If you live in a small town or rural area of the United States, you may have noticed that family doctors are becoming an endangered species. Private and public health insurance reimbursement rates are so low that survival as a solo practitioner (without the economies of scale of a large group practice or hospital system) is next to impossible. Some primary care physicians are staying afloat by refusing to accept insurance – this allows them the freedom to practice medicine that is in the patient’s best interest, rather than tied to reimbursement requirements.
I joined such a practice a few years ago. We make house calls, answer our own phones, solve at least a third of our patients’ problems via phone (we don’t have to make our patients come into the office so that we can bill their insurer for the work we do), and have low overhead because we don’t need to hire a coding and billing team to get our invoices paid. Our patients love the convenience of same day office visits, electronic prescription refills, and us coming to their house or place of business as needed.
Using health insurance to pay for primary care is like buying car insurance for your windshield wipers. The bureaucracy involved raises costs to a ridiculously unreasonable level. I wish that more Americans would decide to pay cash for primary care and buy a high deductible health plan to cover catastrophic events. But until they do, economic pressures will force primary care physicians into hospital systems and large group practices. My friend and fellow blogger Dr. Doug Farrago likens this process to being “assimilated by the Borg.”
Doug offered a challenge to his readers – to customize the definition of Star Trek’s Borg species to today’s healthcare players. I gave it my best shot. Do you have a better version?
Who are the Borg:
The Borg are a collection of alien species that have turned into cybernetic organisms functioning as drones of the collective or the hive. A pseudo-race, dwelling in the Star Trek universe, the Borg take other species by force into the collective and connect them to “the hive mind”; the act is called assimilation and entails violence, abductions, and injections of cybernetic implants. The Borg’s ultimate goal is “achieving perfection”.
My attempt to customize the definition:
Hospitalists are a collection of primary care physicians that have turned into cybernetic organisms functioning as drones of the collective or hive. Hive collective administrators (HCAs), in association with partnered alien species drawn from the insurance industry and government, take other primary care physicians by economic force and connect them to “the hive mind”; the act is called assimilation and entails crippling reimbursement cuts, massive increases in documentation requirements, oppressive professional liability insurance rates, punitive bureaucratic legislation, and threat of imprisonment for failure to adhere to laws that HCA- partnered species interpret however they wish. The HCAs’ ultimate goal is “achieving perfect dependency” first for the drones, then for their patients, so that HCAs and their alien partners will become all powerful – dictating how neighboring species live, breathe, and conduct their affairs. Resistance is futile.
To learn more about my insurance-free medical practice, please click here. We can unplug you from the Borg ship!
I don’t read The Economist frequently enough to be sure that I dislike its entire staff of writers, but I have been repeatedly disappointed by its health coverage. In this latest article, “Squeezing Out The Doctor” the writers describe the increased healthcare needs of an aging western civilization, combined with a relative shortage of physicians to care for seniors. The conclusion? This is a “win” for patients.
Now, in case you find that conclusion as irrational as I did, let me summarize how they arrived there. The argument goes something like this: doctors have been unfairly controlling the practice of medicine for the past century, and now with the oncoming flood of patient need (and relative MD shortage), they won’t have time to do everything they have in the past. Physicians will therefore be forced to narrow their scope and outsource many of their current tasks to nurses and support staff. This is a win for patients because they will have shorter wait times for care and lower healthcare costs with the same care quality because most of what doctors do can be replicated by ancillary staff. At last we will be able to remove the self-important, over-educated, control freak physicians from the delivery of healthcare!
Oh, here’s another great idea: why don’t we improve our school systems by squeezing out the teachers? Who needs teachers when mature students could train others in the same subject matter? Most of what teachers do is just baby sitting, right? We could easily outsource that to daycare centers or teens with a little baby sitting experience. The few teachers we retain should be reserved for only the most difficult cases: severe learning disabilities. Just think of the cost savings in teacher salaries! Imagine the improved access to schools if we didn’t have to adhere to some arbitrary teacher to student ratio. What a win for students. The only possible downside is that teachers may lose some of their current social standing, but so what?
