Dismantling the Cottage Industry

Last week I went to see a doctor about an EHR. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed “two and a half” days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene’s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn’t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Dr. Greene collects 99.6% of his charges and he never used a collection agency and he never will. Wait a minute…. This is impossible. Insurers deny payments all the time and they certainly don’t pay what you bill out. Not to mention that patients are not very quick to pay either. How can you collect 99.6% of charges? How about allowables and adjustments and write offs and all other administrative nightmares that are part and parcel of a medical practice? Dr. Greene walked out of the kitchen and returned with a piece of paper he picked up at the front desk: his fee schedule.

Dr. Greene’s fee schedule was neatly typed on a letter sized pink sheet of paper and carefully encased in a clear plastic protecting sleeve. The fee schedule contained about fifteen procedure codes, mostly E&M codes for various office visits. He doesn’t do any procedures in the office and if he does an “EKG or some other simple thing”, he doesn’t charge separately for it. The fee schedule had two columns for each code; the Medicare allowed fee and the actual fee he charges all his patients. I had to look several times at the column headings to understand – Dr. Greene charges less than Medicare is willing to pay him. For the most common visits, he charges a lot less than Medicare will pay. He bills these lower charges out to Medicare, to all private insurers and to his cash patients. Why????

Dr. Greene was laughing and Mrs. Green was smiling at my total lack of understanding. I guess city folks are not so bright after all. For Dr. Greene this is a matter of principle. It is an entire philosophy. This is about fairness and honesty. His patients are his neighbors and he knows all too well that most cannot afford to pay the Medicare deductibles. He charges what people can pay and he makes it simple, straightforward and fair. His fee schedule is displayed at the front desk. In return, his patients pay their bills promptly. Fairness in small communities is usually reciprocated. Medicare and commercial payers, probably assuming he is mad, are quickly paying his claims just like a quarterback quickly snaps the ball to avoid a challenge. That’s how you get 99.6% of your charges collected with very little overhead. And, no, he is not at all interested in changing things. He is making a very nice living, thank you.

Dr. Greene wants an EHR. Why? Because he wants to receive lab results electronically from the little hospital down the street, and because he wants to use templates. Templates??? You mean you want to click on boxes instead of writing those beautiful golden notes? He thinks a dozen or so customized templates would make him more efficient and allow him more time with his patients and perhaps he can go home a bit earlier too. He wants to send prescriptions to pharmacies and not have to write down the medication list each time. No, he doesn’t want to create documentation for higher billing codes. And he doesn’t want to be left behind.

Dr. Greene, unlike some of his colleagues in town, has no plans of running away and retiring early in the face of new challenges. He will get an EHR and he will exchange clinical information and he will advance with the times. He will be exploring quality improvements and medical homes and even accountable care organizations. Dr. Greene knows that EHRs slow you down and are well positioned for improvement, but he also knows that his grown children, who are themselves physicians, will expect an electronic office if and when they return to their hometown to continue the tradition. There was a faraway dreamy look in his eyes now. Lunch hour was over and there was one patient in the waiting room.

For all the pundits and the health economics experts, and for the political activists on either side, who are actively trying to dismantle our health care cottage industry and reconstitute its remains into large corporations of efficiently employed physicians, this is what you are attempting to dismantle – Dr. Greene, and the thousands of others like him who practice medicine four to five hours away from a major airport beyond miles and miles of cow pastures and fields of corn.

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

33 replies »

  1. Hey, Doctor Urbach, here is a return quote, I think you’ll recognize it:
    (Me)”I want the truth”
    (obamacare supporters/defenders)”You can’t handle the truth”
    You don’t like what I have to say, well, solid feces to you to, sir. Don’t like what the majority of Americans said by voting last night, well, you have about 730 days to convince some of those voters to change their minds and vote for what you champion for in 2012. But, until then, let’s see what the Repugnacants come up with that just might make this legislation a bit more realistic and palatable, eh?
    Frankly, I am sick and tired of the majority of my colleagues sitting on their asses just waiting for someone else to do the work in protecting our profession. Silence is death, sir, and I would like to practice the way I was trained for another 20 or so years without the continuous intrusions and disruptions that have enabled politicians to add to the discomfort. So, I am going to say what I believe as long as it stays in the boundaries of dialogues like this.
    Take some Maalox for your guts!

