A year into direct pay: It doesn’t suck to be a doctor anymore

How’s my practice doing?

I am now up to nearly 400 patients, and while Jamie and I have talked about hiring a new staff person, we seem to be hitting our stride in this different practice model and have not yet been overwhelmed.  New patients are coming with regularity, some still coming from my old practice and many others through word-of-mouth from satisfied patients.  Yes, people still seem very satisfied with the care they are getting from me.  If they have medical problems that need immediate attention, they can come in and be seen.  I frequently hear from patients in the office how happy they are that I am doing this kind of practice.

I’ve also stepped up my effort to coordinate care by calling specialists or sending them detailed letters explaining why I need them to see the patient.  The specialists I’ve contacted are delighted with my efforts to make their jobs easier and to give better care.  While it is still difficult to get them to adopt secure communication tools, I am getting a small number who I can throw curbside consults to, and who can give me updates on the patients from their computers or phones.

I’ve been working on adding new services as well.  One of the first things I did when I opened the office was to negotiate a very inexpensive fee schedule from a lab who would bill me for the tests.  Most docs mark up the tests and make a profit off of it, but I do very little mark-up of the tests, instead offering things like a CBC for $4.50 and a TSH for $8.00.  I am now working on doing the same thing with an x-ray facility, giving them the opportunity to get guaranteed cash up-front (reducing their overhead) while avoiding the many traps of compliance with Medicare billing (which forbids providers from giving discounts to other patients that they don’t give to Medicare patients).

I can attest: get into the cash-pay world and life becomes simpler and overhead is much, much lower.  You can afford much cheaper rates.  In the end, I hope to negotiate this kind of rate for other procedures, like echocardiograms, colonoscopies, and perhaps even minor surgeries.  As my patient population grows, my credibility in negotiation grows as well.

What’s the thing that patients appreciate the most about my practice?  Accessibility.  If they need me, they can reach me.  In fact, I just answered a question for a patient right before I wrote this sentence.  One person had a child with flu-like symptoms on New Year’s day and was contemplating taking them to the ER.  I told them to meet me at the office and I ran a flu test and took a quick look at them.  No big deal; it took me about 10 minutes and I saved an ER visit.  This kind of thing happens with regularity (not usually after hours, thankfully), and having an office that at most has one patient present, it’s easy to handle them quickly and efficiently.  My only challenge thus far has been to convince people to call me before they go to the ER or urgent care.  Many of them still imagine their phone calls or secure messages are “bothering me,” despite my reassurance that this is exactly why I charge a monthly fee.

The past week has produced a couple of promising opportunities, one with a self-insured local business of 200 and one with a labor union of nearly 1000 people, inquiring about my services.  While both of these may not work out, the fact that I am getting these contacts encourages me that there are many such entities out there looking for an alternative to the agonizingly irritating and inconvenient world of American medicine.  My job is to work with these groups to give them what they need without compromising the quality of care I have been able to give.  I need to grow, but grow in a way that lets me add new services, expand my staff to broaden the scope of my care, and allow for more investment into making a business and clinical infrastructure that will scale up without overwhelming me or my staff.

That’s probably the best thing that has happened: I’ve become much more patient with the process.  I won’t dive at opportunities that offer revenue without taking the time to work out a plan.  I am in no big hurry.  My original goal was to grow this to about 1000 patients, but the fact that I can handle 400 patients with one (beloved and highly capable) nurse and not feel at all overwhelmed, makes me think that it could go significantly higher than that.  But it can only go there if I am careful to build it well, with much planning and care in implementation.

A Rob Lamberts blog post would not be complete without a mention of (of course!) computers.  My home-baked (and half-baked) EMR system is working reasonably well, and I’ve been able to pour much of my creative time and energy into building a much more stable “2.0″ version of it.  Since I had no good record system when I made the first one, it was put to use well before bugs were worked out (and before I really knew what I was doing).  This new system is much more efficient, stable, and reflects some of the radical changes to my clinical thinking this new practice has allowed me to embrace.  More on that later.

At the beginning of 2013 I stared into the great unknown of this new practice.  I had no idea which plans would succeed and which were foolish dreams.  The road was much more difficult than I expected, but also much more satisfying.  I spent much of my time learning what doesn’t work, but in the end learned that most good ideas grow out of the remains of a hundred bad ones that didn’t survive.

