House call on a hundred-foot cliff

House call on a hundred foot cliff

Johnny’s disabled. He can’t get to my office anymore. So I drive 100 miles up the Oregon coast to check in on him. I get lost, but finally discover his little white house on the edge of a cliff overlooking the Pacific Ocean.

House call on a hundred foot cliff

House call on a hundred foot cliff

“Last time a doctor come to my house, I was 9 years old. That was over fifty year ago!” he says as he takes me to his garden.

House call on a hundred foot cliff

House call on a hundred foot cliff

House call on a hundred foot cliff

House call on a hundred foot cliff

“Wow! Johnny your blood pressure is lower than it has ever been — 108/68.”

“Getting my blood pressure taken right here at the beach, right at the house, it is so much easier and I feel so nice and relaxed. I don’t have to have the pressure of driving to the doctor’s office. I get to be home. It’s a wonderful feeling.”

House call on a hundred foot cliff

House call on a hundred foot cliff

I complete his Oregon Disabilities Hunting and Fishing Permit. He doesn’t hunt, but Johnny has fished all his life. Due to bad arthritis in his hands he can’t hold his fishing rod so long. With the permit he may legally fish with an assistant who can hold his rod for him. This 11-page document I’m completing will also serve as a disabled clam digger permit that will allow Johnny to have another clam digger fill his container as long as he is within 100 feet of his assistant.

House call on a hundred foot cliff

Now Johnny completes the publishing consent and HIPAA paperwork so we can share his story with the world. He is happy to help other patients and doctors get back to true healing. In fact, Johnny has an important message for America’s doctors:

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears. Watch her TEDx talk, How to Get Naked with Your DoctorPhotos by Geve.

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  • ninguem

    Nice view from the back yard. He’ll be able to collect souvenirs of Fukushima from that beach.

    So, round trip Eugene to Agate Beach.

    Figure you spent, what, forty, fifty dollars in gas for the privilege of filling out a Disabled Hunting and Fishing permit.

    Came straight to his house for this.

    Yeah, I bet he likes you.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yes. He has already called in that large dock that came to shore a while back. You may recall.

      He is in Newport – north of Yachats (my favorite coastal destination in Oregon.

      Got a Prius so fuel is cheap. Spent the weekend on a romantic getaway with my photographer whom I am dating. And so we went to visit John and do some paperwork and refill his meds.

  • Suzi Q 38

    Wow.
    Dr. Wible…
    You certainly look content treating your patient in his uniquely beautiful habitat.
    How much to you charge for such of service??
    Do you get to charge for travel time and gas?
    How do you put a price on the quality of your day?
    I am fascinated by the way you have chosen to do your life’s work.

    Good for you and your patients.

    • Dr. Drake Ramoray

      I don’t know about that line of thinking. My assumption when reading this piece is that this is a former or longterm patient (used to drive to see her) with whom she has a particularly strong bond. I doubt highly, although it is certainly possible, that she is charging routinely for these services (particularly with the distance driven). I could see myself coordinating an annual visit like this to coincide with a summer vacation at the beach (beautiful scenery, actually so beautiful reminds me of the movie the Truman Show, or as if they are in a studio with a green screen). Catch up with an old patient, fill out his bueracratic paperwork, maybe bill it as an annual physical to Medicare, and it makes great PR for her practice. I’m pretty sure the primary driver here isn’t money, but also think this patient may be an exception to her practice model rule (with possibly others).

      Good questions, and I too am interested in the responses. No doubt regardless, Dr. Wible is pretty awesome.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Primary driver is not money. Never has been in my life. However, I can make more money as a solo doc than I ever have working for the big box clinics. Why? Cut out the middlemen so I am not supporting no-value-added intermediaries who can take up to 90% of the take in large clinics where I live.

        Yes. He is a longtime patient who used to drive to my office. Now having trouble getting to me. Yes. Strong bond. Yes. Combined with a vacation. This is what I do on vacation. I see patients. Because if I don’t – I miss them!

