Home Forums Discussions General Discussion A sinking ship....

It is no surprise that primary care medicine,as traditionally practiced, is on life support. I am a solo practice Internist in a rural setting, with a local hospital that has employed everyone else. What are the rest of you in this same situation doing to lower the water level in the boat? Looking for discussion and creative ideas. I don't like what I see on the horizon. I do not want to sell out and become employed. 28 years in practice and holding on.

Tom,

For the first time, we had clients leave AC last year, and the two main drivers were selling to the hospital, or retiring.

We have also seen more Physicians go non-par or even stop taking Govertment payer programs.

Several practices are getting off the Meaningless Use bus, they have just become too burdensome to jsutify compliance.

Everyone's situations is different, but Physicians and Providers are increasingly changing tack and lightening ship. (To stay with the nautical theme)

Some practices are changing their offerings/payers, some are offering services outside of what payers cover. Several have found that once you aren't taking government money, your population changes to more compliant patients, and you have the freedom to be more flexible in what payments you take, and their structure.

We end up talking about this at every Meetup we have, so you are welcome to facilitate the subject when we get together in Laramie this summer.

The TL;DR is that Physicians and Providers continued to get pushed further into the corner, and they are smart people being badgered by mid-wits. Push them hard enough, long enough, and they begin to find ways out of the corner.

Bye Bye Miss American Pie
Drove my Chevy to the levee but the levee was dry
Them good ol boys were drinking whiskey and rye
Singing this will be the day that I die.

Thank you Leslie. I kind of expected you to comment. We are maybe a little alike re: our love for the local dictatorship hospital. May have to open the "Mom & Pop Doc Shop with my wife, Cindy. Cash only, little to no overhead, (or just massively reduced) and no employees. Might have to go the route of the 88 yo southern Doctor who was making "parking lot" visits in his Camry.

Thanks for the response Indy. There are times, at the end of the day, when I serenade by lovely bride(of 37 years) with the lyrics of the "big green tractor" song.

She had on a new dress and she curled her hair
She was looking too good not to go somewhere
Said "what you want to do, baby, I don't care
We can go to the show, we can stay right here"

And I can take you for a ride on my big green tractor
We can go slow or make it go faster
Down through the woods and out to the pasture
'Long as I'm with you it really don't matter



Read more: Jason Aldean - Big Green Tractor Lyrics | MetroLyrics

Another holdout, in NW Oregon.
There are 8 of us, mostly in individual practices -- everyone else is a hospital employee.
The ranks are thinning, however, and there are likely to be further defections to the hospital, and soon a spate of retirements.

We soldier on, but getting us together is herding cats, and reimbursement is problematic.

I don't see any hope for a "cash only" practice. Obamacare is supposed to make not having insurance "illegal" -- and very few people are going to pay for medical care outside of their insurance plans.

Up here in the NW corner of CT there are a few of us Solo private practice primary care types and we make up the majority(for now), just to our north the hospital system is trying to gobble up the market but that is Mass so probably will leave us alone for a while. Got to take the Nancy Reagan approach...just say NO!

Thanks, Tom and Koby. It is nice to know that there are still some hold outs.

It may be the blustery winds of Montana but I am of the opinion in 22 years of practice this is the best it has ever been.
I have decided to take an approach not unlike the world re-known paleontologist Jack Horner. All he wanted was a hammer to bust up the fossilized egg to enhance his understanding. He was continually being told no until he dug his own eggs, and took the hammer to work to revolutionize the theory of nesting dinosaurs being warm blooded. Now six books later, his TRex soon to be displayed at the Smithsonian & a new one in Bozeman, and third Jurassic movie (Jack being the dinosaur expert for Spielberg) to be released he has made his mark.
The fossilized egg is a bit like the exam room at the point of care. I decided to take the hammer to MU & PQRS and figure out ways to make the EHR work better for what I need. I think I have. But I have had to change my concept of what the EHR can do.

That a way Jimmie, don't rely on the Borg to think for you or solve your problems.

Well, Jimmie, I am glad that things are going well for you, and in fact better than ever. I am not on the PQRS or MU band wagon. But I am definitely making less than I did years ago. I place a high value on my autonomy. But, I don't like declining salary in my presumed peak earning years.

Thank you Tom & Koby,
I should clarify. Since being unencumbered, with the unnecessary and extra steps of MU & PQRS (as I see it) has given me a sense of freedom to focus on the patient in a way I have never been able to especially with the positive aspects the EHR can bring to the patient encounter.
I realize this approach may not work for others, but for me I cannot imagine doing without the EHR.
This approach does come with penalties and no incentives, but for me the freedom is worth it.

"Never get out of the boat..
Absolutely, God-Damn right.
Not unless you're getting all the way out.
Kurtz got out of the boat. He split from the whole f***ing program."

******************* Martin Sheen as Capt. Willard in Apocalypse Now

I's 82 degrees right now, and I sit on the porch overlooking the jungle and the Philippine Sea. Tomorrow I get to go back to a job I am really enjoying.

I'm never getting back on that boat again.

Well, we can't all go to the Philippines or the Andaman Sea, or wherever you are now.
But I'm glad you're happy there. It sure beats Fairbanks! My sister lives there, has retired from the hospital, and more recently the health department. She loves the place. It horrifies me.

I am taking my cue from Gary Snyder ?Find your place on the planet. Dig in, and take responsibility from there.? I wound up in Astoria, it's the best place I have ever lived, and at 72, I'm not going anywhere else.

MU and PQRS and all the rest are just ways for the administrative class to lord it over the functional class -- but as long as they can find compliant functionaries, they win.
I hope doctors wake up pretty soon -- but I'm not holding my breath.

I will stay in my little refuge of a mid-20th century practice until I fall over. I'm not making any income right now, but I am paying my expenses and living off the good days of yore.

I don't honestly think any doctor coming out of training program now could do what I do.

When you have $2500-$10,000 deductibles, you don't really have insurance. It's only catastrophic coverage. If your lucky you have a MSA, and it makes it easier to document the deductible items, and makes them pre-tax.

The concept of high deductible health "insurance" works in favor of the hospitals primarily, but I think it probably won't effect the cash (credit card) practices.

it affects it in one way at least. When you have an uninsured patient, you may charge them your full fee or you may set a conditions whereby they get a discount (like payment in full at time of visit) but you still set the fee. With the deductible plans, its a covered service and you can only bill the patient based on the insurance company's fee schedule. So, if for a particular visit for an uninsured patient, your standard fee is $120 but the insurance company's reimbursement is $65, you can actually charge that patient $90 (still a discount from a fare-market-value fee which is what your fee schedule should be based on) provided they pay in full at the time of service. They pay $120 if they want a payment plan.

Well, I am going to keep bailing water, see more patients, do more procedures and live in the river de nile.