Category Archives: Uncategorized

You Are Welcome

When you call your doctor’s office, do you feel welcome? Who answers the phone at his office, is it usually a person or is it always a machine? If you call because you’re sick or hurt, do they sound eager to see you, or do they sound like they’re doing you a favor by “trying to work you in?” When you get to the office, do you feel like you spend a long time waiting just to be rushed through your visit? Don’t you want something better?
At my office, the phone is answered by me or Delzora most of the time, 24/7/365. We miss a few calls, but not many, and you can text us if that works better for you. If you need to be seen today, I will make every effort to see you today, or at least tomorrow. When you get here, I will give you the time you need for me to think carefully about your problem, and for you to understand how we’re going to take care of it. I don’t want you to be sick, but if you are, I want to see you. You are welcome.

Well! I Guess People Do Read The Newspaper!

I gave an interview to a Northwest Indiana Times reporter, Giles Bruce, a week or two ago, about my practice and Direct Primary Care generally. It was published yesterday, September 1,2017. The response has been fantastic, and very gratifying. I have received a number of requests from people wishing to join the practice, and I apologize in advance if I am not able to schedule all the appointments quickly. I also heard from another Direct Primary Care practice near me, Matron Health, LLC, that I didn’t even know was there. I am looking forward to ramping up the practice and the revolution in health care.

Healthcare In Rural America- Some Thoughts On An Endangered Species

I’m going to leave the current news cycle, in which Sen. McConnell is trying to get another proposal to repeal the PPACA through a reluctant Senate.  I’ve been thinking about what we ought to do about healthcare in rural America.  Here is a link to a good article on the closures of rural hospitals from the Kaiser Family Foundation a year ago:

http://www.kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/

Rural hospitals face a lot of challenges to their survival. First, much of rural America is losing population.  Since hospitals’ revenue is still based largely on the volume of services they provide, it is hard to pour money into building or maintaining the capital-intensive resources of a traditional hospital when the need for the resources is likely to decline. Lack of investment in resources, though, leaves these hospitals unable to do some of the high-tech, high margin care such as major orthopedic cases and invasive cardiology that supports money-losing lines of business.  Also, the lack of resources causes patients with private insurance to avoid these hospitals and drive to bigger hospitals for all but truly emergency care.  The patients left to use the rural hospitals are those with Medicare, Medicaid, or no insurance at all.

The rural population is older than the nationwide average, and they are more likely to be on Social Security, either due to age or disability, which means that the patients in rural America are likely to be sicker than average, and less likely to have private insurance.  The question is, as hospitals close and access to medical care disappears, will these patients have to leave the country and move to more urban areas in order to access care?  I think the loss of population will accelerate with the loss of access to healthcare and the disappearance of healthcare jobs from these communities.

A supporter of stringent free-market economics will view the collapse of rural healthcare, economies, and populations as the working of the invisible hand, inevitable and perhaps only mildly regrettable.  For those not so completely sold on this philosophy, the article above details some interesting ideas on how to maintain access to healthcare in rural areas.  What I think is most important is that we recognize that we will not serve patients in rural areas best by tweaking the current system of payment for individual services, nor can we expect a commercial market to create access where there is so little demand.  The solution will be a political decision that the government will have to simply commit to having healthcare in rural communities, and then decide how it will be delivered.

American Healthcare: We Basically Need To Start Over- A Book Review of Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong by Robert Pearl

Dr. Pearl, a plastic surgeon and an executive with the Kaiser Permanente Health Plan, has written a book about the American healthcare system that should make everyone a little uncomfortable.  We want to believe that we are smart, well-informed consumers of healthcare, and that we are able to make good choices in our the best interests of ourselves and our families.  Dr. Pearl shows, with both stories and statistics, that we make irrational choices for our care, selecting doctors and hospitals with less thoughtfulness than we spend on choosing breakfast cereal.  There is no upward pressure to improve the quality of healthcare because we choose our providers and treatments for all sorts of reasons that have nothing to do with outcomes: the hospital is convenient or it has a nice lobby, the doctor did a good job of care for a family member years ago, and so forth.  This kind of decision making is probably all right for low-stakes medical care, like where to go for a physical for Boy Scout camp, but for something as risky and expensive as a hip replacement we ought to show more care.

Patients are not entirely or mostly to blame for poor choices, though.  Dr. Pearl takes up the theme of how our healthcare system creates incentives for providers to do things that are often useless or harmful, all the while insisting that our care is “state of the art,” or at least, “the standard of care.”  If patients have a hard time making good choices, it is often because the healthcare system often gives them bad alternatives.