        Sorry I am late on my responses on this post. I usually write sooner, but I have a national news crew here from Washington DC doing a TV story on my practice for AMERICA TONIGHT–an investigative news show. Watch for it!

        • Dr. Drake Ramoray

          Agreed and working towards cutting out the middle man myself. Will look for your TV spot. Always good to read your articles and see how in my view medicine can and should be practiced.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yes. Medicine can and should be practiced by physicians. Not politicians. Not MBAs. Not high school graduates at call centers.

    • http://www.idealmedicalcare.org PamelaWibleMD

      With really poor folks I accept what they can pay. I do not charge for gas and travel and thankfully these 100-mile trips are not frequent and most of the time I combine with a vacation to the coats so it is really a “pleasure” trip for me, but it means a whole heck of a lot to my patients. Since I am doing what I love, the quality of my days are priceless

  • Dr. Drake Ramoray

    Agreed. That was part of what I meant when I indicated that this patient is probably not a regular component of her business model (ie. she doesn’t make mone doing this, is a relatively rare occasion, etc.). I did the rural, historic, scenic, gig but in a southern state. I literally got chased out of there by the regional hospital system. I am not naive to the workings of reimbursement, which was why I found the orginal thought of this being a money making for the encounter (PR and TV shows aside) doubtful at best. As for medicine being practiced the way it should be, that is more related to the middle man. I have a few pro-bono patients even now who “pay” me with farm fresh eggs and produce, but that doens’t mean I think I can make a living that way.

  • Dr. Drake Ramoray

    Yup I was the only Endo for two entire counties. Hospital bought up a bunch of practices. I figure my new job description would have taken 3 maybe 4 docs to run effectively. Buh-bye. Still check periodically just for kicks. Still no replacement.

    I’m in a better place (both job and geography) and they got rid of an Endo that they apparently didn’t want. Win win for us I guess, sucks for the patients though.

  • Suzi Q 38

    True.
    That is why I was asking how much was the pay for doing so.
    When I had my FIL living with us for 7 years in Southern California due to a series of heart attacks, strokes, and seizures, there were times I needed to take him to the doctor.
    Sometimes, he was fine with my doing so, other times, he just didn’t feel well enough to get in the car.
    I would have loved a house call from a physician, but did not want to trouble his doctor.

    I realize now that I should have at least asked.
    We lived less than 10 miles from his office.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yes. Can’t hurt to ask!

    • querywoman

      Medicare home health and hospice cover house calls.
      You really missed the boat on that one, Suzi Q. States also have programs to keep the really sick elderly and disabled out of nursing homes. House calls is one way to keep
      ‘em out.

      • Suzi Q 38

        Yes.
        We paid for a few things that we shouldn’t have.
        He wasn’t covered for a nursing home or to live in our home as far as custodial care, but his doctor’s visits were covered.
        I just never thought to ask if a doctor could come to our house.
        Thanks for the tip.
        At least I will know for when my husband and I are older, or when my 90 year old mother needs a doctor.

    • ninguem

      Well, can’t speak for another practitioner, except to say the Medicare fee schedule is a public document.

      Assuming Medicare. Assuming a midlevel office visit for an established patient:

      If Medicare participating
      - $70.99

      If Medicare nonparticipating – Medicare
      pays $67.44 and limiting charge $77.56

      “Limiting charge” meaning you can charge the patient the difference between the $67.44 Medicare pays directly, and the limit of $77.56, or $10.12.

      If “opted out”, Medicare pays nothing, and you directly bill the patient for whatever fee has been agreed upon.

      • Suzi Q 38

        Thanks for the prices.

  • http://www.idealmedicalcare.org PamelaWibleMD

    A small ideal clinic could work anywhere. Set up the proper business model with the proper doctor and you can have your cake and eat the scenery too!

  • http://www.idealmedicalcare.org PamelaWibleMD

    Why can’t they attract and keep physicians on the Oregon coast?

  • http://www.idealmedicalcare.org PamelaWibleMD

    Nothing can prepare us for real life education.

