Friday, April 09, 2010

The changing face of primary care

I ran into one of my patients today at the grocery. We chatted in the bread dept. about footwear and fiber, then met again in books. I was there considering whether or not I could justify adding yet another book to my 'to read' pile, she was just browsing on her way up one aisle and down the other. By the time we parted, I'd learned that her older son, once my patient, had moved home again and was struggling with depression. Her younger was now in his 7th year battling an HIV infection. Who knew I could learn more about her personal life at King Sooper's then ever I knew from our not infrequent exam room encounters?

This small town sort of intimacy in the middle of a moderately big city represents all that I love about my practice of medicine. Alas, it looks like things will change mightily in the coming year as my partner and I strike out in new directions in order to continue practicing medicine at all.

Strange how primary care is front and center in the middle of health care reform, yet remains undervalued and underfunded in ways that will soon completely preclude the sort of Mom and Mom shop that she and I run. In the face of falling reimbursements and rising expenses, here's what we view as our two choices:

The first is to become employees of a large hospital corporation. Economy of scale and deep pockets will remove the agony of the overhead--buying medical supplies and injectibles in quantities and at per unit prices of which we can only dream in our current situation. Being able to negotiate with insurance companies for contracts that two docs in a 1950's style little medical box could not begin to command. more funky offices adorned with antiques and artwork (and leaky basements!), no more elevator-free hop, skip, and jump from parking lot to office door, January 2011 would find us working out of a medical building reeking of disinfectants and cleaning products instead of coffee and popcorn.

The other option is a gradual shift to a membership practice. Many dollars short of a concierge version which requires an annual fee of $1,000 or more, this concept involves a much smaller cost, say $25/month, which not only brings in the sort of yearly revenue that covers property taxes and hazardous waste disposal, but also benefits members with 24/7 ask-a-nurse access, wellness and nutritional counseling, as well as e-mail access and same-day appts. While there is no requirement to join in order to remain our patients, this nominal-ish sort of fee would be each patient's affirmative vote that small practices reap big satisfaction for all.

Obviously, my language screams of my preference, but we worry, rightly, about 'willingness to pay.' Particularly in light of the new health care legislation, there is increasing belief that health care is a right for which one should not have to pay much at all. Our time frame here is short in terms of decision-making; I'd love to get your opinion--especially from my patients but honestly, from anyone who'd like to chime in--about what you'd like your future relationship to be with us or whomever your PCP may be. Feel free to use my e-mail address or to leave anonymous observations.


Anonymous said...

I live in Charlotte NC and see a PCP who left the big hospital practice for many of the reasons described in your article. Granted Charlotte is a larger city and his practice (sole practitioner) is in an upscale area, I am ever so grateful that I have a dr that truly listens and spends the necessary time with me. I too left the large hospital practice after seeing the same dr for 7 years. My mother died suddenly and afterwards I was spiraling deeper into depression. She wasn't listening during office visits and repeated calls to the nurse for help, referrals, etc. Her mantra: you will be ok, it takes up to 3 years to recover. I left the practice and found someone who would listen and work with me. There aren't many of your kind left. I don't know the answer, but I do believe a personal service deserves an environment conducive to preserving the ability to provide one on one time and attention. I have yet to find that in a larger practice or hospital affiliated office. My doc has two physicians assistants to help him, but he runs the show and runs it well.

Connie Barris said...

Interesting post...I live in Georgia.. small town but huge medical community.. I am also a RN that has practiced for 30 years so I have seen the ever changing medicare laws to now government mandated changes come and go. I remember when DRG's first come on board...And we thought we would die.. we survived.

Our community has had a big change in that our physicians no longer make hospital visits when their patients are admitted.. this is the responsibility of the Hospitalist or a specialist. Do I like it, heck no!

But to answer your question, if I hear you correctly...I want and have a physician who will listen and be my gate keeper... he will find the resources I need for whatever situation is going on in my life at that time...

PS and doesn't mind if I call from my hospital bed if I don't like what is going on!!!

thanks for your information...

Connie Barris said...

very interesting.. I did leave a comment...

I am in this wondeful (NOT) time of my life..

I think I will put you up on my blog for reference.. I need all the help I can get... ;)

Anne Morley said...

