Good night, and good luck
This will be my 41st, and last, "Making It" entry. I’m still making it. Hope you are, too.
I’m giving it up because I don’t have anything else to say. That seems like a good enough reason to me. I never intended to become famous, or write a book, or go on the lecture circuit. This was just my best effort to pay back some of the debt I owe to the profession I love.
For any family practice resident with the moxie to manage your own practice, as opposed to working for a salary and taking your marching orders from Big Brother, there’s plenty to chew on in these columns.
If you want a short course, read “Solo Practice: The Way of the Future” from Family Practice Management in 1998. Or read the redo in 2003 – pretty much the same thing. C.S. Lewis once wrote that "all that is not eternal is eternally out of date." I haven't written anything eternal -- but nothing important in the running of a good, profitable practice has changed in the last 12 years, or the last 30.
For the long course, “Making It” is largely an expansion of those articles. Start at the beginning. It won’t take more than a couple of hours. If you have questions, email me or call my office (785-271-6161) or cell (785-845-3792) or home (785-357-1854). My wife and I are among the 27 living Americans who do not screen our calls. If you phone, and I hear the ringtone, I'll answer. That's the way it works for patients, too. It's a good policy. Trust your patients, and they won't abuse you.
When a new family enters my practice, I give them a notebook to keep their medical records. It has about 20 pages of general information about diet, exercise and rehab of common problems. I wrote it in 1986, and I have deliberately never changed the dot-matrix original. When it comes to living well, things don’t change much, either, and I want them to know that.
Running a productive practice is like that. The practice of medicine changes all the time. The practice of practice is “same ol’, same ol’.” So when I don’t have anything new to say, it’s time to shut up. But what I've said will be just as applicable a decade from now, because the habits of highly effective clinicians will be the same in 2020.
The only question is whether you want to be one of them.
The collapse of health care "reform"
I've had a draft of my "final" blog pending since roughly the middle of November, awaiting administrative action on a future incarnation (stay tuned). Now political events in Massachusetts have eclipsed my opportunity to appear prophetic -- so trust me, this is what I wrote back then:
As I write this, Washington is on the cusp of health “reform.” I want to go on record, so I can say “I told you so” in a few years, that this reform (praised by the Academy) will be an abject failure. Before long we’ll be back to the drawing boards for a do-over.
Here’s why: All legislation currently under consideration has no provision for cost control, and medical costs are going to bankrupt us within the decade.
The predicted cost of Medicare in its first year (1962) was $12 billion. The actual turned out to be $110 billion. So much for the prophetic ability of the Congressional Budget Office. The projected figures you read in the paper every day are sheer fantasy. Hardly anyone points this out – certainly not the AAFP, which would forfeit its (assumed) place at the trough.
If you want a good laugh, followed by a gut ache, read Dr. Epperley’s letter to Rep. Pelosi on Nov. 3. He praises HR 3962 for a few provisions that will not survive the legislative process, while begging for the biggies to be added: tort reform, permanent payment increases for primary care, and CMS’s most recent skewering of family medicine. And don’t make that 21-percent cut in Medicare payments on which the entire phony edifice of cost savings depends!
There are only two ways to control costs. One is a single-payer system, with the federal government the payer. Control would come through denial of cost-ineffective services and rationing, leading to queuing. I could live with that. I enjoyed my five years in the U.S. Army, and if they had agreed to let me stay at Ft. Bragg for my career, I’d be a retired Colonel by now.
For a good example, consider the response to the USPSTF recommendation that routine mammography not start until age 50. This recommendation is not unreasonable. It is based on cost-effectiveness, including the costs of false-positive tests. Now witness the outrage. Get used to it, if ObamaCare passes.
Seven or eight years ago my wife and I spent a delightful week at the Stratford (Canada) Shakespeare Festival. We stayed at a small bed-and-breakfast run by a gourmet cook who once served as the top health official for the province of Ontario. He was chuckling after breakfast at the newspaper headlines, in which the Canuck version of USPSTF had just recommended that women no longer be trained in breast self-examination. "Just wait till you see the response tomorrow," he laughed. Oh, my. Full-page pictures of women who had -- guess what? -- discovered their cancers by self-examination. Every such recommendation becomes a political football.