  2. “Larger groups have better negotiating power”
    As Ms. Gur-Arie points out, what these studies show is that larger groups are better at being measured on parameters that have nothing to do with better outcomes (insurers have for years been telling me that I’m doing a lousy job of ordering mammograms on low-risk women in their 40s, and PSAs on men -and sometimes women- in their nineties).

  3. To Dr. DeterminedMD,
    A quote from James Joyce, just for you:
    “Arrah, sit down on the parliamentary side of your arse for Christ’
    sake and don’t be making a public exhibition of yourself. Jesus, there’s
    always some bloody clown or other kicking up a bloody murder about
    bloody nothing. Gob, it’d turn the porter sour in your guts, so it would.”

  4. Gee, Ms Mahar pads her sources to defend her thinking. Uncomprehendible she would do such a thing! I do commend you, Ms G-A, for deflating her last response.
    Wonder what else will come out post election that will embarass the Democrats in cramming this legislation down the throats of Congress and the people? Hey, what will one expect as the reply once caught: denial, projection, minimization, and rationalization.
    Hey, if narcissists and antisocials use these defenses so well, why not politicians? Oh, that’s right, these are the basic personalities in Washington in the first place!
    Makes you wonder why Ms Mahar wants to associate with such a group. Hmm, we are judged by the company we keep. Coincidence, or murkier agenda.
    Hey all you supporters of Obamacare, if it was so good, so right, why is the House now a Republican majority?
    Prepare for the insults of American voters.

  5. Maggie,
    I just skimmed through the Health Affairs article, and I will read it carefully later today, but a couple of things attracted my attention:
    1) By the authors own admission, the population served by the larger groups was younger, healthier and more affluent, which could affect the findings, even when adjusting for these factors.
    2) A savings of 3.6% for Medicare could easily translate into a larger loss for commercial insurers. Larger groups have better negotiating power and can more than make up for this small savings to Medicare. This is why I suggested a similar study for non-Medicare patients, and I know this is a difficult proposition.
    3) As to quality, the authors readily admit that their measures are “crude” and do not include things that are hard to measure. So we are back to the perennial debate of quality measures being defined by what we can measure, not what we should measure.

  6. Regarding real estate, in my area it would have made sense 20 years ago to buy my office. Now it doesn’t. Rent is fairly high, but nothing compared to Manhattan, so the comparison isn’t apples to apples in that case.
    Regarding best practices, collaboration, medical record, etc, all I can say is that I am an evidence based medicine practitioner, and when I don’t know what to do and can’t find it in the literature, I call my specialist colleagues. They’re usually a block or two away. It doesn’t matter if they are in the same office space nowadays. I use a laptop for office notes and I’m able to access the hospital records via secure connection. I copy my specialists colleagues, and they copy me. We are always looking at the same record. I’m sure that if we were all on the same software and network, there would be some advantage, but really I’m not convinced that it would be great enough to justify the costs. My charting does not get lost. My office is so small that even if a chart gets misplaced, it is always found within a short time. My computer crashes every now and then, my charts never do.
    I see that payers will be demanding electronic records. This is an administrative decision, not a clinical one. I have never known an administrative decision to improve clinical practice. I also have never seen one that didn’t result in added costs without significant benefit. If my survival as a practice is threatened by an administrative rule or two, I will duck the wrecking ball once again. If that means an electronic record, I will use what I have to, and I hope that doesn’t mean paying enormous sums to middlemen.

