Tuesday, October 8, 2013

Two [remunerative] roads diverged in a wood...

"and I -- I took the one less traveled by, And that has made all the difference."  I love Frost and this seemed an apt observation, especially given the fall weather.  One road takes patient insurance; the other does not.  In the swirling mass of ideas from which my vision for better healthcare delivery will congeal is this fundamental divergence.

I have already long ago negotiated most of my contracts with insurers, the  relationships with which only need be redirected to whatever my new endeavor becomes.  I also know and understand the remunerative process in clinic medicine better than most.  I speak CPT, ICD, HCPCS, etc. and  understand the tools to assure prompt and satisfactory payment.  But most importantly, the majority of my potential patients will have some form of health insurance, which they will want to use with me.  With the Affordable Care Act in full swing, that number will rise.

However, once inured to the payors the bureaucracy compounds.  Complex and expensive practice software need be purchased/leased, often in a commensurate hardware environment, particularly if you decide to avoid "The Cloud."  After the initial "ooooffff" of those expenses, there is the time needed to verify insurance.  Mr. Jones may think he is insured when he shows me his little wallet card, but it is not until I contact the payor that I can verify that this is the case.  If I don't do this, and he is not insured, he is really not obligated to pay for any service already rendered.  And that process must happen every time his insurance changes.  Then there is the hard job of helping him understand that he has not met his $1500.00 deductible, so his visit will all be out-of-pocket today.  And some medications, depending on lengthy and plan-specific formularies, may not be covered, or will require several pre-authorization forms to be submitted first before coverage will be considered.  There is a labyrinthine tier of rules regulating the quality and quantity of clinician documentation requisite for different levels of remuneration from the payor.  With the growing presence of integrated health quality reporting tools, even more data must be collected, mined, and processed, modest returns notwithstanding.  The EOBs, or explanation of benefits, if readable, often prompt questions from the patients.  "Why was I charged for this?" or "What does that mean?"  Overcharges and undercharges are not uncommon.  Co-pays ranging from $5 to $50 must be collected at the point of care, and should never be waived, as this is a form of insurance fraud.  And the clinician will be deluged with mail and email about this or that new program the payor has instituted to assure compliance, payment, etc.  In some cases, these letters -- often "reminders" -- appear to be offering clinical advice and suggesting courses of treatment (all too often based on insufficient evidence), in what appears to me to be a violation of the Texas Medical Practice Act.

All of this makes the Sirens' song of direct fee-for-service much more attractive.  "Mr. Smith, I'll take care of your sinus infection for $50."  Done, simply and cleanly.  No loose ends or hanging chads.  Sure, one needs some form of accounting software, but it has to be more simple that the above.  The majority of the bureaucracy above disappears in this model.  I am working on a different name than "cash-only."  Perhaps "chickens optional?"  Whatever the name, it must be positive, as I shape the brand essence of this nouveau passe approach to meeting people's needs.

The downsides to divorcing my payors are protean, but none are dealbreakers.  Long-term and repetitive care issues (e.g. wound care) pose potential challenges, but there must be a way to structure this simply and make it achievable for every person.  What if complex testing must be considered (e.g CT scan, MRI)?  As an experienced clinician, retrospective evaluation of many outpatient clinical scenarios suggests that higher level testing does not change outcomes in the majority of cases, particularly in the arena of repeated/serial exams, and direct contact with the clinician.  Blood tests could be drawn and submitted to a national reference laboratory cost effectively.  And medications?  One proposal to make this model of simple care more attractive is to offer a simple and common array of medications to the patient at the point of care, obviating the headache of a pharmacy visit.

Perhaps it has all been done before, however.  Some urgent care facilities only take cash/credit, and have a structured tier to payment that emulates my thoughts above.  Often these facilities have not addressed well-enough the hurdles of triage/wait times, availability, and over-testing.  In this, and other ways, I hope to be different.

While I generally disdain those whose bearishness prompts routine counter-culture arguments, I do believe that the Emperor of American Healthcare is quite naked, and I believe that my countrymen are starting to realize this too.  (The Emperor, however, seems to think he looks pretty good.)  Ultimately you must decide.  Most are tired of long office waits, of not being able to speak promptly to trusted authorities about their health concerns when they arise (invariably on Saturday night), of being inundated regularly with a flood of  paperwork (enrollment, EOBs, medication flyers, etc.), and ultimately of only getting a brief moment of face-time with the one person whose experience and background may provide answers and/or reassurance.  There is no sense of value here.  Only a hopeless sense of loss of control.  Life isn't this hard.

