The Good Doctor Learns to Fly

This is my new office. I signed the lease for this property yesterday – another big step in the process of getting my new practice off the ground.  I should feel good about this, shouldn’t I?  I’ve had people comment that I’ve gotten a whole lot accomplished in the 4 weeks since I’ve been off, but the whole thing is still quite daunting.  Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.

I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don’t know what I want done, and nobody can tell me what I should do.  Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don’t really know which of my ideas about the practice will work, I don’t know what my needs will truly be.  How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse?  I want a space for group education, but how many resources should I put toward that?  I also want a place to record patient education videos, but some of my “good ideas” just end up being wasted time, and I don’t know if this is one of them.

I come across the same problem when I am trying to choose computer systems.  I know that I want to do that differently: I want the central record to be the patient record, not what I record in the EMR.  I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their PHR.  So do I build a “lite” EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product?  Do I use an EMR company’s “patient portal” product, or do I have a stand-alone PHR which is fed by the EMR?  I have lots of thoughts and ideas on this, but I don’t really know what will work until I start using it.

Here’s the real rub in all of this:

  • There’s a large group of patients waiting for me to open my doors and take them in as my patients.  These people will need excellent care and all that goes into providing that care.  I am confident in my care as a doctor, but the doctor is only a part of the equation; there are referrals, labs, and other care-coordination services that need to be done.  If people are going to be trusting me enough to pay a monthly fee in exchange for better care, I have to deliver on that.
  • This must become a viable business.  I quit my other job, and now will rely on this new business to support me and my family.  The incredibly low overhead of it all helps a lot, but the final say of any business is this: do I offer a service that is worth what I am charging?  Decisions like how to redo the office, or what computer systems to use have a twofold impact on this: they impact the quality of the care, and they cost money.

It feels like I have been given the task of learning how to fly in three months.  But instead of taking flying lessons and flying in the conventional way, I have to build a whole new kind of airship from the ground up.  I need to design it, build it, and then learn to fly well enough to take passengers.  My ideas were good enough to take this challenge, and I have lots of smart people willing to help me, but I will be the one who has to make it fly.

That’s scary.

Some of this is ego.  I wouldn’t have quit my old practice for a new way of doing things if I didn’t have the confidence to pull this off, much less write about it for thousands of people to see.  So when people give me advice, my ego wants to assure them that I know what I am doing.  I want to say, “well, that may work for you, but I am doing something different.”  But then there’s the small fact that I don’t really know what I want, so I should at least listen to any advice I get.

In the end, all that matters is that I give good enough care for my patients that they are willing to keep me in business. Keeping that reality in front of me as the center of my focus will give me the best chance to get this baby off the ground.  Once I am flying, it will be much easier to know how to improve it from there.

In the mean time I just pray that I don’t crash.

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.

37 replies »

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  6. Barry: All good points. I will write more about this as time permits, but my overall experience (both as a doctor and a patient) says that there are a lot of unaccounted costs of care related to people not having access to help when they need it. My wife is in Oklahoma right now with her mother who just had heart surgery (whether it was really wise to do on an 85 yr old with memory loss is another issue), but despite having a husband who is a doctor, she feels like she’s in above her head with the complicated questions that come up after discharge and when and how she should seek help should she need it. I think this disconnectedness of patients (and their families) caused by the episodic nature of care may actually be the biggest cost. Even when people have access to care, they don’t know when to use it.

    I do think most Medicaid patients can afford $30-50/month, although some can’t. Most Medicare patients definitely can afford it, and simply managing drugs better will potentially free up that money for many of those people. My hope is that if this system really does work, insurance companies (and even government programs like ‘caid and ‘care) will see the monthly fee as a small price to pay for giving people the connection they need.

    All said (and in response to some previous comments), my ideal would be to help shift the system away from a consumption-oriented mindset, perhaps causing a change in the basic paradigm of primary care. But all I really care about is summarized in the last paragraph. I want to give better care to MY patients. If that is all I accomplish, I will be very happy. Any systemic changes that happen as a result (which may be delusional on my part, I admit) would be frosting.

  7. Rob –

    I understand that your new business model will allow you to better serve your patients in terms of timely access to appointments, handling routine matters like prescription renewals via phone, fax or e-mail instead of an in person visit and the ability to spend more time with patients to more fully understand and assess their complaints.

    I’m not sure, though, about how much of an impact this model could have, assuming a large number of primary care docs embrace it, when it comes to reducing costs for the healthcare system overall. I hear the experts tell us that 75% of healthcare costs in the U.S. relate to the management of chronic conditions. Yet, complications related to diseases and conditions like congestive heart failure and diabetes have more to do with patient non-compliance with respect to taking medications and adhering to an appropriate diet than with inadequate access to primary care.

    Though you may have commented on this before, I wonder what percentage of the Medicaid patients in your prior practice can afford the minimum $30 per month subscriber fee to join your new practice. If it’s a fairly large percentage, it contradicts the traditional liberal contention that Medicaid patients are too poor to be charged even a nominal co-pay to see a doctor and requiring such a fee would cause many low income patients to not seek care when they should.