  • http://www.idealmedicalcare.org PamelaWibleMD

    I’ve been in Sylvia Beach Hotel. Not to stay. Just to look at the rooms. Yes! Wow! A write off. What a great idea!!

  • http://www.idealmedicalcare.org PamelaWibleMD

    Wow! Yes! That house is like right next door. . . .

  • DeceasedMD1

    You always have the most interesting things to say. A truly beautiful composer. Hope his health care was better than what you both report now in Oregon.

    • ninguem

      Well, you’re both deceased, I figure you could ask him.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Start with my teleclass and retreat:
    http://www.petgoatsandpapsmears.com/teleclass.php

    The love drug comes later.

    Pamela

  • http://www.idealmedicalcare.org PamelaWibleMD

    So rural Oregon docs can’t make it because of substance abuse and domestic violence?

    ?

    ?

    • ninguem

      Pam, I’m not talking about a couple of hippies smoking a joint. They busted a meth lab next door to my office. Another blew up a block away, with a couple dead from massive burns.

      Actually, they were busting two, three a week at peak. There’s not as much pseudo smurfing nowadays, so it goes to big cartel setups, Mexico and BC Canada. Not production as much now, but distribution, and they’re still using.

      I’ve tended to find such patients are not covered in the Methamphetamine Producers Group Health Plan.

      Same with the domestic violence and other people affected by grinding rural poverty.

      If you’re in specialty medicine where you have to use a hospital, you’re stuck with the entire patient population. My town, the ORTHOPEDIC SURGEONS could not make a go of it privately, one left town, the other became a hospital employee.

      A medical practice can be resistant to certain economic realities, but not immune to them. Otherwise one could set up an ideal clinic in Zimbabwe.

      Primary care? Possibly, even in a rural area. Bearing in mind, the people likely to self-select for such an arrangement, perceive the Valley docs to be superior, the locals are stupid horse docs. So routine care goes to Eugene and Portland.

      Non-Oregonians, “Valley” = Willamette Valley, the Portland-Salem-Corvallis-Eugene corridor on Interstate-5.

      Well……until it’s not convenient for them to go to the Valley. Then when there’s a mess to clean up, then the locals will do.

      Case in point……..say, for example, a man with, oh, let’s say hypertension and arthritis, who might need a blood pressure check, medication refill, and incidental completion of a disabled hunting and fishing permit.

      git r done by the local talent?

      Doesn’t seem that way, does it?

      And hey, fine. Thing is, multiply that story by a thousand.

      But don’t wonder why all the local docs left. and the recruitment adverts go unanswered.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Aha! Got it. I’m there on the weekends buddy. :)

      • http://www.idealmedicalcare.org PamelaWibleMD

        But I still think the right caring family doc can make it work anywhere – including the Oregon coast!

        • ninguem

          If it could work anywhere on the coast, I suppose Newport would be a good choice.

          And they are, seriously, hurting for quality docs.

          Nobody stays. Worse since Samaritan took over. You know the drill, and Oregon is one of the worst for this. As soon as a hospital system “owns” the area…….and Samaritan owns several counties…….they will turn on you like a rabid dog.

          They bought up all the practices, squeezed everyone out, and most of the docs left.

  • http://www.idealmedicalcare.org PamelaWibleMD

    I LOVE that game.

    So will I ever meet you in REAL life? Or will I only know you here as “ninguem” on kevinMD?

    I guess the closest I can get with you otherwise is to stay in the Collette room at Sylvia Beach and then I can say I slept in the bed that the romantic ninguem couple once shared.

    :) Pamela

  • Suzi Q 38

    How do you doctors keep up with all of this stuff?

    • http://www.idealmedicalcare.org PamelaWibleMD

      Fun after-hours hobby.

  • Suzi Q 38

    How do you doctors keep up with all of this stuff?

