Re: Walmart Health: Just had a great dental visit this morning, which was preceded by helpful reminders from Epic, and…
Intelligent Healthcare Information Integration 6/8/09
Feeding the Fire of Non-Participation
Amid all of the hubbub around ARRA incentives, federally-mandated disincentives for non-EMR adoption, and best-practices-outcomes-based-evidence-based medical standards with which to comply in order to be ‘allowed’ to be a paid player in healthcare provision, did anyone ever stop to consider the huge – and I mean HUGE – motivational log being thrown onto the fire of non-participation?
I mean, come on, I’m committed to provide the best care possible for my patients. Plus, I’m a techno-geek-gadget-guy from way back. I love and encourage the intersection of healthcare provision and technology. But, when you consider the following, even I have to wonder if the conjuncture of the two worlds might best be promoted outside of the current realm of ONCHIT, CCHIT, and a variety of other ‘chit.’
- In order to remain profitable, I participate in around 40 private insurer programs.
- If I generate $4-500,000 yearly, I take home somewhere just into the six figures.
- In order to maintain those numbers, as a primary care pediatrician with a heavy dose of Medicaid patients, I have to see somewhere around 30 patients per day in order to pay my bills and make a decent living. (“Decent living,” by a pediatrician’s standards, as you can see, is not what most specialists would tolerate.)
- If I didn’t have to chart, make phone calls, review labs and other assorted outside medical data, attend hospital meetings, assist my staff, and otherwise run my practice, that would give me 16 minutes face time per patient average in a 40-hour week. (40 hours! Wouldn’t that be nice?)
- I’ll now have to consider 155,000 ICD-10 codes instead of the paltry 17,000 from ICD-9.
- None of this even mentions hospital rounds, emergency C-sections, or 24/7/365 availability.
- I rush through most days and barely know some of my families. (Not to mention my own family.)
- Studies suggest physicians spend at least 1/3 of their time in non-direct patient care work. (I’d suggest that is low-balled.)
- After all of this, in order to “follow my bliss” and pursue technological enhancements of my medical services, I need to detract yet further from my family time, my personal time, or sleep. (Guess which goes first.)
So, follow me here, if I wasn’t a genetic geek, if I didn’t enjoy the thrill of resolving “Blue Screen of Death” issues, if I was like the majority of non-techno-minded primary care docs who lead very similar lives to the list above, how much do you think I would want to add a giant new learning curve into my scheduled chaos? How much do you think I’d want to risk my already meager monies on an electronic health record system that might get reimbursed in a few years?
Now, instead of maintaining 3-4,000 active patients with the life- and work-styles mentioned above, what if I abandoned all of those who can’t pay or who pay poorly and who place excessive non-medically-related demands upon me (both patients and insurers) and switch to an old-timey, doctor-patient-only practice? (Some call the new version, “concierge medicine.”)
I mean, if I didn’t have to answer to insurer and CMS requirements and wasn’t worried about “meaningful use:”
- I would still chart, make phone calls, review labs and other assorted outside medical data, attend hospital meetings, assist my staff, and otherwise run my practice.
- Instead of 30 patients a day, I might see 15 (maybe 5!) – and I would know all of them.
- I could limit my total number of families to a handful of hundreds charging less than $100 per month each.
- Prepayment could include the costs of vaccinations, simple labs, and all office work and procedures, and
- Hell’s bells, I could even do house calls while still more than doubling my take-home pay!
All of this would be allowed without worrying whether or not I have the necessary number of bullet points, if a vision screening or required immunization will get paid or not (or enough), if my receptionist got the co-pay upfront, or if my EMR was being used meaningfully.
Guilt for not helping those less financially endowed? Why? Don’t the families who can pay also have legitimate healthcare needs? Plus, wouldn’t I be actually serving those for whom I work better, with care from a more relaxed, and ergo more focused, medical brain? With the reduced restraints on my time, wouldn’t I have even more ability to help out at the local free clinic or some other philanthropic venture?
Remind me again why I continue to participate with all the restrictions and requirements and rules imposed by sometimes even non-medical people. Jog my memory as to why possible reimbursement of $44-64,000 of my hard-earned moola for the privilege of learning a whole new way to record my work is considered an “incentive.” Tell me once more why participation in a broken medical model, now about to add – oooo, ahhhh! – “Technology,” something often hard to understand and even harder to use, makes sense.
Seriously. Remind me. I think I’m starting to forget as I feel the warm glow from the growing fire of non-participation.
Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or email@example.com.
IMO, there is a huge, interesting story if you would write about the switch via a blog or other outlet. I would even imagine that you could get all sorts of sponsorship — a free web-based EMR (to support mobility), discounted hybrid car from a local dealer (to make house calls), free laptop and iPhone (on the go), free or discoounted wireless broadband service (again, on the go), etc.
The pitch to yourself and the “community” (that can afford you) is better care, lower stress, and more time with the bigger things in life.
Others will complain that you’re leaving the poor and underprivileged behind. Turns out that this is still an option and is legal in our current system. It is no different that becoming an physician that specializes in most-optional procedures — say, cosmetic dental or cosmetic plastic surgery.
Ultimately you’re running a business. There needs to be a “reasonable” profit at the end of the day — and a sense of a job well done, doing the “right thing” for your community, etc.
Don’t be afraid to choose the option that provides long term value for you and your family. It is still your legal right to run your practice (“business”) however you want.
I feel your pain Gregg, because I have been there…and I opted out of the rat race. It hasn’t been easy, as I was one of the first to actually set my practice up branding it to be the practice personified in “Royal Pains.” As a matter of fact, because of some of the phrasology used in the show and the fact that I live in LA and I have spoken to a few people in the industry about what I do, I think the idea of this show may have come directly from my practice. I have been utilizing the phrase “Robinhood of Medicine,” since 1995 when I incorporated the practice. The term was actually coined by Johnnie L. Cochran, Jr., who mentored me in the earlier stages of development of the practice concept. I was going through the struggles in my head that are besetting the show character “Dr. Hank Lawson” on Royal Pain and just as he came into his comfort zone by having it pointed out to him that he could be the “Robinhood of Medicine,” so it was with my conversation with Johnnie. All of this to say, there are other ways to do this medicine business and I believe that the only way that we as physicians are going to continue to find meaning in this profession that we have dedicated our lives to is if we take back the control of it from the insurance companies and take responsibility for it again. I almost walked away from medicine, but instead I walked away from a broken system…and only looked back to sigh in satisfaction to know that I did the right thing for myself, my patients (both the affluent and the destitute), and my family. I only wish I had found my way sooner!
Peace, Blessings, Health and Longevity,
Cheryl BryantBruce, M.D.
Elite Personal Physician Services, Inc.
Oops…correction, I incorporated in 2005! Johnnie first spoke to me about it in 1995.
One of my favorite personal physicians was a woman in Tampa, FL who took no insurance. She was fee for service. (she did print a 1500 for me)
She had two people employed and did a strong business without the hassles of dealing with reimbursement. You paid when you went. Simple easy and not run by the government or the insurance agencies.
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