  7. Margalit–
    People have done reserach on quality and practice size– lots of it.
    See this piece about a Health Affairs article published in May
    The reserachers include Bill Weeks, Larry Casalino, Steve Shortell, Elliott Fisher– all excellent.
    Larger mutlispecialty practices win hands down–higher quality care as well as lower cost. Better co-ordination and collaboratoin among PCPs and specialists who all are looking at the same chart; better adherence to “best practice” guidelines (docs are looking over each others’ shoulders–no one is doing things the way they did them 25 years ago becuase “I’ve always done it that way”) -and doctors have better support (electronic medical records, nurse practioners, colleagues to consult with.)
    Manhattan is simply a larger, somewaht more expensive version of cities across the U.S. Office space would be as expensive in L.A., San Francisco, Boston, D.C., etc. etc., etc., and nearly as expensive in cities ranging from Chicago to Atlanta.
    And of course, how much a doctor can charge, per visit, varies depending in large part on the cost of real estate where he practices. (This is why insurers use zip codes to determine “reasonable and usual” fees.)
    Margalit, you suggest that it probably would be a good idea for a doctor to buy his office space. The truth is that it would have been a good idea 25 or 30 years ago. Today, real estate is too expensive in most of the country for a solo practioner or even a two or three physicains trying to open a practice. Add the cost of property taxes, equipment, a secretary, etc and the cost is prohibitive.
    This is why more and more young doctors leaving medical school join large groups, work for hospitals, etc. They also want the regular hours that come with large group practice.
    And, yes, we are likely to see new Geisinger’s cropping up across the country. The CEO fo Geisinger is talking about forming a network of accountable care organizations, much like Geisinger. This won’t work everywhere–docs in the Boston to D.C. corridor treasure their autonomy. Many don’t want another doc looking over their shoulder. Some are suspicious of evidence-based medicine, feeling that they “know best.”
    But in much of the country, doctors will join accoutnable care organizations, and under reform, those that deliver better care will receive bonuses.
    Finally, the wife- as- office-manager belongs to a 1950s practice model, back at a time when a doctor’s wife often didn’t go to college (she worked to help him get through med school.) Today the vast majority of doctor’s spouses have degrees, and either want to pursue a career that is more challenging than being a secretary or want to stay at home with children. Also, today half of med school graduates are women; if they are married, their husbands definitely do not want to manage their office.

  8. I take exception to the idea that large group practices are necessarily more efficient than solo and small group practices. While large groups offer doctors advantages including better ability to afford IT and other equipment, the ability to more easily collaborate with colleagues, and freedom from the business aspects of running a practice, such organizations are more complex and therefore require more administrative infrastructure.
    I remember a few years back hearing from a couple of doctors that there are modest economies of scale until you get up to 5 or 6 doctors. After that, you need a practice manager and, as the organization scales up, additional layers of management are needed to control it all. So, while large ACO’s offer the potential to improve care through use of electronic records and collaboration with colleagues and would be in a better position to assume financial risk inherent in episode pricing or capitated payment models, whatever savings they might be able to achieve for the healthcare system overall are unlikely to be attributable to lower administrative costs per practicing physician. From an administrative standpoint, there are more likely to be diseconomies of scale, not economies.

  9. “Extremism is being rejected now by those like me who realize that either party does not represent us, but just resents us to have to come to the public every 2-6 years to keep their cushy jobs, insulated from the realities that even doctors deal with every day!”
    Many share this view. The happenings in DC and in most state capitols are despicable. The needs of the people are neglected by all of the parties, including the Tea Party. I never saw an election in which so many felons and inbeciles ran and gor elected.
    The populace of this country has become dumb…and you can thank the control and demise of the media by big business and the obfuscation of reality by computerization of life. Robots and dumb people rule!

  10. This isn’t about random trauma, Ms G-A, but just partisan politics that ruin it for the independents and moderates who are a sizeable voting majority now, and we are telling the Democrats tonight to stick it where the sun don’t shine, your “progressive” rhetoric is not going to progress this country any further than the Republican garbage of 2003 selling war in Iraq.
    Oh yeah, the Democrats didn’t support the Republican agenda to send American soldiers to either die in the Middle East or come home and be scarred for life and have the highest rates of suicide since statistics have been kept for the Armed Forces. And so we watch the sheer hypocrisy of the Democrap Party do the same within these borders this past year. Extremism is being rejected now by those like me who realize that either party does not represent us, but just resents us to have to come to the public every 2-6 years to keep their cushy jobs, insulated from the realities that even doctors deal with every day!
    So, to use your terminology, for now I’ll reluctantly accept the devil I know to neutralize the devil I despise who sold us out who should have known better, and hope that future saints of real representation for 2012 fully reflect what are responsible and realistic needs for the American citizens.
    Starting with crafting real legislative health care needs that defend those who need support, not the profit driven portions that drove health care into the ground in the first place. This legislation first and foremost benefits the insurance and pharmaceutical industries. To argue othewise is so insincere, your pictures as defenders of this legislation is part of the defintion of insincere!!!

