Being There

I'd like to think that every family doctor experiences this kind of moment at least once in their career. For many of us, more than once. For someone who doesn't practice medicine, they may not "get it". But there is power in just simply caring, even when there is nothing else that can be done.

This is the power of a man who cared, and which is so strong, some of his magic still lives in his violin.

This is what being a family physician is all about. This is what has been dying from the modern healthcare system.

We need to bring it back.

Pay vs Worth

As further proof that our healthcare system is totally screwed up, I present the following.

On the one hand, we have a family doctor making $500 house calls in New York City which one patient describes as "ideal medical care". (Hint: it's not.)

Then as a polar opposite we have another family doctor in Chicago who chose to go "bare" (that is, go without any malpractice) in order to maintain his solo practice when his premiums jumped from $10,000/year to $40,000/year. Like Dr. Schleider above, Dr. Macumber doesn't accept any third party insurance. Unlike Dr. Schleider, he charges only $40 per visit.

What do they have in common? It is becoming increasingly harder for primary care doctors to practice "in the middle", and stay within a dysfunctional system that forces them to work long hours with inadequate pay. You either have to cash out and go for the high end, or do something radical like not have any personal possessions worth protecting.

In my former job as a staff physician, I calculated that my actual pay rate worked out to about $56/hour if you counted my actual hours worked. While that sounds pretty good, it makes me wonder why anyone would want to subject themselves to at least 7 years of postgraduate studies, amass mounds of student debt and live with the constant threat of being named in a malpractice suit when they could make $60-70/hour doing this.

More Micropractice Publicity

Another opportunity for me to talk about ideal micropractices, this time on public radio's, "Marketplace". Thanks, Pat!

But I'm even more proud and honored to be mentioned (albeit briefly) in this soon to be literary classic.

Blue Pill or Red Pill?

(With apologies to the Wachowski Brothers)
Dr. Moore: I imagine that right now you're feeling a bit like Alice. Tumbling down the rabbit hole? Or perhaps like you’ve been running on a hamster wheel?
Dr. Neo: You could say that.
Dr. Moore: I can see it in your eyes. You have the look of a doctor who accepts the amount of work he gets because he's expecting to get paid a fair price for his services. Unfortunately, this is far from the truth. Do you believe in fate, Dr. Neo?
Dr. Neo: No.
Dr. Moore: Why not?
Dr. Neo: 'Cause I don't like the idea that I'm not in control of my life.
Moore: I know exactly what you mean. Let me tell you why you're here. You're here because you know something. What you know, you can't explain. But you feel it. You felt it your entire life. That there's something wrong with the world. You don't know what it is, but it's there and you want to use your knowledge to help make people's lives better. But there is something in your way, holding you back. Like a fallen tree across the road -- blocking your path. It is this that has brought you to me. Do you know what I'm talking about?
Dr. Neo: The Medical-Industrial Complex?
Dr. Moore: Do you want to know what it is?
(Dr. Neo nods his head.)
Dr. Moore: The Medical-Industrial Complex is everywhere, it is all around us. Even now, in this very room. You can see it when you look out your office window, or when you turn on your television. You can feel it when you go to work, or when you go to church or when you pay your taxes. It is the world that has been pulled over your eyes to blind you from the truth.
Dr. Neo: What truth?
Dr. Moore: That you are a slave, Dr. Neo. Like every other medical graduate, you were matriculated into indentured servitude, trained inside a prison that you cannot smell, taste, or touch. A prison for your medical career. (long pause, sighs) Unfortunately, no one can be told what the Medical-Industrial Complex is. You have to see it for yourself. This is your last chance. After this, there is no turning back.
(In his left hand, Dr. Moore shows a blue pill.)
Dr. Moore: You take the blue pill and the story ends. You wake up in your on-call bed and believe whatever you want to believe. (a red pill is shown in his other hand) You take the red pill and I will show you a way out. (Long pause; Dr. Neo begins to reach for the red pill) Remember -- all I am offering is the truth, nothing more.
(Dr. Neo takes the red pill and swallows it with a glass of water)

----------------

What happens after you swallow the red pill? You may start posting messages like this one:

I work in an oppressive corporate IPA environment- I am nothing but a worker bee. I spend more time in paper work than patient care. I gotta go!