The other way is self-rationing through health savings accounts, or something similar. That’s the only way to avoid the specter of elected officials making medical decisions, which seems preferable to me. I spent a couple of years fighting a law in Kansas that mandated the exclusion of students from school if they had nits in their hair, despite authoritative evidence that the presence of nits, after treatment with a pediculicide, was irrelevant. Turns out that the law has a hard time keeping up with science.
Does that sound like fun?
Now I'm going to say again what I've said many times over the past five years in FPM or this blog. The only rational approach to reforming our system is to start the long-term project of teaching our patients to be consumers of health care, like they are consumers of food, shelter, automobiles and electronic devices.
The insurance industry has strayed so far from the principles of insurance that our patients have lost their minds. Health savings accounts can teach them to think again. If everyone had a high-deductible HSA, with a $25 co-pay for routine visits to their primary care physician, the insanity would cure itself in a decade.
Price signals would govern the introduction of new procedures, drugs and devices -- without bankrupting the country through profligate consumption of Other Peoples' Money.
The government would have to replace Medicaid with contributions to the personal accounts of the poor and uninsured, who would become smart enough to spend this money responsibly. Everybody would be covered, and everybody could afford primary care, which is dirt-cheap, relatively.
Barbara Starfield told FPM what needs to happen to fix this problem, but she didn't say how. Health savings accounts are how. All of the things listed would happen automatically, without bureaucratic oversight, through personal private initiative, if everyone had an HSA.
There. Now I feel better.
Advice and consulting
Here's a recently posted comment to my Oct. 2 post, "RVU Ramblings":
"I am in my second year of residency with desires to practice OB/FP. I agree with your point about med-peds, however there are so many forces at work. Many of my colleagues go on to practice in urgent care, small town ER’s or Medicare-based practices for a weak salary compared to subspecialists. So how do I help Family Medicine survive (appeal to me and pay off my student loans)? Your setup is essentially what I’d like to be doing. Do you have any advice for a budding family physician who wants to own or partner in an OB/FP practice? Is an OB fellowship worth my time? I’d like to understand how to set up and run a successful practice 6 months prior to graduating. This gives me about a year. Where do I start?"
I wish I knew how to help this young family physician. This blog was intended for folks like him, and I think there is plenty of good advice to sort through. But his letter made me think about the difficulty of making absolute pronouncements in a profession as complex as ours. Part of the problem is that, just as "all politics is local," so is all medical practice. And then there is the issue of personality, and luck.
So here is a hatful of imponderables:
1. How much of my success is due to the fact that my market is dominated by Blue Cross, and that their payment schedules have always been fair to family physicians?
2. If I had not taken an Army health professions scholarship, which resulted in my finishing residency with no debt and money in the bank, would I have had the freedom to start a solo practice, and do it the way I wanted to?
3. Was it just luck that my residency program offered me unlimited access to patients, thanks to young, recently trained specialist mentors who had every incentive to teach me quickly and let me have just enough rope that I couldn't hang myself, an obstetrics unit amply populated with laboring women 24/7, and a Filipino colonel who introduced vacuum extraction to America?
4. What if my six years in the ER hadn't enabled me to save enough money to buy a medical building, and convinced me of the need for an urgent care facility running in tandem with my office? And was it luck that I partnered in building ownership with an excellent FP from my residency program who also wanted to go solo, but share coverage?
5. To what extent was my success dependent on a CPA with a deep understanding of medical accounting, who set up my reports in such a way that I could understand them?
6. Is it just luck that I've worked with the same employees for most of my career? Sure, I treat them well, but really – none of their husbands ever transferred to another town!
7. My Army family practice office experience taught me to be lazy. After all, we had one nurse for every 4 doctors, which is pretty much a rate-limiting step, so who cared? My emergency room experience taught me how to move and think fast. And never being on salary in private practice put a big burr under my saddle. Once I learned how to hustle, though, I came to like the stimulation. Just luck?
8. I started exercising regularly halfway through my life, at age 30. In the beginning, it was because I thought I should, and I wanted to practice what I preached. In the end, I came to love it. The benefit is that I never experience dead-dog fatigue. I depart the office with as much energy as when I arrived, leaving plenty of reserve for family and hobbies. Is that commitment teachable, or inborn?
