Do Over. Part Two.

New practice. What should it look like?

A couple of weeks ago, I posted a “Shoot for the Moon” Facebook question asking my friends and contacts what they would like from their physician’s practice. I posted the not so surprising results here: Shoot for the Moon.

Dusting off the ashes of burnout, I decided that if I did return to practice, I would have to be true to myself and return to the roots of why I became a doctor in the first place—to interact with people in a meaningful way and try to be their guide in the pursuit of wellness. (I need to go back and check my Med School application to see if those were the exact words.) As such, I need to open a practice that is as much the opposite of my former one as possible.

It turns out that a lot of what people asked for in my Facebook poll are the kinds of things that should only facilitate such interaction. Things like online access to your medical records, same day appointments, decreased (even rare) waits in a waiting room (in fact, I’m not planning to have one), after hours and weekend access and appointments, and no robo-telephone answering service. These aren’t just patient-friendly enhancements designed to market a practice, these are the kinds of changes needed to help patients stay involved in their healthcare, to break down the current barriers to getting any healthcare at all (i.e., appointment availability), and to refocus towards wellness and prevention, instead of just “treat and street” medicine.

In the Facebook thread I am referring to, after about 180 messages of people talking about how to re-engineer the typical current doctor’s office experience, including non-sense requests like “home-cooked meals,” a colleague and friend of mine chimed in.  Janet Chaffee, a wonderful, experienced island nurse wisely replied:  “You are going to need one heck of a staff. Coming from 30 + years in an office, it would be wonderful to do all these things, but is it impossible? I think yes. Doctors are people with lives. No one can expect 24/7 and be upset if they don’t get it. Evening hours? Weekends?? Deliver babies. When do you sleep or see your family. Sorry, I’m coming from the other end.”

She’s right, of course. But…

I am going to work out of the cottage on our property and open up initially with a skeleton crew–me. I’ll be answering the phones, seeing the patients, and shoveling the steps if it snows again.

I am going to offer online access to medical records, same day appointments, online self-scheduling of appointments.

My patients will have my cell phone number and email and will be encouraged to use them when needed.

I will be available for appointments outside of the usual 9am-4pm timeframe, most days of the week.

I will offer housecalls as well as online visits for when you just need a simple follow up visit and don’t need to miss a day’s work.

How?

I am hoping to provide this better, more personalized care and improved customer service by seeing a lot less patients (the roster will be limited to 500 patients total, a number that might fluctuate depending only on how easily I can meet these promises) and by ignoring health insurance companies–the myriad of their regulations and the frustrations of their denials and the armies of personnel needed to interact with them!

I am opening a Direct Primary Care practice. It’s a new model, gradually catching hold around the country. The idea is that a practice stops billing health insurance companies and instead bills patients directly for the enhanced care, often using a monthly retainer and/or nominal visit fees to cover all services.

“Ahhhhhhh. The Catch.”

I’m sorry. I’m sorry the system is so broken as to make me buck it like this. I’m sorry that you have health insurance that purports to cover services like mine; maybe you even purchased it yourself at great costs (as opposed to having it provided for you by your employer). So Sorry.

Ask yourself this:  how well does my insurance cover the primary care services I need? Most plans have a $15-25 copay. Often there is a $2,000 deductible that is out of pocket. Most plans have a $150-250 ER copay, and making multiple trips to the NCH ER every year is almost a given these days, given our extreme shortage of doctors and appointment slots. It is not uncommon for a family of four to spend $1,000 on ER copays and another $250 for office copays. So what if you could redirect that money in a way that allows you to mostly avoid ER visits, to see the same physician every time you need to see one and who answers your phone calls at night when you just want to know it’s okay to not go to the ER, and gives you the convenience of making an appointment that best fits your schedule?

I have not completely settled on the price yet for this service. Most DPC practices charge anywhere between $60-120 a month for such services. And, if there is enough interest, and the practice matures (allowing me to bring more services in-house, e.g., nutritional counseling, on-site lab tests, a health coach), I can see a price point that falls somewhere on the lower side of that range. (I am going to focus harder on controlling overhead than raising revenue.)

