Dropping Out

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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  3. First, I want to congratulate you Dr. Rob on your willingness to step out of your comfort zone. I would love to work for a practice like this. I am a NP in a primary care practice and even I feel pressure to see x number of patients per day. Second, I have a high deductible insurance plan so that I am covered for something catastrophic, everything else I pay for out of pocket or through a HSA. I am healthy, get regular screenings and take a few medications that are generics. My impression of the ACA is that Congress took a sledgehammer to the healthcare system when a scalpel might have been a better choice. The system is a mess but the solutions should be collaborative not forced.

  4. I am amazed at how someone can, with pretense of sincerity, suggest it is my civic duty to stay in a failing system and burn myself out. The good news is that I will be able to prove myself right while Ms C tries to spin it on her direction. I guess this is how actors feel about newspaper critics or athletes about TV analysts. I will now do my civic duty and start ignoring the hot air in hopes to stem their effects on our global climate.

  5. By the way, let’s have a moment of brutal candor here, neither party honestly promotes autonomy and independence in their deeds, justs says it in campaigns and then write and pass laws to further suppress real independence. Patriot Act? Gimme a break! PPACA, a covert military action by slow and insidious process.

    Choose your own doctor, and premiums go down. Do you hear laughter in the alleyways and at the tops of those tall buildings in the financial districts across America? Their biggest belly busting laugh is they got the president to do the bidding. Who that is not a partisan hack would argue otherwise?

    The Lamberts of this process are frightening to PPACA proponents, because if enough doctors follow suit, who does this care you all claim will come? Oh yeah, and be ready my fellow invested and skeptical colleagues, if the democrats do regain full control of the legislative branch, they will amend PPACA to make Dr L’s choice illegal. Just an opinion, based on the history of power gone mad.

    • ACA provides money to boost primary care, but then again, you might be required to actually look into the facts behind the law to know what I’m talking about.

      I’m done (and I was speaking to YOU not Liz in this comment. catherine says:
      September 12, 2012 at 3:42 pm

  6. I wish every Doctor thinks the way you do.

    It seems that you want to change complete health system of America. You want to get out the system and want to start your own. That’s really appreciable. However, it will be very difficult. But someone has TO start for the change. I believe you may be the one…

    Wishing you all the best…

  7. Rob –

    I’ll be interested to hear if this idea gains any traction with employers. I’ve been told that in any given year, 25% of the population incurs no healthcare costs at all. Even within Medicare, the healthiest 50% of beneficiaries account for only 4% of program costs. It seems that a small employer already paying a high price for health insurance in the small group market would perceive a service like the one you propose as a high cost add-on and I question how many middle income employees would be willing to pay for it themselves. I view it as a more attractive option for someone who already has significant medical issues like heart disease, diabetes, asthma, hypertension, etc. and for more affluent people who simply want a higher level of service than a conventional PCP practice can offer.

    I don’t know if employers could offer to pay for it for only those employees who want it unless it can be offered as an optional add-on beyond the regular health insurance policy and as part of a cafeteria benefits plan.

  8. Liz says:
    September 11, 2012 at 5:34 pm

    Irregardless, DeterminedMD used a legitimate word…

    For reference:


    Did you read the cite you link to? It says it’s a “non-standard” word, meaning not legitimate.

    Word Origin & History

    an erroneous word that, etymologically, means the exact opposite of what it is used to express, attested in non-standard writing from at least 1870s..

    John Ballard says:
    September 11, 2012 at 5:50 pm

    Is that anything like “legitimate” rape?

    Good one, John Ballard!

    • Irregardless of your efforts to diminish my earlier comment, I am a doctor and just trying to use a “racist type” ploy to distract was lame.

      As are the ongoing efforts of PPACA advocates who do NOT want people to know the specifics and possible consequences of PPACA and further deterioration of medical care. Wow, Dr Lambert’s post really did stir a nest as said by another here! Can’t let people find out truth, eh?

      • “Racist-type ploy.” Wonder what that’s supposed to mean. Too bad the “Democraps” are not only going to keep the White House and Senate, they just might pick up more seats in the House. You want people to know the truth, so one wonders why you keep lying.

        • Your partisan agenda only serves you and your cronies. Nice projection about the lies, what have I “lied” about? Most of what I write is opinion and conjecture, when I state facts I usually include a link to show it is not my only opinion or position but someone of some level of authority notes prior or concurrently.

          You are a Ms Mahar clone. Just spouting democrat rhetoric and when challenged basically retort “it is law so it is true”.

          Hmm, wasn’t there once a law that denied women and African Americans the right to vote? That law was shown to be wrong, and wasn’t it Democrats who used to suppress black rights, until they conveniently changed course just to get their votes?

          Enslave and then maintain dependency, now there is a campaign slogan for the Left. Oh, don’t feel I am picking on your party alone, I’ve got a slogan for the Right too, “if you’re not with us, you’re against us”.

          Oh yeah, that could apply to democraps too. How about “middle class, we’re too above that crowd”, so the Right is about abandonment.

          Wow, this is what 2012 politics had to offer, enslavement or abandonment. Goes along with the PPACA agenda for me. And again, that is not a lie, catherine, an astute observation.

          Irregardless of what you think.

          • I honestly hope you’re not a doctor because your comments reveal a highly unstable person.

          • Yeah, instability is based on a point of reference, we just don’t all share and bow to yours, catherine. People said Ghandi was unstable, and yes it was not his followers. To me “racist type” accusations can be applied to comments you make, because I argue against you, I can’t be a doctor or I am unstable. Just like your party has said over and over, “if you don’t agree with Obama, then your are a racist”.

            Care to defend that one, ma’am? Biden was right, people are goin’ to be back ‘n’ chains, but it won’t be just if Republicans win. Another moment of projection by politicians.

            All this man said at the top of this post is he is going to provide care more on his terms. That really frightens you and your party’s agenda, doesn’t it?

        • @catherine

          Irregardless, you expect people to take you seriously even though you don’t even capitalize your first name.