  11. I’m sorry… I know I shouldn’t say this, but I can’t resist… 🙂
    “what about those who are in good health, responsible with choices and life style decisions, who HAVE to buy health care insurance…”
    The chances of getting hit by a bus are equally distributed amongst saints and devils.

  12. I’ll take you on one at a time, as I am staying up to watch the mayhem and carnage of this election, hoping for as many incumbent losses as can happen!
    So, for every person who is sick without insurance, what about those who are in good health, responsible with choices and life style decisions, who HAVE to buy health care insurance as this democrat bs demands, at prices that will be higher than what they could have pursued without this intrusion? What do you, as entitled dictators mandate by this legislation, say to these people, who are not a minimal minority?
    Oh, you didn’t think about the people who are appropriate and thoughtful about their health, so they get screwed to cover those in our country who smoke, eat irresponsibly, engage in reckless lifestyle choices, make no effort to maintain preventative health care visits, and then come into ERs at 1 in the morning demanding, not respecting efforts to help them after years of dumb ass decision making?!
    Yeah, this is how the Democraps think. Because they want to make this population of less than thoughtful people beholden to them as voters, as giving them both figuratively and literally a bone to support Deomcrap causes!
    Hey, we’ll get to hear plenty of reciprocal Repugnacant promises and agendas that will equally screw middle America too, but, now is the spotlight on greedy, power driven democraps today.
    Who is next?

  13. “MS. Mahar, your unconditioned love for large medical groups (which, in my experience as a former employee of several, are much less efficient than small ones) is really preventing you from seeing that there are other effective ways in which to deliver quality health care. It’s not one size fits all, either for the doc or for the patients.”
    Hence how slavery is manipulated and sold to the public as acceptable and viable. If the elections play out as polling potentially indicates, Ms Mahar’s backers will be scrambling to try to enforce this legislation before the other party can try to disrupt it. You can’t control as easily 20 solo practices as easily as 4 group practices, especially if the groups are beholden to medicaid/medicare for a sizeable portion of their patient populations.
    Per the movie “Batman Returns”: the mind of the criminal is not complex, but very simple. And they flourish when they get the naive and simplistic to buy into the message that evil cannot be stopped.
    Sorry, this legislation is more evil than good, hence why more than 50% of this country is not accepting of it’s implementation. Simply put, you cannot make people buy insurance if they do not want it. That in itself is a red flag the size of the Capitol!
    And now we get to read the arguments to why this is acceptable. Well, ask for the fine print to their positions.

  14. The HSR on small practices vs. larger practices on an array of quality and safety outcomes is pretty scant. It has mainly focused instead on efficiency instead.

  15. Maggie, as pcp writes, New York City is rather different than most of the country. There are very efficient and successful solo practices in urban areas, and yes, owning your real estate is probably the right thing to do. Perhaps, Dr. Urbach can comment on his urban solo practice.
    My concern is that we are pushing one particular model of practice, which may seem efficient on the surface, without examining the side effects. It would be very interesting if someone did some research on cost & quality based on practice size in various geographical regions. I understand that contractual cost data is not publicly available and quality data is hard to measure, but it may be worthwhile to attempt something like that even if it’s just for one large national payer (other than Medicare).
    MG, I believe the recent legislation makes funds available to ease student debt problems. Perhaps it’s not enough and perhaps, if we really want to address disparities, we should divert some of the technology money to incentives for young physicians to practice in rural areas. They will probably bring the technology with them.