As way of introduction, however, especially as I work the kinks out, I am going to charge less. I am considering $50/mos with a family cap of $125/mos. This will include everything. I will not ask for a co-pay or per-visit fees. If you need an ECG or a strep test, it will not cost extra.

I should point out that this plan is in no way a replacement for health insurance. Your health insurance will still work, and be needed, for example, if you need a $6,000 knee MRI at NCH, or a $300 Lyme test, or a $15,000 Medflight transport, or $55,000 worth of treatment for a cat bite. But, given my non-participation, it is unlikely that health insurance will cover my monthly fee.

So, there you have it.

What’s next? I have to renovate our cottage, turn the turn ground floor bedrooms into consultation rooms. I have to buy some equipment. I need to get a license to work out the building. I have some important decisions to make when it comes to Medicare and how to handle people who have managed care plans.

In the next week or two, I am going to redesign this website and blog and flesh out the details of how it will all work. I’m sure there will be many questions, so I’ll need an FAQ section. There will be a sign-up if interested page.

Still a lot to think about. But I think I can start seeing people within 4-6 weeks though!

Please feel free to comment below or email me at info@ackdoc.com if you have questions or comments. Be nice.

22 Responses to “Do Over. Part Two.”

  1. cinda gaynor Says:

    it reminds me of how and where i grew up – a new old model and i hope it is a good journey for you greg. i’m not sure how money was handled,i just know it was always great to have one of our doctor friends drop in when in need – or to walk over to the ‘clinic’ and be known – it was intimate, it was personal, it was a community and we children thrived.

  2. Georgia Raysman Says:

    Greg– I hope very much that you succeed with this kind of direct participatory practice. I rather think that if you limit your participants to 500 or so you might well have found the right “sweet spot” for it to happen on-island.
    Good luck!

  3. Kelly John Says:

    I think the goal of providing more personalized care is a great one, and it seems like this model will help you achieve that. But, I gotta tell you that I was pretty surprised by this model. It is so anti-establishment! But you are right, the only way to get back to basics is, well, to do just that. Get away from everything that has complicated healthcare.

    For those without insurance, this seems like a model that will work easily.

    For those without insurance, I think it raises many questions. How will this dovetail with the patient’s current health insurance plan. How will it affect specialist referrals? Will people need to have a PCP “in-network” on paper with their insurance company and see you on the side? Will other aspects of care (I.e. outside of family medicine) be impacted? I don’t know if the lay person will know or understand this and will therefore need some help understanding. I think this patient education will be key to the success of this model.

    It may also be interesting to poll the island’s employers to see what types of plans most of the employers have to see if that could help you become more able to answer these types of questions.

    I wish you all the best. It is somewhat of an idealist approach, but I think it could really work when people start seeing the benefits of that personal care. Instead of a trip tot he ER.

  4. Christine Smith Says:

    Greg, On the whole, I think this is an wonderful idea. My private psychotherapy practice was originally in the front part of my large Victorian home (in New York) and now resides in the basement of our cottage on our property. Once in a while, the dog gets loose (brought someone a bone yesterday) or the kitty climbs on someone’s lap. Its as it should be; a family practice in a family environment. It is quieter, less confusing, and entirely more confidential than a typical practice.People feel safer and tend to open up in a way that they often do not in a sterile environment. I don’t own a fax (I don’t think they are a safe way to transmit info at all), and because I work for myself, I don’t have to. I answer my cell phone night and day, and very rarely is this abused. People tend to respect your personal time, usually. There are a few health insurances I will not accept, as they require me to treat a patient according to their plan. MassHealth is one of these. There are several others, however,that I am a participating provider of, and I can simply bill with the patient’s ID number, date of birth and procedure code. If there are any insurances that are historically unreasonable, I just do not take them. I do my own billing, by the way, which for me, takes hardly any time at all. It may be different for physicians, though. I applaud your willingness to think outside the box. You are a wonderful doctor, but should be able to practice medicine in the style that suits you best. So I say, GO FOR IT!I look forward to hearing more about your work in progress!

    Christine

  5. Katie Mooney Says:

    I think this is awesome!

