“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees. I pay him to give me the stark reality of things, but his optimism made me uncomfortable. ”You’ve got to go for this. I know you don’t feel ready for it yet, but this could really be huge for your business, and I don’t think you should pass this up.”
I sighed. Yes, this is a victory of sorts (still only theory, not reality), but what if I can’t deliver? What if I fail?
“You know,” a colleague told me during another phone conversation, “you are the buzz of the medical community right now. We talked about you for half an hour at lunch today…and it was all good!” He went on to use phrases like “our only hope,” and “the way out,” to describe the potential for my practice model.
“No,” I thought, “I am not Obi-Wan. I’m not your only hope.” I sighed. I don’t want that kind of pressure on me before I even see my first patient. What if I fail?
Even worse: what if I succeed?
One of the main things that separates good clinicians from the rest is the ability to think through contingencies. When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z. Or, here’s the plan if you get better on the medication, and here’s the plan if you don’t. The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem. I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.
Obviously, if I fail to get enough patients to support the business, things could get really tough. I have bills to pay and the evil overlords of college tuition to placate. The fear of this failure has driven me to spend a large part of most days over the past two months working. I don’t want to fail and I will bust my butt to prevent that outcome. The question is not simply, “can I succeed?” I must also consider the possible consequences of success, and plan how to deal with them. When I consider those consequences It quickly becomes clear how scary they could be.
Consequence 1: Getting Overwhelmed
This is the easiest danger caused by success to anticipate. When I open the practice, I may be met with an overwhelming number of people wanting to sign up. If I open the doors too wide and too many patients become my patients at once, I could have trouble keeping up with demands. It’s like a restaurant that opens up to a flood of patrons before it is ready to handle the volume. The result is poorer quality food and longer waits, which could doom the ultimate success of the business. This is one of the reasons I was nervous when I was contacted by the business about becoming their “company doctor.” I don’t want to put out a poor quality product.
The solution for this is to open the practice slowly, or have a “soft opening.” As much as my former patients are banging on my doors to open up, I may be tempted to let people in before I am able to give care that is worthy of their trust.
Consequence 2: Getting Distracted
I had the husband of a patient pay me an off-handed compliment after hearing my presentation about my new practice: “So when you become real successful in this, how long will it be until you don’t have time to see patients any more?” I appreciated use of the word “when” rather than “if” in his question. He not only saw the merit in the idea of what I was doing, he saw the potential for building a big business on this idea.
My answer was simple (and perhaps somewhat over-confident): “Never,” I said. ”I am leaving my old job so I can do what I love: see patients. I am not going to allow this business to take me away from the very reason I started it.”
Others have suggested starting a franchise, writing books, or making money as a consultant for practices who want to follow my path. I hate this, not only because I haven’t seen a single patient or gotten a single check (and thus have the practice equivalent of vapor-ware), but because I see this as a real possibility. The solution to this will largely depend on the people who I end up working with. If I hire well (which is not an easy thing by any stretch), then I can delegate to people worthy of those tasks. But I am not a micro-manager (unlike most docs), so my temptation will be to get lazy and put too much in the hands of people who haven’t shown they deserve that trust.
Consequence 3: Kicking the Hornets’ Nest
Let’s say I dodge consequences 1 and 2, have a thriving practice and a bunch of money coming from consulting and from my show on Oprah’s TV network (giving Dr. Oz the heave-ho in the process). It’s a roaring success, the money is coming in, and doctors are leaving traditional practices in droves to emulate my incredible business model. I’ve been able to dump the administrative tasks to others, leaving me to see patients and scoff at the pittance demanded by the tuition gods. That would be a dream come true, wouldn’t it?
Not necessarily. One of the most common criticisms I hear for what I am doing (and one I often bring up to myself) is that it is not generalizable to the whole of health care. I am cutting back my patient load from approximately four thousand patients (the number I carried in my old practices) to one thousand. That is one of the keys to this type of practice: keep patient volume down so patients get more time. So what happens if this business model takes off and a significant percentage of primary care doctors “abandon” 75% of their patients? It turns a shortage of PCP’s into a crisis. It turns direct care practices into a real threat to the viability of the entire system.
It would create a huge backlash. Direct care would have enemies, and those enemies could do things like requiring doctors to accept Medicare and/or Medicaid to have a license to practice. I’ve heard it suggested already, and it terrifies me.
This is one of the main reasons I’ve become increasingly focused on a new goal: to grow my practice back to the same size it was in the old system. I would have to do so using my “organic medical home,” hiring dietitians, home visiting nurses, social workers, counselors, and other professionals to manage aspects of my patients’ care, allowing me to increase my overall panel size (and perhaps even lowering my monthly fees). If primary care physicians can have a profitable business without selling their souls, if patients can be given more access to care, better care, and save money, and if all of this can be done without threatening to destroy the system itself, perhaps some specialists will become envious and come back to “real medicine.”
Wouldn’t that be cool?
Yes, this could be big…. Now I have to decide if that’s a good thing.
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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Shortage of primary care as a crisis? Not likely…reason for everyone wanting to be a specialist is weird supply/ demand dynamics caused by insurance pricing.
If primary care became a scarcer resource that drove income up as insurance reimbursement for specialty care came down…well let’s just say I look forward to seeing all the internal medicine sub-specialists return to the front lines to boost their income…this would be a great problem to have!