    Finally, with respect to Peter1’s point about the need for data to better understand what works and what doesn’t in healthcare, the vast majority of care delivered by specialists and, of course, through hospitals will likely always be covered by Medicare, Medicaid or commercial insurance even if most primary care migrates to the direct payment model. The aggregate cost of care delivered directly by PCP’s, which excludes referrals to specialists, admission to hospitals, imaging and prescription drugs, accounts for only a tiny fraction of total healthcare costs.

  8. With a good cost accounting system a hospital knows its costs. But this seems off topic.

  9. My experience with charge master price is that it is like the MSRP, a fantasy number that the seller never expects to get but one that allows the word
    “sale” to be used and still make a hefty markup.

    Previous discussions on THCB say hospitals have no clue what their actual costs are.

  10. We calculate direct cost of labor and/or supplies related to the chargeable item. For each year we calculate overhead (not in direct cost), and try to calculate unreimbursed costs from charity, bad debt, and payer contractuals. We are nonprofit, yet try to budget a reasonable profit to save for the very expensive capital items, often championed by physicians.

  11. “Also, wanted to make clear that even though I am in hospital finance (and in an accounting firm I had my share of billable hour goals) I understand his perspective.”

    You are the problem Leslie – hospital finance and billable hours. Can you tell me how hospitals arrive at their chargemaster rates?

  12. There actually is a physician on Nantucket who practices like the old days, sometimes exchanging for food by necessity and isolation. Lepore. He has written about it. Place for that.

    My point in empathizing with Rob was in response to some of the comments criticizing his stepping out of the system. Also, wanted to make clear that even though I am in hospital finance (and in an accounting firm I had my share of billable hour goals) I understand his perspective.

    The main thing that I was trying to convey was that he will have to engage with the current health care system and keep up with a lot of rules still if he wants to do the best for his patients in other settings.

    None of this seems like fuzzy thinking to me. I haven’t read any other blogs here because I just discovered this web site.

  13. Try a bit harder.

    That’s the conventional excuse.

    One that I happen to agree with, btw. I think good docs should be paid more like lawyers. Our HIE outside Counsel costs us $500 an hour. For what of any value, precisely, escapes me. “Further research may be warranted.” Yeah, to protect us from OTHER lawyers.

    Were you to trouble yourself to check my blog, you’d know that one of my persistent rants is Change.The.Payment.Paradigm.

    In a way that favors the clinicians.

    Having run a small business, working 7 days a week, for years, often to 11 at night, and having managed to not go bankrupt (doing paperwork etc), I’m not a big fan of fuzzy have-it-both-ways thinking.

  14. Yes BobbyG, everyone wants less controls, less paperwork, less accountability. Docs should not be felt sorry for any more than anyone else. My feeling is if docs want the simple life then they need to go back to the “good old days” of a couple hundred years ago – when they took livestock as payment. : -)

  15. BobbyG, I do not understand your comment. Health care is more complex than other professions. Cynicism doesn’t add to the conversation.

  16. “I have so much respect for primary care physicians who want to practice pure medicine without struggling with paperwork and productivity worries.”

    Well, yeah, but…

    “I have so much respect for ______________ who want to practice pure ___________ without struggling with paperwork and productivity worries.”

    Insert any other skilled business line of your choice.

  17. I have so much respect for primary care physicians who want to practice pure medicine without struggling with paperwork and productivity worries. Concierge practices/cash-only practices are another choice for patients. Personally I could never leave my great PC doctor in an academic medical center.

    As a CPA/MHA working in hospital finance, I see the generation of a lot of unnecessary costs and unreimbursed services when physicians order tests and procedures without prior approval, without a supporting diagnosis, etc. Rob will still need to keep abreast of coverage policies of Medicare and other payers to avoid causing his patients and their other providers to incur unreimbursed bills (hospitals, specialists, therapists).

  18. Rob, I don’t doubt you are a good guy trying to do good things. Your own disillusionment with a broken system is shared and I know fixing your part gives you sanity, but it is not the solution for a system with no solution in sight for either of our lifetimes. I go off the grid myself when I can, most people though don’t get that choice or are nnot capable of testing that choice.

    The broken health care system is just another tentacle of a broken political system that infects good people with disenchantment and isolation from staying as participants. Many strong societies have failed because of this.

    I wish you personal success, but I don’t agree that this is the solution because it really does not disrupt the “system”, it allows people to work along side the system.

  19. @DrDan: I’ve gotten that suggestion a lot. I think it’s a good idea.
    @Margalit: Yes. It’s hard to do 50% Pediatrics without doing Medicaid. I’ve decided to charge only $30/month for kids ($10 if away in college) to keep a substantial pediatric practice. I’ve already had a good number of Medicaid patients say they are joining, which makes me very happy.

  20. Rob, As a primary care internist, I understand what you are doing and wish you success.

    Have you thought about asking your patients to help you design your practice, such as physical layout of the office, patient/work flow, and virtual services? Not sure how to do that but, theorectically, it sounds nice to have the purchasers of your service actually design the service or at least have some continuous input. Perhaps you could have a few ‘practice design parties’ in your unfinished office space and invite patients to tell you what they want.

