Ideal Medical Practices

Family doc describes the difficulty practicing as a professional in a toxic policy and payment environment

I am a family doctor, who recently joined a family practice group after working for 13+ years in a community health center setting. Loved serving patients in great need- was driven out of the health center by bosses playing power politics.

When I arrived at my health center five years ago things were a mess- clinical numbers were abysmal, revenues barely covered expenses, staff morale was terrible and patients hated visiting our facility. As site medical director, I worked collaboratively with the site director and all staff to get the center on track. Staff turnover was very high early on.

We hired hard working intelligent staff dedicated to our mission. I'd like to think that sharing my productivity bonus with staff, who after all shared in making seeing more patients possible, helped with boost staff morale. I worked pretty hard at the health center, where my 3.5 patients an hours was a high productivity outlier.

I boosted my numbers by serving nearly 100 Suboxone patients and a large panel of not-to-difficult psychiatric patients who required quarterly follow-up. Before I left our clinical numbers were enviable, revenues far outpaced expenses, staff turnover was low and patient satisfaction was high. Our patient panel mushroomed from 2,500 to 7,500, FTEs of providers grew from 1.5 to 4.5, staffing increased from 18 to 45.

All of this was accomplished within a larger organization of 300 with three practice sites and without much input from senior management, who decided to reassert control over our facility. With some stimulus money they purchased a building with the intention of again tripling the size of staff. But if they were to control the move, the needed a new medical director. I was out.

Six weeks ago I joined a private Family Medicine group. Mea culpa. I should have done a better job vetting them. They are caring, intelligent practitioners but practicing a style of medicine that would burn me out in no time!

In the interest of efficiency, there are times when three doctors are supported by only one MA. Patient waits at the front desk to verify insurance can take up to 45 minutes. I am routinely 45-60 minutes behind schedule. Patients routinely wait interminably only to spend a few rushed minutes with me. Adding insult to injury, I was informed that I was not permitted to discuss anything with medical assistants. If I had concerns of any kind, I was to contact the often unavailable office manager.

I love being a family doctor. I am honored to serve folks as they struggle with disease and strive to live healthy lives. I enjoy the intellectual breadth of primary care. It is a wonderful gift making a living serving appreciative patients.

Until these last six weeks I was perplexed by doctors who never would have become physicians had they known how odious the current practice environment has become. I hate this ridiculous rat race. There are no winners. Patients get inferior care. Providers burn out.

Inspired by my wonderful personal physician, I am entertain jumping aboard the Ideal Medical Practice bandwagon. I needed the trauma of the last six weeks to prompt conservative me to contemplate so radical a move.

Hope everyone has a productive and happy day.

ACOs: boon or bust? Physician Practice Acquisitions on the Rise - like déjà-vu all over again.

In the 1990s when hospitals anticipated capitation, they binged on primary care practices.  Too many came out of that era with a whopping hangover.  Will ACOs merely replicate the worst of the 1990s?  Will hospitals gorge on and then disgorge primary care practices?

I'm hoping we can avoid making the same mistakes.  There is great potential if we can work together and much misery if we continue our fragmented-silo approach.  There are some excellent examples of physicians, health plans, and hospitals working together. Let us learn from them and learn how to avoid the mistakes of the past.

We can't afford to put primary care through another round of what Kathy experienced (below).  If we want to build high-performing health care delivery we need good primary care.  Good primary care will be more likely when the primary care workforce is supported in their work and not forced into big-box treadmill care.  This will happen when the financing of health care aligns with improved outcomes and experience of care and not just doing more and more stuff for money.