Dr. Pearl’s recommendations for improving the healthcare system are, to my mind, very sound: capitate primary care so that there are incentives for handling problems efficiently and effectively, not for churning through brief office visits that are paid equally whether they are helpful or useless.  Procedures should be paid in a lump sum for an episode of care.  It is absolutely scandalous how much some hospitals profit by the complications caused by the care they give.  Expensive surgeries should be done at “centers of excellence,” facilities that do a large volume of a certain operation and have demonstrated that they are really good at it.  I was surprised to learn that half of gynecologists do fewer than 12 hysterectomies a year- at some point, if a doctor seldom does something, he’s not doing it often enough to do it well, and should stop doing it altogether.  I don’t share all of Dr. Pearl’s enthusiasm for corporate management of healthcare, probably because I don’t think people outside of primary care understand the complex motives of patients in the office.  It’s a lot easier to manage appendectomies, where everyone more or less agrees on the problem, the solution, and the desired outcome.  Many days I wish office practice were that simple, and that healthcare executives like Dr. Pearl understood that it’s not.  But if Dr. Pearl got the opportunity to reform the way we do the big-ticket events in American healthcare he could do a lot of good before he started telling me how to do camp physicals.

There’s some stories from the annals of behavioral psychology in this book which are there to show that it has been scientifically proven that people are irrational.  I have accepted this for a long time and so I thought these digressions were longer than necessary, maybe others need more convincing.  Altogether, though, this book is a clear vision of how healthcare can be less wasteful, more helpful, and more humane.

Making The Diagnosis, But Falling Short On The Cure- A Book Review of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal, MD

This book by Dr. Elisabeth Rosenthal, an internist-turned-journalist, starts with detailed, well-researched, and appropriately indignant description of the factors that have turned the American health care system into an expensive, inhumane, and dangerous mess in the last twenty-five years.  I consider myself well-informed to the point of wonkiness about the shortcomings of my industry, and yet I learned a lot from this book about the actions of hospitals, insurance companies, drug manufacturers, and, yes, my fellow physicians in building a system that comprises a fifth of our national economy and does an incredibly poor job of achieving its stated gains.

Every libertarian who believes that the individual pursuit of self-interest will result in a functioning marketplace for medical goods should read this book and prepare to lose their faith.  Hospitals compete for market share by adding expensive but useless amenities, recommended by expensive and nearly useless administrators and consultants.  If that’s not enough, the hospitals in a market gather together to exert monopoly power in pricing their services.  They are in constant battle with the insurance companies, who have discovered that the road to prosperity is to enthusiastically take in premiums but only reluctantly pay medical bills.  But even though hospitals and insurers are adversaries in individual transactions, they rely on each other to keep our bloated, expensive system of healthcare in place, enriching each other but impoverishing the patients and taxpayers who are paying for this bureaucracy.

Pharmaceutical companies spend as much effort rigging the market in old drugs as they do in finding new drugs.  Patients are charged hundreds of dollars a month for drugs whose development costs were recovered decades ago.  Device manufacturers bring new models to market with the same gusto as the fashion houses bring out new dresses, and for much the same reason.  There are devices that have been on the market for years that work perfectly well, but once their patents have expired the manufacturers dismiss them like last summer’s frocks in favor of newer, more expensive, “cutting edge” devices. 

Doctors in this environment, I think, are driven as much by envy as by greed.  They know how much the executives of hospitals, insurance companies, and the drug and device manufacturers are paid.  They resent their salaries, because they feel that they add more value to patients’ lives than these overpaid former B students.  So too many doctors read articles, attend seminars, and cut deals so that they can learn how to earn more money for doing no more than what they were doing last year, or, at least, no more that adds value.  They want the money to salve their hurt feelings, but they disregard the welfare of their patients. 

There is a frantic quality to all of the conniving that Dr. Rosenthal describes.  I have to believe that all the players know that this horrible game cannot go on forever.  They are investing their lives and fortunes in a financial bubble.  Some of them may be unaware that American healthcare is a financial bubble, but experience has shown that even when investors know they are facing a bubble, each of them believes that he can get out just before it pops.

Unfortunately, Dr. Rosenthal doesn’t see the bubble, either.  Her prescription for improving the American healthcare system is a combination of optimistic consumerism, preaching virtue, and small adjustments to great mistakes.  She encourages patients to engage in a level of comparison shopping and informed advocacy that is frankly well beyond the capacity of an average person.  In order to take care of yourself in the healthcare system as well as she advises, you pretty much have to be her: Harvard educated in medicine and a black belt in healthcare finance.