9. At times I think I am a very selfish person. (There is also evidence that I am a very generous person; it is possible to be both at the same time.) From the beginning of my practice, I was determined not to be overwhelmed by its demands. So I set parameters. I scheduled my day, and I finished on time. I decided how much vacation I wanted, and I took it. I taught my patients what I expected, and they responded. Was that selfish, or just good sense? If it is good sense, can it be taught?
So who do I think I am to give specific advice?
Rethinking the EMR
The few hardy souls who have read this blog from the beginning, 15 months ago, know that my primary purpose was to enhance the financial productivity of family physicians. My secondary purpose was to help increase the number of American medical students matching to family practice residencies, which I am convinced will only follow the money. Call me cynical.
Along the way, I started carping at the Academy. This was not my original intent. It only happened when I began to suspect that Academy policy might be inimical to increased FP earnings. While I admired the courage and initiative it took to launch the patient-centered medical home (PCMH) demonstration projects, I was shocked that there was no method of financial scorekeeping incorporated in the project design. (See my previous post.)
Since I am a pragmatist, not a utopian, that raised my hackles.
The more I learned, the worse it looked. The medical home guidelines seemed to be written with large practices in mind, although the great majority of FPs work solo or in small groups. The EMRs promoted by the Academy were expensive, lumbering dinosaurs, a fact that was explicitly noted by the review team. The uncritical support given by the Academy to ObamaCare, whatever that turned out to mean, seemed foolish given the lack of cost controls in all plans under consideration. The AAFP president, at a White House “summit,” sounded sycophantic. And when the Wall Street Journal published a silly editorial bemoaning the potential siphon of funds from specialists to generalists, the Academy didn't respond.
By now all my bells were ringing.
Then I couldn’t convince my state academy to allow a debate about the PCMH, which badly needs an honest debate. Then I went to the national meeting, and the Town Hall had been moved up to a “delegates only” time slot.
I feel like a Grinch who is trying to steal Christmas. Gone is my optimistic, forward-looking personality. I have been mugged by reality, and let me tell you, it’s no fun.
So I’m going to wrench myself back in a positive direction. Let’s start with the EMR.
Dr. David Kibbe, the closest thing the Academy has to an IT guru, wrote an excellent article for FPM about what is wrong with the current EMR approach. What we need in EMRs is modularity, not comprehensiveness. We need “plug-and-play” capabilities that can be tailored to specific practice needs, and swapped out when better ideas come along. We don’t need high-overhead vendors who control vertically-organized software that makes aircraft carrier redirections in a swift-boat economy.
Dr. Kibbe writes, “It also signals that it's time for the AAFP to reconsider its recommendation that members adopt comprehensive EHRs.” What we want are iPhone apps, not mainframe computers.
In a lengthy Wall Street Journal interview, the owner of a company designing web-based EMR components (“cloud computing”) makes the same point. “If a regulation changes or an insurer adjusts a payment policy, it is reflected on Athenanet almost in real time; on the clinical side, the program can adapt at the same rapid pace as medicine itself. … the main benefit is the ‘collective intelligence’ that he [CEO Jonathan Bush] is starting to weave together from the 87 percent of American physicians who practice solo or in groups of five doctors or fewer.”
Locally, the president of the Kansas Medical Society (KMS), Dr. Joe Davison, is a family physician. With his leadership, KMS is promoting a Health Information Exchange – which would use cloud technology to create a platform solving the problem of interconnectivity among the thousands of different computers and medical software programs in our offices and hospitals.
Now I’m not dumb about corporate politics and finances. Web-based solutions threaten the fat cats in a lot of software companies who may directly or indirectly support the AAFP.
But surely this is more deserving of a dialogue than a monologue, which is what we have been given up to now.
I have been waiting for years for the AAFP to show some political leadership. This is one place to start.
Health savings accounts: friend or foe?
Back in the days when the Academy hosted a town-hall forum for hoi polloi like me at the Annual Assembly (I'm thinking of Chicago, 2007), I got up to ask a question. Why, I wanted to know, did the Academy not promote health savings accounts?
The answer was that they did, as long as preventive services were subject only to a nominal co-pay. If preventive services were completely out-of-pocket, so that patients had to pay for their physicals and mammograms out of their health savings account, that might serve as a disincentive to primary prevention.