          • You’re right. That’s a great move to deflect from your failure to provide the “specifics and consequences” you predict from the ACA, nor debate on facts, acknowledge facts, recognize corrections I provided to HSA numbers and other wrong statements, etc. Feel free to continue raging and engaging in barely literate and shrill fear mongering (such as the usual empty smear of the IPAB, which, to date, has done very little). Solo practices are closing up every day. I fail to see how this one will succeed, and it certainly will not be able of provide the range of services and continuity of care that patients deserve and has been show to improve outcomes. Most importantly, by “dropping out” Dr. Lamberts’ services will only be available to those who can afford what he wants to charge and whether he actually improves the health of his patient base will be a secret as he won’t be reporting to anyone. National public health goals be damned, I guess. But let’s not pretend this is noble or ground-breaking and it’s certainly NOT the Qliance model.

          • Nice of you to insult the writer of the post for taking a stand about quality and integrity of care that, by your inferring you speak for PPACA to stand as us, seeking quality and integrity of care is inconsequential to the purpose of the legislation.

            Thank you for highlighting that perspective per my interpretation. I guess I capitalized on the opportunity, irregardless of what others might think.

            This partisan shrill by both parties had got to stop. Maybe public unions can cripple the democraps and the same for the Tea Party and repugnocants. Well, we can hope anyway.

            Last sentence from me dangling from the thread, do what is right Dr Lamberts, just don’t wait for the masses to thank you.

    • Thanks.
      Twitter has taught me much about brevity, the soul of wit.
      Too bad it’s not contagious. This thread has become too long now for recommended reading. Sad, because there is an unusually rich variety of ideas and opinion here, mostly well articulated. It would be a good piece for a seminar.

    • Thanks.
      Twitter has taught me much about brevity, the soul of wit.
      Too bad it’s not contagious. This thread has become too long now for recommended reading. Sad, because there is an unusually rich variety of ideas and opinion here, mostly well articulated. It would be a good piece for a seminar.

  9. This is not a workplace clinic. I would have an independent practice and would just contract with the business for the care of their employees and give the benefit of better care and fewer absences to the employer. Instead of the employee paying me per month I get it from the business to whom it has most value.

  10. Rob –

    Workplace clinics are a fine idea for employers large enough to afford and support them. They could also work for groups of smaller employers located in close proximity to each other. As I understand it, there are roughly 8,000 of these in the United States today. Some are staffed by doctors and some by NP’s. Walgreen is a market leader in this segment as a result of a couple of acquisitions it made a few years back. Employers generally pay for them on a cost plus basis. They vary greatly in both physical size and the scope of services offered. Employers expect the cost of the clinics to be more than offset by lower healthcare costs for their employees and family members. Convenience for employees is generally not enough to justify the expense.

    By the way, the workplace clinics are a separate business from small clinics located within retail stores and staffed by NP’s. Walgreen and CVS are co-leaders in that segment. People who use them generally like them.

  11. I think the family docs and general internists who have been practicing for decades and still are supportive of NPs and PAs joining the primary care workforce have a pretty good idea of what goes into medical care.

    You are making this far too binary. Substitute or nothing. There are many tasks done by the average primary care physician, or any physician, that people without a lick of medical training could do. I’d love to see that waste quantified in all of these IOM estimates of the money we dump down the drain in healthcare.

    Then there is a bunch in the middle that could be done by NPs/PAs, especially if aided by clinical decision support and good working relationships with a doctor.

    And then there is a small amount in the average primary care clinic that could only be done by someone with the depth and breadth of clinical training held by an MD. Ideally we have physicians doing more of what they alone do best (ie less referring and more management and time spent on medical decision making in complex patients) and less of this “only a doctor can do all of that” mentality with no evidence whatsoever behind the claim.

    The role of the primary care physician, and primary care itself, needs to evolve with the needs and capabilities of the wider medical system. I despise that any person who suggests that is attacked for undermining primary care.

  12. Good luck thinking NPs and PAs will fill what will be a fairly large void with physicians dropping out of the system. Only those who minimize the needs, or more likely just have no clue what goes into medical care think people doing less training can deliver the same services.

    These other professionals are adjuncts, not substitutes!

  13. My hope is that getting a system to do this type of thing efficiently (building systems is my main strength that has earned awards and acclaim), adding additional patients using either extenders (PA’s NP’s) or even using nurses who are well trained in the system, then the overall number could be brought up. The goal would be to then lower the cost (sorry to Cathy who thinks I am greedy), so more patients could access the system without making me hop back on the hamster wheel. The main application of this, however, would be to reach out to businesses who want to offer something for their employees without breaking the bank. The benefits of having a system that allowed people to get care without leaving work are obvious: less absenteeism and healthier employees. The value to businesses would be huge, and it is a place where the cost for individuals could be offset by charging businesses more ($100/employee would be worth it if I can deliver the goods).

    Alas, big dreams.

  14. Re the NP question, I do agree that bringing in other allied health professionals is key. However these individuals respond to the exact same work environment and income pressures that MDs do. I have many friends going the NP route, and 9/10 have chosen to do a subspeciality (derm NP, NICU NP, etc) rather than primary care, and all of the reasons sound just like those given by my medical school classmates when we made our decisions. Interestingly some of my NP friends actually say that they feel more competent to take on a subspeciality than primary care since the breadth of knowledge required is less extreme. Lets also not forget that there is also a shortage of nurses to do traditional nursing jobs, we are draining one pond to fill another.

    Its worth mentioning the importance of creating an expedited system for getting foreign providers fully up and running in the United States. Obviously there needs to be some quality assurance, but requiring another round of indentured servitude (residency) in an American hospital is ridiculous. I remember scrubbing into a cardiothoracic surgery alongside a 40 something Asian man just beginning training to be a PA. The attending surgeon needed only ten minutes to realize that this guy had been a skilled surgeon back in his own country. Such an enormous waste.

  15. Regarding the issue of a potential shortage of primary care doctors which could be exacerbated by more docs moving to the direct practice model, it’s worth noting that we already make more extensive use of NP’s in rural areas than in more populated areas out of necessity. Moreover, I’m told that in Europe, most well child care is provided by pediatric nurses instead of pediatricians. Historically, most of the opposition to allowing NP’s to practice at the top of their license came from the physician lobby because they don’t appreciate competition from outside the guild.

