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Anyone seriously thinking about ways of changing this mess we call primary care? I am just mentally and physically preparing myself for the explosion and wanted to guage what people were thinking or doing. Concierge medicine? Going into administration? Academics? Cosmetics?

's'
I am in an area with a heavy concentration of managed care, (80% of my practice). I have given this some thought over the past 20 years and I am more excited about the future than I have ever been with the possible exception of when I got accepted to medical school. I got involved in doing a few lectures on the EMR for our state Osteopathic medical society and from that I was asked to speak to the Freshman class at Western University of Health Sciences in Pomona, Ca.

In the process of all this I came to see the database generated by the EMR as a tool for the practice of medicine. I believe that the use of the database as tool for the practice of medicine allows sweeping changes in how we practice, and the possession of the database means we have a tool for the negotiation of payment based on our OUTCOMES. (See my earlier thread about the "Outcome Oriented Medical Record".)

I may be full of hot air, but I don't think so. I think ultimately we must go to a single payer system or at least a single policy system, (you can't be excluded for pre-existing conditions) and it is inconceivable to me that all physicians will be paid the same. I believe that there are some who simply should NO LONGER be practicing. If you accept that premise, then you must agree that some are also better than average. If we are, and we can prove it, I think we can get paid for it.

The first step remains to be substantially better than average.

Martin
As much as an EMR can, could and should be used to improve thing for both the patient and the doctors, I can not back down from always oppossing a P4P type system. As long as we are treating free thinking, in a free society and free market human animals, way too many of the measured variables are simply outside the scope of the doctors' controls. And as a civil libertarian I would have no other way. You are teachers, advisors, leaders, but you are not big brother. And worse yet, big brother should not expect all of you to do half of their dirty work for them, nor do you have the invassive tools with which to do such.

I know you mean well, it is clear in you passion and well spoken position, but I fear folks like you (not you personally) only help feed into these bastards stance and make it all the harder to fight and resist. P4P is the road to your own bondage as a proffessional. You are the end provider or retail services and the real judge of you quality should be the second party in the relationship, your patients. Only in this insane business do we have 3rd and now even 4th party interlopers skimming all the cream off the top for their greed selves, denying the hardworking, well schooled, 1st party in such a relationship, you doctors, some of that cream that you worked so hard to have access to. Just like in free democratic elections, with very modest regulation, I think the patients know, they know who gives the good care and who is in and out of the room in 7 1/2 minutes. Let us start to freely charge and justify via competition who is the better of the practioners in town and I trust that armed with some good basic information, most patients will get it right.

You can have the factory down the road at 10% less or you can have my solo wife who knows your name, remembers your family members and your issues over here for 10% more. It's your call. In such a real free choice, free market, I think you would see some radical changes back to small personable practices that move at a slower pace and take better care of the patients in their care. But the expectation of a certain level of quality without the real possiblity of return on one's output of that quality is doomed to failure.

It is the medical equivalent of "No Child Left Behind". Instead of practicing medicine as you know you should, you will end up practicing to "the test"; just as all the teachers are doing now in all the school districts around the country. You will do what is measured, not what is proper or correct, or you will do both, what is correct because you know you should and have a conscience, and what is measured so as not to be penalized for doing the right thing, that is wasteful.

There will become a new class of patients who have bounced from doc to doc and practice to practice because they are outlayers and hurt your numbers, be it because they are difficult patients or because they have difficult bodies that are harder to pin down. Now that is truely bullcchitt. How many patients are you willing to dismiss and how quickly just to look good, just to keep your numbers up so you can be properly paid??? This should never even enter the equation and it certainly will in a P4P system. We must resist P4P at all costs. It is bad for patients and it is bad for docs. These two parties in the relationship actually do have a very symbiotic relationhip and so what is good or bad for one almost certainly affects the other likewise.

Let's keep medical choices in the hands of medical proffessionals, not bean counters who just want to make you all a bunch of monkeys chasing your tails. And while we're at, yes please arm docs with go products like AC with graphing and charting of various blood values and the like to empower you all with the best information to make those choices in the best manor possible. Isn't that a whole lot bette way to attach this monster?

But as to SF's real question. Unfortunately I think we are all just kind of riding the wave and making it up as we go along. Some of us have small ideas for a Schtick as Leslie puts it, but for the most part I see the tidal wave wiping most PCP's out...

"WIPE OUT!!!"

