optional models but felt that they relied still too much on the office visit as the ultimate place where care is given. I want to go beyond that and try and build a system where care is done whether a person is in the office or not.

        • Northern lights

          Sherry, I think you misunderstand the root causes of our systemic dysfunction in healthcare. There are inherent cost drivers in healthcare that are a function of demographics of an aging population afflicted with self-inflicted ailments related often to personal lifestyle choices, including obesity, type II diabetes, lack of exercise, hypertension, and substance abuse. Additionally, the individual physician, subject as we all are to a finite 24-hour day, is increasingly distracted from patient care by mounting unfunded mandates from Federal and State governments, affiliated private “non-profits” organizations like the ABMS with their onerous MOC which they wish to tie to MOL, and other mandates such as immunization registries that triple documentation requirements without providing elementary tools to improve efficiency. In the realm of the roughly 50% of HC costs from the “private” commercial insurance sector, physician’s reimbursements (as opposed to the nominal ‘charges’) are dictated by oligarchic third party health insurers that literally reward their executives (diverting premium dollars from patient care and physician reimbursement) to the tune of $100 million plus annual CEO compensation, factoring in stock option values. Yet there is no national discussion to make health insurers more like public utilities, while these private non – and for-profit insurers add little of value to the patient-physician interface and genuine care.

          On the government side we have the specter of a faceless , complex multilayer bureaucracy intruding into the relationship between physician and patient. The latest example is the ACO concept – an untested system concept of vertical integration that thus far has failed to deliver on the promise of healthcare savings and efficiency. The foisting of EHRs upon physicians – a tower of Babble record silos that fail their most important goal of intercommunicability and data exchange – with a carrot-and-stick approach rather than a well thought out plan for regional databases for unique patient identifier numbers into which healthcare encounters could be referred as a repository for medical, imaging, lab, and pharmacy data, maintained by the Feds and their health insurer partners, is yet another example.
          Physicians are not Luddites resistant to change. But truth is, government in symbiosis with crony corporatism has become a metastatic cancer on the body politic and medicine, and unless radically extirpated, will kill the patient.

          • southerndoc1

            As long as Ms. Reynolds continues to chant (here and elsewhere) her mantra of “80% of primary care visits are unnecessary and are for self-limited conditions,” I think we can safely discount everything she says.

    • buzzkillersmith

      Change the system. We hear this a lot. I say nonsense. It is the responsibility of the American people to change the system, so get work Sherry. We docs has much less power than you think, and much much less time. You want us to care for 3000 patients and change the system. Ain’t gonna happen when those whose life’s work is resisting changing the system don’t in fact have those 3000 people to take care of. Oh how easy it is to judge others when you have no idea what they do!

      • southerndoc1

        You obviously didn’t read her post carefully. 80% of what you do is worthless (all those self-limiting MIs, sepsis, pyelo, etc.). If you just got those patients off your schedule, you’d have all the time in the world to change to system.

        • buzzkillersmith

          You and I obviously need to go out for some beers, maybe even some Wild Turkey. If you are not are not a married man, let’s meet in cougar bar because I likada ladies. I’m in WA. Howbout Dallas?

  • http://twitter.com/Greg_HC311 Greg @Healthcare 311

    Rob,

    how can non-patients help you & your patients succeed in your new model? For example, it seems certain a big part of your strategy for “keeping people away from health care” will entail lots of “mass-customized” open-to-interaction communication among you, requiring you to

    - adopt/maintain a flexible tech infrastructure;
    - engage a network of trusted contributors;
    - adapt the infrastructure to your patients and your practice as conditions change.

    How do you plan to source/engage the extra skills & ‘stuff’ your patients and you will need?

    Good luck, however you tackle this new approach.

    • http://doctor-rob.org/ Dr. Rob

      I’ve already been working on this (especially the tech infrastructure) with PHR/EMR vendors and other tech folks. Some of it I will DIY, having a video studio at the office where I can record information I think will be helpful to my patients. One of the problems being a writer is that I don’t trust what other people write (or simply think they do a bad job explaining things) and would rather give my own explanation. This has more meaning to my patients, as they trust what I say over most online resources (or at least want to measure what they read by my opinion). I have always encouraged patients to bring in outside information/resources and to use what’s online, so I hope they will point me to any good resources they’ve got. I am really trying to group source this whole process, getting my patients involved in making my practice better. So far they’ve helped me with office location and my logo.

  • http://www.facebook.com/dayna.gallagher.9 Dayna Gallagher

    My Brother – Your lists are most noble in my opinion & I am in tandem.
    The etiology of your cornerstones may have to come from Patients. Patients must be healthcare consumers & act as such.
    Turning the clock back to “fee for service” as it was prior to the 60′s could be a beginning Families directly paid their Physicians. Payment plans were via the Physician’s own business offices. Insurers should not pay for a regular office visit.
    Moreover patients these days are unaware what the costs actually are (ie..office visits, medications).
    Perhaps it has not occurred to the Choir that healthcare is not a right
    endowed via Federal or State Governments. Office visits, medications, & alike are not
    free.

  • PamelaWibleMD

    Awesome decision Rob. Most important thing for doctors to do is to be happy and healthy and model that behavior to patients. Before I went into my solo practice, I invited my patients to design the clinic for me. held nine town hall meetings ad collected 100 pages of testimony, adopted 90% of feedback and opened one month later. Not rocket science and I have NEVER been happier! LOVE my practice. LOVE my patients. Life is great and just wrote a book with my best 101 patient stories from 20 years in practice. Doesn’t get any better than this Rob! Good luck and let me know if I can be of any service.

    :))

    Pamela

    Pet Goats & Pap Smears

  • Amy NP

    I’m a Family Nurse Practitioner and in additional to clinical practice, I’ve spent a number of years in academic medicine doing applied research in outpatient quality improvement. Clearly ACA doesn’t address the systemic dysfunction in health care, but think we may end up driving change by necessity with so many people added to the system. One of the paths to change are individual initiatives like this one. It will not be the solution that works for everyone or even most people, but how about the idea that patients should own their record? Or that I should be able to manage care via text, e-mail and so forth? Congratulations and best wishes.

    • http://doctor-rob.org/ Dr. Rob

      I believe patients should own their record, and should be able to communicate me in any way that works. It will be one of the cornerstones of my practice.

      • Amy NP

        Right- that is what is in your plan that is translatable to everyone.

        Amy Salunga
        202-674-5801

        Subject: [kevinmd] Re: Frustrations with the health care system drove me to a big change

  • http://doctor-rob.org/ Dr. Rob

    I checked out your website and like your idea of patient communities and linking those with good providers. In all of this mess we call health care, the docs and the patients are the ones who get hurt the most – the patients get poor, uncoordinated care and are largely left to fend for themselves, and the docs (the ones who care) are powerless to help them. While I don’t think your product meshes with the subscription model I am doing at the moment (plus the fact that I haven’t even opened yet), I do think it has great ideas behind it. I think it will take disruption from the outside (I’ve written a lot about it elsewhere), probably from many different points, to change the system. People can (and do) disparage new ideas and innovations, but I think it’s just best to prove them wrong through success. If I can pull this off: make my life better, make my patients’ lives better, give them better care, and save them money, it’s going to quiet the naysayers. I think you are doing the same from a different angle. I’ve met a lot of people, both doctors and non-clinicians, who are fighting the same fight in different ways. I’m really encouraged at the innovation I’ve see. I guess it proves that necessity is the mother of invention (I always think of Frank Zappa when I see that). A broken health system has created the necessity, so now it’s time to invent.

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