    At the end of the day, though, if new payment models and efforts to use more NP’s to satisfy some of the demand for primary care still leaves us with a shortage of PCP’s and access problems for patients, we can always resort to the tried and true market based solution – just pay them more. It would be easier to justify paying them more if the doctors practicing the way Dr. Lamberts would like to in the future can demonstrate that the patients they care for actually cost the healthcare system less on a risk adjusted basis than patients treated by primary care docs practicing in the traditional way.

    Complicating the equation is the fact that Japan only spends about 8% of GDP on healthcare vs. 17%-18% in the U.S. while they enjoy long life expectancy. A typical primary care visit in Japan lasts all of about thee to five minutes on average. This seems to support the contention that the quality of healthcare one has access to accounts for only about 10% of a given individual’s health status. 40% is attributable to personal behavior (diet, exercise, smoking, drinking, etc.), 30% relates to genetics and 20% to socioeconomic status and environmental factors. As former manager Tony LaRussa once said about successfully managing a major league baseball team: “A lotta stuff goes on.” The same is true in spades for managing the health of a large diverse population like we have in the United States.

  16. Congrats and respect for taking a risk to practice medicine in a way that fulfills you.

    I entirely agree lanierbrian that its not up to individual physicians to slave on the hamster wheel just to ensure there are enough primary care doctors out there. A great deal of nonsense is put up with by doctors because its so easy to play to our commitment to patients. We are all just people who need to find the work environment and problems to solve that make us come alive.

    Yet its naive to think that DPC will recruit enough physicians fast enough to primary care to not only address the existing access issues, but make up for the fact that DPC docs have panels that are 25-50% of the average primary care office. I don’t think “med students will see how fun it is and it will solve all of our problems” is a good enough argument for society to be reassured. The income and respect disparity is still huge, it takes years to train a primary care physician while the access gap grows every day, and again and again surveys of medical students indicate that there is rapidly dying (some would argue long dead) interest in dealing with the business side of medicine/owning an independent practice.

    I’m far more interested in asking how we scale all the parts of primary care that don’t necessarily need a clinician’s training using technology, other types of people, (I love diagnosis and demographic concordant health coaches), and even stand alone companies like Teladoc that answer the simple health questions and diagnosis, or Omada Health for group chronic disease management. What I don’t think works is just shifting a bunch of administrative tasks and algorithmic triage down to expensive RNs or unqualified MAs, while the doc’s role is basically whipping into the room for for a few minutes and running the whole complex show and all of the staff, the latter all skills that we receive zero training in during residency.

    Again- this is not a moral argument about what individual doctors should or shouldn’t do with their practices. Its just pointing out that there are significant problems and opportunities out there for the people who would solve them in primary care, and we shouldn’t let the hubbub around DPC or PCMH blind us to this fact.

  17. Best of luck to you. One quick question though: one of the “burdens of non-patient issues” you mentioned was “drug formulary problems.”

    Are you referring to the typical prior auth hassles, or other issues created by insurers? Thanks.

  18. Dr. Lamberts,

    I want to join the chorus of those congratulating you on your decision. I am a third year medical student, and I intend to be a family physician and practice in this model. I have had the fortune of spending a good deal of my free time during school with one of the pioneers of this model, and I have the following observations for you and others here (some strictly for you, some for the peanut gallery, in no particular order):

    First, some have implied that when you reduce your panel of patients, that you will be contributing to the reduction in patient access to a primary care physician. I would like to point out that you are not responsible to the forces that have resulted in medical students fleeing from primary care specialties. On the contrary, by practicing the kind of medicine you envisioned when you decided to be a physician, and doing it with financial success, you are likely to inspire many more students than you would by showing them what it’s like on the hamster wheel. The way to increase access to primary care is to have a system where students want to be primary care doctors, and you have made the decision to be part of that.

    Second, I want to clear up some of the wordology confusion that permeates this subject, in this and other forums. I prefer to think of a Direct Primary Care (DPC) practice as one in which a patient has a direct financial relationship with a doctor, that is unfettered by any third payer. A “Concierge” practice is one where the patient pays a fee, above what is charged for services, just to be a patient of the practice. The most well known of these is MDVIP. From my perspective, what the patients are paying is the “administrative tax” of being with a insurance-based practice (btw, I know some fantastic MDVIP physicians that had decided to throw in the towel and leave clinical practice before they had the opportunity to become MDVIP physicians, so I tend not to be critical). Then there is “boutique” practice—a term I despise because it muddies the water and when applied to DPC practices makes them sound as something elitist—which couldn’t be further from the truth.

    Third, and this is more for you, you are not the first guy to try this, and there are many trailblazers to learn from. Here is a great example: http://www.aafp.org/fpm/2007/0600/p19.html. One of the most interesting new practices I’ve seen is https://www.neucare.net/NeuCare/Home.html

    Fourth, some have raised the issue of labs, imaging, specialist visits, etc, in the context of DPC. The fact is, a DPC physician can negotiate extraordinarily low-priced ancillary services for his/her patients. These are my own observations, not theories I have read. Labs can be negotiated for very low fees for the cash payer. Just peruse some of the DPC practices on the web and look at what they charge for diagnostic services. We have been so conditioned to think that every medical service has to be exorbitantly expensive, and that someone else should pay for it.

    Fifth, some here have suggested that DPC might be good only for well people, or that DPCs are cherry-picking well patients. Actually, DPC is perfect for those with chronic illness. A person with a chronic disease can can manage those diseases with a predictable cost for their primary care. Take for instance someone with diabetes. Let’s say a DPC practice charged $45/month and $20 per visit. With quarterly visits and a couple of extras thrown in, that patient would pay $660 for their primary care in a year. Many diabetes medicines are available on the $4 Walmart list, and some are even free. When you factor in that the whole idea of DPC is to spend more time with your patients and to better manage their care, it stands to reason that there are lower downstream costs in terms of emergency room visits and complications. The practice I’ve spent time with excels at taking patients with poorly controlled diabetes and hypertension and turning them into healthy patients. The current, predominant system pays a lot more to amputate a diabetic foot than it does to prevent the march of the disease in the first place.

