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Letter To A Young Doctor Starting A DPC Practice

When a true genius appears, you can know him by this sign: that all the dunces are in a confederacy against him.

 Jonathan Swift
Direct Primary Care is a threat to any established healthcare organization, because it turns their assets into liabilities.
Their first asset is capital: they have a lot of money sunk into hospital buildings, MRI’s, billing software, and a whole bunch of other expensive things which cannot be used for another purpose.  Your purpose is to keep your patients from using these things, by providing high-touch, low-tech care that keeps them away from the hospitals and their specialists that subject patients to expensive healthcare of often questionable value.  It happens that a lot of these capital goods are paid for with borrowed money, and leverage turns a failing business model into a full-scale rout very quickly: see mortgage-backed securities circa 2008, or the earlier savings and loan collapse of the ’80’s that brought down a lot of the banking system of Texas.  When hospitals become a source of losses instead of profits, the capital markets are going to punish big healthcare organizations mercilessly.
Their second asset is management expertise: the skill set required to run a business with 3 employees is much different that that for a business of 300 employees or 30,000 employees.  The folks at (Big Healthcare Company) know how to run a big operation, and they are paid handsomely to do so.  But if you open a small self-supporting practice, they have nothing to offer you.  If many of us in primary care walk away from their jobs, the people paid to manage us will not have enough to do, and will lose their jobs in turn.  They would never think this with their conscious minds, but they can hear the low rumble of a threat in what you are doing.
Next quote:

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”― Upton Sinclair

And this:
Do you think that I have come to bring peace to the earth? No, I tell you, but division.  From now on there will be five in one family divided against each other, three against two and two against three. -Luke 12:51-52
I suppose what I am trying to do is to warn you that you are leaving the community of traditional healthcare providers, and you cannot expect their support.  But you are joining another community of providers who feel as you do, and want nothing but the best for their patients.


What Dr. Berwick Does Not Understand About Quality Management in Healthcare


Donald Berwick, MD, former head of CMS, has written an article for the Journal of The American Medical Association, April 5, 2016, Entitled “Era 3 For Medicine and Healthcare.”  In it, he describes Era 1 of healthcare as the time when doctors and other health professionals were simply trusted to practice, and spend healthcare dollars, without much oversight out of respect for their education and status.  This era ended because clinicians, left to their own devices, proved unable to restrain healthcare spending or follow scientifically-proven best practices.  Era 2, of which Dr. Berwick was an important proponent, was the era of overweening healthcare management, with clinicians forced to use electronic health records that worked very poorly in pursuit of dozens of goals, many of which were of no proven value.  This era is itself in the process of ending badly, with CMS publicly backing off its support of Meaningful Use, the widely reviled initiative to dictate to physicians how to use the EHR’s they weren’t sure they wanted in the first place.  Era 1 was unsustainable, but era 2 has had the effect of demoralizing physicians to the extent that physician burnout is being described as an epidemic.

In his proposal for era 3, it is clear that Dr. Berwick has not repented of his role in inflicting era 2 on American healthcare.  Some of his proposals have merit: the number of outcomes that are measured should be drastically reduced so that attention can be paid to a few, important outcomes.  Professional prerogatives can be a barrier to doing things better- physicians should not be able to pull rank when making decisions about outcomes that require the actions of teams.  Some of Dr. Berwick’s recommendations are simply wistful: we should all behave civilly to each other.  We should reject greed, and focus upon the common good.  But the heart of Dr. Berwick’s essay is his belief that the problem with era 2 was that sound ideas were badly applied.  He does not seem to see that quality management, as he conceives of it, cannot be applied to much of healthcare.

There are certain healthcare processes with clear, measurable good and bad outcomes that lend themselves to quality management as if they were industrial processes.  It is clearly bad to have a wound infection after major surgery, and the processes of major surgeries should be managed to decrease the number of wound infections.  The way that myocardial infarctions are properly treated in 2016 is better than how they were treated in 1986, and steps should be taken to ensure that MI’s are treated as they should be in the modern era.  The situations in healthcare that are well-suited for scientific management are highly important, but they are few in number.  For the great majority of healthcare encounters, quality is hard to define, let alone manage.