Gordon

It may be hard to believe, but many experts believe the days of the independent family doctor, running a small, highly personal private practice, may be coming to an end. An estimated 2,910 physicians were involved in mergers or acquisitions last year - nearly double the number in the previous year - according to a new report from PricewaterhouseCoopers.  via www.midcapadvisors.com, October 22, 2010

To me this is like déjà-vu all over again.  The hospitals just want to make sure they are part of the equation.  So they are doing the same thing the did in the mid 90’s saying that solo and small practices can’t survive and our lives will be so much better if we let them handle this difficult job for our nonbusiness little brains.  I was part of a successful practice in the early 90’s; before capitation fees were ratcheted down to peanuts as well as everything else.  The hospital was buying up primary care practices or offering management contracts.  WE knew we didn’t want to be owned but the management contract sounded too good to turn down.  We were also expanding and needing to build out a new office, etc. 

It was a total failure.  None of the economies of scale they promised.  None of the taking away management issues so we could just practice medicine.  Staff were constantly being hired and leaving.  We still had management meetings and would be handed 100 page reports of detailed accounting saying “see more people”.  Billing dropped to poor performance.  Layers of management were added to our practice that we didn’t need and all these new fees assessed.  The build out probably cost twice as much as it should have and took months to make every decision.

I don’t see what is happening now as any different.  The hospitals know they need to create a new profit center.  They don’t want to be left out so they are trying to become the foundation.  They are running around pronouncing that this will be our only hope.  We don’t have to listen.  I don’t see it as being any more successful today than it was 15 years ago.  Just keep your fingers in your ears until they go away.

Kathy Saradarian, MD
Branchville, NJ
www.qualityfamilypractice.com

Vertically integrated delivery system can be a boon or bust depending on the principles driving the process

With permission from the author I post below a long anecdote about a high functioning solo primary care practice looking to link up with a local group.  This is supposed to be the way to a future state in which primary care practices operate as the front lines of vertically integrated Accountable Care Organizations.

The notion makes some sense on paper but the real world is a bit messy.  I post this example as a caution that even good intentions can go awry and leave both sides feeling burned.

We are in the midst of another wave of mergers and consolidations on the delivery side of health care.  With thought and care this can be done well.  Let the principles of high performing health systems guide this work. High performing health systems stand on a foundation of effective primary care.  Doing this well means working with the front lines, not just swallowing up practices with boiler-plate contracts and top-down management.

High performing primary care and vertical organizations are not mutually exclusive, but we need to consider the effect of organizational policy has on the ability of a practice to deliver on the promise of effective primary care.

 

This email is long and I know that some of you will yell “WHAT WERE YOU THINKING?!?!”  Please refrain from that, as we’ve already kicked ourselves in the head over and over about this.  If you don’t want to read it, I won’t be offended if you hit your “delete” button.

Background:  We were sharing our space & staff with another MD up until July, 2009.  At that point in time, we compensated for the lost overhead from the gentleman who does research in our office by charging him rent (previously we took only a % of what he earned, now we are supposed to be paid rent + a %).  Things were going OK, but Rob’s practice was not as busy as our current spending habits dictate, so he started working for a company called X which does concurrent chart review for hospitals to determine inpatient vs. outpatient status, mainly for Medicare patients.  He started there in February this year, and while it is a lucrative job, it is not personally fulfilling in the same manner that a clinical practice is.  Rob shared with our former practice management advisor about this position, in case the PMA knew of any other physicians who were looking to add income after hours.  The PMA shared with us that he was now working for a large hospital organization, and that they were looking to expand into our area.  Thus begins the saga….

Rob started talking to the Medical Group in April or May.  They were definitely interested in folding our practice into their group.  It required multiple interviews with multiple physicians, and at the outset, we thought this would be good.  The group would provide a stable income for the next couple of years, would promote the practice (thus increasing patients to the level needed to make the sort of income that they were offering while not being on a hamster wheel), and would give Rob what he thought he wanted back – a collegial group of physicians with which to practice, a say in how the office would be run, while at the same time allowing him some time “off” (not being on call while on vacation).  The group’s non-profit Foundation would provide everything that the practice needed – paying all of the bills, including rent, an EMR system, payroll, etc.  And the group’s Research Division would contract with the research guy in our office so that research could continue.  Talks with the Medical Group went well in May and the first part of June and then stalled out when the president of the group went away for a month.  At the end of July, agreements were made and a formal employment contract was sent to us the week before we left on vacation in August.  Mid-August, we came back from vacation and Steve signed the employment contract.  Things started to progress.