Much more to write and share.  Thanks for reading.  Give me your thoughts if you have a moment.  I welcome them!

Dr. P

Saturday, September 21, 2013

Not Concierge?

This morning I received a follow-up telephone call from a physician in the Southlake, Texas (Dallas) area who is involved in concierge medicine. He described a few essentials to success.  First, he weds an "executive physical" model, to a concierge model, by which he gets more reimbursement and risk stratifies his patients.  "They come in and spend the whole day with us," he described.  Secondly, he believes that "you have to have corporate investment to make this successful."  He secures contracts for large numbers of patients from corporations to provide the revenue to do all he feels is needed to make his model work.  He was very candid about these and other aspects of concierge medicine.

This call, others, and online reading has me thinking that it is not concierge care for which I'm looking.  Not at least as it seems to be commonly represented today.  I really have an ethical problem with the "executive physical."  Why should any complete physical exam be different from any other?  I swore to treat all equally.  Executive physicals imply that they are better than other exams, ostensibly because more testing is involved, and imply that those who cannot afford it get a less thorough exam.  I don't know which I like less, the patient who insists he is better cared for because he gets an executive physical, or the patient who feels he is missing out because he does not get one.  The key here is to get what you need, not more, not less.

I also found myself in an unusual minority in my search for concierge medicine.  Most companies that sell their networks and resources to you want to help you transition your existing practice into a concierge one.  Virtually no one knows what to do with the individual physician who wants to start such a practice.  I am leaving an physician employment position, with no patients to bring with me.  But my wife is very supportive, and she has a good job.

Here are my ideals:  I want my patients to have my number so that they can call me directly.  I want to meet, wherever possible, my patients where they are.  While I hope to have a clinic, I anticipate going door-to-door as well.  I want to provide more than the standard of care, but not to ridiculous extremes like "executive physicals."  I want to draw people away from traditional delivery systems by showing them the value of the convenience of direct, 24-hour access, with therapy provided at the point of care wherever possible.  No drives to the pharmacy at night.  No antibiotic prescriptions to fill.  No paperwork headaches.  And I will be the same doctor for them every time.

I am persuaded, in part from having employed some of these principles in my private practice, that patients really do not want to disturb their physician.  But they really like knowing that they can, if they need to.

More to come...

Dr. P

Thursday, September 19, 2013

First Things?

I have no good idea about how to start a concierge medical practice.  Numerous corporations online will help you with this, and I am looking at some of them for ideas and guidance, though I don't want to contract with any.  I wonder how many more days will pass, however, before I find myself laughing at the absurdities that today seem like great ideas.  C'est la vie!

