My oasis of care is being threatened

I am a solo, independent family physician and my practice is not a silo. It is not a cold, stagnant, immobile, potentially dangerous storage facility where data to be used by insurance companies and statisticians is held until it is finally purged. No, my office is a visually and emotionally comforting, innovative, healing environment where information is shared and confidence is enhanced. It is an oasis.

My practice is embedded in my community and many of my patients are also my neighbors. I offer 24/7 access, home visits, same day appointments, little to no waiting time, a patient portal with secure e-mail, and unlimited free education sessions with an RN to enhance the patient’s confidence in their health management. My patient appointments are 20-minutes long (40-60 minutes for new patients), which gives me the time I need to go through the entire list of patient concerns without feeling rushed. I take most insurances and do not charge any added fees. Measurements of my practice show twice as many of my patients say they get “perfect care” compared to national average. To them, my practice is an oasis.

When I started my practice over 10 years ago, I figured it would last about 4 years. The truth is that instead of burning out, I am more energized and engaged about practicing medicine than ever before. The autonomy of being in a small practice means it is a continuous experiment done on my timeline with the resources I have available. I can quickly change policies, try new concepts out, and cast aside ideas which do not seem to work. Given the small size, there is little chaos and the flow through the day is smooth. Most days I go home for lunch and most evenings I have time for a run. The practice is integrated into my life and lifestyle, and although sometimes frustrating and always challenging, it is indeed an oasis for me.

But climate change in the medical system threatens to destroy my oasis. Significant numbers of experts believe practices like mine should not exist. Instead of looking at the oasis, they see a silo. Many believe coordination is the most important pillar of primary care, but they mistake structure (lines of communication) for behavior (actual communication). Others believe expensive technology with disease-based registries is the cornerstone to higher quality, but they mistakenly equate disease with ill-health and ignore the fact that family medicine is fundamentally relationship-based. Still others feel that cost containment can only be achieved by thrusting onerous administrative burdens onto primary care practices, but they mistake cost containment for cost shifting.

And all of this matters. It matters because without comprehensive family medicine costs soar and quality drops. It matters because the incessant push to follow the latest metric distracts us from what is really important and prevents us from finding a metric which accurately measures what we do. It matters because joy is found through a sense of autonomy and the more we sacrifice our autonomy for job security, the less happiness we will have. It matters because small practices have the freedom to innovate and change and can and should lead the way into the future. And it matters because at a time when we need more family physicians than ever, independent practices are shutting their doors at an alarming rate.

So now is the time to discard talk of silos and how to dismantle them. Let’s begin instead to discuss oases and how to create and nurture them. Let’s recognize failed policies which lead to dead zones and work to reverse them. Let’s unite our oases locally and nationally in an exciting network of innovation and quality. Let’s understand what is truly important in family medicine and change reimbursement policies to reflect this. And let’s eliminate unnecessary administrative burdens which constantly distract us from the important job we have to do everyday.

The life of my oasis, and thousands more like it across the nation, can no longer afford to wait.

John Brady is president, Ideal Medical Practices.

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  • Patient Kit

    Here’s hoping the oasis doe not become a mirage!

  • QQQ

    “Doctors Begin To Refuse Obamacare Patients”. Obamacare plans have
    shrunk payments to physicians so much that some doctors say they won’t
    be able to afford to accept Obamacare coverage, NPR reports. Many of the
    eight million sign-ups in Obamacare exchanges nationwide already face
    more limited choices for physicians and hospitals than those in the
    private insurance market. But with low physician reimbursement rates,
    the problem could get even worse.