The next step involved the purchase of our assets by the Foundation.  Within 2 weeks of signing the employment contract, an appraiser was sent to our office.  We were told it would be about 2-3 weeks and then we would get the purchase offer for our assets.  3 weeks went by, and we then started calling on a weekly basis to inquire about the appraisal.  Foundation’s Legal department would NOT release the appraisal to us.  They were working on the purchase agreement.

Meanwhile, the Foundation computer and phone people started hounding us.  Multiple visits to our office were made so that they could look at where they would need to install “their” equipment.  There was to be a computer in every single exam room.  “What a waste!” I thought…..Rob currently uses a tablet and carries it from room to room and it works great.  They also wanted to put phones in every exam room…..ditto the wastefulness.  Our office is so small that one simple yell for help will bring the staff running from the farthest corner.  The phone lady was like a Border Collie; she really “needed” to have AT&T come out and do work in our suite.  We kept telling her that until we had a signed Purchase Agreement, that was not going to happen.  The other thing that was supposed to be happening during this time was the Foundation was to hire our LVN.  Even after coming and talking to her personally, no one bothered to mention to us OR HER that she was supposed to apply for her job online through their website.  It was only after we pushed and told the President of the Medical Group that it was unacceptable for her to start working for an employer without knowing what her salary and benefits were going to be that they even bothered to tell us that she would need to apply online “for any job – just tell us which one.”  She complied, did the online application and had many phone calls with confused HR people wanting to know why an LVN would be applying for an MA position.  Our first clue that the left hand of this organization does not know what the right hand is doing…

Move forward to the last week in October.  Three days before the end of the month, with Rob supposed to be starting to work for the medical group on Nov. 1, we finally get the purchase agreement.  Not only is the amount bottom-dollar for the Fair Market Value of our assets, but in it they state that he cannot continue to work for X.  We told them that this is a deal-breaker.  Back in August when we signed the Employment Contract, we specifically asked if his work at X would be a conflict.  We have IN WRITING that it would not.  (They made a HUGE assumption that it was an Independent Contractor type of employment and not and Employment Agreement when they answered that question.  That has now come back to bite them because it wasn’t until October that they even bothered to ask for a copy of his employment.)  Foundation’s Legal department is stating that anything that uses his medical license is a conflict of interest and all income must flow through them and be passed on to Rob.  We knew that X wouldn’t do an independent contractor agreement because we asked about that in January upon the advice of our CPA.  But their Legal Beagles wanted to try anyways.  So the start date was pushed back to Dec 1.

On 10/29, AT&T called to state that they were on their way out to do work in the suite.  I said NO WAY.  I had a password protection put on our account because the Border Collie was ordering things to our account without telling us and without authorization.  (She was told - in no uncertain terms -  that there was to be NO WORK done in our suite until we had a signed Purchase Agreement.  And I have Building Management on my side for this one.)

We gave them until Nov. 5 to work something out with X.  Nothing was worked out.  On Nov. 8, Rob send a “Dear John” email to the Medical Group and told them that he appreciated all of their hard work, but without him being able to continue his work at X, we could not progress with the deal.  Never mind the fact that a deal had not been worked out with our research guy and our LVN still did not have an offer of employment.  That got the Medical Group freaked out.  They called and asked Rob if he would consider an “administrative” position with the medical group to offset the income that we currently get from X.  He said yes.  They told him by the middle of this week that they would have something.  He told them that they had until yesterday to come up with an agreement for research and a written employment offer for our LVN.