  16. I am unsure why the setting is that important. I know docs who practice patient-centered, resource aware EBM in MSGs and in small practices as well, and I also know of revenue oriented entrepreneur type docs in small groups and in large MSGs (MSGs that compensate based largely on production). It has to be said that small or midsize practice owners may more often practice in a revenue centered style just because they ARE entrepreneurs and have to watch the bottom line. I personally wish that the prectice of medicine had no personal business aspect, although I admit that there are many docs who are great patient centered caretakers AND succesful businespeople.
    And EMRs? IMHO, they make little difference (or may in fact make a small office less effective) UNLESS THEY ARE CONNECTED TO A LARGER SYSTEM/GROUP.

  17. The price of real estate in Manhattan mandates that solo and small practices are no longer viable in this country? Is this where you tell us again that you see Park Avenue specialists?
    NEWS FLASH: suburban office space is renting and selling at fire-sale rates across the country. I would strongly urge all docs to own their office before they own an EMR!
    MS. Mahar, your unconditioned love for large medical groups (which, in my experience as a former employee of several, are much less efficient than small ones) is really preventing you from seeing that there are other effective ways in which to deliver quality health care. It’s not one size fits all, either for the doc or for the patients.

  18. Dr. D,
    EHR is NOT the savior of medicine, but it may very well be the savior of affordable health care and available health care in rural areas.
    Right now I see three types of docs in small practice (mainly rural):
    1) Have EHR, or actively looking to connect – concerned, but going about business as usual.
    2) On paper or partial EHR – thinking about early retirement or “doing something else” if things get worse.
    3) Either paper or partial EHR, looking to sell and become employed (some are taking hospitalist jobs).
    Of course there are exceptions and in-between cases, and the mindset largely depends on many more factors, such as age, geography, savings, etc.
    So while you may be concerned with someone trying to sell EHRs to unsuspecting victims, my only question here is who is going to provide care to the people living in those rural areas in, say, 5 years?
    My thinking is that information technology can keep the boats afloat a while longer.
    If you have a different suggestion, I would love to hear it.

  19. Is this scenario plausible for a doctor who just finished his residency who wants to set up his own practice in a rural environment even if he went the incredibly low-tech, efficient model discussed here? Tend to doubt it especially if he has a debt-service load at say 200-250k at a moderate interest rate and needs to purchase initial equipment/materials to get their office up and running let alone the time to really build up a full patient panel.

  20. Margalit–
    Small or solo practices make great sense in thinly populated rural areas.
    But in cities the cost of real estate, labor, etc. is much much higher. Real estate in Manhattan, for instance, would cost 10 to 15 times more than in remote areas of upstate New York. (Whether you rent an office or buy it.)
    This is why the economic model of a solo PCP practice rarely works (unless the physician purchased his office space 25 or 30 years ago.)
    The only solo PCPs that I can think of in Manhattan take no insurance of any kind and charge their patients far more than Medicare would pay.
    Only very wealthy Manhattanites–or those that have very expensive insurance policies that pay 90% of whatever an out-of-network doctor chooses to charge can see these doctors. (At one point, when I worked for a very large coporation, they offered such a policy. But even they no longer offer it.)
    It’s great that the cost of living and maintaining a practice is low enough that your doctor is able to charge less than Medicare. But that, plus his generous spirit, is the key to his success.
    This is not a model that could be duplicated by doctors working in U.S. cities or suburbs.

  21. “…and right now, I don’t see any other way for dinosaurs to thrive. They must go high tech, and they must do it right. It’s a delicate balance.”
    Gotta love when people speak in absolutes. What is this “must” crap!? It is advisable for this doc you wrote of to consider this purchase, that I would agree, but they must? This is why I don’t trust your writings and perspectives for the most part, Ms G-A. It gives the impression it is about the sale first, and if it benefits the buyer, well, oh, how nice.
    That is why people like me who share my skepticism and concern are wary and suspicious of this “EHR is the savior of medicine” mentality. Your piece sounds good, maybe, too good?