    Sixth, DPC is not a substitute for health insurance. This is obvious to those familiar with DPC. The purpose of insurance is to manage financially devastating risk. If my house burned down, and I didn’t have homeowner’s insurance, I would be devastated financially. If I wrecked my car, and it was my fault, I would not be devastated, because it is a piece of junk—therefore, I only have liability insurance. My primary care does NOT present a threat to my financial stability, it is very predictable. I am well, but even if I had a chronic disease, the predictable costs of that care could be very well managed with a DPC provider (see above). I would choose the level of risk I wanted to monetize and transfer vis-a-vis the level of deductible vs premium I wanted. Some people prefer to transfer more risk than others. I have had a cell phone for 16 yrs and have never paid for insurance, but many people do. People should have some choice with the level of risk they want to assume concerning their health costs (within reason, but I won’t get into that).

    Seventh — and this is a big one — I don’t think that the DPC practice I see myself with in five years is the be-all-end-all. It is my earnest hope that the stakeholders will see the value in this way of financing primary care and realize that this is the way forward There is no reason that primary care cannot be delivered to every person in this country, from the poorest to the richest, via the DPC model. We provide food to the poor via a plastic EBT card. The recipient goes to the store, picks their food, swipes the card, the grocer gets paid, the person gets their food, done deal. We can deliver primary care the same way, with the doctor and patient having a direct relationship, with the patient having direct input into their care, with the doctor caring only about what is best for the patient. In this model, the patient will be a consumer with power to make decisions and choices about their care, rather than the part of a panel that the physician loses money on and has to pump out more privately insured patients to cover.

    Again, congratulations on your decision, and godspeed into the future of medicine!

    • I am most impressed (and humbled) by your insight and advice. I have already been in contact with Dr. Neu, and will be making other contacts. I think the breadth of the gaps in my knowledge will become evident to me. Thank you.

  19. Dr. Lamberts
    You have certainly stirred up a hornets nest by posting this Dropping Out healthcare blog. I am happy to see that you are not dropping out of caring for your patients, but rather dropping out of all the falderal (I had to look that up) associated with documentation for reimbursement. It is too bad that the powers that be do not understand that unless the care-givers are themselves taken care of there will not be enough care-givers to provide the needed care. This will then create a worsening crisis of healthcare access with longer wait times for appointments as well as in the doctor’s office itself.
    And, your take on Meaningful Use could not be more on target. I consult with physicians to promote practice profitability and can see how the focus on meeting the MU requirements detracts physicians from focusing on the actual needs of the patient. I am sure this whole EHR thing was well intentioned to improve quality as well as reduce Medicare cost, but between ANSI 5010, ICD-10 and the EHR Meaningful Use Incentive, plus value-based reimbursement and bundled payments, I don’t know how you doctors can be expected to meet all these documentation demands, provide high quality care, have any kind of family life and remain sane.
    My hat is off to you all.

  20. Dear self vs community –

    I’m not quite sure where to start really. But let me try….

    1. I agree – you should try to spend less time with selfish greedy doctors and see nurses for the majority of your conditions. When you need someone for a serious condition that takes years-decades of experience and training, you should try prayer and hope. It has done wonders for the investment community and I’m sure will serve you as well.

    2. I’m so pleased to hear that CMS covered medical school tuitions. The additional 400k of debt (compounded over 4yrs of college, 4yrs of medical school and 3-6yrs of residency and fellowships) must have been in the imaginations of those selfish greedy physicians.

    3. If you think that he’s giving up, you’re missing the entire point. If you’ve ever been in a system where you either wait for a long time to see a provider or see them quickly but only for a few minutes, then you understand at least some of the pressures on the system and on the individuals who provide it. He is simply acknowledging the realities of adding 30mil new people on the demand side and trying to figure out how to manage the demand side of the equation. He is working on new delivery models, which is exactly what the government is encouraging and honestly, what we need, since the current system is broken and unlikely to be resolved with the ACA which has only impacted 2 sides of the stool – quality and access, but not financing.

    There are days when I think the system should be allowed to blow up, so that people who think as you do can experience the other alternatives, take a step back and reconsider their views.

  21. Rob –

    I also wish you the best in your new venture. From both a business and a healthcare system cost standpoint, there are a few things I wonder about though.

    1. Since you will have far fewer patients to care for, you will presumably be better able to devote an appropriate amount of time to each one that needs access to you. If patients better understand their illness or condition as well as you treatment recommendations, there should be less need for defensive medicine. At the same time, might you be inclined to order more tests for these patients, in part, because you perceive that they expect you to, just to be sure and to be thorough?

    2. Will your approach to end of life care be any different from what it was before? Will take advantage of the extra time to explain available treatment options and the quality of life implications of each? Will you encourage your elderly patients to execute living wills or advance directives and engage their spouse and adult children regarding the care they want and don’t want in an end of life situation?

    3. How will you deal with the risk of winding up with too many patients with multiple co-morbidities that require a disproportionate amount of your time if you intend to charge a flat monthly rate whether the patient is relatively young and healthy or old and sick?

    4. As Peter1 noted, might patients contact you, at least by text or e-mail, much more often that they should just to try to “get their money’s worth” out of the monthly fee that they are paying you?

    5. Finally, even at a proposed monthly charge that is below what some other concierge practices charge, how much of the potential patient population in your geographic area will be both able and willing to pay it?

    • These are great questions (ones which I ask myself often at this stage). I must address these if I am to be successful, especially doing so in the light of public scrutiny as I am. I am going to be blogging on this subject a whole lot over the next few months. Hopefully readers (like you) will help me see where problems will come before they happen. I do plan on making a clear list of deliverables which people can expect for their monthly subscription. That is one of the first big task I am trying to tackle, followed by the decision on how much to charge and who to take as patients (as I expect to have a waiting list – as judging by my overwhelmingly positive responses from patients).

      This weekend was the “official” announcement, and I have been touched at how many patients expressed happiness for me as a person. It’s really been overwhelmingly gratifying. I will address these, I promise.

  22. By requiring cash payment on an on-going basis you will also not be taking Medicare and Medicaid any longer. I am curious are you going to pay back the cost of your training?

    95% of all doctors in the US have their training paid for by CMS (Medicare and Medicaid) to the tune of about 500,000 to 1 million (interest free). The assumption is that we pay for you to become a doctor and in return you care for those that paid for you to treat them as well as the private patients.