Does Your Health Insurance Keep You From Getting Health Care?

I would welcome comments on this observation: I have had conversations with people who either just got health insurance for the first time, or have had changes in their health insurance, and find that after they have paid their monthly premiums they don’t have much left to pay the out-of-pocket costs left to them by their insurance plan.  They stay away from the doctor unless they have a catastrophe first that maxes out the amount they have to pay for health care that year, and only then do they feel they can afford visits for maintenance care and minor illnesses. I want to provide care at a reasonable price that heads off some of the catastrophes.  It’s not as good as waving a wand that keeps my patients from needing my care forever, but it’s the best I can do.

What If You Don’t Need A Diagnosis?

In fee-for-service medicine, a doctor accepts money in exchange for a diagnosis.  This is especially true if health insurance is involved, because without a diagnosis (accompanied by a ridiculously arcane code) the bill won’t get paid at all.  I worry that this exchange is sometimes harmful to patients.

There are some problems with diagnoses.  The first is that they usually lead to treatment, which may or may not be helpful.  It takes a really good relationship with a patient who has a problem to tell him to do absolutely nothing about it, even when that is the best advice he could take.  It’s far easier to write a prescription in the hope that it doesn’t cost too much and helps a bit without causing much harm.  This seems to be what happens in the minute clinics, urgent care centers, and other sources of hit-and-run medical care.

The more harmful thing about diagnoses is that patients often absorb them into their identities.  They start with, “my knee hurts,” are told by a doctor that, “you have arthritis,” and from there go on to conclude, “I am a person with arthritis, and this means that I am always going to have pain that changes my life.”  The diagnosis emphasizes the patient’s disability and dependency, and makes the patient lesser for it.

This is especially true of mental health diagnoses.  You can’t bill for an office visit because the patient is “sad” or “apprehensive,” so doctors diagnose “depression” and “anxiety.”  This creates the expectation that the patient is going to receive an antidepressant or anti-anxiety medicine, perhaps the one that was advertised on television last night.  After that, it is too easy for further office visits to center on the medicine: Does it work?  Are there side-effects?  Should we increase the dose, or try a different one entirely?  It is too easy for important conversations to get lost in managing the diagnosis.

I don’t want to earn a living making diagnoses.  I will use them when they are helpful, just as I use everything else at my disposal.  Sometimes patients come in just because they are confused, or frightened, or unhappy.  That’s not a disease, it doesn’t need a diagnosis, they’re just folks who need some help.


Why Medicare Is A Bad Deal

I don’t think there are many Medicare patients out there who, if asked to comment on their primary doctor, would report, “The problem is, he spends too much time with me, he has this annoying way of really listening to what I’m saying, he explains so much that he makes me know what’s going on with me, and he doesn’t shoot me off to enough specialists who treat me the same way.”

Doctors who take care of Medicare patients don’t act rushed and harassed because they are bad people, or even bad doctors.  They are, in fact, rushed and harassed.  They are paid by the visit, and the price of visits is not keeping up with the increases in overhead.  They feel as if they are working harder and faster to just keep up, and the government requirements for electronic health records and billing and paperwork have added to their burden.

Medicare patients should have the option of going outside of Medicare to get better care, but this is really hard.  A doctor who takes any money from Medicare at all cannot open a cash-for-service practice for Medicare patients who want more time, access, and attention.  If Warren Buffett, 84 years old and worth $66.2 billion dollars, came to me and offered me $100 for a one hour office visit, I would have to turn him down.  He can well afford it, I want to offer the service, but the government would jump on me with both feet if I took this deal.

