Friday, July 09, 2004

The Third Path

It is the eve of my Family Practice Boards Recertification exam. Once every 7 years, I and many of my fellow FPs take the test, and if we pass, we can proudly claim that we are "Board Certified" in our specialty. It will be my 2nd recert, and even though I haven't studied very much, I'm not worried. I answered some practice questions and got around 70% correct. Plus the pass rate for the ABFP boards averaged between 92-96% between 1986 and 1996. Although there was that one year in 1993 when only 85% passed. Whoops.

There are courses every year to help you review for the Boards, and I took one 7 years ago for my first recertification. But my opinion now is that for most FPs, they are probably unnecessary, given the high pass rate we already enjoy. It appears to be a lucrative enterprise, though.

In the past week, I've had to deal with a new kind of problem: what to do when established patients call with a new complaint?

One woman got rearended in a car accident, and developed whiplash-like neck pain. A patient's mother had a form that needed to be filled out so he can go on a summer educational cruise. Another patient had been having vertigo for a few days. Another patient's mother emailed me asking if her son should get orthotics for knee pain that began ever since he started training for cross country 2 weeks ago.

All of these problems could be handled, more or less, without an office visit. My dilemma is that, without an office visit, I won't get paid for my services or time. My choices are:

1) Encourage everyone to make an appointment to be seen by me in the office for a "proper" evaluation, and risk alienating each patient who may conclude that I am only making them come in to make money off them.

2) Help them out by phone or email, then charge them a separate fee to be billed later. One flaw with this option is that I have not established any kind of policy on charging for these services. Until I establish a more formal policy and inform patients beforehand that they will get charged, I think I will avoid doing this. I did read, however, that there is now a CPT code available for online consultations. Read about it here.

Even if I were to establish a policy of charging for telephone or email consultations, it might be seen as "nickel and diming" patients. I recognize that other professionals, such as attorneys, bill for their time, such as for telephone advice. As a physician trying to get a new practice off the ground, it might not be in my best interest. Maybe later, after I am more established. Which brings me to option number...

3) Help them for free, which is what I've been doing. It's building goodwill, and hopefully I'll get compensated for it later on with a new patient brought in by a good word from these patients I've helped for free.

This is in contrast to the transition of a local doctor's practice from a traditional office to a "concierge medicine" practice. I don't know who it is, but I've heard about it from a couple of patients or their relatives. I keep thinking that if people only knew about me and my practice model, they would realize that they don't have to pay that extra retainer fee to get good service and personal attention.

Unfortunately, this brand of medicine does not yet have a catchy buzzword name to describe itself. In my search for a suitable descriptor, I came up with "The Third Path". It sounds kind of mystical, like a spiritual movement, and I suppose to a certain extent it could be that.

The First Path of modern medical practice is what physicians do now. Reimbursements are fixed by third party insurers. Expenses keep going up. Those who follow the First Path try to make ends meet by seeing more patients to generate more income. This generates more work, more claims, more charts. So more ancillary help needs to be hired, which raises expenses more. Which means even more patients need to be seen. It's a hamster wheel.

Those who take the Second Path are boosting their income by charging patients more, an extra retainer fee to insure good service and to pay for all the services that don't get reimbursed. This is the "Concierge" or "Boutique Medicine" that seems to be getting more and more popular. More income means they don't have to see as many patients to cover their expenses, so they can spend more time with patients. Which means doctors can relax and enjoy practicing medicine again. Everybody wins. Except those unfortunates who can't afford the extra fees. This is medicine for the wealthy and well to do, and creates a second-class patient. Plus, Medicare will probably go after anyone who charges extra for what it considers covered benefits.

The Third Path is the way I've chosen, led by our prophet Gordon Moore. Instead of raising fees, we seek to control expenses by doing as much as we can ourselves, by streamlining operations with EMR's and email and cellphones and the Internet. And by thinking small, as in small offices, short waiting times, minimizing barriers and hassles as much as possible. The Third Path is not the Usual Way Things Are Done. Hopefully, it's better!