    • Patient Kit

      I’ve been doing some info “shopping” on the NY exchange in case I need to buy a plan via the exchange. There are 10 different companies selling plans on the NY exchange for NYC. As far as I can tell, I haven’t found one single hospital in NYC that is not accepting some, if not most, of the plans. That includes all of the many good hospitals here like Memorial Sloan Kettering, Hospital for Special Surgery, NY Presbyterian, NYU Med Center, Lenox Hill, etc etc etc. The networks of providers for these plans look fairly big. Maybe they are all hospital-based docs and not private practice docs. I don’t know. But if that’s the case, so be it. There are a lot of excellent docs who will accept these plans and treat patients. That, for patients in need of medical care, is the pertinent fact.
      The hospital where I am currently being treated is accepting 7 of the 10 exchange plans. My awesome doc is accepting most of them too.

      The hype that “nobody” will accept these plans is coming from rightwing politicians and media who passionately want the ACA to fail. The right is trying to scare people into thinking that no doctors or hospitals will accept these plans. That is simply not true. At least, not here in NYC. NY is one of the states that is trying very hard to make this work. I feel very bad for Americans who live in the states that are trying very hard to make it fail.

      I have said many times on KMD that the ACA is far from perfect. It needs to be fixed. But this constant screaming that it isn’t working anywhere for anyone is simply not true. Millions of Americans are depending on it to work right now until we have something better in place. People who are sick and injured right now are real. We can’t wait for this obscene political battle to play out.

      • Eric W Thompson

        I have similarly good care in Madison, WI. Though not quite as good as you described. But I have traveled a lot and lived many places. The rates are too low in most places. Many patients across the country are having trouble finding doctors who will take the low rates. This is a serious problem. Trending cheaper may in the future affect even your area’s access to care.

        • Patient Kit

          I’m happy to hear that the exchange plans are working in Madison, WI. Does WI have its own state exchange like NY or are you using the federal exchange?

          Here in NYC, I’ve only done some preliminary “in case I need it” research on my options. But I’m pleasantly surprised that my options on the exchange don’t look nearly as bad as some had led me to believe. Here in NYC, it seems like there is a big difference between now and nine months ago re who has signed on to accept those exchange plans. In October 2013, media was predicting that “no good hospitals” will take it and now, in August 2014, all good hospitals here are taking it. I think it just took some time to negotiate contracts. That all, of course, should have been in place before the initial launch of the exchanges. But a rough launch is not the end of the story. I’ll be sure to report on my actual experience with the exchange if it comes to that for me.

          I keep saying “here in NYC” because I do realize that there are many places across the country where patients are having trouble finding doctors who accept the exchange plans. I agree that is a serious problem and we need to work on doing something about that. If raising the reimbursement rates would solve that problem, then that’s what we need to do. I know. Easier said than done.

          • Eric W Thompson

            I have asked before and will say it again. Who pays? It is already a huge bill and getting higher. Most of the people who have signed up are paying under $100 a month. The $1000 plus is being born by the taxpayer and it is rising. I would have been much stronger for the ACA if the USA capped medical expenses to be at the same per capita rate as the most expensive country in Europe plus 10%. Instead it is only going higher. this was supposed to make it more affordable. Only for those taking the nearly free ride.

          • Patient Kit

            I think the obvious answer to who pays for healthcare in the form of the ACA, Medicare, Medicaid and any potential single-payer system are the tax payers. And I’m okay with that. I’ve been paying heavy taxes my whole life that go to wars I don’t agree with and corporate welfare (I’m not ok with that) and education for other folks’ kids (I’m fine with that). I’m fine with taxes funding a healthcare system for all Americans.

            And tax money doesn’t only have to come from individual hard-working taxpayers. It can come from taxes on corporations who make boatloads of money selling unhealthy products. Here in NYC, a pack of cigarettes costs $15 because of taxes. Some of those taxes or similar taxes on McDonald’s and other junk food, for example, might be a potential source of revenue to fund healthcare.

          • Eric W Thompson

            I am all for cutting military in half, and I served 28 years. Pull out of NATO and bring all the troops home. End foreign aid and cut the UN contribution. But if you want the government to provide free what people think are rights, then what about guns? I have never owned one, but since it is my right, the government should buy one for every adult and provide a stipend for low income people to buy ammunition.