Needless to say, no administrative position has been offered.  No offer of employment for our LVN.  No contract for research.  No Deal.  Rob called the Medical Group yesterday, said “Enough is enough, thank you for the offer.”  Oh, and I forgot to mention that meanwhile, we have learned that their EMR is 1990’s technology (way behind our current EMR system, which just got certified this week for Meaningful Use), that many physicians are unhappy with the Foundation due to the top-heavy management and inability to get things done (like repair holes in walls and fix non-working computers), and we have decided that it’s just not going to be a good fit for an entrepreneurial physician to work in this monster of a system.


The past 6 months have been an exercise in patience, but have also been a learning experience for us.  Although large organizations may be the only way to make it work going forward with Healthcare Reform in areas such as ours, we are going to make sure that we participate in an organization that is not top-heavy and where the physicians have a say in the running of the business.

What will we do now?  The future is uncertain.  We’re not sure that we can sustain a practice and live in the area that we do.  Our house payment alone is 65% of our income because we moved here right before the market peaked and then tanked.  We don’t really want to move – our kids are doing really well in top-rated schools.  They have lots of friends (which is hard for our son to do).  We love our community. We like our house (even if it is overpriced).  My mom lives close by.  We are looking at sharing our office space again with another provider.  Rob will continue with X and research, and we will try to get creative about marketing our practice. Our story will continue, but without a top-heavy, unorganized group.  We are looking at migrating our EMR system to an ASP, Rob is drooling over the fact that he might be able to use an iPad, we don’t relish him continuing to work 20+ hours per week plus holidays for X, but we see it as temporary, although it is a long-term “temporary.”

Lesson learned:  Solo is the best option for us at this time. Just say NO to the big groups when they come knocking on your door.  And really do your research if you think you want to not be solo any more.

Happy Saturday and thanks for listening to me vent!

Being valued for the work we do - a positive story from the front lines of primary care

I wanted to share this with fellow IMPs [Ideal Medical Practices] to thank you for making a different
 to people:



I went to visit a patient at a hospital I haven't been at since I stopped
 doing OB a year after my second daughter was born (so 11 or 12 years)....I
 didn't see anyone knew. I was lost looking for things in an unfamiliar
 chart and wandering around the huge remodel.

A cool thing happened though. 
The nurse taking care of my patient saw me coming down the hall with a 
stethoscope around my neck and yelled out, "You must be the doctor from
Irvine who does house calls; we so wanted to meet you."

I had faxed in the summary sheet from Amazing Charts as the patient was on 
his way.

My patient's wife said all the specialists, nurses and the social
worker were so impressed at how much information was and easy it was to 
read. It was nothing that we don't all do everyday, but I sometimes forget 
that much of the medical world is too rushed to do even things that seem pretty basic and straight-forward.



It was nice to be welcomed as an IMP (even though they don't know that 
term).



Sharon McCoy George MD


Renaissance Family Medicine

10 McClintock Court; Irvine, CA

Those twicky twicky insurance denial folks! Such a yuck. Gotta love them. You too can play The Payment Game!

From a colleague in Georgia a warning of new fun and games.  This is what makes primary care so much fun.  We have to take time to carefully scan every payment that comes in to find these little games, then get on the phone to these guys.

We don't get the 'member' line where they are nice to people - that's where they MAKE money, so they treat 'em nice. 

We have to call the 'provider' line - that's what the insurers call 'medical loss.'  [Yeah, that's right folks, what we do for people the insurers call a 'loss.']

Once we key in our 'provider number' and verify it with a bunch of other codes and wait on hold and are finally blessed with the opportunity to talk to a billing clerk we can ask why they've played games with a $13.11 payment.

Why does the doc care about $13.11?  Because the cumulative effect of these games will cause her practice to fail if she doesn't.