    This is a selfish but understandable decision (1000 patients at $100 is over 1.2 million a year) but hardly scalable- where did the other 2000 patients from your panel go to? What if even half of the doc’s in the US follow this model?

    Clearly what we need to do is spend less time with doctors (since they want to maintain a high income lifestyle) and use more nurses and others who can treat the majority of conditions. Seeing less patients benefits you and the few who can get in but hurts the community at large.

    Rather than working collectively to change the system it sounds like you are giving up.. How very sad.

    • Everyone has their higher education subsidized to some degree by the federal government. What do we expect in return from the non-doctors?

      CMS education payments go to hospitals that use interns and residents as slave labor for three to six years, freeing up funds to build more fountains in the marble lobbies.

    • This is very hard to respond to in a respectful way, given the tone. You obviously think I am a selfish SOB who is leaving my patients and is not grateful for the job I have. You are wrong about that, and if you would like to know my real character, please go to the blog and read my posts, and read the comments my patients are making on my now practice blog.

      First, I was over $100,000 in debt after medical school and have paid that back. Then I worked for 4 years being paid under $30K for workweeks that were sometimes above 120 hours, and usually over 80. For the past 18 years I have accepted Medicare and Medicaid patients even though it is not in my financial best interest to do so. I have accepted the reduced payment from government insurance in exchange for the opportunity to care for the poor and elderly.

      That said, I am not leaving my practice because the pay isn’t good enough. I am leaving practice because I can’t do a good enough job taking care of people in our system as it is. This post makes that point fairly clearly, I think. Some may be satisfied with this level of care (my partners are at this time), and that’s OK with me; but I believe there is a way to offer care of much, much higher quality than people think possible. Call that hyperbole, but I am staking my future (and that of my family) on that belief, as well as making my decision in the full view of the public. It’s been done for rich people before, but never at a level that is affordable to the average person.

      I do not plan, by the way, to charge $100/person for 1000 patients. I left the numbers vague while I worked through important details.

      Your comment made me laugh at its audacity and sad at its speed to jump to the worst conclusions. I am passionate about my patients and the care they get, which anyone who reads my writing will soon see. I understand how you expect a doctor to be a selfish SOB who doesn’t care for patients, as many seem to be just that. I am sorry that is your impression of all doctors. I am sorry you misunderstood my post. I hope this clarifies things.

      • Don’t apologize for these anti physician brutes who know little to nothing about what honest and devoted people sacrifice not only in training but for the next 40 or so years treating people. Some of these “commenters” still wouldn’t be satisfied if we took a vow of poverty and lived in a van down by the river. The Internet just feeds this frank abuse of health care, and I honestly believe politicians were strongly determined to keep physician input OUT of the PPACA dialogue in crafting their witches’ brew of distain to force the public to drink.

        Take my word for it, or better yet, George Carlin’s last show before he died, both the politicians and the real leaders behind them on Wall Street and oligarchs elsewhere do NOT want an informed, educated public. It is nothing less than incredible how the general public and a minority but outspoken few leaders in our profession will give up what are our legitimate autonomy and independence for a few token scraps while the main meal is served to the privileged few.

        But, enjoy the denial spewed daily here by the hacks and zealots who do not want people like Dr L and others to promote the true philosophy of invested doctors. IPAB will cripple the profession.

        Again, deeds not words, why does that element of a bill of such magnitude go into effect well after this election process. That alone is criminal if not at least disingenuous of the fake interests of the Democraps.

    • I don’t know about everyone else here, but when I finish my residency training, earning roughly $13/hr while providing valuable medical services (not to mention the time that I’ll miss with my wife and two sons), I don’t think I’m going to feel like I owe CMS anything. I’m not complaining about the reimbursement, as the training is indeed valuable, but so will be the services I provide during that time. I certainly won’t feel obligated to practice in a system under constant threat of audit, with 27% of my reimbursements subject to the whims of Congress.

    • Not trying to speak for Rob, but like many burned out physicians, this is his plan to continue practicing medicine. The alternative would be to retire and find different employment, making the issue worse.

      So, this is not selfishness, this is his way to maintain sanity and continue practicing medicine to help others.

  23. If the gig doesn’t work out as you hope, I can assure you, you can always go into consulting. Heck maybe even a TV show, look at Mehmet Oz, who’d have thought it. Good Luck and Good Health. May the forces of a new primary care model be with you.

  24. Several years ago, I changed to a midlevel concierge practice after being told that the wait for an appointment with my internal medicine practice for an emergent problem was 6 weeks. I have never looked back. Don’t use much health care, but it was worth the annual cost to be able to call my doctor from Tokyo when I ran out of one of my hypertension meds to find out what dose to increase the other one to until I returned home. I checked the clock to make sure I wasn’t calling in the middle of the night and had an answer to my question in 5 minutes.

  25. Doctor Lamberts,
    It is sad to see that you (or we) cannot wait for Washington to fix our country’s health care. I am sure you have waited long enough and thought deeply about making this difficult decision. I admire your tenacity in your endeavor and believe it will be a win/win for you and your patients. I look forward to your future postings.
    Be well, Michelle

    • Actually, according to what Greg Masters posted toward the top of the thread, Dr. Lamberts falls right into the spirit of reform.

      I looked it up and he is exactly right.

      ‘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

      ‘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.’

      This may not be precisely what Dr. Lamberts has in mind, but it’s moving a lot closer to the spirit of reform than most of those beating the drum to “repeal Obamacare.” I will be so glad to see the next few years fade into history.

      • yeah, until the IPAB is in place. Then we’ll see how many people are championing the cause when bean counters set the pace of the participants of PPACA.

        History is an endless loop, isn’t it!?

        • You should be happy, Dr. D.
          Rationing tax money will drive more people into the private sector where they will either pay out of pocket or take advantage of ever-competitive lower premiums offered by the insurance industry, seeking new customers.
          Concierge is the future. You know, capitalism, free markets and all that.
          It’s worked so well, you know.

          The best doctors will treat those who can pay most and others will find a price point somewhere down the curve, all the way to the bottom. Heck, some of them will actually be treating (hold your nose) Medicaid beneficiaries.