I am developing my sea legs- gathering information with the hope that I too can be an IMP.

Currently, I have panel size of about 4000 (yes, you read that correctly). I cannot imaging doing "today's work today" - I go crazy everyday w/ an already full schedule and patients wanting and demanding to be seen ASAP. Most of my work is "in the future". When I read Gordon Moore's reply "huge pent up demand that has been consistently shoved to the future and very limited capacity "today," hence poor access.", it struck a cord.

I never wanted to be in the situation I am now, overwhelmed by the demands of patients. I feel as a child who had the experience of accidentally going underwater, not knowing how to swim. Subsequently, being near water is frightening. Not being able to accomodate patients is very scary.

Otherwise, I think I can do an IMP.

Yes, Dr. Neo. You can.

A Practice Update

Well, I had meant to post something on my practice's 3rd year anniversary (Feb 14th) but . . . better late than never.

I recently got mentioned in various media sources: a WSJ article on micropractices, a podcast on the CAFP website. (Perhaps that's why you're here?) So this is an indication to me that word about Micropractices and Practice Redesign is continuing to spread.

Brief background: approximately 3 years ago I left my position as a staff physician in a managed care organization (Kaiser) and opened a solo family medicine office a la the Gordon Moore hi-tech, low overhead model AKA the micropractice model. For the record, I still think Kaiser is a fine organization with many excellent physicians and employees working there. In fact, we still have Kaiser as the health insurance for our own family. But like any large organization, there is a lot of bureaucracy and inconstraints that I found wasn't well suited to the kind of practice I wanted to have. I think Kaiser could benefit from trying a satellite version of a micropractice model.

As I've pointed out last year (and which is still true), my practice is atypical of most solo practices (even for a micropractice) so this should not dissuade anyone who might be thinking of going solo. Most of the solo physicians that I know of who are trying this model generate a much higher income than me. I am fortunate to have a spouse (Hi, honey!) who has a sufficient income so that I can continue to grow my practice slowly. Here are my current statistics (previous years' numbers in parentheses):
Unique patients seen since practice opened: 719 (523) (201)
Total patient visits: 901 in 2006 (805 in 2005) (265 in 2004)
Average # visits per week: 17.33 (15.48) (5.76)
M:F ratio: 49.8% male, 50.2% female
Average age: 37.8 years old
Oldest patient: 97 years old
Youngest patient: 2 months old
Sources of patients: Word of mouth 31%; Relatives of current patients 23%; Insurance provider list 20%; Paid advertisements 6%.
Payor mix: PPO insurance 79%, Cash 13%, Medicare 4%, HMO 0%
Average charge per visit: $128.48 ($133.73) ($114.27)
Average payment per visit: $83.88 ($74.31) ($70.06)
Total charges: $115,760 ($112,400) ($40,785)
Total collections: $67,105 ($54,976) ($17,515)

Bottom line, my practice is still continuing to grow slowly but steadily. I have intentionally closed my practice to new patients at various times during the year in order to control my practice's rate of growth. Currently I have been closed to new patients since the beginning of the year, but will probably open up again next month.

Medical practices have a life cycle, too. As another solo doctor has observed, "I do remember this major all-consuming time of figuring out how to open the practice, followed by the major all-consuming job of figuring out how to bill, make appointments, get efficient, feed the family, survive. Now, it's just figuring out how to keep up efficiently with the health needs of over 1000 people." I am at that "get more efficient" stage.

I still rarely get phone calls in the middle of the night, much to the continued relief of myself and my family. I also rarely make housecalls, mainly because no one is asking for them. I am able to take vacation, thanks to local family medicine colleagues who cover for me.

Speaking of traveling, I am currently attending the California Academy of Family Physicians Annual Scientific Assembly in San Francisco and will be one of 3 speakers at a seminar titled: "The New Family Medicine Practice: New Models to Consider". The other speakers will be talking about their concierge medicine practice and insurance-free (AKA cash-only) practice.

The biggest change in my practice in the past year is that I've engaged the services of a part-time biller to take over my billing duties. She is much more efficient at it than me, plus she has the time and tenacity to wait on hold with health plan agents trying to find out why a particular claim didn't get paid. She has also been helping me catch up on previously unpaid patient bills that I hadn't gotten around to mailing out. Hopefully this will make a big difference in my bottom line.