Small changes to how all the vendors get paid in the system are unlikely to result in any meaningful change.  They are all of them ardently minding their own business, and the public good is none of their business. Hectoring them from a pulpit won’t change that.   Legislators and regulators will slowly make rules to limit abuses, and the hospitals, insurers and everyone else making money off this system will quickly find loopholes in the new rules just as they found them in the old rules. The rule makers are motivated by what they see as righteousness, but the people selling goods in this market are motivated by profit.  As long as this market exists, my bet is on profit to win.

I want to call out Dr. Rosenthal on one particularly naïve and destructive assertion that she makes about doctors: that they should be available, presumably by telephone, 24/7/365, and do this for free as part of their calling.  She was a general internist, so she knows that this is a burden that has usually fallen to primary care physicians.   A few years ago I noticed that very few primary care physicians will do this uncompensated work any longer.  Nowadays, the patients are sent to the ER for every question, or they now have the option of consulting by telemedicine with a physician who has never seen them, let alone examined them.  These are terrible options, but you get what you pay for. 

Personally, I take call for my patients nights and weekends, as this is part of the service I offer with a direct care subscription fee.  I think it is a shame that this is not available to more patients.

I recommend to Dr. Rosenthal, and everyone reading this review, to stop trying to fix the current American healthcare system and to think about what they want to replace it when it collapses.  She recommended some models of healthcare, such as the Kaiser Permanente system, that are possible models for how we should do things differently in the future.    I am an advocate of public financing for universal healthcare, perhaps these models can be a template for this.  I am also an advocate for a free market for innovative businesses providing private healthcare, because there is no single system that can meet everyone’s needs or invent better ways to care for people.

Healthcare prices can’t rise faster than inflation forever, this system can’t keep taking up more and more of the economy, greed cannot reach all the way to the skies.  The healthcare industry is an unsustainable bubble. It is the nature of bubbles that bubbles don’t gradually deflate.  Bubbles pop.  When this one pops, a lot of sick, terrified patients are still going to need healthcare.  Dr. Rosenthal has written a book that everyone should read to learn how this bubble formed.  I would like to hear what she would recommend after the pop.

J. Timothy Ames, MD

Insurance Companies, Fearing Repeal Of The PPACA, Ask For Continued Government Support

http://www.modernhealthcare.com/article/20161205/NEWS/161209962?utm_source=modernhealthcare&utm_medium=email&utm_content=20161205-NEWS-161209962&utm_campaign=am

I realize that I’m recycling the headline from earlier today, but I’m making a point about who has really benefited from the PPACA.  Actually, the insurance companies have not made out as well as the hospitals, because a lot of young, healthy people decided to pay a fine instead of paying health insurance premiums.  Unfortunately for many insurance companies, they did not see this coming, and they were counting on the profitable policies of the young and healthy to subsidize the money-losing policies on old codgers like myself (I was on a marketplace plan for a few months, and it turned into one of the worst deals MHS ever made).  Too few young’uns, too many codgers, and many of the insurance companies lost money on their marketplace policies.  They were already planning to retreat from a lot of their PPACA markets before the election, and now I cannot imagine a set of circumstances that would keep them in this business.  Insurance companies hate uncertainty above all else, and with a Trump administration vowing to repeal the PPACA without a backup plan, the whole healthcare industry is up to its neck in uncertainty.

One thing is certain: if you hire someone to help you out with your own money, he is accountable to you.  Direct primary care is you hiring your own doctor with your own money, and I would be very pleased to help you.

Hospitals, Fearing Repeal Of The PPACA, Ask For Continued Government Support

http://www.modernhealthcare.com/article/20161206/NEWS/161209953?utm_source=modernhealthcare&utm_medium=email&utm_content=20161206-NEWS-161209953&utm_campaign=am

Another way of reading this plea by the hospital industry is that they have an unsustainable business model that has been made viable and even prosperous for many years by the government voting them money.  Whatever else the PPACA, DSH payments, and facility fees were, they were ways for the feds to favor hospitals over their competitors (private physician offices, outpatient surgery centers), with the justification that all these hospitals are necessary to provide medical care in their communities.  I reply, no, they’re not all necessary, and showering money on hospitals only delays the transition of health care toward innovative means of providing outpatient and in-home care.

I don’t think that all hospitals should close, of course, but we have more than we need in this country, and we will not be able to find out how few we need to meet our healthcare goals until the government quits propping them up.