The oncoming physician shortage will not bring the glorious improvements in healthcare delivery touted by The Economist. More likely it will create a two-tiered system whereby the poor and underinsured will get a substandard level of care. If you think that only doctors balk at long hours for low pay, try pitching that deal to nurses. They are just as savvy as physicians about personal economics. Having them take over primary care under the current (or worsening conditions) will burn them out just as quickly and nurses will specialize or quit nursing in droves. There is no magical, “let’s just get someone else to do it for less” model in healthcare when we’re already scraping the bottom of the barrel in terms of ROI for providers of any stripe.
Physician scarcity can be ameliorated by setting doctors free to spend more of their time in patient care, and less of it on distractions (such as excessive documentation for coding and billing purposes). But the solution is not necessarily outsourcing that work to someone else. It’s killing it all together. Radical idea? My practice is doing that now and growing a thriving business to boot.
Primary care doesn’t have to be expensive. Most patients need less than a full hour of a physician’s time per year, an annual cost of about $350. In my practice, we bill for our time and we spend it however it makes best sense for the patient – via phone, email, office visit, or house call. It’s in our interest to see as many patients as possible, and therefore we are increasing access to services. Office wait times are non-existent because many issues can be handled via phone (patients are not required to come to the office for every and any request for the sake of billing).
What’s the catch? We don’t accept insurance. Patients can submit claims to their carrier for reimbursement for our out-of-network services, but we have opted out of public and private insurance plans so that we can spend our time with patients instead of coding, billing, and being beholden to third party documentation requirements and regulations. This system works marvelously for any patient open-minded enough to see that a high deductible health insurance plan (for catastrophic coverage only) saves them thousands per year in premiums, while their primary care “out of pocket” will cost a few hundred or less. The math works for all. Access is improved, costs decrease, quality is maintained.
Now that’s a true win for patients.
No matter where one stands on appropriateness and advantages of each patient being involved in self-diagnosis and treatment of their own medical problems there are two inevitable conclusions:
• First of all, self diagnosis and treatment are as natural as breathing and as impossible to extinguish as thought itself.
• Secondly, given today’s healthcare system, there always will exist a dynamic tension between self-determination of the individual patient and the powerful healthcare system which often insists on patients falling back in line and complying with orders.
Few would argue against the need for a powerful alliance that embraces the benefits brought to the table by both the practitioner and the patient. Simplistically, the physician would carry the role of healthcare consultant and guidance while the patient ultimately becomes responsible for the choices. Read more »
The famous late 19th and early 20th century physician, Sir William Osler, said that “a physician who treats himself has a fool for a patient.” How would he have felt about patients diagnosing and treating themselves? Would he have written in support of the Journal of Participatory Medicine or against it? I also wonder how he would have practiced medicine in the “information age” when many of our patients present with a diagnosis already made, right or wrong.
I recognize that bringing Dr. Osler into a discussion set in the information age is, perhaps, anachronistic. Yet I believe he still has something to teach the 21st century on the topic of patient participation. When he advised that “the first duty of the physician is to educate the masses not to take medicine,” he offered one of the earliest lessons on a physician’s role as educator.
He also said: “The great physician would treat the patient with the disease while the good physician would treat the disease.” For me, this marches lock-step with the reality of today’s patient as consumer and active participant in the doctor-patient relationship. Simply put, it is impossible to separate the patient from a pre-conceived and often well-researched opinion — correct or not. So to treat the “patient with the disease” requires me to think of my patient as an intellectual partner. Read more »
I often am asked how I incorporate wellness in our family medical practice, and I must admit that I’ve mixed feelings when it comes to the question because it implies that I’m not already trying to practice wellness simply by practicing medicine. I feel that the two are synonymous.
To those who want to know more about wellness and primary care, here’s my approach:
• I never try to sell anyone on a “wellness” program.
• I follow specific guidelines on certain chronic illnesses, mostly adhering to evidence-based guidelines and not expert opinion or opinion by committee.
• I offer the best advice I can to patients and try to guide them in the right direction when I feel they are taking pathways that worry me and that could be harmful (e.g. like using megavitamin and nutrient therapies or colonics, to name a few).
• I try to be as cost effective as possible when it comes to treatment.
• I see our patients once a year to comply with the legal definition of “face-to-face visits,” but not because scientific evidence substantiates this time honored ritual as “wellness.”
• I use calendar reminders in our electronic health record, MD-HQ to set up needed labs like cholesterol or Hgba1C or to schedule flu shots based on guidelines.
Read more »