          • Come on, there is no comedy/sarcasm for what IPAB will do to the health care system within a couple of years in place. I just want to know what is clearly spelled out in the PieceACrAp, er, PPACA, as of now to delineate what such administrative oversight will do.

            I can’t stand looking at Pelosi, Reid, and McConnell anymore, these old wind bag politicians are so out of touch with what is main stream America. And this public still returns them to DC without even a blink of an eye.

      • Thanks John:

        The ACA hand wringing and relentless whining has been beyond boring and formulaic, yet to paraphrase George Barnard Shaw:

        ‘To be a force of nature or a feverish little clod of grievances and ailments complaining that the world issn’t sufficiently devoted to making you happy..’

        is precisely the opportunity afforded by the Affordable Care Act. It has something for everyone one, yet, the chorus of anti Obama-ites are far to busy to actually read something, as complaining is far more satisfying.


          Sometimes deeds are words, or in this case, lack of words.

          Some good does not eliminate equal bad. I can’t wait should the fates be kind, to see how many rote provider supporters of PPACA will still feel the same way after a couple of years of entrenched 2014 applications.

          • Dr. D: Thanks for offer. Here goes…

            …. sum up the complexity of the $2.7 trillion ‘cottage industry’, and be sure to capture and explain for the often health illiterate masses the tender underbelly of medicine & it’s internecine circle the wagons ‘ready, fire, aim’ shooting medico politics. Seriously dis-organized aka ‘sinkhole’ medicine need no external enemies. It has exquisitely crafted the very beast (the my revenues are your expenses paradigm) of which it rightfully complains. Add to this tapestry, the fact that fee for services medicine has constructed the equivalent of ‘commission based’ doctors, embracing a production vs. quality practice orientation, that voluntary hospital medical staffs are the equivalent of the ‘clubs’ presiding over medical turf via credentialing and privileging geo-politics, and that corporate practice of medicine (in California, Texas, etc..) prohibition is really about quality and not economics, then some of that complexity begins to take form. Now, put that on a bumper sticker for a town hall ‘discussion’ or health reform.

  26. Rob:

    Your move is a perfectly rational choice in an irrational non-system. I get t took quite a bit of ‘processing’ to come to your decision. Bravo.

    I also appreciate the distinction you’ve made between ‘membership based’ medicine v. the more elitist ‘concierge’ (high end retainer) type practices. Clearly as everyone knows a perfect storm is in sight, ie., an acute primary care shortage exacerbated by ‘cherry picking’ outmigration courtesy of the likes of MDVIP, SignatureMD and others, while demand is expected to explode due to the boomer demographics.

    I look forward to your continued reports from the front!


  27. Rob, congratulations. THis is a courageous move. I am a firm believer in being mission driven..but just remember…no margin, no mission. Having said that, some suggestions:

    1) Proactively seek the input from patients (and prospective patients) on what services would be important to them. Too often, doctors assume what consumers (yes, consumers) want and what is right for them…but we aren’t always right.
    2) Be courageous enough to use DATA to demonstrate that you offer better care and service. Use DATA to explain why you are referring patients to certain specialists. You will be successful if you differentiate yourself with data.
    3) Don’t be afraid to market yourself. Practice telling your story….and perfect your elevator speech. If you get this right….you will not only pay for college tuition and pay for that windshield…you’ll get the new car. The real benefit of perfecting your message is that you will crystallize FOR YOURSELF why you are offering a better service that improves health for people.

  28. I agree that this is a good dialog, and one that will undoubtedly continue. Let me clarify a few things:
    1. Regarding “.org” – (which I think is a silly point, but it’s a good story) – My original blog was “Musings of a Distractible Mind” and when I was looking for a URL, distractible.com was taken, so I opted for distractible.org. I realized soon after that distractible.org was an oxymoron, and that I probably deserved the “.disorg” URL. So on doctor-rob.org, my tag-line is “because they wouldn’t give me .disorg.” I’ve kept using the .org domains just for consistency’s (and irony’s) sake.
    2. As to meaningful use being a bad thing, please refer to my other post, “A funny thing happened on the way to meaningful use” (https://thehealthcareblog.com/blog/2012/06/13/a-funny-thing-happened-on-the-way-to-meaningful-use/) which prompted a personal call from the medical director of ONC. He understood my situation well.
    3. Defensive medicine? It’s something you don’t do as much in a primary care setting (I probably do more “defensive e/m coding” to avoid Medicare audits), but it is always a pressure.
    4. SouthernDoc – thanks. Yes, you need to read my posts to understand that this decision does not stem out of my desire to avoid patients or be lazy. It’s the opposite that drove me to this decision. I am passionate enough about patient care that I couldn’t tolerate the half-ass job I saw myself limited to by the system. If I didn’t care as much I would not have a problem just doing less for everyone and making more money.

    There are a huge number of questions I must address, some of them quite difficult. But the reality is that I am not just writing posts about this; I am putting my future on the line with this bet. If I am right, then I will prove it not through good arguments, but through better care and happy patients. If I am wrong, then I will be an object lesson to all who will follow. That risk is mine to take, and doing so in the limelight of social media puts the pressure squarely on me to produce something worth writing about.

  29. Rob,

    I applaud you and support your efforts. This is, indeed a disruptive and entrepreneurial approach and should work very well for you AND your patients — win-win.

    My dad sees a concierge doctor. He’s 85 now, and as of this week, enrolled in hospice. His concierge doctor has been a blessing in his life for more than two years. Those two years have been more in QUANTITY than we might have expected, but even more so, they have been far better in QUALITY. A great deal of that credit goes to his doctor.

    Of course – as others have pointed out here – in addition to his Medicare, he must still carry insurance for all his lab tests, specialist visits, prescription drugs, etc. But for his primary care, he’s had a doctor who could actually REALLY coordinate his care, making sure he didn’t undergo unneeded procedures or take unnecessary drugs, paying attention to symptoms that others might have missed, and more.

    I absolutely see you succeeding with this new approach of yours. In order to be successful, the situation must be win-win — and that’s what this will be.