There are “concierge” practices that do offer better services to Medicare patients, by very carefully charging subscription fees for services that Medicare doesn’t cover.  If there were enough demand for this, I might start one, because I think it is ridiculous that everyone covered by Medicare has to accept the same mediocre level of service.  I enjoy not acting as if I’m rushed and harassed, because I’m not.  I’d like to share this experience with Medicare patients.

Meaningful Use: The Autopsy Results

With very little fanfare, and certainly no apology, CMS recently canceled the Meaningful Use program.  This program was designed to give medical practices cash incentives for not just adopting electronic health records, but for also using them up to their potential, not just as expensive word processors.  I happen to believe that EHR’s are very helpful in maintaining good patient records, but the MU program was a classic example of bureaucratic overreach, which alienated many physicians and set back the cause of promoting EHR’s by several years.

The first mistake of MU was that it assumed that all patients need a very detailed medical record.  Most people don’t.  A small percentage of the population requires a lot of medical care, and for them the effort of creating and maintaining a meticulous chart up to MU standards is well-spent.  We’re talking 5-10% of patients.  For the rest of them, a much less elaborate way of record keeping does an adequate job of taking care of their medical needs.  Medicare, for example, estimates that half of its beneficiaries use only 3% of its money in any given year.  This disproportionate need for medical care is probably even more true for the population at large.  Many people go years without needing a dollar’s worth of medical care.  Clearly, people who use medical care so little need only simple charts to keep track of their occasional use of the health care system.

Patients who make infrequent visits to the doctor have simple needs: they just want a single problem fixed, be it a sore throat or a sprained ankle.  MU asked that all sorts of information be collected from these patients when they came in for a visit, including family history, their vaccination record, and the date of their last Pap smear.  This had to seem arduous and time-consuming at best, and kind of creepy at worst.  No wonder there has been such a growth in the number of visits at emergency rooms and urgent care centers.  Those venues take care of the problem at hand, and don’t waste time asking questions that are none of their business.

The fact that keeping MU-compliant records makes population-wide health management easier may have been a bug, not a feature.  Doctors aren’t trained or paid, at least not much, to care for a population.  Their obligation is only to the patient in front of them.  And if the doctors care little about the health of the population, the patients care even less.  To the extent they realize that health bureaucrats have access to their records, for the benefit of the “population,” they probably find this alarming.  Patients go to the doctor for the benefit of themselves and their families, not for the public good, and these visits are intensely private.  I don’t think that, even with assurances of anonymity, that patients are eager to share them.

Meaningful Use was the product of healthcare “experts” that fundamentally misunderstand the intimate nature of medical care.  It should start with building trust between two people, a patient and a clinician, and the system should be kept unobtrusively in the background.  Patients deserve medical care, not medical management.  That is meaningful.

A Quick Update From The Goofy World Of Medical Billing

I outlined my personal experience with medical insurance in my post, “But, I Did Get A Birthday Card.”  I had two expensive episodes of medical care in February, 2015 and as of August the hospital and the insurance company were still hassling over the bill.  My complaint to the insurance commissioner resulted in a detailed explanation from the insurance company about why they weren’t going to pay the bill, which satisfied the commissioner, but probably nobody else.

But now the ice is breaking up.  I got a bill yesterday for the first, smaller bill- the ER visit that ultimately led to surgery (no big deal, I’m fine).  The ER bill was for $1488.00.  The insurance company denied $1409.49 of that.  I was asked to pay $78.51.  The hospital apparently is going to write off 94.7% of the bill.

There is no way this makes sense.  I promise you, it cost the hospital more than $78.51 to send multiple bills to me and the insurance company.  They would have ended up money ahead if they had treated me for free and never sent a bill at all.   A system this stupid cannot be sustainable.