So, what needs addressing?  Here is my initial punch list:
  • Establish corporate structure:
    • corporation, sole proprietorship, other?
    • get tax ID
    • malpractice insurance
    • contract and fee schedules
  • Location:
    • primarily floating (out of car?)
    • get PO box
    • consider sublease from clinician friends
      • home for autoclave, microscope, centrifuge, etc.
  • Communication infrastructure:
    • hardware & software
    • paper back-up option
    • credit-card reader (iPhone or computer app)
  • Transportation:
    • Tesla (I wish)
  • Core tools:
    • stethoscope
    • sphygmomanometer
    • otoscope
    • ophthalmoscope
    • thermometer
    • reflex hammer
    • neurosensory tools
    • camera
      • disposable rulers
    • ECG
    • Holter monitor
    • spirometer
    • ultrasound
    • scale
    • head lamp
    • portable exam table, paper
    • cloth gowns
    • speculae
    • Rx pads
    • Triplicate pads
    • medication bottles/containers
    • carrying cases for all portable materiel
    • autoclave
    • microscope
    • cover slides
    • slides
    • specimen droppers
    • pill cutter
  • Medications:
    • Pain/nausea:
      • ibuprofen 800 mg, #100
      • APAP 500 mg, #100
      • APAP/hydrocodone 325/500 mg, #30
      • meperidine 25 mg/mL, #1 mL, #5
      • promethazine 25 mg/mL, #1 mL, #5
      • ondansetron 4 mg dispersible tab, #5
    • Antibiotics
      • amoxicillin 500 mg, #90
      • amoxicillin/clavulanate 875/125 mg, #90
      • azithromycin 250 mg, #18
      • TMP/SMX DS, #60
      • minocycline 50 mg, #60
      • fluconazole 150 mg, #5
    • Cardiovascular
      • ASA 81 mg, #30
      • ASA 325 mg, #30
      • NTG 0.25 mg, #10
      • clonidine 0.1 mg, #30
      • lisinopril 10 mg, #60
      • amlodipine 5 mg, #60
      • furosemide 20 mg, #30
      • HCTZ 12.5 mg, #30
    • Gastrointestinal
      • omeprazole
      • Maalox, viscous lidocaine, Donnatal
      • dicyclomine
      • loperamide
      • polyethylene glycol
      • bisacodyl
    • Allergy/anti-inflammatory
      • cetirizine
      • diphenhydramine
      • Epipen
      • steroids
        • prednisone
        • triamcinolone
        • triamcinolone
    • Psychotropics
      • alprazolam
      • diazepam
      • sertraline
      • zolpidem
      • melatonin
    • Miscellaneous
      • insulin, regular
      • glucagon
      • Mircette
      • testosterone cypionate
      • rizatriptan
      • dihydroergotamine inj
      • metoclopramide tab, inj
    • Vaccines
      • tetanus toxoid
      • pneumococcal
      • flu
      • portable cooling unit/device
      • certified refrigeration device at office with temp audit
  • Wound care
    • Kerlix rolls, pads
    • Army battle dressings
    • Hypoallergenic paper tape
    • Silk tape
    • Normal saline
    • Hydrogen peroxide
    • Betadine
    • Elastic bandages
    • Instruments
      • scalpel, blades
      • Adson forceps with/without teeth
      • hemostats, curved & straight
      • scissors, iris, standard, bandage
      • Weitlaner retractor
      • periosteal elevator
      • needle drivers, two sizes
      • ringed forceps
      • ear spoons and/or loops
      • punch biopsies
      • towel clips
    • Silvadene
    • Antibiotic ointment
    • Silver nitrate sticks
    • fenestrated and non-fenestrated drapes
    • Blue pads
    • green cloth towels
    • gloves, sterile and non-sterile
    • kidney basin
    • large basin
    • syringes, large
    • suture
      • Vicryl 3-0
      • Nylon 5-0
      • Prolene 4-0
    • needles
      • butterfly 23
      • 18 gauge, 1"
      • 27 gauge, 1.5"
      • 23 gauge, 1.5"
    • syringes
      • 1 mL with 27 gauge needle
      • 1 mL
      • 3 mL
      • 5 mL
      • 10 mL
      • 60 mL, Luerlock and standard
    • lidocaine with & without epinephrine
    • loupes
    • IVF normal saline
    • IV tubing
    • IV needles, assorted sizes
  • Specimen collection:
    • Vacutainers, assorted, with needles
    • Thin prep containers
    • Urinalysis containers
    • Urine collection bowl
    • Formalin specimen containers
    • Dry specimen containers
    • Culture swabs (aerobic, anaerobic)
    • pregnancy tests
Likely there are other things that I have not included in this otherwise reasonably thorough list.  Adding in pediatric care changes things a bit, but will likely be necessary.  My vision has a brand essence that is contemporary old fashioned:  a modern-day James Herriot might epitomize my ideal.  Thoroughness, privacy, affability, and dignity are to be the hallmarks of my trade.  A servant's heart at the bedside, a shrewd businessman at my desk.

I imagine a tiered remuneration structure with a free introductory consultative visit, hopefully at the individual's/family's home, where the terms of our relationship are clearly outlined and questions answered.  I would offer a contract for their review over the next several days.

"Good fences make good neighbors."  While Frost's eloquence argues that this is unnatural, I believe it to be excellent advice.  There are limits to my capacities.  I cannot do appendectomies on the kitchen table (ah, for the good old days!).  Some issues necessitate referral and/or medical facility admission.  With the proper connections, those transitions can be fluid and painless.  I will not write some medications at all (e.g. amphetamines like Vyvanse, Addrall, for adults; or opiates like MS Contin).  Some offerings will be outside the anticipated tiers, such as botulinum toxin for cosmesis.

So, a lot of ground to cover.  Lots of regulations to review and relationships to reforge.  In the end, will it work financially?  I'll leave that analysis to a future post.  If you've read to this point, and have a moment to spare, let me know what you think.