Paul you continue to COMPLETELY miss the point. We have let the "bastards" drive the bus for so long, 99% of what we do is what they tell us to do or what is demanded. (You must chart it or you didn't do it,and we don't have to pay; you must chart it or you will be sued and can't defend yourself.)

I am talking about breaking WAY out of the box. A type and style of practice that will have such success that the PATIENTS will vote with there feet, everyone else will be left behind. The insurance will pursue us.

I may have to stop by your place on my way home from Branson, buy you a beer and 'splain this to you until I wear you down! (LOL)

Martin,
As much as I respect you as a friend who cares deeply about his patients and puts them first (always a great thing) by doing thru your PO/IPA via contract terms with the carrier I still feel your intent is wonderful but your execution is all wrong. Everything is great up and until it is part of measures and contract terms with "Those SOB's".

You're the clinician, you call the measures to be measured because as early as tonight while doing some bathroom research (I do some of my best research in there myself...) reading the next issue of whatever peer reviewed journal, a lightbulb goes off in your head (ah ha, that's the ticket!) and you start tracking or approaching things differently. This is why Clinical PhD's, MD's, DO's and other clincial persons are taught how to read and pick apart scientific models and research results. But now we all have to wait for the contract with some carrier via a PO/IPA to expire just to start tracking what we already know what is best? Come on... This is why it is the art and the practice of medicine, science is evolving, growing, changing all the time...

I guess in the end I have no respect for their Kangaroo Court and therefore I refuse to submit to their juristictional rule here. I, we, you are not bound by their self serving rules and we should do our damndest to be bound by them, and I see this as the next step in this loss of control, downward spiral. Using the power of the database as you the clinical person at the helm of the wheel see's fit I have no problem with, that is great, and we should all work together to the goal, but putting in writing, legally binding contract terms, written and forced upon us no less, by their cartel lawyers, in some no idiot left behind fashion I will never go for.

Inside our own offices for you clincal folks and us managment folks to use as great tool, YES! Go for it! But, Inside a contract to be measured and used against doctors and patients NO.... no less each and every measure becomes a chart review for the carriers including the gov't to use against each and everyone of you in the future. That is basically the position of the NYS Medial society, although they don't see the connection between CCHITT, P4P, and regular chart reviews, requests for more information that they are warning us all about... But I keep trying to teach them and assist them in connecting those dots that are so obviously linked.... You can lead a horse to water but... Hey isn't that just like those darn free willed patients??? Just can't make them stop eating garbage, or get them to exersice more, stop smoking or drinking in excess...

Internal Yes, external NO, Now how's that? Get the difference?
You are a great well intentioned man I'm sure, but I also know that the road to hell was paved with such intentions... Have a great weekend...

Paul

I really do believe we are on the threshold of a time of monumental change in health care in America. But not everyone will change. Paul, you and I will definitely not resolve this without a pitcher or two of beer! I look forward to meeting you someday.

I didn't have time to read all of the above. But, the only way to resolve this (and we never will because doctors just aren't business people, period) is to say the hell with antitrust laws and go on strike against these payors. For instance, if all PCPs in Maine stopped treating Mainecare until the government sat down and negotiated a fair price, the system would come to a grinding halt. I laugh at the thought of quickly the ED would collapse under the weight of all of the Medicaid patients showing up for diaper rashes and ear infections and eczema.

HockeyRef "resistance is futile...you will be assimilated!" The question still remains how much do you want to influence your "assimilation." Welcome to The Borg!!

Martin and George,

A "well said" to both of you. I only wish you could see the smile on my face. Thank you both.

And George as part of my rants about these kinds of things, have you seen my quotes of Jean Luke before??? "The line in the sand must be drawn here!"

Personally I'm just like him, I'm tired of falling back and retreating without a real end game plan of victory in sight. It's one thing to retreat because you have to lick your wounds and re-group. It's another thing to pull back because you actually have a strategy in mind, a plan that might require you to pull back so as to better pull it off, or such retreat is actually part of the larger plan. Heck I can ever tollerate "he who fights and runs away, lives to fight another day", but that does not seem to be the case here in the business of medicine on the provider side of the field.

But what I just can't stand, I just can't swallow is to just keep falling back, because you are simply on your heels all the time and have nothing else to do but to try and minimize your losses, that I just can't stomach.

"The line in the sand must be drawn here!"