            Corporate America has the highest tax rates in the 1st world countries. Lets raise them more so we can send them overseas.

            Finally all the taxes you have paid do not come near to covering the cost of the care you received. If we do go to such a single payer system, the health care portion will be the largest budget item of the federal budget. Americans don’t accept rationing as is done in the countries that have single payer. The 95 year old grandpa would demand transplants and the new joints. I see it where i work.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Why are we inviting third patios to pay for primary care again? Can someone remind me? It makes no sense. Here’s what would happen if you asked your insurance company to pay for your breakfast: http://www.idealmedicalcare.org/blog/when-your-health-insurer-pays-for-breakfast-heres-what-happens/

  • Karen Ronk

    I hope that you will be able to maintain your oasis as it clearly benefits you and your patients. But the trend these days seems to be get rid of things that work because somebody, i.e., the government/the establishment, knows better. If the billions spent on the ACA were just distributed to individuals to use at their own discretion, we would have more people getting the care they want.

    • http://www.idealmedicalcare.org PamelaWibleMD

      More and more doctors are choosing DISINTERMEDIATION (removing the middle men). It’s the most sustainable way to operate a family medicine clinic. Look at Cuba. There’s a doc in every neighborhood responsible for the families in that neighborhood. We don’t need all these no-value added intermediaries. The courageous docs are pulling off these parasites and they are getting back to serving their patients.

      • Patient Kit

        How do you feel about a single-payer system as a way of getting rid of those insurance middlemen?

      • brazilian

        Please, not Cuba. Here in Brazil, we received a lot of “doctors” that are almost killing part of the population with absurd mistakes. If you want to talk about Cuba, look beyond the surface, see the formation of these professionals

  • disqus_McUkQK6a8K

    I have the same job as Dr Brady
    I get it

    I see that elsewhere on Kevin MD Joe Flower says….
    “The current trend toward massive regulatory complexity will most
    likely continue. There are no forces or mechanisms emerging yet that
    would change that trend. At the same time, the economics of running a
    health care organization will get much more complex, which means so willstrategic planning, capital planning, and every other top management task.
    So we can expect growth in the regulatory compliance sector of health
    care employment. At the same time, health care planning, forecasting,
    financing, and strategy skills need to put on muscle, whether in-house
    or through consultants…..”
    Which bodes really badly for Dr Brady. No wait – it bodes badly for all people who ever need health care and all primary care providers in any setting.Unless we figure out the forces that would change that trend .Which I have to hope someone is doing.Otherwise Dr Brady goes home one day and puts the lights out and oh lets see the coutnry is in a worse mess of costs going up and outcomes going down while people suffer becasue noone in their right mind would or should take our jobs It may take a worse mess before someone has the courage to fix it .

  • http://www.idealmedicalcare.org PamelaWibleMD

    Primary and tertiary care are completely different and should never be lumped together in health care funding conversations. You WILL need a team for your lung transplant. You should NOT need a team for your physical Come on gals, do you really want a football team for a Pap smear?

    Too many cooks in the kitchen . . .

  • http://www.idealmedicalcare.org PamelaWibleMD

    “When I started my practice over 10 years ago, I figured it would last about 4 years. The truth is that instead of burning out, I am more energized and engaged about practicing medicine than ever before.”

    When medicine is practiced properly, both doctor and patient should feel invigorated after an appointment. You should NOT feel like you lost a quart of plasma. If you feel that way, you may have parasites in your exam room.

    How to remove no-value-added parasites (who are making a nice living off of physician-generated revenue): Get out your tick removal kit and start with the head and follow along per below –> http://www.webmd.com/first-aid/tc/how-to-remove-a-tick-overview

  • http://www.drkristinoaks.com Kristin Oaks

    Being small improves communication and decreases chaos within the office.and also reflects what some of the problem with the healthcare middlemen is. Too much distance from what is happening in the exam room and in the health of the patient, an inflexibility regarding guidelines and policies. Being smaller (my office is also an oasis) allows me to make changes in office policy (or recognize gray areas in policies) much more quickly than in a corporate style practice. It is the difference between turning around a motor boat as compared to an air craft carrier.