Dr. P

All People Great and Small

An ancient symbol of cyclical regeneration and renewal, the phoenix seemed an apt if not particularly original blog title of my personal and professional story of hope and rebirth.  I am a forty-something family/general physician living in Texas in the United States of America.  I graduated from medical school over 20 years ago, studied surgery and later primary care medicine, and started my own medical practice in early 2001.  It was a "traditional" model, working with insurers like Blue Cross/Blue Shield, Aetna, Humana, United Healthcare, and Medicare and Medicaid to provide services to over 8,000 patients over almost 10 years.  I created, in cooperation with GE Healthcare, a model of primary care efficiency that, even today, I reminisce on wistfully.  The personal price of that exacting life lead to a self-destruction of sorts, from the ashes of which I am now emerging, to find a new and satisfying way to make a difference.

Today I began investigating concierge medical practice.  The phenomenon, likely present for decades, has been gaining momentum in the United States in the past 10 years in response to thematic patient concerns about a combination of slow access to care, perfunctory attention by professionals, and skyrocketing costs.  The emperor is naked, my friends, and everyone but the doctor knows it!

Concierge care -- sometimes referred to as boutique medicine -- is a cash-only healthcare delivery model.  To physicians, it appears deceptively simple and clean, without the hassles of working with insurers, with their deductibles, copays, EOBs, and denials.  I like the fact that it brings one more face to face with the true value of the service.  How much are folks willing to pay for my services?  But it is likely not as easy as it sounds.  The business of medicine, like medicine itself, has never been easy.  This is a discussion for another post, I think.

I worry most that I will marginalize those who need but can't afford my care.  It very easily could become care for the super-rich.  Costs are over and above what folks already dish out for insurance, and who can afford that?!  I have tried to placate my conscience by reminding myself that, with all of the savings, I will have time to give to indigent care clinics.  Of course, if I am not already giving there now, why do I think I will do so then?  This also is an issue to ponder in a future post.

Patients aren't happy.  The aforementioned delays in care, lack of meaningful relationships with clinicians, and costs that betray the true value of the experience, together with inundation by medical information are some of the reasons for this.

Clinicians aren't happy.  Long hours, Brobdignagian bureaucracy, plummeting remuneration, and a growing disillusionment in being able to establish clinical cause and effect all conspire to a resignation to the status quo.  Many wonder if they really are making a difference any more.

Payors aren't happy.  They are trying to meet both parties at some middle ground and all they seem to get is vilified.  Of course, they do raise prices, increase bureaucracy, and, not infrequently, engage in the practice of medicine, typically in the guise of cost-control or preventative care.  I could build a bonfire from the letters any ONE of them sent me, while in private practice, admonishing me to do this test or that, for their client's well-being.  And, not long ago, the CEO of United Healthcare took home in one year 132 million dollars (without stock options).  Who is worth that much?  Especially with the "healthcare crisis" looming.

The government, of course, wants to make everyone happy.  I don't think that new rules and regulations can assure this, not, at least, without more attention to personal responsibility.  We need to re-align our expectations of what healthcare can and should do for us.  This is definitely a topic for future elaboration.

In the end, our healthcare dilemma just doesn't have to be this hard.  The more complex a thing is, the more simple its themes.  When I graduated from medical school, and, later, residency, I was persuaded to rely on tests and x-rays to make clinical diagnoses.  Years later, however, I realize that one does not need all of this testing.  Most of the time, the patterns are evident to those who recognize them, and testing only increases cost with the benefit of increased patient anxiety.  Any job is like this:  we mature in our understanding of what is important.  Have we over-complicated healthcare?  Another exposition in the wings.

So here I am.

I worked for two years, after leaving my private practice, with a large group of physicians, the only job from which I was ever fired.  The hours were oppressive; the pay, insubstantial; and the sense of reward, absent.  The firing left me devastated beyond words.  Subsequently, I worked for a retail-minded purveyor of male hormone replacement.  Here the money was great; but the job, tedious and unfulfilling; and the sense of ethos, lacking.

So I quit.  And that was two weeks ago.

The phoenix.   There has to be a better way to get everyone happier with healthcare.  Is concierge care the answer?  Not as I have too often seen it done, a service to the very affluent.  Hopefully I can find something that obviates the usual payor structure though, but is still attainable by most, and satisfying to all.  There are no good roadmaps for this path, but this blog will record the path I took.  "I shall be telling this with a sigh somewhere ages and ages hence..."

Hoping, on the eve of Obamacare, that I can make a different difference, I will give you

All my best,

Dr. P