Bert,
In theory I agree with your plan to go on strike. But in reality, even then we have no leverage. Insurance companies will simply bypass us completely (as they are already doing) and have their nurses manage our patients over the phone! Or, more and more Wal-Mart clinics will pop up. There will always be those physician extenders (no offense to anyone intended for I was once one also) who will be willing to do the work we are doing now and the states will continue to grant them the legal tools to do so. Medicine, particularly primary care, is already becoming a "job Americans will not do" and I think that would increase dramatically if we "go on strike". Personally, I am a pessimist. I see no way of regaining our stronghold. Everything in this country (the world) is changing. You can't even get a decent pizza anymore. (I know, I know, I've only had it once since the stents!!)

Leslie

"Solidarity forever, solidarity forever, solidarity forever, our union keeps us strong!"

You're correct. I am just thinking of Mainecare. That would be unbelievable if all of us just stopped seeing them.

Paul,

I remember that article you sent me a few months back about that misguided DOJ guy who shut down the idea of an OB/GYN FP union (I think). And, he had the nerve to say in his findings that he was protecting America against the rich doctors again. What a dumbass. And, it isn't that he's a jerk (although he is); he simply doesn't know.

Paul,
I have been practicing medicine in Springfield Missouri for over thirty years. The first half in emergency/trauma and the last half in family practice - most of the last half in an independent 125 physician clinic. I left shortly after we were purchased by a local hospital.
For the last few five years I have practiced medicine in an on site clinic. There is no insurance involved. I am paid a set amount and the practice is "turn key". My patients and their dependents have unlimited office visits at no cost to them.
Insurance companies do not, as a rule have an interest in prevention, but the guys who really pay the bills (the employers) do.
I am told that over a third of the self insured companies on the eastern seaboard have on site clinics.
I am convinced that this is a model that could also transer to the indigent, but it will have to be proven in the private sector first.
This is the most enjoyable practice I have ever had (although I have always been happy with my medical practice). I share Martin's enthusiasm. Why don't you come to Branson next month and Bert, Brian, Martin, Leslie and I will all buy you a beer.
Best,
Jim

Jim, your post is like a flicker of light as seen from the depths of a mine shaft. I have to admit I was filled with some doubt as I sat here trying to frame my argument in a manner to convince Paul or Leslie that there is real hope. I know I sound like some fool, "If you build it they will come". But I am firmly convinced that we are at the threshold of a new age in medicine. We have (most of us our entire careers) been skewed by the insurance into what is right, what is real, what is ALLOWED. But along comes Jim and he finds that he can do ANYTHING, if it WORKS. His job depends on it being cost effective, but his employment situation is willing to listen to any evidenced based best practice that can be applied to the problems at hand.

I will tell you one more.

Glen Lopez, M.D. spent the day with me yesterday to shadow me as I saw patients with AC. Actually he worked as the 'scribe' for a couple of patients so he could take AC for a 'test drive'. He is a clinical Prof at UCLA and is involved in Diabetic Outreach in the Latino community. He has shown me a model practice that is entirely cash based, and I believe he will be fabulously successful with it. I believe he will make a comfortable living and be practicing true, evidence based medicine in a consumer driven model, (what the patient wants, not what the insurance is willing to pay or the hours and location the Dr. is willing to work). He will be bringing needed health care to uninsured patients and he will have a real positive impact on a large number of people. Who among us would not be happy to lay our head down at night knowing that we had done what our oath was framed around and knowing that P4P or "allowed" or "usual and customary" was LOCKED OUTSIDE the door to office?

Paul, Leslie I swear there is change coming, it won't all be bad, don't miss the train.

Jim thank you for your post. What happens when the patient's need is beyond the scope of your practice? If they need gallbladder surgery, hospital stay etc?

Each company is affiliated with a PPO or, in some cases, an insurance company. My job is to provide acute care and preventive care. I practice the same as I have my entire career; the difference is that the preventive portion is encouraged and appreciated.
I have the option of referring within or out of network.
This is done by consultation with the patient. This part is the same as with any other practice; the difference is that I do not bill anyone and I am not controlled by an insurance company. When my friends take over for me when I go on vacation or CME they comment that "this is the way that medicine should be practiced". I agree.

(smiling broadly)

As much as I hope to the high heavens you guys may be onto something here, I feel that like many other cash only set-ups opportunities like these are few and far between. And worse yet, with the major drags on the economy especially in terms of primary care, most people will bitch and moan and continue to go to the big factory practice down the road who still take their crumby insurance. Heck we live on half of what those bastards get because we refuse to pump 30-35 patients thru a day, and we just had a big family, six kids and parents sign out because they didn't get their f'ing referal for a life long, no rush condition taken care of "fast enough". Well if we were a factory who made you wait an hour in our waiting room we could afford a separate "referal person". I hate the position. An entire paid staff member created by nothing more than this monster of managed care, and they don't pay ya even a dime better for all that paperwork and managment. Allow them to access my office on equal terms and we would all "opt-out" in a heartbeat.