Great thoughts from Rob et al. I would second what Barry says, and reassure Rob that perhaps most patients would not want a direct care or concierge model – implies too much commitment on their part and they would prefer a more standardized and McDonald’s style approach to what amounts to a minor part of their lives that they would rather ignore most of the time. I, like Rob, prefer the more traditional direct care approach to primary care, and can vouch for the inevitable fact of lower patient volumes that goes with it. Could it be that the two models are not mutually exclusive – that the combined forces of the market, patient and provider self-selection, payer and regulatory trends, etc will allow a diverse new primary care landscape, rather than the dreaded monolith we all fear? And can we craft the rules that will allow this kind of landscape to exist and grow (to borrow Rob’s term) organically?
It’s quite possible that even if the direct practice model becomes very popular among physicians, the access issue may not be as serious as some fear for a few reasons.
First, lots of patients who do not have any serious medical issues may be more than willing to accept retail and urgent care clinics as well as factory-like staff model HMO’s (Kaiser, VA, etc.) where the patient sees whichever doctor or NP that is on call that day in exchange for lower out-of-pocket costs and insurance premiums. Moreover, fewer and fewer doctors want to run their own business while more and more are opting to work on a salaried basis for a hospital or large multi-specialty group practice.
Second, 75% of current healthcare spending relates to the management of chronic diseases like heart disease, diabetes, asthma, hypertension, COPD and the like. However, that spending is probably concentrated in no more than 20%-25% of the patient population most of whom are over 50 years old. These are the patients that could most benefit from the direct practice model because they usually need more time to explain what’s going on and to discuss treatment options. Perhaps Rob could tell us what percentage of his prior adult panel suffered from one or more chronic diseases or conditions and what percentage were pretty healthy and rarely came in or needed an appointment only for the occasional minor issue. What percentage of the direct care panel is likely to suffer from a chronic disease or condition?
Third, I’m not sure that the direct care approach would lend itself all that well to patients with mental illness or problems with alcohol and/or drug abuse. Nursing home patients also would not be candidates for such a practice.
Really liked your piece. Not a doc but entrepreneur at startup and could relate to some of your anxieties.
Couple questions (apologize for ignorance)
1) what transformation did you make scaling from 4000-1000 patient practice? No longer accepting CMS pts?
2) would you say your pts ad more rural or urban?
Charging a monthly payment instead of insurance ($30-60/month) for all primary care services. I’ve written much about it on my blog.
I think your thought process on this is excellent. The notion of a soft opening and scaling up gradually makes perfect sense. You don’t want to do too much too soon. I would pass on the employer that wants you to be their company doctor at least for now.
How many patients you ultimately take on and the standard of care you strive to consistently deliver is largely a matter of discipline and within your control. Your constraining resource will ultimately be the total amount of time in the day, week or year that you can devote to patient care. Physician extenders like NP’s and PA’s can leverage your time to some extent but there are limits.
As for other doctors who might want to copy your model and materially shrink their current patient panel size, there is a fallacy of composition issue here. It may work fine for a relatively small percentage of doctors but if too many try to do it, it could have an adverse impact on the healthcare system in terms of patient access. However, that shouldn’t be your problem to worry about. In Japan, the typical patient visit with a primary care doctor lasts all of about five minutes. That’s part of how they keep healthcare spending to 8% of GDP or so. Hopefully, it won’t come to that in the U.S.
Thanks, Barry. I am already actually interviewing an NP (with the request from the business) to join me far sooner than expected. If the business is truly interested in what I have to offer, the business would already cover the salary and would open me up to more growth. I don’t think I would do it otherwise.
Yes, I am perhaps over-reacting to the enthusiasm of the doctors in town, but the reaction has been remarkably effusive, even from docs who I would not expect. Doctor burn-out and pessimism (especially among PCP’s) is quite high, and I am clearly not the only one who was looking for something better.
I’ll trust you on that, Val, but getting back to the 3000-4000 patients I had in my practice before will be a challenge. The point of this is to anticipate potential push-back. The way docs in town talk, I may have LOTS of followers if I can make this succeed. I think it’s the fact that I hit a low enough price-point that docs feel better about adopting this than they would if were at the typical MDVIP level. BTW, I’d put the % of office visits that could’ve been handled without a visit at near 80%.
@Lynn – I am doing, not just thinking. The trick is to do AND think. There are a lot of pitfalls, so being circumspect is definitely warranted. Circumspect, however, doesn’t mean that I am holding back. I am working my tail off (and have a strained muscle to prove it). I just don’t want to be unpleasantly surprised when I get to the end of the road.
Sometimes you have to stop over thinking the thing and JUST DO IT! Is is better to regret doing or not doing. My vote is for doing. Trust your instincts and follow your passion. You are a good doctor, you will continue to be a good doctor, this is just a different box for your doctoring.
Our direct pay practice incentivizes us to INCREASE our patient load rather than decrease it because we are paid for our time (no monthly or annual fees). The more patients we see, the more we make – and because about 1/3 of our patient issues can be resolved via phone, our offices aren’t swamped with patients. This model is scalable and solves the concerns about decreasing patient access to PCPs. Something to think about… 😉 http://www.doctalker.com/page.php?id=10&name=The%20doctokr%20Story
This would indeed be the question!