If you bill to Humana for any of their Medicare alternative plans, watch your EOB’s closely.  We got 4 EOB’s in mail today and the allowable rates shown on the claims was only 88% of the Medicare allowable for the code billed.  I was shorted $13.11 on each EOB and when we called them on it we were told that the problem had to do with the reduction that was put on hold a few days ago.  When I pointed out that the claim was for services rendered the last week of December and that had the reduction gone into place it was for DOS [Date of Service] after 3/1/2010 and that the 4 claims in question were still prior to any change in the allowable fees.  I told them that we would expect payment within 15 calendar days or we would file a complaint with the GA insurance commissioner’s office.  I followed up the phone call with an official appeal letter sent certified so we can prove we tried to resolve this issue should it become necessary to take the issue to the insurance commissioner.  I am tired of these plans playing games with my reimbursement.  I just thought I would give everybody a heads up to watch out for shorted payments.

This is why more and more docs are ditching these games and figuring out other ways to serve their patients instead of spending their time playing The Payment Game with insurers.

The future is here but unevenly distributed: thriving happy PCP versus doctor hell

Like characters in a Dickens novel health care in the US demonstrates the best of times and worst of times.  We hear real horror stories and witness spots of brilliance.  My heart is heavy as Dr E's light is extinguished but gladdened by Dr B's resurgent hope.

These anecdotes highlight both the urgent need to change and what that change might bring.

We are crushing primary care practices with payment policies that fail to account for much of the work we should do on behalf of those we serve.  We exacerbate inadequate payment with unfunded mandates calling physicians away from their patients to address administrative trivia.  We thwart effective care with denials, delays, and mind-numbing bureaucracy that sap the time and destroy the spirit of the primary care work force.

But some physicians have figured out how to work outside this toxic environment and deliver great care in vital and satisfying practices.   They enjoy their work and the finances are lined up with doing right by their patients.  They are professionally and personally satisfied and delivering care in a supportive environment.

The worst of times

I've known Dr. E for years.  His soft caring voice and gentle manner must touch a lot of his patients.  As a primary care physician with a long career he has deep relationships with the people he serves that give him great insight into the right treatment recommendations and the compassion that is core to our work.

Dr. E can't sustain his primary care practice any more.  He's crushed by the administrative burden of the paperwork, the denials, the rejections that dog his every move to care for his patients.

The toxic policy environment takes down another good PCP and leaves a large number of people to seek care from strangers.

I enjoy practicing medicine.  But I hate spending so much time and energy dealing with the barriers and controlling inequities that 3rd party payers impose on my time and energy.  I am deciding to wind down over the next year or two,  giving  patients time to find other providers (I have a lot of Medicare pts who will not be happy about the task of searching for someone who accepts Medicare).  I just this week, called our local free clinic and told them I would volunteer for an additional day each month (if I am going to provide free care to patients under the disguise of insurance companies who refuse to pay,  I might as well avoid the hassles of dealing with them and up front, give care away ).    I can do locums work  for 6-8 days/ month and earn as much as I do now working 5 long days each week.  What is wrong with this picture. Sorry to sound so discouraged. 

The best of times

But not all environments are equally toxic and some have found ways to thrive. 

I was basically inspired by Obama "to be the change" and somehow decided to risk everything on some vague notion I had on how to create a medical clinic.  It was a bit of an experiment in some ways where I wanted to show that a Jr doctor with no name recognition, zero patients, no funding, and no media coverage could incorporate design into a medical environment and harness the power of social media to build a large and successful practice.   After 13 months and starting with zero patients, we are now staffed and open 7 days a week with 4 doctors and have seen over 3,300 patient visits in a fee for service model.  We have seen around 2,400 unique individuals and are averaging 7 new patients daily. 

Here's the predominant tone of patient experience in his practice:

This is the way medicine used to be and this is a refreshing change to the managed care that medicine has become. He reminds me of my grandfather who was a physician in a small town in Kansas.

I think I just found my new primary care establishment.  Right price, great service, and best of all, they value my time as much as their own.