    Trisha Torrey
    Every Patient’s Advocate

  30. This is a great dialogue. I am a second generation physician and my daughter is likely to go to med school. The current costs to become a doctor are not compatible with being a doctor; the debt burden against future wages are out of sync. I believe that some form of concierge practice, where expensive or not, has a long run in redesigning how we care for one another. I have an expectation of broadening networks enabling cost effective collaboration and referral. I spend a lot of time in HIT focused on tech enablers of collaboration rather than strictly data management- I am presenting som of this at health 2.0 next month

    Bill Frist, a friend, suggested the only way to change healthcare is to come up with relevant business models, show success, and then others will follow. This is certainly worth exploring and watching moving forward. The real question will be one of scale for the masses as a solution for care.

  31. Catherine, no disrespect but anyone who believes that defenisve medicine is a myth perpetrated by the Republicans isn’t a physician. You can show me all the movies, research studies and political commentary to the contrary, and I will still tell you that practicing defensive medicine is a reality and absolutely any physician will tell you so. RN’s, NP’s and PA’s haven’t gotten on this bandwagon yet because the liability has not yet impacted them in the same way. And so it’s clear that I’m not supporting a right wing agenda, I am a registered Dem.

  32. My clients and I would find this kind of practice very helpful. Most of my clients have Medicare and a top of the line supplemental, they are basically healthy and just need someone who can take the time to look at them as a person, not a form. Last week, I went with a client to a prominent geriatric specialist. The doctor has the records of all the tests we have taken this past year for the patient’s choking problem and chronic hip pain. The patient has scoliosis and stenosis as well as an esophogeal tilt. She does not take any pain medications and is not a candidate for surgery at 87.

    The doctor quickly went through all the previous discussion as shown on the records. Since nothing much had changed, she was ready to say goodbye and was half way out the door, when the patient said, “Can I ask a question ?” Of course, said the doctor. “Well, I havn’t been able to go to the bathroom in weeks.” The doctor asked the patient if she had been having accidents. “No,” said the patient, ” I mean the other way.” The doctor took out her pad and scribbled Metamucil. “You’ll have to start taking this for the rest of your life.” As the patient followed the doctor down the hall she asked, “I’ve been taking fish oil and having accupuncture treatments, do you think that can have any effect?” She didin’t mention that she pays $40 a visit for the acupuncture from an Orthopedist and $30 a month for the fish oil she buys at the office.

    The doctor replied, “It always shocks me that people who don’t take any medication are so open to these non-medical remedies. I don’t believe in them as there is no proof.” So, after the appointment, we ran right over to get the Metamucil.

    The next morning, the client called me to say she choked so badly from the Metamucil, she wanted me to call the doctor and ask why she hadn’t known that there was a big warniing on the can that said, “Don’t use if you have a problem swallowing.” I emailed the doctor, who returned my email the following day saying that this could be caused by a more serious problem and we had better come back in for an office visit.

    My client feels that the doctor just didn’t have the time to devote to her in the first appointment and now wants to change doctors. I think your kind of practice is what she’s been looking for.

  33. Best of luck, Dr. Lambert. I’ve about stopped leaving comments at this site but I still lurk. It’s encouraging to me that you are getting mostly encouragement and good wishes from your peers. As someone said above “It sounds like he wants to take care of well people. ” It was meant to be a stinging criticism but my immediate reaction was something I saw about hospitals in one of the Scandinavian countries, that they see empty beds not a a failure of the system but an indication that the community is in good health. I would think all doctors prefer seeing well people. After all, isn’t that the ultimate mission?

    I presume when you say you won’t be taking insurance it doesn’t mean your patients are forbidden to use insurance. I coud be wrong, but I see no reason why anyone with a valid invoice from a properly licensed physician can’t file a claim on their own and recover some or all of their costs from an insurance company. Same applies to high-deductible plans or group plans that may charge an “out of network” rate if a beneficiary files a claim personally.

    In any case, your services will not likely be the only medical resource for your patients. I’m sure you will still direct those who need it to specialists or other places you feel may be more appropriate than what you are able to furnish. As such you become a valuable personal ombudsman helping your patients navigate one of the world’s most convoluted (and inefficient) health care systems. And if you do little else, simply having everybody’s meds all in one place may save as many lives as your actual practice by protecting against contraindications, duplications and over-medicating.

    I’m obviously very impressed. And I’ll be looking forward to the coming “rant” you mentioned.

  34. As mentioned above, I see an endocrinologist who practices like this. I pay him up front, but my insurance covers all tests and imaging he orders. My insurance also reimburses me 80% of the costs I pay up front for my visits. I have to file them, though, instead of him filing them. That’s how it used to be everywhere when I grew up. I remember my parents filing every doctor visit with insurance to get reimbursed. It’s not a new thing.

    Oh…my endo is on the other side of the continent (U.S.). He’s worth the travel and up front costs. He also offers phone and email appointments. He’s awesome.

  35. My biggest hesitation to trying this sort of practice arrangement, which I strongly support, is health-related. My husband had a heart attach at the age of 50. He is self-employed and thus depends on his health insurance through me. I am an employee of a large healthcare system. Do you worry about your own personal medical insurance?

  36. How are you planning on dealing with lab tests and other procedures? Your patients are likely still going to need referrals to have their insurance cover the costs, and are unlikely to have the money required to pay for them out of pocket.

  37. I beg to differ.

    This does nothing to support the continuity of care. The fractured healthcare system is the reason for high costs, and this will add to that. Doctors who exist on the fringe taking only patients who can afford to pay cash–and then all their other ambulatory primary costs are out of pocket?

    The ACA hopes to discourage this.

    Costs and care will not be helped by docs who “drop out” because they, essentially, want to make more money. Meanwhile, the gap between the “haves” and “have nots” continues and widens. No one chooses a high-deductible cost for any reason other than that’s what they can afford. It is not clear these will even be permitted in exchanges, because participating plans will be required to provide a minimum benefits package.

    It’s fine to talk about this as working when you don’t understand what’s coming.

    High deductible plans are something that people are not going to want once a full service plan is more affordable, such they even be permitted, which is doubtful. I don’t see businesses wanting this, either.

    Why doesn’t Dr. Lambert investigate joining an ACO? THAT is the provision in the ACA that is designed to give doctors more control.

    Why didn’t he submit to be eligible for this?

