Dropping Out

Dropping Out

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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 burn-out 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 lesstime 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, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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111 Comments on "Dropping Out"


Guest
Adrian
Sep 8, 2012

Good luck to ya mate! Keep us posted on your progress.

Guest
Sep 8, 2012

Rob, sounds interesting but how is this different from all the concierge practices cropping up around the country, albeit perhaps at a slightly lower price point?

Guest
Sep 8, 2012

Rob, sounds interesting but how is this different from all the concierge practices cropping up around the country, albeit perhaps at a slightly lower price point?

Guest
Sep 8, 2012

The obvious difference is the price-point, in that I want it to be low-priced enough to be affordable for most of my patients. If I charged the typical Concierge price, I would be limited to wealthy patients. But the way in which I differentiate most is that I will be working to empower my patients. Concierge practices, and even some DCP’s I have seen, tend to offer a “first class” experience, doing extra tests on you every year and giving you two hour long appointments. Patients need extra tests like my car needs and oil change every 1000 miles. Extra just makes me feel pampered – it’s an ego thing. No, I want to give patients control of their health, and giving them the chance to do the thing all patients want, but that most health systems fear: avoid care. I want my patients to be bad health care consumers, spending far less than average. I want my patients staying at home or at work being productive instead of being sick or sitting in my waiting room. Everyone is talking about how to run the business of health care better, while people would rather not patronize HC establishments.

I won’t rant any more. I’m going to save it for my next post.

Guest
Sep 8, 2012

Ok, makes sense. But then, how do you get patients to keep coming back? At what point does their empowerment lead to less need for you and a question of whether the services are worth the money, esp if they aren’t going to be using them extensively?

Also, I think there are other mid-priced concierge services coming out around the country as well, to address the very issues you’re raising. How to keep distinguishing one’s services?

(Fyi, in case I seem confrontational – I actually support your idea and completely agree with your frustrations)

Guest
Sep 8, 2012

That’s a good question. I guess if my patients don’t need me any more, then the system works and I get more patients. If it works that well, I will probably have a long waiting list.

I may not be different from mid-priced concierge practices. I don’t know about them. There’s a lot that I don’t know, to be truthful. I hope this doesn’t seem like I think I’ve thought of something entirely new. I am certainly putting my own ideas on to the model others have built, trying to give tools that my patients use and value to help them maintain their health and minimize their need for the system. I am also very well versed in IT, and adapting it to workflows so I hope I can do new things there. I will study what others have done, and will take time to build a product worthy of the cost.

I appreciate any questions, to be truthful. I have tons of my own, but if I can avoid problems through others’ criticism, I am much the better. The biggest fear I have is that I won’t be able to deliver the goods I hope to deliver. Fortunately, my practice has given me a 3 to 6 month window to build this and not have to worry about my salary. It’s a really bit thing to have that time. I need to stop talking and start walking. It’s easy to write stuff in posts, but now I have to show I am not just words.

Guest
Sep 8, 2012

Good luck. And please keep us updated about how it works and doesn’t work. Perhaps a few guest posts from patients about their perspective…?

Guest
DeterminedMD
Sep 8, 2012

Sounds like this physician has come to a sensible decision. My advice, for what it is worth, is be prepared for too many patients expecting you to think like a doctor but charge like a mechanic and offer competitive pricing like you are an auto shop. And you might want to rethink PPACA’s role in your life if stays in place. You will be seen as an enemy to their “cause”, because you promote autonomy and independent choice. Not what government as Obummer wants.

But, good luck in your pursuits.

Guest

ACA Truth squad:

Courtesy of Garrison Bliss, MD, Co-founder, Qliance, in:

Get Ready for More Direct Primary Care Medical Homes:
Opening the Door to Insurance-Free Primary Care in State-Run Exchanges

‘…..tucked into the health care bill President
Obama signed into law is a relatively little-known provision
that could lead to one of the most significant
health care reforms in decades, reducing cost while simultaneously
increasing access and quality.’

‘Sec. 10104 of H.R. 3590, the Patient Protection and
Affordable Care Act of 2010, states that the secretary of
the Department of Health and Human Services ‘‘shall
permit coverage in the exchange to be offered through
a qualified direct primary care medical home plan.’’