I’m Back

I’ve spent most of the last three months studying for the test to be a Certified Financial Planner candidate.  I passed, and I am glad to have it done.  I signed up to take the CFP qualifying course about a year and a half ago because I was thinking about getting out of medicine and I didn’t want to retire.  I don’t know if I ever want to retire, at least not completely, but I don’t want to keep practicing medicine when I reach the point where people are taking about how good I used to be.  So I need an encore career.   I think I would be a good financial planner, because I see it as a job that could be similar to what I’ve been doing: I talk to people about stuff that is scary and confusing, and I work with them to come up with a plan for dealing with it.  Also, it is another field where people are spending a lot more than they should for advice that is meant to baffle the advisee and benefit the advisor.  The parallels with my present field are uncanny.  At some point, I will go into a fee-only financial advising practice, where my only product is candid, caring advice about money.

But not now.  There’s still too much to be done for the Medical Revolution.  I continue to work down at Knox, Indiana one day a week with my friend Rafal and that crew.  I’m still inventing the job of pediatric hospitalist at Porter Hospital, which I like quite a lot.  The medical teaching job at Indiana University School of Medicine Northwest Campus (I was taught to use the long version of the name) is ramping up, now that I have figured out the system a bit.  I am also picking up some additional hours of work at Marram CHC, a new FQHC near the university.  It is run by my friends at Porter Starke Services, and I try to always help my friends.

The disorder of multiple gigs is part of the revolution: I work where I’m needed, but I still feel independent, if a little scattered sometimes.  The direct primary care practice continues, but it is small.  When I talk to people about it, they all agree that it makes sense, but the concept is so foreign that few have made the commitment to join the practice.  I’m having the same problem with doctors: they seem to assume that the misery they are having in fee-for-service, insurance-driven practices is mandatory.  I feel like Henry Ford showing them the Model T and having them ask me where the horse poop comes out.  Guys, put down your shovels, there is no horse poop.

I am not discouraged, I am discovering, I am inventing.  I have some ideas about how to work for the liberation of patients and doctors from the tyranny of the present system.  More later.

But, I Did Get A Birthday Card

When I left my job at the beginning of 2015, I dutifully went out and purchased health insurance from the website.  It was the rock-bottom cheapest plan that’s sold, in the metal scheme I think it’s below bronze, probably aluminum.  It featured a $6500 deductible, which I figured would hurt if I used it but it wouldn’t ruin me.  Besides, I am pretty healthy and don’t need a lot of work.  Famous last words.

So, about three weeks after I bought the insurance, I needed work.  At first some work, then more work, then a good lot of work.  I’m fine now, thank you, but I ran up quite a bill.  Thank goodness I had insurance, sort of.  My insurer proved very efficient at collecting premiums, dunning me without fail once a month. They haven’t been so good at paying bills, or anything else.  After four months I dropped them because I got married and got on my wife’s insurance. I notified my insurer of this in the recommended fashion.  I kept getting premium notices.  I called to remind them that I dropped them and I still kept getting premium notices, which I then ignored until I finally got a rueful letter telling me that they were dropping me because I wasn’t paying them.

I also kept getting explanations of benefits periodically, which listed in great detail what bills they were refusing to pay, which was pretty much all of them.  I’ve been through this before, I just let it all go, figuring that at some point the hospital and the insurer would hash out their differences.  Then, two weeks ago I got a bill from the hospital for $24,548.75, because they had not heard from my insurer.  I filed a complaint with the insurance commissioner, then went to the hospital and called my insurer with a member of the billing department standing at my elbow. The explanation I got was that there was an incorrect code on one line for one charge, which held everything up.  The nice lady at the billing office said she would fix it. I was irritated but hopeful.

Two days ago, I got two pieces of mail from my insurer.  One was an EOB denying payment of all the charges because the claims had been filed too late.  The second was a generic corporate birthday card to their loyal customer, four months after I had stopped paying them and two weeks after my birthday.

I don’t even think this insurance company is especially inept or dishonest.  I think they are pretty representative of their species, based on the similar stories of health insurance I have heard from my patients.  I began this year thinking that health insurers should get out of primary care medicine, and vice versa.  Now, given that they seem to have no talent except collecting money and no benefit to anyone except their employees and shareholders, I am coming to wonder if commercial health insurers should exist at all.