I thought it was a fair answer to a fair question. And I've since learned that the Academy does offer HSAs and a high-deductible health plan to its employees. Still, the Academy in no sense of the word "promotes" HSAs on a national level. I'm sure there was a resolution or pronouncement somewhere back down the road in support of the HSA concept. I know how politics works.
HSAs produce decentralization of power; cost-effectiveness decisions devolve to patients, who would demand the knowledge needed to make good judgments, once they figured out how the new system works. It wouldn't take long to understand, because they are used to buying cars and washing machines.
But bureaucracies don't really, honestly, want decentralization. They believe in centralization, as in "let me make those decisions for you, with other peoples' money." Patient-directed medical decisions are the enemy.
In an article that I have previously recommended as the best I have ever read on this subject, David Goldhill writes in the Atlantic Monthly that if a 22-year-old starts at his company today earning $30,000 and health costs grow at 3 percent, by the time he retires he'll have paid out $1.77 million in premiums, lower wages, out-of-pocket costs and both sides of the Medicare payroll tax. Mr. Goldhill wonders, if all that money were instead available via an HSA, including the ability to borrow against future contributions, couldn't we all afford to pay for our own care?
That's a fair question, too. It's important because health care is going to bankrupt us, and there are no cost controls in the bills under consideration in Congress. We know what happens when we try to promote evidence-based, cost-effective medicine through centralized controls: We're accused of advocating "death panels." But what if those decisions were made by the affected individuals, with the advice of their family physicians?
Writing in the Wall Street Journal, Rep. Bill Cassidy notes that the "Kaiser Family Foundation found that HSAs are 30 percent cheaper than traditional insurance policies with similar benefits, that those with HSAs use preventive services frequently, and that 27 percent of those currently covered by HSAs were previously uninsured."
R. Stewart Eads, MD, a primary care physician in Mount Pleasant, S.C., writes that "because the funds in the HSA are our money, we are appropriately frugal with respect to our health-care spending. We comparison shop for specialty visits, procedures and medications. We make sure that we are getting the most 'bang for the buck.' Isn't this the alleged goal of those currently crafting health-care 'reform' legislation on our behalf in Washington?"
Nobel laureate in economics Vernon Smith says the same thing. We have to get back to the normal, everyday state of affairs where the patient pays the doctor and insurance helps out in catastrophes. That's the way every other kind of insurance works. It doesn't pay the plumber when my disposal quits working. It helps out when the toilet overflows on vacation, and water damage ruins the floors of the story below.
I would credit my HSA with saving Blue Cross a $10,000 surgery. After a volleyball injury left me with a torn medial meniscus, I was sorely tempted to go under the knife. Two things gave me pause: first, that the first $2,500 would come out of my HSA, plus 20 percent of the next $7,500; second, a meeting with an old friend, the starting safety on Kansas University's 1969 Orange Bowl team, who submitted to surgery for a similar injury and developed osteochodritis dissecans, resulting in a total knee replacement. I took glucosamine and chondroitin, pursued low-impact cardiovascular exercise, and after two years I'm back to running 12 miles a week with no pain whatsoever.
Did the HSA make the difference? Life is too complex to say. It didn't hurt.
Skeptics will say that "sure, that's great for you intelligent folks in good health. What about the dummies with diabetes?" My response to that is that life is too complex to say. It depends, in part, on your philosophy of mankind. Mine is that dummies with diabetes are human beings too, and they are capable of making reasonable decisions about automobiles, washing machines and knee surgery -- with the right help from me, at least about medical affairs.
Of course, with the health care reform proposals currently on the table, it's likely going to be a few years before patient-directed medical care gets its chance, when the system finally collapses.
My worry for the future of family medicine, as I have said before, is that our specialty has lost its elan vital, its evangelistic and missionary optimism. I'm not sure that family physicians want to sell patients on the value of our services, because I'm not sure that we all believe in the value of our services.
That's a sorry thought.
I was killing time last week with Super Freakonomics, a mildly interesting compilation of counterintuitive economic factoids, when I was struck by a term that explains a lot.
The authors were attempting to explain why nobody is ever going to do anything about global warming, other than what politicians do, which is contribute their fair share of hot air and methane. The problem, they claim, is the problem of externality.
Externality is the term economists use to describe a situation in which I create a problem, but somebody else pays the price. That is, the cost of my action is “external” to myself.