Hi Judy, I live in upstate NY. I vote for option 2. You and your patients will be much happier. I can't even picture you in that "corporate" setting you describe as a possibility.
If I was your patient, I would definitley be willing to pay that once a year fee.

I have a great family doc now. She reminds me of you. She listens and takes the time to explain..and she remembers that I'm a nurse and slants her advice that way. She considers the same options that I do. AND she can and will refer to alternative practitioners when she believes they can offer what I need. Our office visits are heavy on the side of talk and light on the side of exam which I like.

I am sorry that health care has come to this point where patients feel entitled, insurance companies dictate what can be done when, and good doctors struggle to hang on to their practices.

Anonymous said...

My dearest doctor, healer, confidante, and more,
Over the last 18 years we have built a relationship built on wellness, trust and attending to far more than simple aches and ailments. Over the last year in particular, you have guided me with grace through the bigger system as I have faced major health challenges. You are not only a gatekeeper, but a navigator. Not only would I pay a fee...since I believe what you and your partner offer is priceless, I believe I could fill your office with others eager to do the same for the kind of care you and yours provide. Your devoted patient, Rose

Anonymous said...

I am not one of your patients, but wish I was! In this situation, I would definitely pay the fee (if kept reasonably low) to continue to receive the same kind of service I believe you provide now. All too often (and often with we, as patients, partly to blame) doctors have forgotten that they are servants and in a service profession and only look at themselves as "Professionals" with a capital "P!" You are rare, indeed, and I wish I knew a doctor like you on the west side of town! Thanks for all you do!!!

juno said...

I am a patient. I'd be very willing to pay $25 per month to your practice. I have been appalled at what you get from insurance after I see you!
Alice Kober

Anonymous said...

Hi Dr. Paley...I am a patient, and although the $25 a month might be a little hard for me right now (I'm currently unemployed and having a heck of a time finding someone who wants to hire an administrative support professional with over 20 years experience!), once I DO finally secure a job, I'd be more than willing to pay it. I've been so comfortable with having CHIM in my life and as my providers that I can't imagine it being any other way. I know that when I come in, you and your partner KNOW who I am, where I've been, and where I'm headed, health-wise. You know I don't abuse drugs, so when I need them, you don't have any problem prescribing them. I have more confidence in both of you than I've ever had in a physician before, and I would gladly offer my "tithes" to you, since I don't attend or support a church. I feel my offering would be well spent, if it helped you stay right where you are, and just HOW you are! All blessings be yours, Erica

Sue Artone-Fricke said...

Thanks Judy for posting this. It's one of the things I like about you - that you share your thoughts with us. Yes, I would be willing to pay the $25/mo for several reasons:

1. I am able to do so at this time.
2. I appreciate you and your style of companioning patients, me for almost 20 years now.
3. I believe you witness to what's possible in healthCARE and I want to be a voice with you in promoting your m.o.
4. I'm confident you manage your business well.
5. I'm sure you care for persons who can't pay much, if anything, and I would also see my monthly/annual amount as contributing to a circle, or net, of care for others.

Many blessings, dear Judy. Sue

Anonymous said...

Though I can see the benefits of economy of scale, etc. of option 1, I would not be surprised if they also dictate how it's providers will treat their patients: how much time they spend with them, how many tests they should order so as to reduce liability...

I am not a patient of yours, but have been reading your online articles for some time now. Unfortunately, I have had to see many doctors (fibromyalgia...) and know how few truly care. I would have no problem paying $25 per month to your office so that you would be able to continue to provide highly-personal medical care.

Good luck!

Anonymous said...

I too, cant see either one of you in a hospital setting or other. If you championed me, i would be loyal and champion you also. I dont know how you decide who to champion and who not to, the losers in the long food chain of life., or your perceptions...heh. So, I think most patients will want to stay, but some wont be able to afford it. You all can work that out somehow...maybe thru increased fees for those with insurance or something.....idk....something.

Anonymous said...

I have a great doctor here in Houston who is in a solo practice.
I worry about him and how he will survive in the new environment.
I would happily pay an annual fee to him. I'm surprised in the 2000+ pages of the bill they didn't outlaw this sort of idea.

Go to a Tax-Day protest today - vote in November.

Cindy said...