Now, as I face 2014 I see great opportunity.  My dreams are still big; I am more convinced than ever that this model of practice could be a game changer for American health care.  But my ambitions have grown smaller.  I now enjoy the practice of medicine more than I have in many years, and am delighted by the same expression on the faces of my patients.  It doesn’t suck to be a doctor anymore, and it doesn’t suck for my patients to go to the doctor!  My ambition is to keep that reality alive for me while making it available for more patients.  I want them to be happy, and I want to be happy.

It’s nice to think it actually could be a happy new year.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.

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  • Kristy Sokoloski

    I am glad to hear that you are doing so well with your practice.

  • http://hautuconsulting.com/ Shane Irving

    Nice post…. I agree that we will see more of these types of practices along with the Membership type models. Hope 2014 is another great year….

  • Robert Johannes


    Congratulations on stepping into the “concierge” medical world. (hopefully that’s not a bad word) We, as a business with almost 50 families, are contemplating this as our medical model in 2015. Most reports have been very favorable, both on the practitioner side and the patient side.

    I am interested in your thoughts about where you think the patient threshold limit is before care does start to suffer “normal” logistical kinks.and how you think you will solve them. How will you go on vacation or do continuing education classes? Will an associate in the future have the same commitment that you do? What about house calls?

    You sound like someone who cares a great deal about your patients and wants them to have the best care. I as an employer want the same thing. My employees are my family and I of course want them treated as such.

    Hopefully others will begin to see the light on this “new” model, which is of course really the way medicine use to be practiced long ago.

  • Greg Hinson

    Give us an idea of what a typical day is like for you now that you have reached the level of 400 clients. How many visits, calls, emails, do you get/have? (And Congrats for sticking it out!)

    • http://doctor-rob.org/ Dr. Rob

      Most of the time the office is empty. We get maybe 3-4 calls per hour and maybe 6-10 email type messages per day. My typical day sees 1-2 new patients and then perhaps 1-2 sick people or disease management visits. It’s not bad.

  • buzzkillerjsmith

    3 questions:
    1. Are you happier? Are you happy practicing medicine?
    2. Do you ever get any time to go out of town with someone else covering for you?
    3. Least importantly, what is the income situation?

    I am following your experiment with interest.

    • http://doctor-rob.org/ Dr. Rob

      1. Absolutely happier. I actually enjoy patient care.
      2. I have not worked out an on-call relationship at this point, but I have gone off to Atlanta (2 hours away). The call is very light still, so it’s not a big deal for me to carry my cell and answer most questions.
      3. Still getting there on income. If I can get up to 600 patients I should have a healthy income. If I can get near 1000 (with significant increased staffing) I will greatly exceed my old income. My goal is to do so without feeling like I used to: that I never had enough time for patients.

      • buzzkillersmith

        Thanks for the info. and good luck. Please keep us updated.

  • Jim Ingham

    Thank you for your blog postings, they are always interesting. In communicating regularly with concierge and direct pay practices concerning their branding and business development efforts, I see few doctors helping patients negotiate pricing for lab services, procedures, etc. Assisting patients in this way can more than offset the price of a practice membership. For different reasons price erosion is becoming a force in medical care. Embracing this trend will help the direct pay movement become more widespread.

  • http://frugalnurse.com/ Frugal Nurse

    I contemplated signing up with a direct-pay practice for my family last year, before Obamacare kicked in. I thought then, and still think, that the direct-pay model has to be the future of primary care. Now, however, our premiums have increased by 80% and we simply can’t afford the extra monthly fees. Also, the direct-pay practice in our city practices out of a different hospital than our new, narrow-network plan allows. So although I would love to switch to direct pay, the ACA makes it too difficult.

    • http://doctor-rob.org/ Dr. Rob

      I think the initial shock of the ACA made things slow down, but the fact that most people have a high deductible insurance brings back value to the DPC, as I work hard to try keep deductibles from being spent.

  • Patrick Randolph

    Great post, am hearing many physicians discussing making the move. It’s a scary move, but this type of writing can give them insight on how to prepare.

  • LeoHolmMD


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