I had an amazing day on Friday. It started with a phone call from a local physician, one who I have never seen as an outside-the-box thinker, who was very excited about what I am doing. He feels much of the same frustrations as me, and thinks my approach to the problem is intriguing. He asked me lots of questions – many of the ones I keep asking myself, actually – and had some good thoughts on the answers to some of these questions. Apparently, there is quite a buzz around town about what I am doing, and most of that buzz is positive. That’s quite reassuring.
Then I got an email from a local business, asking me if I would consider being the doctor for their 100+ employees. I spoke to them on the phone and was very much encouraged by their insight and enthusiasm. They have seen their costs of insuring their employees go up dramatically over the past few years (as have all businesses, including mine), and are looking for a way to tame this cost. They were even more excited about the possibility of working with me when I pointed out two things they didn’t realize: 1. That a contract with my type of practice would, along with a high-deductible insurance policy, qualify them for the requirements of the ACA (thus avoiding the fines), and 2. My focus on care on the continuum (care outside of the office between visits) would have a potentially big impact on reducing absenteeism. This is exactly what I was dreaming about a few months back when crystalizing the ideas of my practice, so the reality of having an employer contact me about this is incredible.
The coup-de-grace of my amazing day came in the evening, when I had dinner with a large group of my patients who belong to a Christian “community.” This community has been very supportive of my practice for years, and has been even more excited with my new direction, as it speaks to their belief of community. I was greeted with hugs and handshakes, handed a glass of wine, and directed toward pots of gumbo and lentil soup. The fellowship was loud and joyful, with updates on the health and life status of community members not there. Despite the fact that the group filled three rows of tables in this large living space, they apologized for the small better turn-out. I smiled.
I was peppered with questions about the nature of my practice, what it would cost, and how it would work in comparison to my old practice. My answers were met with nods of understanding, and more questions. They were very happy with the answers I gave, and made it clear that they wanted to be on my list as early as possible. Then, one by one, each family recounted some way in which my care had impacted their lives: a child diagnosed with ADD who was actually having petit-mal seizures, a quick discovery of an electrolyte imbalance in a mentally retarded child, the diagnosis of leukemia in another. Tears were in everyone’s eyes, including mine. What a privilege to not only know these people, to fellowship with them, and to consider them friends, but also to have really made a difference in their lives with my care. This is why I went into medicine, and this is why I am starting my new practice: to spend my time touching lives and making a difference.
In the aftermath of this momentous day, my sense of urgency has greatly increased. It’s as if I have been overwhelmingly voted into office, given a huge vote of confidence for the campaign promises I’ve made, and now am met with the hardest part: to deliver the goods. It’s one thing to say I am going to do something; it’s a whole lot more to do it. I don’t want other doctors simply impressed with my ideas; I want them to be impressed by what I’ve done. I don’t just want companies signing up for me as their doctor; I want to save them money by keeping their employees healthy and at work. I don’t want people to love me for what I’ve done for them in the past; I want to do even more for them with my new practice.
This is the big difference between writing about change and doing it. Yes, my financial future and the success of my business depends on my ability to deliver the goods, but my big day showed me that this was much bigger than a business. At the end of the dinner on Friday, one of the community members asked me directly, “Is there anything we can do to help you? We have people who can hang wallpaper, pound nails, whatever you need. You know we are all praying for you, but is there anything else we can do?”
I smiled, and said, “This dinner alone has done more for me than you can imagine.” Then I thought for a moment longer, seeing that the offer was an earnest one, not simply a token offer of support. ”I will think about it. Right now I’ve got a bunch of ideas that are forming something concrete, but I’m not there yet. But I know that to turn down a sincere offer of help is to take away the blessing of generosity, and I know you really mean it when you say you want to help.”
My answer was met with a big smile and a long hug.
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.
The question posed by Douglas Farrago, MD above is an excellent one. Perhaps one of the biggest secrets in the Affordable Care Act is section is the following:
SEC. 10104. AMENDMENTS TO SUBTITLE D.
[a] Section 1301[a] of this Act is amended by striking paragraph  and inserting the following:
‘ TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PLANS- The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.
The Secretary has been empowered to define the conditions under which a membership or direct medical practice model qualifies for inclusion in an health insurance exchange as a ‘qualified health plan.’
As far as I know, we are still in rules issuance phase, since much of the ACA implementation was put on hold by HHS pending the outcome of the election, see: http://www.ihealthbeat.org/articles/2012/11/12/hhs-extends-deadline-for-state-insurance-exchange-blueprints.aspx and the Secretary’s letter here: http://www.modernhealthcare.com/assets/pdf/CH83821119.PDF
Given the pro-consumer choice nature of the ACA, and it’s intent to encourage local, alternative and innovative models to deliver on the triple aim, I’d say it is highly likely Sebelius et al, will find ways to express workable models and criteria for direct practice inclusion into HIEs.
So the answer to the question is yes, assuming the Secretary deems such ‘arrangements’ as eligible.
FWIW, we’re working on a ‘network of networks’ model that adds value to the name plate direct practice progenitors, i.e., Qliance, Med Lion, etc., into a local, regional if not national tapestry of direct practices that delivers value to employers direct or via association vehicles, emerging Co-ops, or TPAs. The model delivers the required provider contracting relationships spanning primary and specialty physicians, hospital services, outpatient surgery and the range of key ancillary services. See DirectMed.org for concept only (details soon to be updated).
I am planning on doing this change very soon. Unlike you, I moved to a new area and do not have my old panel of patients to work with. There are tons of big businesses here and I would like to meet their HR person to explain my plan. That being said, why would “a contract with my type of practice would, along with a high-deductible insurance policy, qualify them for the requirements of the ACA (thus avoiding the fines)”? They do actually have to have a signed contract with me? Is there a link explain this better? Good luck in your transition!
Rob. LOVE what you are doing. Would be thrilled to discuss further. We are seeing a ton of interest along the same lines with employers who are building out their own physician networks, cutting costs, and ensuring better access to care at the same time while physicians retain autonomy over clinical decision making and are better compensated. Let me know if you are free to connect.
Rob, after many years of sitting around physician lounges complaining about the state of affairs in healthcare, I feel inspired by your stories and hopeful about the ability to do good again for others. Thank you.
Death blow? Hmm….I always felt my readers found my gaffes endearing (albeit frequent). Silly me using french when I should stick to the language I have marginal command of: English. Thanks for the heads-up. I’ll try to avoid death blows.
I’m very excited for you and I’m following your progress with interest.
Now, I know what you meant, but coup de grâce actually means death blow. I think you want the term pinnacle or zenith or something like that.
I know, if you knew what I meant then why bother correcting? I think your blog is so good I hate to see anything stand in the way of excellence.
Anyway, I look forward to the next installment.