  • Steve Beller

    As a clinician and health IT software architect working in several Federal (ONC) workgroups over the past three years, I can confirm that government focus has been on the “big guys,” i.e., large provider organizations and EHR vendors participating in health information exchanges (HIEs). I’ve been fighting to have the focus extended to supporting the needs of small practices and EHR vendors (the “little guys”).

    Having had a solo practice in NY for twenty years (as a clinical psychologist), I empathize with Dr. Brady’s sentiments about the importance of autonomy and independent practices in terms of clinicians’ quality of life and the well-being of their patients. This extends to primary care practices and specialists of all disciplines.

    While I contend that care coordination and next-generation decision support are important to increasing healthcare value to patient, it is unwise to ignore or destroy the little guys in the process.

    A case can be made for the government’s centralized, top-down, tightly-coupled network (TCN) model that it benefits larger organizations. Primary benefits of the TCN are control and consistency because this model limits participation to people within the same discipline, department, region, organization, etc.; who have access to the same information sources, share similar experiences; who do things in similar ways; and who are under the control of central authority.

    An equally valid though opposite model can be made for decentralized bottom-up loosely-coupled network (LCN) of independent collaborators that benefit small practices and organizations. In addition to the professional autonomy benefit, the LCN’s other benefits include creativity, innovation, and attention to differing needs and circumstances of different parties. This is because collaboration among people with wide diversities of knowledge, ideas and points of view provides a larger collection of resource intellectual pools, and offers access to a greater variety of non-redundant information and more content on which to base decisions. As such, the LCNs provide the greatest opportunities for stimulating multifaceted discussions, out-of-the box thinking, and creative clinical and economic solutions.

    An example of an LCN is the communities of referral that form patient centered medical homes/neighborhoods in which a primary care physician and specific specialists and facilities collaborate in the care of a specific patient. Another LCN example is a provider-researcher network, such as PPRnet (https://www.linkedin.com/groups/PPRNet-5151941/about) in which clinicians and researchers collaborate to share, evaluate, and evolve evidence-based guidelines. These LCNs could even interconnect with each other on a nation-wide and world-wide basis, as well as connect with TCNs. Given the political will and adequate business incentives, this global interconnectivity can be achieved rather quickly, easily and inexpensively. It can be done using
    a software architecture in which pub/sub nodes exchange information via simple encrypted e-mail (such as the ONC Direct Project).

    Realization of this vision would enable independent-minded individuals to maintain their autonomy, while at the same time enabling them to
    collaborate in regional and international LCNs for the purpose of improving clinical decision support to increase value to healthcare consumers and reward providers who do so.

  • David Feig

    Great post. The medical home is constantly touted as a solution, but isn’t it really just a way to get a small amount of primary care providers to service a much larger panel of patients? I kind of like the communication back and forth with my patients, I see problems when its harder and harder for patients to get to me directly. In my previous jobs when others tried to help, at least 50% of the time their mistakes lead to more work for me anyway

    I love technology but endless investment in huge EHRs is just making more problems. No more simple cheap solutions since they aren’t officially certified. Trying to customize a big EHR is so expensive, its like being forced to buy a huge expensive car with tons of options you won’t use, and none of the ones you actually want.

    I have heard many smaller groups complaining about declining reimbursement. The irony is that when these smaller groups get bought out, the hospital system raises their prices through the roof. And yet we complain about the rising cost of healthcare when indirectly payers are making it happen– By forcing small efficient groups to join huge inefficient systems.

  • pjp

    Excellent piece, please write more

  • Sofia Pirela

    Great article, thanks

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