What it's like in the front lines of health care

From a colleague in a rural practice:

1)  I saw a new patient with no insurance a week ago Friday on Sept 4.  I told him the yeast infection he had in his throat was not usual at his age and that we needed to do further workup. He rejected it and would not let me do anything but give him a swish and swallow because of no money.  He died this last Saturday after an ER visit and an emergency laparotomy for an acute abdomen.  He had a perforated rectum from a stage 4 stomach cancer that had spread from his Barretts Esophagus.....a completely treatable issue if caught early.  He was 55 years old.  Today I treated his wife for anxiety and irreconcilable grief.

2)   For those who are following my patients as I mention them dying of health care neglect....the bed ridden 79 year old guy who would not see another MD and wouldn't accept any treatment because he was afraid the costs would leave his wife with no home, as he had no Medicare secondary.   He neglected his congestive heart failure that caused liver and kidney failure.  He passed last Wednesday;  at least he only worked up a several thousand dollar bill (his ear was scratched and started to bleed two days before he died and the family had to send him to hospital as the bleeding could not be stopped. The ear bled because he had another fall, just after the last week fall and the last month fall when he decided to get up and shoot the damn deer that was eating his wife's petunias)  The hospital said he had "cirrhosis" but I had been doing his blood tests, and had an ultrasound from a year ago....not very primary, the cirrhosis..  Probably directly because he would not see an MD for three months when he got CHF for fear of costs...

[congestive heart failure (CHF) can lead to blood backing up into the liver and produce signs that look like but are not cirrhosis of the liver]

I had to pretend to be buying his home picked blue berries and pretend to accidentally find him sick to get him on to diuretic treatment this last June... He was bedridden with 19 century medicine the last three months.

3)     Also for those who know about my previously mentioned patients:  the homeless man who was living under the covered bridge is now dead as well as of two weeks ago.  He had been employed until November 06 and should have been on SSDI because we helped him apply in 2008 before the 2 year deadline, but they rejected him because of inadequate documentation of his disability...schizophrenia and organic brain damage with seizures secondary to a beating by teenagers which resulted in blood coming out of his ear.  He couldn't get to an ER, and couldn't see to drive anywhere, had no family.  There is no outreach here, so he could not get to the city for a workup by the federally funded clinic.  My report and the report of the monthly visiting nurse practitioner from the clinic was not enough for SSI.  So he lived under the bridge until he died of some blow to the head that left a lot of blood all over the ground and that gave him a flight in a coma to the tertiary care center in [major city] where thay spent, I am sure, more than he ever made in his life in the last four days of his life.  If he had had SSDI he would have been in a local apartment (preventing the attack by another teen if that is what happened) and been on medication (that prevented the seizure and fall if that what was happened).  The county police called him a transient and have closed the case..  He wasn't transient, he was just an unemployed mill worker. Probably a quarter of this community is about 3 months away from possibly living the life he led in the last two years. People are not happy.  I will report if there is any vigilante activity.

     .  Welcome to 21 century American medicine;  at this point all I can do is document.

A day in the life of two front line docs

Here is a link to a post by Timothy Malia MD of Fairport NY (picked up by the NYT as an example of 'a day in the life.'  He describes the incredible variety of conditions and issues arising in a typical primary care practice. 

Below is a day with Dr. Jose Battle in NYC NY.

I post these as an example of the wonder and complexity that is destroyed in assembly line medicine.  The assembly line (or hamster wheel as many professionals are now calling it) is one of the consequences of a broken system.

Note in particular the difficulty we would have pigeon-holing these docs based on the current technology-infatuated 'medical home' or disease-based 'pay-for-performance.'  Sure technology and incentives to 'do the right thing' can help, but they are in themselves woefully inadequate measures of the real life of primary care. 

Through innovation, bravery, and by collaborating with others, these docs have created practices capable of getting beyond hamster wheel care and becoming the physicians they imagined they would be when they entered medical school.