  • eqvet2015

    BTW, same goes for those horse docs and cow docs, who also have loans to pay off. Wonder how the mid-levels are going to do when (not if) the next foreign animal disease hits U.S. agriculture and there are no rural veterinarians to identify it in time to limit the fallout…or the next outbreak of disease related to the food supply, now with carbapenem resistance, because farmers don’t want to and can’t get a veterinarian to supervise their management and haphazard medical treatment with the umpteen antibiotic classes available OTC at the feed store. But if the AVMA or someone else tries to sell you a story of a shortage of rural veterinarians, don’t buy it. There are plenty of veterinarians who would like to do rural mixed or food animal practice who decided they can’t afford to take a vow of poverty to be able to pay off 6 figure loans to get paid like a schoolteacher. Medicine may be sinking fastest and hardest, but it’s not alone.

    • ninguem

      Hey, waitaminnit.

      If they call us dumb rural family docs horse docs, what do they call rural veterinarians?

      • eqvet2015

        Overworked and impoverished? Foolhardy? And/or about to retire?

        • eqvet2015

          Or maybe, to get things back on topic, without a doctor? Maybe the best course of action would be to get your family practice NP, then go to vet school and open a practice in an independent-practice state treating ALL members of the family (tongue firmly in cheek).

  • Suzi Q 38

    “……There’s a bloody good reason why they can’t attract and keep physicians.”

    Why is that??

    It is so beautiful, you would think that someone would want to live and care for patients there.

    Is it because there aren’t enough patients to make it worthwhile?

  • http://www.idealmedicalcare.org PamelaWibleMD

    Liked and shared. Thank you!

  • ninguem

    Yes, one in particular.

    Are you SURE you are disenrolled with the Oregon Health Plan?

    Are you ABSOLUTELY SURE?

    Check with the state to make sure ALL AGREEMENTS have been cancelled.

    Ever do a two-week locums gig at an urgent care somewhere, ten years ago? Bet they enrolled you in the Oregon Health Plan.

    I had old “legacy” agreements from 20 years ago, discovered when I disenrolled from Medicaid.

    You bill cash for an Oregon Health Plan patient, it’s illegal, fraud or whatever, if you’re participating.

    Make sure you’re not “participating” on paper from some old gig that you barely remember.

    Listen to Michael Corleone. The State will treat you the same way.

    http://www.youtube.com/watch?v=UPw-3e_pzqU

    • http://www.idealmedicalcare.org PamelaWibleMD

      Absolutely sure. 100% out. I am off their list and have been out of their system since 2005.

      • ninguem

        Good for you, I see you’re on top of that, it can bite you.

        I suspect your patient population self-selects somewhat. You haven’t had people come back to you, claiming Medicaid after-the-fact?

        In other words, I’ve had patients claim “no insurance”, so they want to pay cash. The medical issue is a defined thing, that can be addressed in a few visits. Problem addressed. Patient treated, pays agreed-on cash.

        The “look-back” with Oregon Health Plan, I forget, I think about six months. So, at five months, patient calls and says “by the way, I have Medicaid”, and asks for a refund. We had been in, but not accepting new patients. We had enough people misrepresent themselves, deliberately, that I had to pull out of Medicaid completely.

        The issue, for other readers, is that patient coming back after fine months, if I’m in Medicaid, is that person misrepresented self to get in (I don’t take new Medicaid), pays cash, then after a few months, demands a refund of money paid, telling us to bill Medicaid.

        And that person gets the money back. Which was that person’s plan all along.

        One or two of those was enough to change our policy. At first, we stayed in Medicaid and checked eligibility of people who claimed to be cash-pay. They were misrepresenting selves to get in my practice. There were clinics that took Medicaid, the patient didn’t want to go there patient wanted to come to me. From time to time, we’d find a “cash” patient really on Medicaid, we’d cancel the new patient visit.

        Ultimately, we bailed out of Medicaid completely. That’s when we found all the legacy contracts.

  • http://www.CommunicatingWithPatients.com/ Edward Leigh, MA

    Hi Pamela: One question — how do we clone you? Healthcare would be an amazing place if there were more people like you. Keep up the great work! Eddie