‘This provision enables Americans who shop in the insurance
exchanges to elect an alternative to traditional
insurance plans in which patients and/or employers pay
a flat monthly fee directly to a primary care provider for
all primary and preventive care, chronic disease management
and care coordination throughout the entire
health care system. Under the new law, a flat-fee direct
primary care medical home (DPCMH) membership,
which starts as low as $49 per month and acts much like
a gym membership, can be bundled with a new, lowercost
‘‘wraparound’’ insurance plan that covers unpredictable
and expensive services outside its scope, such
as specialist care, hospital stays, or emergency room
visits.’

‘This single, short provision is one of the best-kept secrets
of the new law. It not only will help ensure that
health care will be available to people of modest means
employed by small businesses and currently uninsured
individuals with low incomes, but it also has the potential
to completely change the way primary care—and
insurance—is delivered and paid for. If implemented
correctly, it could save taxpayers, individuals, and employers
billions of dollars in unnecessary costs in the
years ahead.’

Gregg

Guest
Sep 13, 2012

Ah yes, Gregg, you always read the fine details. Once again my mind has been changed..Obamacare seems to cover it all. Maybe not so bad if folks read the finer print. Thank you for edifying me

Guest
Brian
Sep 8, 2012

Love your idea, best of luck, we need more moral entrepreneurs with the guts and heart to pursue new models of healthcare.

Guest
catherine
Sep 8, 2012

Can you explain why you are blaming “meaningful use” as a reason to quit? EHRs aren’t mandatory and you say you already have one.

Also, you are misinformed if you think “Obama care” favors the kind of practice you are contemplating. Unless you accept insurance, you are out of all exchanges–out of the game completely.

The “cause” is people being able to afford their healthcare and not go bankrupt if they get sick.

Patients will be at complete financial risk if they stay with your practice and on the hook for all hospital care, which any insurance plan “Obamacare” tries to make more affordable. This is the last thing the ACA promotes. The mandate calls for people to buy insurance. Which you aren’t planning to take. I think your business model won’t work for you (not to mention patients).

Guest
steve
Sep 9, 2012

Actually, it should work quite well for those who were going to choose a high deductible plan. I think it is pretty clear his patients will still need insurance since some will need hospitalization at some point.

Steve

Guest
Helen
Sep 9, 2012

Catherine: From the patient perspective, the model DOES work. I am a patient of this type of practice. My insurance covers all other services (hospital care, specialists, etc.) Patients who choose this model don’t drop their insurance coverage.

From a business perspective, the model also works as long as the doctor is comfortable with limited income. The time (and expense) freed up from the “business of medicine” is considerably more than Dr. Lamberts has outlined in his post. And that time can be dedicated to actually practicing medicine and attending to patients.

If, under healthcare reform, my insurance becomes more affordable, then I benefit and can still choose to go to a cash-only/concierge physician.

I wish Dr. Lamberts only the best on his new journey and know that he won’t be disappointed.

Guest
Sep 8, 2012

Dr, Rob, my endo practices like this and I love it. It works well for me. Best wishes on your endeavor.

Guest
Brian
Sep 8, 2012

Take a look here http://simplecare.com/about.asp I am not affiliated with them, but their model seems to align well with what you are saying, and their experience will not have you feeling like you are going it alone.

Guest
Sep 9, 2012

Good Luck. Sometimes changes are necessary positively.

Guest
bev M.D.
Sep 9, 2012

Good luck! Wish I lived near you; I’d come!

Guest
Peter1
Sep 9, 2012

If I was paying a flat fee per month I’d want to use it, not sit at home using less health care while my doc sat by the pool answering emails. Good for chronically ill but not the healthy. Isn’t this the complaint we have about Medicare, too much use, too little personal responsibility – except the tax payer is paying the flat monthly fee.

If there weren’t enough docs to go around though this is the system that guarantees payers access and blocks access for others – not a solution for the country, even if it is for the doc. “Get your doc chair locked in before the music stops.”

How does this solve the overall cost of health care issue?

How does this solve the so-called defensive medicine argument? Will this model keep docs out of the court room?