Friday at noon 74 y/o lady walks in to my new office asking to see the Doc.  Patient comes from her actual provider who just gave her an appointment, 3 weeks from now, when she showed up complaining of vague abdominal pain.  As our policy is that if “you believe that you need to see the Doctor I would see you” my staff said off course no problem.  Lady’s son asked my staff if I was “any good” and they responded that “Dr. Batlle knows his stuff”.  Mrs. P gives me a story of “stomach problems” for a long time usually controlled by diet and some PPI [proton pump inhibitor] but this time is bothering her enough to go to the Doc, all she wanted was a prescription for a PPI and that was it. 

I take a look at her and find some abdominal discomfort and a positive Murphy sign and I tell Mrs. P that most likely this time it is gallstones and possible cholecystitis and that, most likely, she would need surgery.  Mrs. P proceeds to blow it off on her usual “stomach problem” but I convince her to go and get an US [ultrasound] at an associate’s facility very close by,  I give them a call and they say off course send her over and I’ll call you with the results. 

At 145pm Mrs. P passed in front of my door, with her son, stating that she is going for lunch; I told her to just wait for my call at home prior to trying to eat that I would have the US results.  

At 2pm I get a call from my colleague stating that Mrs. P’s gallbladder is full of stones and it is very inflamed and telling me that he is sending her to the hospital, he was pretty surprised when I told him that she just left my office.  I get a hold of Mrs. P who does not want to go to Hospital as she is not really sick, at that point I get son on the phone and explained, strongly, the implications of the diagnosis and that she can get very sick at any moment.  They came to the office and picked up the US Stat report and a letter and went to ED where another colleague was waiting for her. 

Mrs. P got surgery that evening with the findings of a gangrenous gallbladder and a Hospital staff that told them that “your Doc pretty much saved your life as you would have been septic pretty soon”.  Monday morning Mrs. P calls from Home, discharged pretty early that morning, thanking me for making her go to the hospital even so she was sure that I was just nuts.  Son took on himself to come to the office to thank me and give me a hug.

The amazing part is that all every provider involved did was what they are supposed to do: take care of the problem at that moment, no questions asked.

Jose from Upper Manhattan, NYC, NY

Inspiring residency graduation speech - getting compassion back into care

here is the speech i gave at residency graduation.

it contains NO STATISTICS a miracle!

...

people often ask me what my intentions are, since i'm taking a career track that's different from most of ours.

i'm planning to work by myself as a primary doctor, without any nurse or other staff, and i'm going to just give my patients my cell phone number so they can call me directly, and i'm going to try to minimize my interactions with the insurance industry as much as possible, to maximize the interactions with patients directly.
i hope you don't mind if i take 5 minutes, to explain why i'm doing this.

i'm starting a practice in a university town in oregon that is less than one-quarter the size of the wisconsin city we live in now. it has about 140 thousand people.
i chose it because it has very progressive politics, including around health and spirituality, and because it's nestled in between two mountain ranges, and is only an hour away from the pacific ocean.
and there are a lot of vineyards nearby.
i thought it seemed like a friendly place to start trying to live out my vision.

a long time ago, i kind of became that one person you might go to for advice - if you didn't have health insurance - when you broke out in a weird rash, or got pregnant, or twisted your ankle.
it worked out that way basically because i was pretty fearless, and not easily grossed out, and i liked to buy old science books from the used book store.
my kids were young, and i had a couple of teenage baby sitters who would come over and hang around sometimes.
i was living in a place with a really great kitchen table.

so we'd sit at the kitchen table, and i'd tell them about birth control, and ask them about their self-esteem, and tell them what an immune system is, and why it's so cool.
and they would bring their teenage friends over, to talk about birth control and self-esteem and immune systems some more.
and i started thinking, maybe i could be more effective if i had some teachers.
so i went to college for the first time when i was 30.
but i kept having these conversations at the kitchen table, about health and self-esteem and science, because they were really fun and interesting, and plus, i had this really great kitchen table.
and that's one reason why i want to have my own practice. i want it to be kind of like that.

