Monthly Archives: September 2016

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.

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.

Tim