Direct primary care is a threat to hospitals, because its goal is to give patients good, thoughtful, attentive care that prevents the need for many ER visits and hospitalizations.  DPC is bad for hospitals, but it’s good for patients, and if the government wants better health for its citizens it should find ways to be supportive of direct primary care instead of pouring more money into the hospital industry.

Letter To A Premedical Student.

Dear [Student],

It’s good to hear from you, and I am never to busy to promote the revolution and build the future of healthcare.

In the present medical education system, students and residents are unlikely to hear anything about direct primary care, or about the business of healthcare generally.  Forgive the analogy, but medical education approaches money the way most parents approach sex: if we don’t talk about, the young people won’t think about it, and their purity will be preserved.  The result, in both cases, is that ignorance leads to a lot of misguided behavior and unintended consequences.  Doctors owe it to themselves and especially to their patients to become knowledgeable about the economics of this industry, and  to experiment with payment schemes that improve the delivery of services.

Direct primary care is not for everyone, patients or doctors.  It would be great for the elderly, if they weren’t covered by Medicare.  They are the wealthiest part of the population, measured by net worth, and they would really benefit from having enhanced access to primary care to avoid having problems evolve into catastrophes.  It is possible to provide direct primary care to them, but Medicare makes it difficult.  Patients on Medicaid are usually incapable of paying anything for their health care, and they are well-served by Federally Qualified Health Centers and similar venues for primary care.  I have worked in FQHC’s for the past fifteen years, and they are organized specifically to meet the needs of this population.  There doesn’t have to be a single type of clinic to serve the primary health care needs of different populations, anymore than there has to be one kind of restaurant or clothing store in the world.

Young practitioners coming straight out of residency have opened direct primary care practices, for example, Dr. Josh Umbehr of Kansas.  It all depends on the market, and anyone who wants to open a practice will probably need a lot of savings or some moonlighting jobs as they get started.  I personally would recommend an FQHC for any young family doctor getting started as a place to get experience as well as getting loan forgiveness.

Find below an incomplete list of doctors I consider to be leaders in this field.  If you have a chance in your last semester, take a course on entrepreneurship, or at least read the books The Innovator’s Dilemma and Freakonomics.  Further, if there is a premedical society or some such that would be interested in hearing about direct primary care, I would love to speak to them.  Good luck, create the future.

Josh Umbehr, MD

Pamela Wible, MD

Brian Forrest, MD

Samir Qamar, MD

Zubin Dumania, MD (aka ZDogg).

Tim Ames, MD

blog at jtimothyames.com

The Family Medicine Education Consortium Wanted My Opinion. I Can Do That.

The Family Medicine Education Consortium is an organization promoting direct primary care.  They sent along this article detailing the failure of primary care management in British Columbia, Canada and asked for comments.  The short version is, you can’t take a system with misguided incentives and manage, or bribe, for better results as a last resort.

http://www.huffingtonpost.ca/kimberlyn-mcgrail/british-columbias-health-care_b_11667690.html

Name (with credentials): J. Timothy Ames, MD
Organization: J. Timothy Ames, MD PC

Comments: I agree with this quote from the article:

“This time around, before spending billions, we need to agree on what success looks like, and monitor progress from the start.”

British Columbia put a relatively small amount of money on the table for primary care physicians in order to encourage them to do chronic disease management, then simply hoped that things would get better.  The physicians had little guidance, and less motivation, to achieve the ill-defined goal of “better” health care.

I disagree with this quote from the article:

“Most importantly, we need to broaden the team that is involved in choosing reforms to include health authorities, nurses and other service providers — and patients. All are necessary to delivering primary care and so all should have a hand in shaping it.”

This is a formula for talking the problem to death but not improving anything. The government needs to resist the temptation to over-engineer solutions with inputs from dozens of stakeholders.  They should simply define an easily measurable goal, e.g., decrease the rate of hospitalization for a cohort of 10,000 patients.  They should decide who are the best people to direct efforts to achieve this goal, e.g., physicians.  They should pay for what they want, e.g., “We will deem you this patient’s primary care physician, and we will pay you $25 for every day that this patient is not in the hospital.”  The government should then walk away and see what happens.  The physicians receiving the money will then figure out what resources they need to assemble to achieve the goal, whether it is nurses and pharmacists, or cooks and housecleaning staff.

We have to admit that we don’t know how to achieve population-wide healthcare goals, and that the attempts to do so by “building teams” guided by “smart management” and “seeking diverse opinions” have been reflections of bureaucratic prejudices about problem-solving, and have been wretched failures. We need to decide what we want from public healthcare, arrange to pay for what we want, stop paying for what we don’t want, and prepare to be surprised by what naturally evolves.