Global warming is, maybe, kind of, a byproduct of industrial civilization. We Americans contribute more than our fair share by living the Good Life, which includes automobiles and clothes dryers, both of which my parents lived without in the early 1950s. Honest. Now we are asking Indians and Chinese to forego the lifestyle we have come to enjoy, and the answer is (no surprise here) "Hell, no."
If we’ve been externalizing the problem for the last half-century, why shouldn’t they have the same privilege? Good luck explaining that to them in Copenhagen, President Obama.
But it struck me how often I feel like the Chinese. When I get a preauthorization request for a medicine, who benefits from the work of my nurse to fill it out and fax it back? It ain’t me. An insurance company is trying to save some money, and using my free labor to do so.
When I get a four-page disability form to complete, who benefits? When an attorney asks me to appear at a deposition or be available at a moment's notice to testify at trial, who is footing the bill? When a consultant prescribes a drug for a medical problem or a dentist performs a root canal, and makes himself unavailable for refills or questions on the weekend, why is it my problem just because I make sure someone always answers the phone?
The challenge is to figure out a way to make these yahoos internalize their externality, which is a fancy way to say “feel the pain they cause.”
Because we are lowly family physicians, we have to take this problem seriously if we want to eat dinner with our wives and children. Sometimes, I confess, passive-aggression is the best tool.
For my patient’s attorney, I always ask if he is wanting expert testimony or mere factual testimony. He has the right to subpoena me, for free; I have the right to do absolutely nothing more than read what I have written in the chart. If we wants an interpretation or explanation, well, now I’m an expert, and my fee for that work is my hourly gross income. The trial will be out of town? Now it’s getting expensive, because every minute I’m asked to be out of the office is going to be paid in advance.
That’s why I’ve never had to testify in court.
Forms are a time-consuming hassle, and I find that I just can’t fill them out accurately unless the patient is with me, in the exam room. The record is never sufficiently detailed. That costs the patient a co-pay, and the company (indirectly) the rest of the cost of the visit.
Because I can’t punish my patient for the dereliction of other professionals, and I can’t get my pound of flesh out of them, I just have to let them externalize all over me. Ditto with preauthorizations, unless I simply refuse to use expensive drugs. Because I’m fanatic about cost-effectiveness and generics, I suspect I suffer less than my colleagues.
Old business: In a past article I recommended investing in offshore hospitals if American medical care keeps heading toward the edge of a cliff. A fascinating front-page story in the Wall Street Journal on Nov. 21 (“The Henry Ford of Heart Surgery”) shows how close we are.
India’s Dr. Devi Shetty, once Mother Teresa’s heart surgeon, is going to build a hospital in the Caymans that would serve Americans seeking lower-cost health care. And he can do it. His flagship 1,000-bed heart hospital charges an average of $2,000 for open-heart surgery, with better results than in America, where the comparable charge is $20,000 to $50,000.
Highs and lows of the AAFP convention
Every two years I go to the annual AAFP convention, almost without fail in my long career. This gives me the benefit of perspective, which I will now pass along.
This year’s event in Boston was exceptional. If you’ve never gone, you should. It might become addictive.
Since the Chicago convention in 2007, there has been a major change in format. Previously there were “headline” presentations in a huge hall, with a confusing variety of other talks in several formats – lectures, demonstrations, conversations, etc. The schedule was so overlapping and confusing that I sometimes missed events I wanted to hear, or could only work in half of the presentation.
All that chaos was junked in 2009, hopefully for good. All the events, except for fee workshops, were one hour in length with 30 minutes between. Many were repeated, so I didn’t have to wish I could be in two places at one time. The half-hour intervals provided plenty of time to breeze in and out of the exhibition hall, if I wanted to, which I didn’t. But that’s just me, this year. In the past I enjoyed the dog-and-pony shows.
For the first time I stayed at the hotel attached to the convention. You have to book early. The advantage was the ability to easily stroll down to the optional breakfast and dinner meetings, which were useful and also provided a free meal – a good one, in all cases. I could even get in a quick workout in the exercise room between lectures, which is impossible if you're using the shuttle buses.
