We're not in it for the money

I have a patient who occasionally e-mails me interesting articles related to healthcare. Recently he (Hi, Mr. S!) sent me an article about how doctors are nickel and diming their patients for things like filling out forms, refilling medications or giving advice over the phone:

When Jill Wolfson called the psychiatrist last year for a prescription refill for her son, she had an unpleasant surprise. Up until then, the over-the-phone refill had been free. This time, she was charged by her doctor for the service, to the tune of $25.

"I was really astounded," says Wolfson, of Santa Cruz, whose son had long been seeing this psychiatrist for attention deficit disorder. "We go in for regular checkups to get his meds looked at, so it's not like we call in for refills without ever seeing him. It just seems like it should be part of the service when you're being charged $100 an hour."

Okay, since she's being charged $100/hr, that either means she doesn't have insurance or, more likely, he doesn't accept third-party insurance, like a lot of psychiatrists. But I see her point: why charge extra for a refill?

Langston and others blame nickel-and-diming on a broken-down, outmoded system of healthcare that rewards physicians only when they have "some skin in the game," meaning face time with the patient, says Dr. Daniel Sands, an assistant professor of medicine at Harvard Medical School.

"The only kind of healthcare that is valued [by insurers] is the care delivered in the office," says Sands, who lectures on physician trends. For example, he says, doctors have been "giving away" care over the phone for years, unable to bill insurance for the time. Medical intervention by phone or e-mail, he says, is time-consuming, requires solid medical judgment, carries the usual malpractice risks - and is completely uncompensated.

Here is another perspective on rising health care costs, and who has to pay:

Many patients are lumping doctors in with insurance providers and pharmaceutical companies as greedy components of the escalating heath-care crisis, but in many ways, doctors are simply struggling to keep their practices afloat. Rising overhead costs, lower reimbursement amounts from insurance providers and delays in receiving payments due to haggling over bills, among other things, have put considerable pressure on them.

"The burden of running the health-care system has been shifted over to physicians," said Daymon Doss, CEO of the Petaluma Health Care District. "Insurance companies have created very complex billing systems that often deny reimbursement for services. So, doctors and their staffs have had to become very skillful at filling out forms."

Despite the financial burdens and dangers, there are still some of us who swim salmon-like against the healthcare system stream:

Some physicians, such as Petaluma primary-care doctor Eric Holmberg at 108 Lynch Creek Way, prefer solo practice, despite the mounting obstacles. He returned to a solo private practice more than two years ago.

"In a large, clinical-practice setting, patients are juggled between physicians and nurse practitioners, so doctors don't get to know patients very well," he said. "As a solo physician, I am able to provide better, more personal care. I don't try to run a lot of people through my office."

That's what medical micropractices are all about.

Holmberg has had to run a very tight ship, though.

"I've kept my overhead expenses as low as possible, partly by cutting down my staff to one employee, who serves as a medical assistant and front-office worker," he said. "If I had the financial capacity, I would hire another person."

I know what Dr. Holmberg is talking about. I have been trying to manage a solo medical practice on my own for the past 2 1/2 years, and while I have enjoyed the freedom of spending as much time as I need to in a visit with a patient, it has been a struggle for me to get paid for the work I do. Therefore this week I finally hired someone to help me with the medical billing and chasing down denied or "forgotten" payments from insurance companies.

So if you think you are paying too much for health care and aren't getting your money's worth, you're absolutely right:

For the fifth year running, Blue Cross of California has spent less than 80 percent of premium dollars on patient care, according to a report released by the California Medical Association.

Blue Cross, the state's largest for-profit health insurer, spent 78.9 percent of its premium dollars on patient care in fiscal year 2004-2005, with 21 percent to profits and administration, according to CMA's 13th annual report examining annual health plan expenditures.

"Vital patient care is being short-changed by for-profit HMOs that send ever increasing portions of premium to Wall Street instead of spending it on patients," said Michael Sexton, M.D., CMA president. "If a substantial part of these profits were kept in the health care system, it would help make Californians healthier, stabilize the endangered emergency care system and ensure that all patients get access to the care they expect and deserve."

So where is the money going?