then when i was in medical school, i had this great teacher, who was this crazy neurology guy at the VA.
he was very funny. he wrote a book called "extreme clinic," that you should read.
anyway, when i told him i wanted to be a family doc, he said, "that's not medicine, that's a cult! you're too smart for that! you should do REAL medicine!"

and i didn't know what to say to that.
but later i thought... wait a minute!
what's wrong with having a cult?
i think i'd be a great cult leader!
so it's possible that that's another reason i want to start my own practice.
i'm pretty comfortable running my own show, and i'm pretty comfortable taking responsibility.

then last year, i had one of those days that just really illuminated what i DIDN'T want to do.

i had a fifteen-minute appointment scheduled with this one patient.
they'd been waiting in the exam room for a long time, because i was late.
they were very anxious about coming to the doctor.
they had some chronic illnesses that were pretty bad, and it looked like they probably weren't really taking their meds.
and it turned out there had been some domestic violence in the picture, and that alcohol was involved in some way.
so, not sure what to do, i played the efficiency-expert doctor card of asking, "which of all these things is the most important to you today?"
and they said, that, more than anything else, they wanted some advice for how to lose weight.
and they really did badly need to lose weight!
but by this time, most of my fifteen minutes were used up.

and i thought, i never want to say that to a patient again.
i never want to demand again, that a patient make a little priority list for me, of everything that's wrong with them, so i can pick one to pay attention to, all because i have to see 35 patients a day, if i'm going to pay my overhead - if i'm going to be able to pay my nurse and my receptionist and my medical assistant and my biller and my scheduler and my answering service and the rent for the building big enough to hold all these people, etc., etc....

but that patient is the whole reason i'm here!
and that person is NOT a walking priority list, of diseases and disasters.
they're a *person* who's having a particular set of experiences, body and soul, and their whole story matters.
we all say that, and we all believe it.
but we often aren't able to practice it.
and it *really* bugs us.
and that's another reason i need to have my own practice.

now, over the last 3 years, i've had a recurring dream about being a family doctor.

i'm walking down a road, going to a patient's house, and i feel a little ashamed and nervous, because i don't have any equipment with me, not even a stethoscope.
i'm empty handed.
sometimes i'm not even wearing any shoes - you know how dreams are.

but i go up to the house, because that's my real patient.
in the dream, my patient is the home, and everything, and everybody, in it.
so we start going through the closets and bedrooms, and the kitchen cupboards, taking stock of everything, and making a plan for how to to make things easier, and more efficient, and healthier for them.
this usually involves a speech about getting rid of the chips and sodas at some point.

and in my dream, i always start feeling excited and happy, when i finally realize, hey! i can do this!
i don't need to wait until i know everything and am always right.
these are my neighbors!
i can see it their way, and THAT'S my most important skill.
everything else is just a bunch of science classes.

so that's my vision: a kitchen-table cult, of long appointments, figuring out what matters, in a context of neighborliness.
so that's what i'm going to do.

thanks for listening.
thank you for being my teachers, and thank you for helping me get here.

...

my teachers are all very excited because they've never known anybody that started this kind of thing straight out of residency.

leigh saint-louis
drleigh.org

New business models of medicine - shedding complexity in favor of patient care

I don't believe that charging patients directly for their health care expenses is the ultimate solution to our health care problems - there are too many unintended side effects of this model.  It works for some, though, and where it does work, it opens the door to innovation that is blocked by insurance company rules that get in way of good care and desired outcomes.

I am impressed by the level of innovation practices like those cited below.  They can scale new heights because they are able to work directly for their patients without the costly and (often but not always) counterproductive interventions brought to bear by the insurance industry.

There is a lot we can learn from practices that have shed the tyranny of Evaluation & Management Coding from the AMA, especially those that have captured their new found freedom to enhance and improve patient care & reduce the cost of care to those served.

Here are back to back interviews with Garrison Bliss of Qliance in Seattle & Jay Parkinson of hello health in NYC.

L Gordon Moore