    Escaping the burden of ‘pay for documentation’ is a big step toward your having the resources (time) to serve your patients better.

  21. My thoughts exactly.

    I am somehow bad from trying what I see as a better way. It’s easy to put responsibility for our problems on the heads of others; it’s hard to take responsibility yourself and actually try to do something about your problems. Like it or not, I am trying to fix my small corner of the terribly broken system. People want grand schemes to fix the system, but I think it comes down to a bunch of little ideas disrupting a system that can’t fix itself.

  22. Going to India and paying cash: good.

    Going to Georgia and paying cash: bad.

    Makes sense to me.

  23. Rob, accepting Medicare comes with responsibilities for taxpayer money, as does dealing with private insurance as far as someone else’s money. As a taxpayer or maybe an investor in an insurance company, you’d like to know that fraud was being prevented. Another aspect to this is compilation of large amounts of health data to analyse and manage the system. A national majority of indepnedent docs working off the grid accounting to know one but their own patients, who can afford a membership (which I would be able to afford) does not solve national problems or fix unaffordable hospital care. Primary care is not the problem.

    I’m sitting in a hotel right now in Chennai India, for a surgical appointment on the 31st for a hip joint replacement with a world qualified surgeon because I am unisured and the cost is less than half what I would have to pay in the U.S. Your personal life change will not change the system, even though you may think this is the answer.

    My cash pay of half is what the cost would be in countries with single pay, or at least government run health care. Going off the grid, like working for unreported cash earnings for those fed up with the tax code, will not solve the problems in the U.S. health system.

  24. Maybe a 60/40. The main thing that Medicare brings that other insurances don’t is the specter of fraud allegations. If I don’t follow E/M coding requirements (which is very complex and open to interpretation), I am not only potentially going to have to refund money, I may be accused of trying to defraud Medicare. Most docs realize that if Medicare wanted to go after them, they could find some way in which they didn’t 100% comply with the incredibly complicated rules.

    Medicare also dictates how I charge non Medicare patients. If I give an uninsured person a 50% discount on my usual fee, I’ve given someone a discount I am not offering to Medicare patients (and hence, in their eyes, overcharging Medicare).

    Finally, there’s the issue of having extra staff to bill, collect, re-submit, and do all of the rest involved in the financial mayhem of a normal practice. The simplicity of a monthly fee compared to the craziness of normal health care billing is remarkable. Plus, as I’ve said repeatedly, I don’t have to force people to come in to be seen for things that can be handled without a face-to-face encounter.

    I am puzzled as to why you are so opposed to this idea. Do you think I am, as some have suggested, abdicating my moral responsibility and pursuing a selfish course? Do you think I am putting my needs ahead of my patients’ (despite what I’ve said)? Just because this does make my life easier doesn’t mean that’s my primary motivation. It’s just strange to me that people see this as “elitist” when I am offering more care for a relatively low price (between $30 and $60). The onus is on me to give care that is superior enough than that offered in my old practice to justify the monthly fee. I’ll find out when I see how my patients respond.

    You may find this patient’s opinion of my care interesting (in response to a comment where I was accused of selfishness in this move): http://more-distractible.org/2012/09/15/relationship/#comment-680302584

  25. Are you just blaming Medicare, or is the private insurance system also producing unpleasant working conditions and overhead for you?

  26. Yes! Accepting Medicare would double, if not triple my overhead and add a big level of complexity to my coding, to my risk of audit, to everything. The average overhead for a doctor’s office (in my setting) is around 50%. My overhead will be under 20%.

    If you haven’t figured out how radically different this is, all I can do is suggest you keep reading. If it isn’t obvious that this is a huge change, then there’s either something wrong with my writing, or your reading.

  27. So Doc, if you’re getting a bricks & mortar office, a nurse and all the trimmings, then is your savings in overhead and expenses NOT billing through insurance?

    If your trying to divest the traditional office/practice for a more doc/user friendly business, how is this different, except for the club med monthly fee?

  28. What you are doing is what so many other docs should be thinking about/doing. Kudos!

    As a nurse of the 50’s and 60’s, I know what patient care was about but not practiced today. Patient care hasn’t changed. Our patients still need care of a personal sort.

    I think you are trying to return to the more personal, holistic approach to medicine that is so lacking today.

    You have my utmost admiration for dealing with your values rather than your pocketbook despite the needs of being the wage earner. Kudos, too, for your wife who has supported you in your transition.

    Medical care is more trust than science and sticking to trust and still learning science will help more patients than the latest that Big Pharm can dish out.

    Keep up the good work and I hope you can earn a decent living and support your family at the same time. It is a hard life for those of you who deviate from the norm.

    Would you come to New Jersey to practice? I would sign up.

  29. I wish you the best. Please, to the extent practicable, design your physical layout in a way that facilitates efficient and effective workflow. Think Lean. A few wasted seconds here and there adds up hugely across the year. Same goes for the HIT usability — “information flow.”