Wellpoint Health Networks, the parent company of Blue Cross of California, paid CEO Larry Glasscock more than $5.4 million in salary and other compensation. Thomas Snead Jr., another Wellpoint executive, received more than $5 million in compensation. Neither figure includes stock option amounts or values. These compensation amounts were several million dollars more than the average compensations earned by other health plan executives.

Last year, WellPoint reported that CEO Leonard Schaeffer received more than $11 million in total stock, salary and other compensation.

You know, $11 million could pay for a lot of school forms and medication refills, not to mention childhood immunizations and cancer screening tests.

It's gotten so bad that doctors have to resort to doing things like this ("Boost productivity? Walk less") as a way to make more money. Money that is often needed for a practice to survive.

Anyways, like most doctors so far, I do not charge extra for filling out forms, answering questions by e-mail or refilling medications over the phone. But that could change in the future, depending on what changes come about in physician reimbursement from insurance plans. Even so, it's not about getting rich. I just want to be able to make a living doing something that can help others.

If I really went into medicine to make money, I could've done something like this.

Triumph or Tragedy?

I have been following the story of Dr. George Hsu over the past year, and like a Hollywood movie, it is finally approaching the climactic ending, though I still don't know if it's going to be one of triumph or tragedy. Here's the timeline version:

March 2004 - Dr. Hsu, a small town family physician in Elgin, North Dakota, has his license revoked by the State Board of Medical Examiners based on an anonymous complaint. He is accused of inappropriate care in 10 cases.

November 2004 - Rather than accept a hearing judge's less punitive recommendation to monitor Hsu's practice, the medical board revokes his license instead. At the urging of his patients, who are local farmers and ranchers, Dr. Hsu files an appeal.

Rolf Sletten, the board's executive director, said monitoring would have been too intense to be practical in Hsu's case. He said the board said it believed the breeches in Hsu's medical care were too serious and that, coupled with Hsu's attitude and prior history of being disciplined by the board for untimely charting of patients' medical records, revoking his license was the best course of action.
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Hsu said he also is frustrated because the 11-member medical board voted without comment, and he has never heard its explanation for taking the most serious disciplinary step it can take against him.

Sletten said Hsu's attitude worked against him.

He said that when Hsu addressed the board, he complained about the investigation and review process and only talked about being monitored when "nudged by his attorney.
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Sletten said he can't remember when a district court has overturned the board's decision to revoke a medical license.

January 7, 2005 - Medical Board denies a rehearing.

January 29, 2005 - The townspeople of Elgin organize fundraisers to help out the financially-strapped Dr. Hsu.

Klein said people are finding it difficult to replace Hsu.

"It's about trust and that's something you can't get in a pill," she said.

Hsu said he's deeply moved by the response from the community.

He said his practice was characterized by carrying one of the nation's top patient loads, even while his personal income was in the bottom 10 percent of family physicians.

"I have not been able to save a lot of money and the legal costs have drained my personal resources," Hsu said.

February 2005 - Hsu files an appeal in state court. The national media pick up his story.

Hsu's supporters write Letters to the Editor in the local newspaper criticizing the Medical Board's decision. [1] [2]

March 22, 2005 - Dr. Hsu writes his own Letter to the Editor, entitled Price of defensive medicine is steep.

March 2, 2006 - One year later, it's over. Elgin Doctor Back in Business

The state's medical watchdog panel was wrong to revoke the medical license of an Elgin doctor accused of improper patient treatment, a district judge has ruled.

South Central District Judge Sonna Anderson's order said George Hsu should have his medical license reinstated if he agrees to additional monitoring prescribed by the state Board of Medical Examiners, which licenses and disciplines doctors.

"The record does not support a determination that the departure from the standard of care is so serious as to justify the revocation of Dr. Hsu's license," Anderson's order said.
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Hsu said he has been working as an auto mechanic and has started a highway striping business with his son.

He said he has not had a haircut in the nearly two years since the board first barred him from practicing medicine.

"It was a protest, I suppose," he said. "I'll probably get my hair cut now."

March 21, 2006 - Then again, maybe not. Elgin doctor's case still up in the air.

April 4, 2006 - Board revokes license again:

George Hsu was ready to get a haircut and scrub his successful highway striping business in western North Dakota to return to work as a rural doctor.