Judy, you've been my Doc thru thick and thin. I've watched your kids grow up in the pictures in your office and adore your quirky art choices. I can't see you being happy in a large medical coporation and fear your wonderful sense of humor would be squashed by "the man". My vote is to shift to a membership practice.

However, I also fear the realities of medical costs: my prescription drug plan has increased costs and my Plan F Medicare supplemental ins. has increased a whopping $98/month.
Frankly, I don't know how I can handle another monthly medical cost but will certainly stay with you if possible. After all, you never doubted my CFS/Fibromyalgia symptoms (geez, has it really been 20 years ago) and have helped me through hard times. I'd like to be there for you.

femail doc said...

Anon in NC: Thank you for comparing your experience with both kinds of practices. That contrast is very helpful to me.

Connie: We no longer make hospital calls either. I think patients would be better served if we did, but it's completely impractical AND not reimbursed. Thanks for your thoughts!

Anne: That pretty much describes internists, heavy on talk and light on exams--and that cognitive interaction is priceless! I think you can tell I'm biased towards option number 2 as well. Just don't know how it will play out!

Rose: You know I often feel like a fellow traveler with you, and I've always 'got your back.'

Anon on the west side of town: I so appreciate your kind words and encouragement.

Alice: It was good to see you recently, and thank you for your support in person and in the blogosphere!

Erica: Adele and I appreciate your support. It is my belief that this member program will give us the freedom to continue to adjust our fees for those who can scarcely pay for a visit much less a membership.

Sue: You truly have a very clear view of our dilemma, and your analysis gives me hope we can work it out. Thanks!

Anon with fibromyalgia: You are certainly well aware of the value of a relationship with a doctor given the complexity of your condition. I too fear that an employment situation might compromise such a relationship.

Anon: This would not be an exclusive arrangement, so those who cannot afford it would not have to leave the practice. No choices necessary!

Houston anon: These troubles and the troubles of such "Mom & Mom" practices like ours predated the new healthcare reforms, but I too fear that upcoming changes will hasten the demise of medical care as we know it.

Cindy: Again, let me reassure you that if we go to this membership option, we will not be a "membership only" practice. Our hope is that this small fee from those who can will enable us to stick with those who can't.

Mauigirl said...

Just catching up here and will add my vote for option #2. My PCP here in NJ is in a small practice with 2 other doctors and she's great - would hate to have to go to a big medical building in that kind of corporate setting you describe. I would totally be willing to pay an additional fee to keep seeing a doctor like her - or you! Love the idea of ask-a-nurse service. My doctor uses the RelayHealth service where she is available on e-mail through I can ask her questions or ask for Rx refills, etc. She always responds very quickly.

Anonymous said...

I am your patient - one who is on Medicare and who also is overdue for an annual check-up - I'll be calling for an appointment. I have been blessed with good health, so haven't had to see you very often. I can afford a monthly fee and would gladly pay it to see you practice the way you want to, without having to accept corporate dictates. I appreciate the kind of practice you have and also appreciate your true interest in and involvement with your patients. As I said, I have been healthy and haven't needed much care, but that could change at any time, and should it, you're the one I want to go to. Beverly

Anonymous said...

Judy -- I am a sometime-patient, not very good about taking care of myself, etc. (probably one whose $25 you'd prefer not to have --lol!)
Just wondering, would you still accept private insurance, would you still be a preferred provider for any insurers?
How would you encourage patients to pay the $25/month? What if your sometime-patients, or your frequent ones, did not pay? Would you send a bill? Call? I could see this being awkward. Finally, if you tried option 2 and it didn't work for whatever reason, would that diminish your standing with the big group practice a couple of years down the road? In other words, are they counting on your bringing your current patient load with you?
I like option 2 myself as I hate the corporate practice of medicine. I just worry that unless you had a formal agreement with patients who can pay, many would not and you would be in the same financial boat. I'm very sorry it's come to this. I would try to get as many patients as possible to pay for one year up front (this would obligate you for a year, as well) and see if the numbers work with whatever response you get at the outset. For me, it's preferable not to have to worry about who has paid, who hasn't and why, and wonder who will, etc. Finally, the icky question, how would you feel about those who didn't pay -- particularly those who seemed able to but simply did not? BTW, I would pay upfront -- in part because I'm disorganized and would need to, and in part because I strangely prefer budgeting for one big payment rather than multiple smaller ones. Good luck in your decision making!