  22. Dr. Urbach, I have no illusions regarding solo practices, but I do have concerns regarding the population they serve. I do agree that payer mix is important, but in small communities, it is a bit difficult to pick a particular payer mix. The other problem I see is the new and improved reimbursement models, such as ACO and PCMH, which require technology and connectivity in order to participate. If Medicare and commercial payers give preferential treatment to these type of organizations, anyone left out will have difficulty surviving.
    As to efficiency, solo and small practices are exceedingly efficient indeed. I know folks are touting economies of scale achievable by larger organizations, but those are rarely, if at all, accruing to patients. Also, I don’t see a bunch of Mayos and Geissingers sprouting across the country. Instead, I see mergers & acquisitions and medicine becoming corporate.
    Is that what the intent is? Is this really more cost effective?
    As to complex illness and better care, Merle, I think information technology and connectivity can allow the most remote solo doc to be as well equipped to deal with those as any physically aggregated group. This is what information technology has done for other industries, so why not medicine?
    So, Merle, unless you and everybody else moves to the city, who is going to provide health care in rural Vermont if all these “old fashioned” (in structure only) solo docs do indeed retire? HealthcareIsUs Inc. will probably not open a medical complex in your neck of the woods….

  23. A provocative post, Margalit. Living in rural Vermont, I understand the sense of community your Dr. Greene lives with. I also am old enough to remember the “GP” who tended to our over-all health needs. It’s a very satisfying and pleasant trip down memory lane.
    But today, when I hear of or meet docs who practice medicine the “old fashioned way,” I can’t help but worry about the care they are able to deliver to their patients. Today, medicine is far more complex than it was in the good old days. It’s so much harder for solo practitioners to keep up with new developments. Can they really deliver the quality of care their patients want and deserve — but may not now how to ask for or get?
    I think of Tom Lee’s book, “Chaos and Organization in Healthcare” and Clay Cheristensen’s book, Innovator’s Prescription,” which both talk about the need for teams of physicians and specialists collaborating with each other to properly diagnose and successfully treat patients with confusing symptoms that mask complex diseases. How does your Dr. Greene and others like him deal with these same types of complex illnesses? To whom does he go for help to ensure he is providing his patients with the best care available today?
    Where I live, a seriously ill patient is referred to teams of specialists at Dartmouth Hitchcock Medical Center for diagnosis and treatment. Do the Dr. Greenes refer their patients to similar organizations or do they try to treat them on their own? If the latter, don’t his patients deserve better?
    I understand the importance of life style or I wouldn’t live in Vermont. But I worry that doctors who place life style first in their priorities may unwittingly be placing their patients at a serious disadvantage.

  24. You know, it seems to me that for balance you should draw a portrait of a doc in a large group practice who is paid a salary or some mixed capitation model and has much less billing and paperwork to deal with, and who is also a great human being who cares for his or her patients.
    There are Dr. Greenes in health systems, too.
    Now, hospital owned practices where the hospital and doc are paid fee for service…there I share the skepticism.

  25. I really think you are oversimplifying and romanticizing the solo practice. My survival is not threatened, at least for the moment. There is great hype about the EMR, but it is not a threat to solo practice. Look at it this way: I have control over my payer mix, how many hours I work, whether I round at a hospital or leave it to hospitalists, who does my billing, who runs my office, who talks to my patients, what technology I use, etc, etc. It is only old-fashioned because so many doctors have abandoned it. This is because of the enormous movement a decade ago to accumulate large reserves and spread out risk, when capitation seemed to be the only game. This is no longer the case. When I talk to PCPs now, they are only in large groups because they don’t want to consider the alternatives available to them. Their answer to the question of why they don’t leave is a fear of the unknown. This is also true of residents going into primary care. It is unknown to residents because nobody teaches them how to run a practice. That is a great disservice.
    What would threaten my extinction? If the payers demanded that patients all moved into the large groups. How would they force all those patients to move, and why? A good payer mix is the answer to threats to my practice’s existence, just like a good portfolio (usually) prevents your investments from all tanking at once.
    Now, what if Medicare changed its methods such that the hospitals no longer wanted to employ physicians. It’s happened before. About 20 years ago (give or take), hiring physicians was all the rage. Then it wasn’t, and they were all let go. If that happened now, all those PCPs working for hospitals would likely have very big Medicare and Medicaid loads, because the hospital practices are absorbing all those new public insurance recipients. They would have have to trim them, or change to prepaid practice models, or to go out of business. I have been controlling my payer mix for 15 years. It does not hurt me at all that patients like a solo office (we’re MUCH more efficient than a big practice) and that there are so few of us around.
    I was part of a couple of big groups before I went off on my own. I worked much harder then, and I didn’t enjoy my job. I’ll never go back.