    Found a cool bag you could have Amy get you for your birthday:

    http://www.etsy.com/listing/86424249/custom-doctor-bag-or-leather-bag-for-men?utm_source=googleproduct&utm_medium=syndication&utm_campaign=GPS&gclid=COfW0Ly-oLUCFYLd4AodHy8ARQ

  6. Donna Fee Says:

    I believe in what you are striving for and it is indeed the reason you are my favorite doctor. If I were still on the island, I’d man the phone for free in total support of your new practice!

  7. Greg Says:

    KM: Those bags look awesome!
    CMS: Thanks! Family style is right.
    KJM: You raise several important points, which I am looking at as we speak. The PCP referral issue is going to be a tough one. I already have a draft blog post discussing this for later!

  8. Heather Woodbury Says:

    I think that this is how medicine and most things in life should be. You should be more that a medical number or 10:35 appt to your Dr. Will you be allowed in the delivery rooms of NCH?

  9. Greg Says:

    DSF: Thanks!
    HWS: Alas. Sadly. I have probably seen the last of the delivery rooms.

  10. Aimless Says:

    Way to go, Gern. Wish we had a practice like this here. All the best in this new endeavor!

  11. Tracy Murray Says:

    I think it’s a great way to go! I am so very interested and curious to see this at work! Best of luck! This seems a much friendlier approach to taking care of ourselves.

  12. Dan Driscoll Says:

    Greg,
    This is a bold move and I congratulate you! In support of this adventure I would love to be one of the first to sign up.

  13. Stacy Barr Says:

    Im sorry to say – this all would be very cool but ultimately it excludes poor people and there is nothing about that which addresses the health care crisis – as far as I can see you are just doing what they do on the TV show “Royal Pains” – being a concierge doctor and just because you’re doing it at home doesn’t make it folksy -perhaps you should consider barter and give less fortunate folks a chance to have a doctor’s care that doesn’t make them feel like a number – otherwise everyone is still a number – the number that you charge!

  14. Greg Says:

    Trust me Stacy, everything you say here has weighed heavily on me with this decision. In fact, let me elevate your comments… Stay tuned.

  15. meg Says:

    This reminds me of Dr. Walker’s practice. Sounds great, simple, flexible.
    What about malpractice insurance? I’d put everything in Amy’s name and not bother. Then be REAL nice to Amy;-)m

  16. Greg Says:

    Stacy, thank you for your post: http://www.ackdoc.com/wordpress/2013/02/06/the-scales-of-karma/

  17. Greg Says:

    Malpractice insurance will now be my biggest overhead expense. I think I will see few enough people per day to qualify for part-time rates though. Everything has always been in Amy’s name. Actually, that is not true. The house is in her name and the mortgage is in mine! I am therefore always REAL nice to Amy.

  18. Rachel Says:

    Greg

    I love your vision and your passion. One of my early childhood memories is of getting a huge bruise on my buttocks when I bucked as the doc was giving me a shot of penisilin in our New York apartment. It must have been right before things started to change, since it is my only memory of a house call from our doctor. Or maybe it’s because we were poor and couldn’t generally afford home visits.

    The lack of continuity and not getting to see the same doctor or even my own doctor during the last year has made it very hard to get a diagnosis and treatment for a serious health issue. In my frustration and desperation I have basically given up on the system and have resorted to trying to manage my illness on my own. Meanwhile I have unpaid bills for services that brought me no closer to answers, and which even may have further worsened the issues (in the form of wrongly prescribed antibiotics).

    So yes, the system be broke.

    My fear is that if all the good doctors jump onto this raft you are building, then poor people like me will be priced out of good health care.

  19. Ema Hudson Says:

    I am SO thankful for your perseverance through the broken system and your dedication to the community. I will gladly pay the cost for the security and relationship with a doctor I know. I’ll be waiting for the sign up page to appear :) Thank you, thank you and thank you!

  20. Rachel Says:

    The part about how we have to keep our health insurance threw me a bit. But maybe there’s a way we could opt out of our current (expensive) health insurance and get something with less coverage and cheaper… Then we could afford this!

  21. Bob Hall Says:

    When does one sign up?

  22. Greg Says:

    BH: I’m redesigning the website and the new site, up next week, I hope, will have sign up info.

    And Rachel, you’re right. This type of practice, elsewhere, often is used with higher deductible policies or HSAs. Worth looking into.

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