Anyway, I was going thru some old emails today and found something Al had sent me a while back. Why neither of us posted it back then I don't know, but it sure does fit this topic pretty well. Enjoy the articles (not!)

Paul

http://www.usnews.com/articles/business/best-careers/2007/12/19/the-most-overrated-careers.html

http://www.usnews.com/articles/business/best-careers/2007/12/19/overrated-career-physician.htm

Paul,
The answer has to be physician run.
No one is going to do it for us.
Primary Care physicians are in a unique position to take advantage of the opportunity to reduce health care costs through prevention. It is a win/win situation. Companies get to reduce their health care costs, patients stay healthier and we get to practice medicine without an insurance company telling us how to do it (or how not to do it).
Any chance you can come to Branson?
Jim

I gotta hand it to you Paul, from what I've been seeing with Vicky that "Overrated" thing is very very true for primary care medicine right now. She's told me many times that if she was picking a career and knew in advance what the medical career was going to be like, she would not do it.

It isn't just the cost savings of prevention. The EMR gives the Primary care Dr. the chance to become the really effective "Medical Accountant" who can gather the most complete set of records in one place, (The "Medical Home") and coordinate the care so you don't have the Neurologist repeating the MRI that was done in the ER and the Neurosurgeon getting a third MRI because the first was too old now and the second was "not available". Same with Labs etc,

Guys,

Looks doubtful. We still need to rustle up a few more bucks just to purchase a billing system and pay a consultant to assist us in taking it back in house. Then there is the issue of these expensive accommidations, airfare, meals out, possibly car rental just to get from airport to hotel and back again (no less go out in the afternoon, evenings), if we have to bring the kids this all goes double plus childcare for the meetings at least. We're a starving FP's office on the verge of going under, we are financing the corporate salaries and profits of these mega cartels. Care to pass around the hat???

I'm going to try and con my mom to come to Syracuse and send a few days with her grandkids so perhaps we could come alone, just the two of us, and at least half our expenses, no less have an evening or two alone as adults with and without our friends we are hooking up.

I love the concept of Jim's clinic, but it sort implies a new corporate master. Is each PCP supposed to have a separate contract with a separate large employeer group? What about small and medium sized businesses like even ourselves?

I just had a great idea that will never see the light of day. Nationalize only the major medical, hospitalization side of medicine, final reign in drug prices, babysit and watch to make sure employeer return most but not quite all of their new found savings to their employees who for years got garbage health insurance instead of increased wages and allow basic office visit care, like PCP's to return to a totally free market, participation is anti-trust, colluding with the insurance companies against those who would care to remain in a free market stance, and privately contract directly with the actual end consumer of our services, the patient, No insurance claims allowed for basic primary care!

"Dream with me, dream for years, dream for the laughter, dream for the tears....Dream on with me, just for today, maybe tomorrow the god lord 'll take you waaaaayyyy"

"Dream on, Dream on, dream until your dreams come true...."

Wayne, tell Vicky she has much company. There is no way on God's green earth I would EVER do medicine again. I count down the hours until I can finish with my last Mainecare patient that I will be reimbursed 1/3 of my charges so I can go do what I love: play with computers and my applications. I would do computers in a heartbeat. Last time I checked, my IT guy charged me $150 to set up three Virtual Machines in a complex way, and I actually had to pay him the entire amount. Imagine that.

Paul thanks for the Aeorsmith.

Paul, I had this idea but haven't had the time to follow up on it. There are so many employers in NYC, or even the self-employed, that might want some type of contracted primary care with a personal physician. They could get their basic primary care needs met. There is still the problem of Rxs though. And specialist care. Here, we often send our uninsured to Bellevue Hospital if they need specialist care. Or some private physicians that can afford a "sliding scale" based on ability to pay.

I dont mean as an onsite physician. Rather, you set up a contracted fee schedule for basic services for that businesses employees. But I am completely in the dark as to the legal ramifications of trying this.

Wayne,
Yes it would be fraught with "legal pitfalls" in terms of your 3rd party contracts. I need to go cry over our personal business finances as I try to figure out how to get blood out of a stone to make ends meet around here. Let me think about this while properly wearing my paraniod practice manager's hat and I'll get back to ya soon.