The result was that I arrived Wednesday around noon, left Saturday morning after running in the 5K race and squeezing in one more lecture, and accumulated 40 hours of group CME credit. Many of the presentations gave 2-for-1 hourly credit because they were “evidence-based,” even if they weren’t really (listen to the popular "Am I Hungry?" diet talk, and you’ll see what I mean). That’s a bargain.
The presenters are uniformly qualified and useful. Once upon a time most of them were experts in other specialties. Now we've grown our own, and they think like family physicians. When I sit down for the lecture, all I want to know is if I should be doing something different. My habits are well established; that's the advantage of being a veteran. When a family doc presents evidence that I should change a habit, I usually do. The result is that I leave the convention with a few things that I want to change back home.
So kudos to the Academy. The annual meeting is as good as it gets.
Now for the downside.
I missed the annual town-hall meeting with AAFP leadership, which apparently happened during the early part of the week when only the poo-bahs were gathered for their Order of the Moose convention. [Editor's note: This is referring to the Congress of Delegates.] You can tell them by their suits and the decorations on their assembly badges, which make them look like South American military dictators.
Although I poke fun (partly because of my aversion to committee meetings) and although their aspirations do not make my heart glow, I can appreciate their willingness to be active in the political process – unless the political process is all they do, because they work in academic centers. In that case, it's a paid vacation.
I just think we're overdue for an honest, no-holds-barred discussion about the direction of our dying specialty. Enough with the happy faces and glitzy promotions. We need a town-hall meeting that isn't buried in safe territory and that offers members not only a chance to speak but also a chance to cross-examine perfunctory answers.
The president of the Academy came to speak at the Kansas meeting this summer on the patient-centered medical home. I asked those in charge if we could make it a debate. The answer was no. I could, however, drive to Wichita to ask one question at the town-hall meeting. That was too much driving to get one answer.
As I was taking cover in the Boston chill prior to the Saturday race, my ear was bent by a political aspirant from the midwest. He had lost his bid for a seat on the board, and he was lamenting that no one represented people who really ran full-time family practices.
I don’t know if that’s true. But the few folks like him who are willing to make the sacrifice – because their service comes right out of the bottom line – are the salvation of the specialty, if it can be saved.
The economics of the health care industry
On Sept. 25, I referred readers to an article I wrote on the health care debate for Front Porch Republic. It was an overview, and as such made no attempt to provide background material supporting or clarifying my views. It sparked a healthy debate, revealing to me how woefully ignorant even intelligent Americans are about the economics of our profession.
Following a recommendation from reader Dan Schmidt, I just read a long article from The Atlantic entitled “How American Health Care Killed My Father.” Don’t be put off by the title; it isn’t a rant. Rather, it is as close to perfection as anything I’ve ever read on the subject of health care economics. Every point and every example rings true to my experience.
If you have any interest in the subject, which will determine the future of our profession and now controls 18 percent of our economy, please – read this article.
When you do, you’ll realize the futility of any attempts to shoulder family medicine to the front of the federal trough. Oh, I know; at the moment, current legislation will give me an 8 percent raise in RVU compensation next year, probably to be snatched away the year after. Instead, our specialty's leaders should be the voice in the wilderness crying for a free market in health care services, where we would quickly demonstrate our indispensability.
Sometimes it takes a famine for people to appreciate farmers.
Fascinating excerpt: “Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings – say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime — roughly $4 million in total.”
And on the other hand, we have a Wall Street Journal lead editorial that can’t discern its terminal colon from a terrestrial excavation.
The editors are upset that the Senate Finance Committee bill authored by Democrat Max Baucus would increase primary care compensation at the expense of specialists. This is an assault on the free market, they opine, blissfully unaware that it was federal regulators who created the income disparities that Sen. Baucus is attempting to scale back.
Tell you what: Sometimes the ignorance of educated friends makes me want to weep.
However, I’m sure the AAFP leadership has ripped off a stunning riposte to the Journal, which is always willing to print a letter from the loyal opposition. I’ll let you know how it turns out next week.
In the "Practice Pearls" section of the latest Family Practice Management, Kent Moore cites the Medical Group Management Association (which gives us the more reliable health statistics in America) on the average work RVUs generated by family physicians not doing obstetrics in 2007.
After a sentence like that, take a deep breath. The figure is 4600.