But Hsu, 62, of Elgin, learned that the state's medical watchdog panel would rather have him painting highway lines in a pony tail than seeing patients.

April 25, 2006 - Judge orders board to reinstate doctor's license

In a sternly worded order received by attorneys Monday, a judge says the medical license of George Hsu, a doctor in Elgin for some 20 years, should be reinstated if he agrees to additional monitoring.

It is the second time South Central District Judge Sonna Anderson has ordered the state's medical watchdog panel to reinstate Hsu, who was accused by the state Board of Medical Examiners of improper patient treatment.

Anderson said her first order, issued in February, may not have been "crystal clear to the board."

"The (board's) order revoking Dr. Hsu's license was reversed," Anderson wrote. "If it was not explicitly clear in the earlier order, let it be clear now."

She used bold letters in part of the order to emphasize her point.

Doug Bahr, an attorney for the medical board, said Anderson's earlier order "at least in the board's opinion, was unclear.

"She has made it clear," Bahr said Monday. "People won't be guessing."

April 28, 2006 - Board to appeal to State Supreme Court

Mar 3, 2006 - The Bismarck Tribune writes an editorial questioning whether an taxpayer-funded appeal is justified.

April 20, 2006 - Dr. Hsu writes another Letter to the Editor: Disregarding Truth and the Law

In 2002, Sletten informed me that a "confidential panel" was not satisfied with my response to a complaint involving three cases, and unless I agreed to some form of discipline, my license would be revoked. I did not understand what it was that I had done wrong, and I asked if I could meet with the board face to face. "If after that, they can look me in the eye and tell me that I was wrong, I'll comply with any discipline they feel is appropriate." But that was "not possible."

I asked what my options were. Sletten told me, "You can fight this and go before an administrative law judge, but it doesn't matter what he decides, because we'll do what we want anyway."

I did not believe this was possible, but the facts speak for themselves. The board's case against me was weak, but the three complaints increased to six, then seven, and finally to 10, even though not a single one originated from a patient or family member.

May 2006 - More Letters to the Editor in support of Dr. Hsu [1] [2][3]

July 6, 2006 - Board ordered to pay court costs, attorneys fees of doctor

The state's medical watchdog panel must pay attorneys' fees and court costs for an Elgin doctor it accused of improper patient treatment, a district judge has ruled.

South Central District Judge Sonna Anderson awarded George Hsu $26,602 in an order dated June 30.
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"It's no surprise," Rolf Sletten, the board's executive secretary, said of Anderson's most recent order. "It was clear that's what she was going to do - there is no news in that. In truth, the cost issue will be decided by the Supreme Court."

Hsu said Wednesday that he expects the medical board to appeal the award of attorneys' fees and court costs to the state's high court.

"I think it will just give them another black eye," he said.
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Court documents show that the board has spent $39,400 in attorneys' fees, court costs and its investigation of Hsu.

Totally fictional yet based on real life movie adaptation version: Psychologically scarred Vietnam and Gulf War vet becomes a maverick, sometimes arrogant, old-fashioned doctor with a heart of gold. When he gets cited for a minor infraction, his bad attitude ticks off the crotchety, iron-fisted Medical Board Executive Secretary who vows to show the rogue doctor who's boss and put him out of business. He misleads the Medical Board with selective evidence and they have no choice but to revoke the small town doctor's license. The once untrusting but now loyal townspeople come to the doctor's aid and despite the overwhelming odds, they win their appeal. But Mr. Executive Secretary refuses to accept defeat and takes the case all the way to the Supreme Court where........a decision will be made. Triumph? Or tragedy?

We must wait for the final chapter.

Primary Care is Where It's At

I found yet another article about a micropractice, this one in Rhode Island, which serves as a rebuttal to some recent opinions that primary care is dead.

Ho has no receptionist or other staff members, so immediately after greeting a patient, the two enter into a conversation about the patient's health, a physical examination, and discussion of next steps. The relatively small size of Ho's practice allows her to spend a relatively large amount of time with each patient: at least an hour for a first visit and a half hour or "as long as it takes" for subsequent visits.

As the visit draws to a close, the doctor handles all of the administrative details, including billing and scheduling the next appointment, herself. The results of focusing so much on her patients are clear: although Ho estimates that she's forced to spend more than 60% of her time on administrative tasks, she has over 600 patients, and will soon have to close her practice to new patients that are not family members of existing patients.