Ya see the issue is to have insurance coverage for the real issues. If and when you need to have procedures, expensive specialist care, or hospitalization. Perhaps drug coverage too. Again I'm just amazed at the idea that the gov't regulates our rates to high hell, while they do not a thing to regulate Big Pharma and all the major vendors (other than DME) that docs and hospitals all have to purchase goods and services from. We need to finally properly regulate things like big pharma.

Hell, half the stuff they have patented, really were not their own idea anyway. We the tax payers pay for most of the basic research that they then ride the coattails of to design a slightly different version of, to then copyright and over charge us all on for years. We are the only country in the world that doesn't regulate drug prices. So we Americans are paying even more to help pay for all of these drugs to be produced for the rest of the world. I'd love to see their books so as to actually see things like how much the make or lose in Canada and Europe, what small percentage of total profits get re-invested into R&D. I hear it may actually be as little as 10%. Sure they pump tons of mony into it, but as a percentage of profits it is still a drop in the bucket. Their arguement doesn't really hold water.

But, if we all had real jobs, that pay real wages, and coverage to insure against the big, wipe you out kind of stuff, while basic office visits and the like were paid in full at time of service (that's my: PIFATOS) then the average doc could charge reasonable fees, see a reasonable number of patients and for the most part all would be right with the world again. But as long as we off-shore and falsely bring in way too many visa engineers to keep good educated Americans under and unemployed none of us can afford the cost of most goods and services at a proper rate that is in balance to our economy.

As much as I am a Jew (by culture mostly) who hates Henry Ford for his facist affiliations, and almost explicit support of the Nazi's his basic premise of the idea that his workers, and all workers needed to be able to afford to buy his car, and so we all only really thrive with a healthy successful middle class is as true today as it was almost a hundred years ago. Most of our economy and it's JOBS come from small business and yet the politicos continue to kiss the @$$ of the largest off-shore, pretend to be US based Multi-nationals is just insane. When everyone has McJobs and McBenefits then all of us small and medium, US based, make most of the jobs, hold up most of the economy businesses suffer. And so as we go, so goes the rest of the nation.

Until we have at total change in nation and international economic as well as geo-political policy, unlike anything coming out of either side we have now, we will continue to spiral downward on a free fall to the bottom. And seeing how much our business has been taken over by those who don't have neither the patients' or the doctors' best interests at heart and have been picked over faster and more than other industreis, we are sort of the Canaries in the mine. Others are close behind....

Lastly, in terms on not going into medicine again, there was a great piece of research and then article published about this a year or two ago. It was sponsored by one of the largest head hunting companies. It clearly showed that 2/3's, yeas 2/3's of all primaries wouldn't do it again, being equally split between not going into medicine at all and going into a well paid, well respected specialty. Very sad indeed. I will try and find the link as it was published in like the AMA newspaper or something similar, maybe AAFP. It'll find it and post it here soon....

Paul

Paul,
I agree with you about the insurance industry being a legalized cartel. That is why a self insured company is best positioned to take advantage of preventive medicine. They are the only ones who truly value a primary care physician because they realize that mortality and costs go down when we are involved.
It sounds to me like you could use a little positive energy. Why not join us in Branson for a couple of days and let Martin and me buy you a beer or two?
Best,
Jim

Paul --

In recent days, I note that you have been offered over a case of beer by various posters, if you add them all together.

If you come to Branson, please bring a designated driver!

I will offer Paul a case of the finest beer if he can write a post that is under 10 MB. And it has to be something passionate to him. J/K Paul.

Gads,
Let's hope if Paul does come to Branson he is not one of those "talky" kinds of drunks...you guys will have him so plowed we'll just have to take him over to Jim Stafford's and leave him.

Love ya, Paul!!

Leslie

Actually Nancy is the bigger Beer drinker between the two of us, I like medium ambers though like Sam, Catamount Amber and the like. Don't worry I am a cheap date, I get buzzed pretty darn easy. But isn't that why hopefully we are all staying in one place, so we can get toasted and roasted and not worry about such things. Now get me or Nancy going and watch out, yeah I've gotta big mouth... "Help I'm talking and I can't shut up!"

But as of right now we really are just about totally broke, I just barely paid the bills this month and I still have to figure out how I'm gonna tap dance some more for the practice no less. One does not need a tax write off on negative income... This is sad. Pass the hat around boys...

"In loving Memory of Village Medical of CNY" The suckers actually thought the primary care paid a living....