That got me wondering how many RVUs I generate per year, since I’m often prattling on about productivity. Right on time, Blue Cross sent me the rolling report on my efforts for the last three years, reproduced here:
If you divide my RVUs for this three-year period by three, and divide by 0.85 (Blue Cross is about 85 percent of my business), you get roughly 8,000. Admittedly, this includes about 20 obstetrical deliveries per year, which is hardly a back-breaking number. Remember, too, that including obstetrics (since I have given the hospitalists my inpatient work) I only work about 40 hours per week, 220 days per year, with about eight weeks of holidays and vacations.
I’m talking to medical students and family practice residents here. You know, those of you who told the Admissions Committee you wanted to go into primary care, or actually chose to do so. Now you’re wondering if it’s a viable choice.
Here are random thought bearing on that choice.
1. If I can generate 8,000 RVUs per year working the same hours as a state employee but enjoying the stimulation of intellectual challenge and terrific personal relationships, avoiding the administrative burden of the patient centered medical home while providing a place where every patient knows every one of my employees and vice versa, and while earning as much money as the average cardiothoracic surgeon, what’s not to love about this specialty?
2. What’s wrong with the practices of all those other family physicians?
3. In his blog, Kent Moore also asks why (based on a Health Affairs article) a family physician would choose to spend an average of $65,000 to comply with the diktats of insurance companies. My answer: That’s half of my expenditure for salaries, so it must be nuts. Where do people get these figures? My nurses must spend at least 90 percent of their time doing meaningful service for my patients.
4. I’ve done my level best to charge Blue Cross for every legitimate 99214 or procedure (thank you, Kent and Cindy, for an excellent column). Still, I keep proving to be 18 percent more efficient than my peers – the ones, I assume, doing only 60 percent as much work as I do. How can this be?
5. I wrote about an old friend and an old student in a recent blog post. The former quit doing OB 10 years ago and is coasting toward retirement with an aging patient panel; the latter doesn’t plan to do OB at all, which is increasingly common among FP residents. I know that OB can be inconvenient, and scary. In the last 24 hours I did a delivery at 3:30 a.m. and a vacuum extraction at 4:30 p.m (followed by a shoulder dystocia resulting in a fourth-degree laceration requiring careful repair). My question: If family physicians give up OB, and therefore a preponderance of potential pediatrics, why choose family practice over med-peds?
As I draw near the end of a year’s worth of blogs, I understand much better why I am successful, and what other family physicians need to do to be successful.
But I am losing confidence that family practice will survive.
A little reason to the health care debate
Once upon a time I wrote an article for FPM called "Ten Hard Questions About the Future of the Specialty." It generated a lot of response, but most of the questions still haven't been answered.
So, having failed at a simpler task, I recently cranked out 3,000 words on the subject of "Ten Key Questions Framing the Health Care Debate." It was written at the request of an editor at Front Porch Republic, a blog dedicated to "crunchy conservatism," that form of conservatism that is also environmentalist and localist in its philosophy.
Go there if the subject interests you, and jump into the conversation. The zanies are winning the battle, and we're losing the chance to have a civil debate.
The amphetamine generation
Yesterday an old friend stopped by for a visit. Jack and I ran cross-country against each other in high school, pledged the same fraternity, moved out together into a rental house (the three guys upstairs ended up in medical school, the three downstairs smoked dope – this was the ‘60s), and graduated together as physicians. Probably hadn’t seen him in 20 years, though, as we went to opposite coasts for our family practice residencies.
Talking to him about life in California reinforced my conviction that all medical politics are local. Managed care is still maybe 40 percent of his practice (it’s now zip for me) and Blue Cross pays him 90 percent of Medicare values (it’s much better in Kansas).
Jack is smart, dedicated and fit. He sees patients the same day they need to be seen, and his practice schedules office hours until 8 p.m. Even on days when he doesn’t have late hours, he may not get home for dinner. As reimbursement has been squeezed, he has responded by simply seeing more patients each day, up to 36. Don’t worry about the quality of their care.
Still, it hasn’t been a hardscrabble existence. He owns a condo in Hawaii and a 700-acre ranch in northern California, to which he escapes to mend fences weeks at a time. It’s a five-hour flight to Hawaii, and a five-hour drive to the ranch. But he’s kept the same wife, a fine one, and raised three boys in the process.