  26. I think, Barry, that it’s a matter of expectations. Yes, the cost of living in rural areas is lower and all that taxation description is probably also true. I know lots of docs, male and female, who employ their spouse as an office manager.
    But, what I found fascinating was the lack of expectations of entitlement to a larger than life income. There is something wholesome and yes, a bit old fashioned, perhaps he too is a dinosaur like Dr. Urbach (who practices in the city it seems). Perhaps if we want to keep health care costs down, we should indeed replicate these dinosaurs, instead of turning control over to Wall Street (Caritas is being sold, Mednax, Inc. is gobbling up practices and the list goes on and on…). Shouldn’t we maybe pause for a couple of seconds and reconsider?
    He knows, pcp. This is why he wants to get connected and stay in the game. And, propensity, I will not let the EMR destroy his practice. I know we differ on this one, but there are decent (and dirt cheap) EMRs out there and they can be implemented successfully, and right now, I don’t see any other way for dinosaurs to thrive. They must go high tech, and they must do it right. It’s a delicate balance.

  27. Great piece about a great doc. Did you warn him that the Maggie Mahars of the world have him in their sights?

  28. I am an internist in solo practice in a metropolitan area (Portland, OR). I love my practice. The other day, a very kind and friendly cardiologist told me I am a dinosaur “in a good way.” I think dinosaurs like me will be cloned. There will be a Jurassic Park of solo practitioners, because we like our practices and our lives. I don’t know why primary care doctors are willing to work for hospitals who will fire them as soon as they aren’t clearing enough dough to pay the managers. I did that for a while. I didn’t like it.

  29. That’s a great post, Margalit. I think some of the following factors might also be at work here, though. First, since his wife works with him, her salary, if she receives a salary, is part of his family’s income whereas for other doctors with a non-relative in a similar role, it would be practice overhead. Second, living costs in rural areas are far lower than they are in major cities and surrounding suburbs, especially for housing, including property taxes. So, his and his wife’s combined income could be far lower than the average for primary care doctors nationally but the standard of living their income can support is probably quite competitive. Moreover, federal taxes on a lower nominal income are also considerably lower, especially taking into account the progressive structure of the income tax. Finally, it could be that even adjusted for much lower living costs in rural areas, his income could still be lower than the national average for primary care doctors, but his personal expectations with respect to the lifestyle he finds satisfactory or even attractive could be quite different from the norm. The bottom line is that his approach, while it appears to work fine for him and his family, probably cannot be widely replicated in large cities and their suburbs where living costs are far higher.
    Separately, his posting of his fee schedule, along with the Medicare rate for each service, is obviously something I applaud and congratulate him for. At the same time, he is not part of an IPA or other non-related group that must negotiate its fees using the “messenger model” or some variant and, as part of the arrangement, is precluded from disclosing fees as Rob Lamberts explained.

  30. There are many considerate, compassionate, competent, and fair doctors out there practicing solo. Some are specialists. They are wildly popular with huge demands for their services. They practice concierge care without the fees. They care about their patients. They are often at odds with hospitals who want to treat the patients as grist for their cash registers. Dr. Greene will sadly learn that he will not be able to maintain his standard of care once he wastes money on the EMR.

  31. Is this a real doc? I am not in primary care, but honestly, I haven’t heard of any primary physicians (other than concierge) who can schedule 30 min visits (and 60 min for new patients).

  32. Dr. Greene needs to just get on the grid, or shut the doors. After all, it’s just a little mark on the right hand or the forehead. It doesn’t hurt.