Do Over. Part one.

I am opening a new medical practice. Soon. This is the first in a series of posts in which I will explain the whys and hows and what-fors of this new practice. Bear with me, I’m still working on the business plan, but I have decided that the best way to handle it all is by being honest and transparent about the whole process. I’m looking to do something new.

In the summer of 2001 I moved here with Amy, James (who was 3) and Jack (only 2 mos old) for what has been an amazing island journey. No one is going to write a book about it or make it a movie; I’m not Robinson Crusoe. But Defoe’s novel is in some ways an interesting metaphor for living as a physician on Nantucket. Crusoe could barely make out a distant continent on the horizon and, but for Medflight and technology, we’re similarly isolated. And, unlike when we first arrived, there are now cannibals to worry about, for certain. Medicine has changed a lot since 2001. Romneycare. Obamacare. Health maintenance organizations. Pay-for-performance. ACOs, PCMHs, and Meaningful use certification. E&M coding. DRGs. HIPAA.

I started my practice with Sally as my assistant and Annie as receptionist. I had a delivery the weekend before I opened and had 25 patients on my first day. The practice had been Dr. LaRochelle’s, and the hospital had maintained it after his departure with locum tenens physicians (including Dr. Hartmann filling in at times). Back then, I outsourced the process of billing and managed the practice myself. Since then, the practice of medicine has evolved (in futility) in the name of cost control and improved care, and it is more and more difficult to get paid.

Electronic medical records have been installed in the majority of practices. These record systems were conceived to make it easier for physicians to get paid, to meet the difficult requirements for documentation required to justify the levels of complexity tied to reimbursement levels set by Medicare and health insurance company contracts. These inefficient systems, with clicks and checks and bullet points, have made it more difficult for a physician to see as many people per day, even as the pressure to do so is increasing. They make it easy to cut and paste records from visit to visit, patient to patient, which results in errors. (I used to chuckle when I received a consult note from a specialist about Mr. Jones that included, in the examination section, details about his breast and pelvic examination; now I just want to cry.) It’s not a surprise then that recent studies show that these systems are not saving money, as hoped for by policy makers, nor are they improving care, though everyone assumes that if records are digitized and easily communicated amongst healthcare providers, and hospitals, and pharmacies, and consumers, we should be able to provide much better and safer care. But this standard of interoperability has proven to be the Holy Grail so far and, instead, we have a splintered industry of hundreds of software providers, none of who have products that easily communicate with others (nor are they motivated to do this in as much as it is perceived is prohibitively expensive and/or as a threat to market share).

Since that time, healthcare reform has attempted to control and reform the costs and practices of health insurance companies (e.g., mandating certain coverages), to curb the need to use Emergency Rooms for primary or even urgent care, and to stop self-referrals to expensive specialists and use primary care providers as gatekeepers instead. A higher and higher percentage of health insurance products available are Managed Care policies, instead of the traditional fee-for-service policies.

This seems like a smart change. In an attempt to control costs and improve care, Managed Care tries to standardize the delivery of healthcare and ration resources. Consumers are not able to see a dermatologist about a simple Poison Ivy rash without being sent there by the PCP on record who, presumably, will see the patient instead—at a cost of $80 instead of $300—and prescribe the simple, needed treatment. PCPs won’t be able to prescribe the latest and greatest antihypertensive, available in the sample closet thanks to the nice drug rep that bought dinner last night, when hydrochlorothiazide at $4/month will work just as well, without getting the insurer’s permission first and needing to justify the increased expense. A well-meaning back specialist will not be able to order an MRI for uncomplicated low back pain just because a patient is insisting on it, without having the PCP call and ask for pre-authorization.

It is easy to see how these kinds of changes are good and necessary, if we are to control the way healthcare costs are threatening to bankrupt our country. But, to health insurance companies, concerned primarily with profit and dividends and astronomical CEO salaries, Managed Care is a means to cause confusion and preserve margins. If you require pre-authorizations and prior approvals, and you change the rules frequently, more things will get retroactively labeled as uncovered, resulting in consumers having to pay or healthcare entities having to eat the bad debt.

The detriment of all of these changes which are on the surface well-meaning but ultimately meant to save recently-created administrator, legislator or bureaucrat jobs and increase insurance company profit margins, was so apparent in my little practice. I started with Sallie and Annie and me. But I finished with Dr. Koehm as a partner, and the two of us being responsible for (and needing) a Nurse Practitioner, Sally in the front primarily on the phone with insurers getting tests and medications approved, 1.5 receptionists and a computer answering the phone, a full-time manager, two RNs, a medical assistant helping out in the back, a part-time translator, and a large billing staff in Boston that withdrew 11-15% of collections right off the top. (I gave this as a range because I cannot remember the exact number. I think it was 11% of collections and a 3-4% “management fee,” but I could be off by a point or two.) And, in the few months leading up to my departure I saw, on average, the same number of people per day. 25.

It does not take a Harvard MBA to see the problem.

The salary I paid myself in 2001 was $150,000. My salary last year as an MGH employee was $161,000, though my charge, for example, for 9 months of obstetrical care and delivery changed from $2,400 to over $6,000, and my charge for a medium complex office visit changed from ~$60 to ~$180. Over the 11 years, employee salaries increased in a manner more consistent with everyone else’s. In fact, in the new MGH practice, the employees were now mostly in a union, with contracted pay increases and a very generous benefits package. (This is a good thing, in my opinion, but it further explains the recent, difficult evolution of small medical practices.)

So, if my salary was relatively static, but the overhead increased as described above, and the number of appointment slots stayed the same, what had to give to keep the doors open? I’ll tell you what: my efficiency, my compassion, my abilities, and my sanity. That’s what.

And that is why I need a new practice and why it has taken me awhile to plan it. I have to make sure I don’t open the same can of worms.

I need a new can of worms.

3 Responses to “Do Over. Part one.”

  1. Margaret Hallowell Says:

    How fortunate we are to have a doctor that cares about efficiency, compassion, abilities and his own well-being! I’m sure this has been an arduous journey but I know I am not alone when I say you are greatly respected fro your unflagging conscience.

  2. Pam Killen Says:

    Doc. Just do pay as you go and get back to work!!!! Medical practice in the states is insane. I just want my doctor and me. In Belize, I get great care because I see my doc and not a technician. Honestly, the first step to healing with medical care is feeling like your physician gives a shit and I always felt that with you.That is what works for me and I bet a lot of people. Good luck and see you in May.

  3. Shauna Pekarcik Says:

    You are by far the best Doctor I have ever had and it pains me to even think about getting another. Hurry Back to us.

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