    It sounds like he wants to take care of well people. Or, he really doesn’t like seeing patients all that much, to tell the truth. That doesn’t strike me as the role of a doctor. If most of that nation’s healthcare bill is also going from chronic care, medications and long-term care, it also doesn’t make him part of the solution.

    Oh, and “defensive medicine?” Please. I give the good doctor props for one thing, not blaming “frivolous lawsuits” as a reason for quitting. Watch Hot Coffee, the movie. The “crisis” in malpractice coverage is a myth perpetrated by the Chamber of Commerce and the Koch brothers (and the Republican party).

    But this does raise a question–will he be able to afford malpractice coverage?

    I won’t see a doctor who doesn’t have this. No one is infallible.

    • “it sounds like he wants to take care of well people. Or, he really doesn’t like seeing patients all that much, to tell the truth”

      If you read the doctor’s blog, you’d be informed enough to know that your personal attacks are completely baseless and qualify everything you post as worthless.

    • What is coming, Catherine?

      The minimum essential coverage in ACA for a bronze plan is 60% actuarial value of the defined benefit. That’s far from a “full service plan”. Most high deductible plans at present are the mid-70’s. People are going to be surprised when/if the Exchanges get going of how skimpy the coverage is.
      30 million people already have high deductible plans, almost triple the number in 2008. It’s where all the growth is in employer based coverage.

      Granted more Robs clearing out of broad based practice is going to create an access problem. Everyone knows it. Few understand the combined effect of boomer doc retirements, the expansion of coverage from ACA (if the Republicans don’t win in Nov) and the withdrawal.

      The market for Direct Pay practice is really limited by the shortage of family cash flow more than any other factor.

      Don’t know what planet you’re living on, but most ACO’s (70% plus) are controlled by hospitals, and have been used by many hospitals as a tool to rearrange physician referral patterns to increase their market share.

    • Catherine- your hopes will surely be dashed if you think ACO’s will reduce costs. ACO’s break-even at best- all of the impact studies focus on ‘cost-savings’ but do not factor in the tremendous costs and resources required to obtain those cost savings. So, although they’ve been proven to reduce costs, they never mention the ROI because in order to reap those benefits, it costs A LOT of money.

      Secondly, you’re not really understanding what this physician is saying- none of the issues that the ACA or ACO’s will address fix his problems. They will continue, and one might argue, they will be magnified as 32 million Americans become insured.

      I wish this physician the very best- good for him to take the plunge and make his career satisfactory to his liking.

      • My comments have never referenced reducing costs. However, that is one goal of ACOs, that and improve outcomes for chronicle ill Medicare recipients. What I said was if he wanted greater control, why didn’t he explore being part of the ACO, which are designed to be physican-led, rather than insurance-company led?

        • Not sure I understand this argument. Insurers and government are still the payers in ACOs, so what if its physician led? There are many physician led hospitals in the current system that have primary care docs on the hamster wheel. I think what’s more interesting is joining an ACO that already understands the ROI of primary care since they are actually paid to keep people healthy instead of serving as referral centers for lucrative subspecialty reimbursements. Though I’m not so sure there is enough upside in keeping people healthy to negate the money to be made in heart caths and major orthopedic procedures, the ACOs whose high level conversations I’ve been privvy to are still pretty focused on volume for these services.

          While I realize this is not a popular opinion- I would also remind everyone that these are million to billion dollar entities you are asking physicians to run. I think the clinical/frontline counterpoint to business perspectives are essential in any delivery system, and should be an equally powerful voice in all decisions. But its idiotic to regulate that 70% of an ACO governing board be physicians. Healthcare delivery is a very different beast from clinical medicine. How many doctors know anything at all about the financing of healthcare, policy any deeper than what about it pisses them off, informatics, systems analysis and improvement beyond the baby steps taking place through QI research projects, etc? We see articles all the time on this blog bemoaning the lack of business training in medical school and residency and how people are fleeing private practice because they don’t have the business interest or chops to make it. Something here doesn’t add up.

          If you have to regulate governance, why not also insist a certain percentage also be patients? Nurses or other front line staff? Frankly I think it would be interesting to have these staff also share in the risk and rewards of high quality, efficient care. Its often the safety and efficiency of the system in which you receive care that most affects your outcomes as a patient, not the doctor. I think the GroupHealth governance model is interesting for this reason. Its recognizes that health care delivery systems are teams.

          • “Not sure I understand this argument. Insurers and government are still the payers in ACOs, so what if its physician led?”

            It wasn’t an argument, it was just a question about what other options Dr. Lamberts had explored, such an an ACO, which is designed to give doctors more control. Not saying it does or will–but that’s what he said he lacks.

            Also, you are not correct about an ACO. Insurers are not the payers, CMS is, and if you see Medicare benes, who else is the payer?


      • @Chase
        No one who has followed the sausage-making has any illusions that ACA will reduce costs in any real way. That may have been the inspiration that got the process into the legislative process, but by the time all the “interested parties” had input cost savings took a place in line over behind the ponies for Christmas.

        There is an old saying that a camel is a horse designed by a committee. ACOs are a crude legislative effort to replicate the efficiencies and outcomes of the few places in US health care that DO achieve better outcomes at lower costs. Dr. Gawande’s articles in the New Yorker and the exemplary operations like Mayo, Geisinger, Cleveland and others were the jumping off place. Unfortunately the end results have been a rather tortured effigy.

        That said, the reality is a step toward either (pick one) reducing costs or rationing scarce tax dollars. The alternative was doing nothing.

  38. Rob …
    I know from personal experience how hard this decision was. Every year I experience a drop in income because I refuse to increase the number of patients… so I can spend the appropriate amt of time with the ones I have. Luckily I am an orthopedist so despite the drop it still covers my burn. Is this a healthy situation — no. But it is one that I pondered upon for a long time. No PAs, No NPs … just me and my patients — and the computer (with two chairs next to it :-))

    Best of luck to you… this is the sad reality — and direct result of the complexities and difficulties facing healthcare pros in this environment.

  39. 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?

  40. 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).

    • 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.


    • 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.

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

  42. 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.

    • 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

      ‘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.’


      • 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

  43. 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…?

  44. 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.

  45. 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)

  46. 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.

  47. 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?

  48. 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?

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