Home Forums Discussions General Discussion Flying Without a Net....

Well Gang,
Nancy just about totally freaked out last night over the present state of primary care medicine and how it is ruining our practice and our lives. It was a weird night to say the least and I will be a gentleman and not go into the details here in public...

But she has closed the practice for the next two days at least and she is insistant that we ditch each and every insurance product right now. Cash only, you the patients have to finally pay me for my time no matter what it is I do for you. No more tons of uncompensated busy work from families, patients or carriers. All cash and totally IMP.

Now if this should work, it would be totally awesome, but I'm nervous as all hell that most working folks in today's economy are not going to get it and are not going to be willing to pony up when they have traditional coverage. They will bitch and moan about the hour wait and the 7 minute visit at the factory practice down the road, but how many of them are actually going to put their money where their mouth is? And at about $.50 a piece just to notify over a thousand patients via mail about what we are doing here, that is a little over $500 right there just to inform them properly via the mail, no less the effort to do such. And all to probably loose at least 50-80% of them.....

I am scared CCHITless here and I'm not sure I totally agree with this plan, even though I agree in spirit. Originally I was going to slowly widdle away our worse payors and see how that went before we did the dirty deed by totally dropping our two or three biggest payors. The local CARTEL Excellus BC/BS that controls over 60% of our market and is easily 33-50% of our weekly income, and then Fidelis our one decent and half ethical S-CHIPS carrier that is run by catholic charities and then Medicare.

And the BC just like Medicare has a two year scortched earth policy of not allowing one to return to the fold if they want to come back, so when we leave, we are really leaving for good, no turning back. So between the two of them that is probably like 2/3's to 3/4's of our weekly, monthly income right there. Now I need to find a way to sell this so we retain a few decent patients and can gather up some new ones. Time to get rocking with the Media here I think.....

Now if this should work it would certainly be wonderful and I will do my personal best to help it succeed, but I am really freaked out and scared about this cliff we are about to step off of together... Wish us luck here, we're gonna need it...

"Pennies for the poor, please???"

Paul

Good luck! You can do this! I am not taking any insurance office visits are $45 and so far from day one of a new practice I have been operating at about 60% of my expected patient volume. Brian Forrest In Apex NC with AccessHealth is a great resource and has writen numerous articles. He can also tell you of others who have done the same who have figured out some creative ways. Mind you there are bumps, for me they are related to me being an FNP. Just today I am arguing with the local hospital to put me as the ordering provider not my supervising that has insurance contracts. If I can help with any ? let me know. I have officially been open two months, my best advice is VERy low overhead. For example I have only my receptionist and myself. It is payment on the day of service, as awful as it sounds 2 of the 3 patients I was tranfering via EMS paid prior to leaving without any complaint. The third was more critical and could not. Gotta love rural family medicine! Good luck!

Wow Paul! That is a big jump. I wish you best of luck and totally sympathize with you two about the plight of primary care and the solo doc. Depending on your location, I am sure it (cash practice) can be pulled off but I would encourage you both to take a cooling off period and look at the numbers, the impact on your staff(you will likely need to let some folks go to curb expenses) and yourself as well as your patients and be sure it is the answer. If it is the right choice, it will still be the right choice in 1 week. If it not the right choice, you have burned LOTS of bridges. I don't pretend to know your situation but the way you described the current decision making process, it sounded like there was one of those straws that broke the camels back and that spurred the decision. From your previous posts I get the idea you two have a lot wrapped up in this practice and it deserves careful decision making. Just my 2 cents.

Dave,
Thanks for your thoughts and insights and you are both totally correct and yet off base but that is understandable because as you said we are not that in touch on a daily basis.

One yes it was a straw that broke the camel's back kind of thing. Our personal and family life is out of control and our kids deserve better than this too. But we have been toying with this concept for quite some time now and we even went to the IMP Camp the same weekend as AC in Branson. Couldn't afford to get out there, while IMP was here in our part of town in the next city west, in Rochester NY.

Best second choice conference we have ever had the pleasure of getting bumped down to. I think I am just about totally OK now with missing Branson because IMP was so eye opening in so many ways in terms of learning things, the good and the dirty about this business we are all in. I can not stress enough that next years AC and IMP must be co-scheduled so as to not conflict, be too close together even, so the many users and members who really are both can have an opportunity to attend and learn from both.... Should we have the funds and the time, that is my goal and plan and it should be just about every other solo, small practice PCP's goal who uses AC as well.

But yes I'm not sure that this is one of the best areas for a cash only IMP. As much as there are frustrated patients here, many are of regular means, have traditional by today's standards plan with only in network bennies, and there are a few too many PCP's because there is both a Ped's and FP residency here, so the competition is a bit much for such a crumby paying part of the country. I believe that the greater Syracuse area is what we refer to as a "Dead Zone". It is so toxic that almost nothing can grow here in terms of healthy primary care offices. We shall see. She is hell bent on doing this now, so I guess our fate is in her hands...

Anyway, thanks to one and all for listening. Have a good night.
Paul

Paul,

Talk to Jim Blaine. He has a really nice set-up. This might be a viable option for the two of you.

Leslie

Paul, you can probably do it successfully with good planning. I'd suggest that she not do it suddenly, cold turkey. Plan the transition. You might want to drop some of your plans that don't mean as much to the practice intially, so that you have some maintained cash flow.

Wayne,
That was my original plan that I thought we had agreed to, and all of a sudden she just bugged and insisted on going all the way in one fell swoop (A thousands points to anyone who knows the real origin of that phrase).