Tony Tarchichi left a comment asking:

"I'm a med student who's very interested in this type of practice. One question that I keep coming up against in all my reading of micropractices is how do all of them make less money than regular practices. What I mean is everyone physician who I've read about in these practices says that they make less than they used to in a traditional practice. Can you explain why this is happening and is a micropractice a reasonable choice for someone who wants to raise a family, pay off student debt & save for retirement. Ideally I'd like to make around 150K but I'm not sure if that could happen in a micropractice. I'm not putting down micropractices by any means, I'm really just looking for information. Thanks for any help you can offer."

Although my practice is essentially a part-time practice right now, it is possible to extrapolate what a comparable full-time micropractice income might be. Based on the following assumptions:
1. Patient panel size = 1000
2. Average daily visits = 0.75% of patient panel size
3. Average payment per visit = $84.00
4. Work schedule = 5 days/week, 48 weeks per year (assuming 4 weeks of vacation)

Avg daily visits = 0.0075 x 1000 = 7.5 visits/day which translates to 37.5 visits/week or 1800 visits/year.
1800 visits/year x $84 per visit = $151,000/year of gross income.
My annual expenses run about $50,000 so that works out to $101,000 of net annual income, if I had a patient panel of about 1000 patients, which I am working towards.

A patient panel of 1500 with the same numbers = 11.25 visits/day and an annual gross income of $226,800.

Compare this to a more traditional schedule in which a patient is seen every 15 minutes:
1. Average daily visits = 24
2. Patient panel size = 3200
Assuming the same reimbursement rate of $84 per visit, and same work schedule, you would have a gross annual income of $483,840. Of course, there is probably no way a solo physician could handle all the associated work of seeing so many patients, so your expenses would increase dramatically as you'd have to hire a receptionist/scheduler, medical assistant(s), LVN or RN, and one or more full-time billers unless you didn't take 3rd party insurance. In short, you'd end up with the typical overworked family physician's office.

I've heard figures quoted that say a typical physican's office has an overhead of about 60-70%. So assuming this is true, a family physician could net between $145,000 to 193,000/year working at this pace. I think a graduating resident who is full of energy and idealism could happily work this hard for this kind of salary for a number of years. I know I did. But as one who has been on this same hamster wheel of medicine, there eventually comes a time when you say, I don't want to do this anymore.

That is how I ended up here, poorer but much happier. You can't buy happiness, but you can trade for it.

And one last thing . . . Go Bruins!

What's a Pound of Prevention Really Worth?

As another example of what is wrong with the current US health care system, here is an article from today's New York Times describing how insurance companies would sooner pay for an expensive coronary stent than for a patient to sit down and talk with their healthcare provider about low cost changes in diet and exercise.

"We have made major improvements in prevention," Dr. Gregg W. Stone, the director of cardiovascular research at Columbia University, says. "But it's difficult. It takes frequent visits, a close relationship between a physician and a patient and a very committed patient."

Which is exactly the atmosphere Dr. Agatston's practice tries to create. Nurses there give patients specific cholesterol goals to meet and help them deal with the side effects of the drugs they are taking. A nutritionist, Marie Almon, meets with patients frequently enough to discuss real-life issues like how to stick to a high-fiber Mediterranean diet even on a cruise or a business trip.

There is only one problem with this shining example of a medical practice: it is losing money.

What's a pound of prevention really worth?

To a primary care doctor, it is the difference between vitality and disability, between having happy and healthy patients vs. long medication lists and repeated hospitalizations.

To a patient, it could be the difference between seeing your grandson's wedding vs. not living to see your daughter's 1st day at school. It could be, to quote a well-known commercial slogan, priceless.

But to many insurance companies, it ain't worth squat.

The Other Shoe Finally Dropped

The North Dakota Supreme Court has finally ruled in favor of that state's medical board and said it had the right to revoke the medical license of Dr. George Hsu because of what it considered inappropriate care.