Dr. Ho is on the Map. I suspect there are a lot more micropractices out there than anyone thinks. Hopefully we'll start reading more about them as the word gets out.

More Micropractices

It's always a pleasure to hear about other physicians who are choosing to go smaller and return to a simpler way of practicing medicine via micropractices. For one thing, it gives me hope that the American medical system can be transformed/reformed into something that makes some sense. For another, it makes me feel like I'm not the only crazy one for trying it.

Here is a recent article from the Santa Cruz Sentinel about someone else who took the leap:

SANTA CRUZ - There's something different about the office of Dr. Maria Greaves.

Sure, there's a tastefully furnished waiting room with a burgundy leather sofa and a toy box. But there's no receptionist, no nurse, no insurance paperwork to fill out.

"I'm everything," said Greaves with a smile.

She is the first physician in Santa Cruz County to adopt a new style of medical practice pioneered by Dr. Gordon Moore in Rochester, N.Y., five years ago.

Here is another article about 2 doctors from Oregon who also decided smaller is better:

Quillin is part of a growing national trend of physicians breaking away from high-volume practices characterized by short office visits.

Tired of seeing more than 20 patients a day and staying on top of the well-being of 2,500 people every year, they are paring down their practices to a few hundred patients, who get a lot more of their time.

Smaller practices can come in different forms. Some are completely solo like Dr. Greaves and myself. Others look like a traditional practice with a medical assistant and nurse. I accept 3rd party insurance like most practices. Dr. Quillen charges a $400 annual enrollment fee plus $75 per additional family member. You can be full-time, or part-time, like Dr. Wible:

Wible worked in several clinics in Eugene and in Washington state before opening her own part-time practice in April.

Her biggest complaint about working in established clinics was similar to Quillin's: not enough face time with patients.
"I like to talk and my patients like to talk. They want to get to know me, and I want to get to know them. You can't do that in 15 minutes," she said.

When she decided to go solo, she conducted several community meetings that attracted about 100 people. She asked them what they wanted from their primary care physician and three consistent themes emerged.

People wanted more time with their doctors. They wanted to be listened to and they wanted to play a role in their own health care.

Wible knew she wanted more time with her patients, the opportunity to help transform the health care system, and more personal time to explore other activities.

To get there, she stripped down the overhead. She employs no one, and does all the accounting and business work in her home office. She sees clients three days a week in an office she rents at the Tamarack Wellness Center in south Eugene.

Because she carries no debt and lives simply, Wible says she doesn't need the typical physician's salary. But she believes that her low overhead will allow her to exceed her previous full-time salary.

So if this is a growing trend, where are all these micropractices?

Well, you could start by looking at this website where 33 55 78 micropractices are listed. And the list is growing.

You may already have a micropractice near you. Or if not, maybe a micropractice will be starting up in your town soon. Then you'll have a choice between the new way of seeing a doctor:

• call to make an appointment and be surprised when the doctor answers
  
• get an appointment for 2PM that same day
  
• barely spend any time reading the magazines in the empty waiting room as you are directed to the exam room
  
• talk to the doctor who sits down and looks you in the eye and actually listens
  
• spend enough time to make sure everything gets brought up and even some things that you had forgotten about
  
• receive a thorough physical examination
  
• leave with all questions answered with an appropriate follow up date (if any is needed)
  
• since it's only 2:30PM you have time to go to the bank/post office/whatever

Or the current way of seeing a doctor:

• call for an appointment and wait on hold
  
• get an appointment for 2PM a week from now
  
• wait in crowded waiting room with sick people
  
• finally get called 30 minutes after the appointment time
  
• wait another 10 minutes for the doctor in the cold exam room
  
• spend 5 minutes with doctor who is busy looking through your chart or writing notes while you talk for 22 seconds before being interrupted
  
• received a rushed and abbreviated physical examination
  
• be left with unanswered questions because the doctor is late for his next patient
  
• spend another 10 minutes trying to reschedule another appointment because there wasn't enough time to talk about everything you wanted
  
• lather, rinse, repeat

Then we'll see who the crazy ones really are.