I totally agree with her in principle and I feel that the kind of experience we give here really is different and so she and we should be treated and compensated differently. So I started setting up meetings with a few carriers to either dump or get some serious increases and positive terms from, when all hell broke loose. Matter of fact I just had one that finished not more than 10-20 minutes ago. Not sure it went as well as I would have liked, but it wasn't the worse thing in the world either.

But the thing I am stressing is that we offer a totally different kind of experience here, not the double, triple booked kind of visits that after an hour's wait you get 7 1/2 minutes of the doctor's time, half the time with the doctor of the day not your own doc even, perhaps even a mid-level... So aren't my wife's high quality visits worth considerably more???

Totally New Paradym, while almost going back to the future in terms of returning to Marcus Wellbee and the best of HMO care model which puts the primary in the real driver's seat.... But for the increase in quality of care and much better access which will positively effect outcomes, save lives and body parts you need to really pay us in a totally different way and amounts in exchange for these positive things.

One fell swoop -------------- This is one of those phrases that we may have picked up early in our learning of the language and probably worked out its meaning from the context we heard it in, without any clear understanding of what each word meant. Most native English speakers could say what it means but, if we look at it out of context, it doesn't appear to make a great deal of sense. That lack of understanding of the words in the phrase is undoubtedly the reason that this is often misspelled - 'at one fail swoop' (or sometimes, stoop).

So, what's that 'fell'? We use the word in a variety of ways: to chop, as in fell a tree; a moorland or mountain, like those in the northern UK; the past tense of fall, as 'he fell over'. None of those seem to make sense in this phrase and indeed the 'fell' here is none of those. It's an old word, in use by the 13th century, that's now fallen out of use apart from in this phrase and as the common root of the term 'felon'. The Oxford English Dictionary defines fell as meaning 'fierce, savage; cruel, ruthless; dreadful, terrible', which is pretty unambiguous.

Shakespeare either coined the phrase, or gave it circulation, in Macbeth, 1605:

MACDUFF: [on hearing that his family and servants have all been killed]

All my pretty ones?
Did you say all? O hell-kite! All?
What, all my pretty chickens and their dam
At one fell swoop?

The kite referred to is a hunting bird, like the Red Kite, which was common in England in Tudor times and is now making a welcome return after near extinction in the 20th century. The swoop (or stoop as is now said) is the rapid descent made by the bird when capturing prey.

Shakespeare used the imagery of a hunting bird's 'fell swoop' to indicate the ruthless and deadly attack by Macbeth's agents.

In the intervening years we have rather lost the original meaning and use it now to convey suddenness rather than savagery


Isn't the internet great ? I looked on ask.com - like I really knew all this. The internet can even make some of us who are relatively "uncultured" find out stuff.

First off a thousand points for Steve even if you did use ask.com which I too like to use as alernative to google sometimes.

Now the real reason I am posting here is to update this thread on playing hardball with one's carriers. I call one of our carriers that I'm not sure of how regional verses local they are, POMCO. They were paying Nancy just aweful and the lady came in and I totally blew her mind sitting there in jeans and a tee-shirt with about 24 hours on my beard no less. And all while talking all my IMP stuff that I suddenly couldn't find my folder to show the articles to her. Now at least she has come back with an offer of a major increase that is certainly above Medicare and I even got her to offer another concession on the way out the door. We will almost certianly ditch them sometime down the road with all the others, but seeing that they almost never want any prior auths referals or any other garbage they can stay for a while and perhaps we ever gain a few new patients thru them. And in the end their plan is PPO so when we drop them some of their patients will probably stay on accessing their out of network bennies.

But all week we have been attempting to find real signs of life at UHC because of all the carriers out there these guys are the epitemy of evil (can you hear the darth vader breathing when you call them to confirm B&E?). Anyway we keep trying to reach our rep and his supervisor and on both their voicemails, we get the out going message and then immediately get disconnected. I'm hoping that our billing company has a copy of our original contract because so far I can't find one. So we kept trying, Nancy on one phone and me on another, to reach the main office and they absolutely refused to give us a direct number for provider relations! At best they would take a message and someone would get back to us in 7-10 business days! Are they not supposed to have system in place for us to contact them for business issues? So I basically don't care at this point, we are getting out as fast as the contract will let us. They are not that big in our area and if this is their totally corporate policy about how to deal with their provider network they can go to hell! I think that over the next few days I am going to try to get our local medical beat reporter to interview us on this including why we are pulling out...

While on another front I have another carrier who our new provider rep actually understands and wants to work with me to propose totally changing how we work together and get paid for services. I'm not too hopeful that this is going to go very far or be too sucessful but he is a great guy and hey, whats the worse thing that could happen. We could design a new model for how primaries and carriers work together and how primaries get paid, and in doing so embarress the hell out of all the other carriers in the state if not the country... Wishful thinking but hey this is the one half ethical carrier around and it just might happen. We shall see.

Anyway, it is just amazing how much one can get once one frees themselves from the stings and stangle hold these SOB's have over us. I am now negotiating from a position of some amount of strength because they know I'm serious about dropping them, I have the goods on them, my model is much better and has better outcomes than theirs, and they sort of know we have some access to the media to boot... Kiss my @$$ or we're leaving... You should all try it at least once or twice and see what happens. Ya never know you might just be able to shake something loose....

Paul

Wow!

My wife/office manager thinks that is a great idea, "going off the grid" as we call it. She thinks that if you're going to do it you should offer something different like a weekend day or even evening hours so that the service could be more convenient for working patients. (I personally am not ready to do this at this time)

If you investigate going boutique, you might wish to look at selling a block of time (like a lawyer does on contingency) rather than a flat rate. That way you can make it more affordable and possibly avoid the crosshairs of state regulators who could claim you are offering insurance (weak arguments yet being pursued against some practices in Washington State I believe).

Good luck.