A quick summary of the case (detailed version here):
An anonymous complaint was made to North Dakota Board of Medical Examiners against Dr. George Hsu. After an investigation they determined that there was poor recordkeeping and that he had a bad attitude when brought before the board. A judge recommended that his practice be monitored. Instead, the medical board revoked his medical license. His patients rallied behind him and with their support, Dr. Hsu appealed. After one year of the appeals process, a district judge ruled that Dr. Hsu's license should be reinstated if he agreed to be monitored. The medical board ignored the ruling and revoked his license again, forcing the judge to order them to reinstate his license. The medical board appealed to the state Supreme Court, arguing that it alone has the right to decide not only what is appropriate care but how to discipline doctors. And the state Supreme Court agreed.

This story brings up a lot of troubling questions for me. Should a doctor lose his license because of bad record-keeping without proof of actual harm? Should a doctor lose his license because of a "bad attitude"? If the answer is yes to both of these, then a whole lot of doctors in this country should be losing their licenses soon.

During the course of the appeal to the state Supreme Court, some startling allegations were made against the process by which Dr. Hsu was prosecuted. The initial investigator in the case may have had a significant conflict of interest in the case. From the appellee brief filed with the North Dakota Supreme Court:

The Board has an obligation to appoint investigators who do not have a conflict with the doctor being investigated. The investigator in this case, Doctor Craig Lambrecht, had a conflict with Doctor Hsu. Doctor Lambrecht's mother was denied a position as an occupational health nurse with the North Dakota National Guard only after Doctor Hsu complained to General Macdonald that Doctor Lambrecht's mother had been sleeping with the command Sergeant Major. In his August 1, 2005 affidavit, General Macdonald confirmed that the accusations were made and that, in his opinion, "...it was inappropriate for Doctor Craig Lambrecht to investigate Doctor George S. Hsu. (See Appellee's Appendix at pages 22-23). An affidavit from a nurse formerly in the North Dakota National Guard also confirmed that Doctor Hsu made the allegations to General Macdonald and that she informed Rolf Sletten of Doctor Lambrecht's conflict of interest prior to the Board hearings against Doctor Hsu.

Dr. Craig Lambrecht also happened to be the chairman of the North Dakota State Board of Medical Examiners that determined that Dr. Hsu should lose his license. Rolf Sletten is the executive secretary of this same Board.

Besides the clear personal conflict of interest described above, Doctor Lambrecht also had the financial motives as described in Johnson. For instance, Doctor Lambrecht is employed by Medcenter One in Bismarck, North Dakota, an institution that had much to gain if the farmers and ranchers in the Elgin, North Dakota area switched from Doctor Hsu's clinic to Medcenter One's Elgin clinic.

........

As the trial hearing counsel argued, complaints should arise from the public and not from the Board's investigator, but the Board could not rely on the public's help in this case as Doctor Hsu has never even had a medical malpractice suit brought against him at any time during his career and has, in fact, enjoyed wide community support during the entirety of these proceedings. (August 17-18, 2004 hearing transcript at page 677 and Appellant's Appendix at page 21).

Doctor Lambrecht's conflicts with Doctor Hsu violated Doctor Hsu's right to due process as protected under the United States and North Dakota Constitutions. N.D.C.C. Art. 1, §9. "A license to practice medicine is a property right deserving constitutional protection, including due process."

As I have said before, I don't know Dr. George Hsu. I've never met him, although he did leave a comment to one of my entries about him. But when there is a shortage of good primary care doctors, you don't start taking medical licenses away because of bad recordkeeping. And in the interest of justice, you shouldn't have anyone investigating or judging him who might hold a grudge against him. I haven't heard it brought up, but I have wondered if Dr. Hsu's ethnicity had anything to do with him getting singled out.

Medical boards serve a purpose. But like the Spanish Inquisition, having the combined power of investigator, judge and jury at the same time seems like a little too much power to me. And you know what they say about absolute power.

Does a medical board alone have the power to decide what is appropriate care/conduct and what the sanction should be? If the medical board decides that a sloppy appearance is unprofessional and worthy of license forfeiture, is that their unquestionable right? What if they decide that pregnancy termination or withdrawal of life support is malpractice? Dating a former patient? Cheating on a spouse? Voting Libertarian? Belonging to the Church of the Flying Spaghetti Monster? Where does one draw the line? Is there a line?

The reason why this story concerns me so much is because, as a fellow family physician, "there but for the grace of God, go I." If something like this can happen to him, it could happen to me or any other physician. Nobody is safe.

Best of luck to you, Dr. Hsu.