He works at medicine more than I do. That’s just bad luck, but more docs want to live in California than Kansas. As he points out, there’s warmth and sunshine every day. That’s the same argument the Left-Coasters made when Utah tried to poach businesses with TV ads promoting low taxes: “Kiss your assets goodbye” is the way they put it. California responded: “Who wants to live in the desert?”
The solo FP with whom I own a building worked hard for a long time, but he’s smelling the roses more these days. Not roses, exactly. He keeps a live-aboard sailing yacht on the Chesapeake.
Why the shameless capitalist-pig boosterism?
Because I’m conflicted, as anyone can tell if they've read these posts from the beginning, last October. On the one hand, I believe that the income delta vis-à-vis the procedural specialties is pirating the primary care physicians we need to make health care work. On the other hand, if you’re willing to work hard, family practice still offers a better life than maybe 99 percent of the other opportunities outside the medical profession.
I had a couple of beers with an old student from the Great Ideas class I taught for six years – at the private school I started in my spare time (there’s that lifestyle argument again). He’s in his final year of a family practice residency and halfway believes what I’ve been preaching. He confirms that his classmates don’t have much stomach for the rigors of private practice.
The dénouement is this: Due to this generational tectonic shift in animal spirits, the AAFP is forced to gallop to the rescue with an initiative that chiefly appeals to bureaucrats, and individuals who used to occupy the low end of the animal spirit Bell curve – which has now shifted to the left.
I suspect this is why so many of my college-age patients make an appointment to beg for Adderall to get them through finals. This is a generation that needs chemical pepping-up. (Mine apparently needed marijuana, but let’s not go there.)
In the interim, I just got word that I passed my boards, so I get another decade to watch the world pass me by.
The Nanny Practice
Due to pelvic pain without a clear etiology by history and physical exam, you schedule an abdominal ultrasound for your patient at a different facility the next morning. Which of the following best describes your personal responsibility for follow-up of this test?
a. You tell the patient to call for a report next week if she hasn’t received results by phone.
b. You tell the patient to call for a report the next afternoon if not contacted by your nurse.
c. You ask the ultrasonographer to call you on your cell phone when results are available, and then you call the patient personally.
d. You set your PDA alarm to notify you 60 minutes after the scheduled sonogram, and you call the ultrasonographer for results.
e. You set your PDA alarm to notify you to call the facility to see if the patient shows up at the time of the exam.
f. You set your PDA alarm to remind you to call after breakfast to remind the patient about the test.
g. If the patient does not answer or show up, you call her work, and if she is not there, you notify the police to put out an APB and escort her to the facility.
From that spectrum of choices you can catch my drift. It is not a simple choice, because it involves two competing values: to do your best to assure a good medical outcome, and to do your best to encourage and empower the patient to take responsibility for her own care.
Last night I watched a DVD of The Soloist, the story of a schizophrenic Juilliard dropout homeless on the streets of Los Angeles, and the reporter who tries to “help” him. It is a frustrating task, because society refuses, as a matter of law, to force a psychotic to take the medicine that would allow him to function.
It’s a story I saw played out before my eyes in 1975, when I was an intern in charge of psychiatric services at a medical school emergency room. The ACLU in those days was judicially emptying the long-term psychiatric facilities, arguing that patient autonomy trumped imposed medical care.
On March 20, 1981, Bradley Boan marched into the emergency room and murdered a doctor, a nurse and a patient. I had admitted him several times, only to see him exercise his right to be crazy the next day. The lawyer for the families of the victims considered naming me in a lawsuit, but reconsidered.
Go figure. No one ever said value judgments were easy.
So where do you stand on the Nanny State paradigm? The legal profession, and society in general, is deeply conflicted on this issue. Are you going to make 14 phone calls to track down a patient who fails to deliver a follow-up urinalysis?
Because there are so many variables, general rules are impossible. That’s not going to stop me from offering a general opinion, in the hope it will inspire young family physicians to think deeply about this issue.
I believe that I have an obligation to do my best to assure that tests I obtain in my office are tracked back to my office, and acted on appropriately. For that reason, one of our staff members maintains a log of these tests.
Once the patient leaves my office, though, I think the responsibility is on him. We do our best to grease the skids, making specific appointment times when possible. But I’m not going to follow him around town or serve as his alarm clock.
From the first day I opened my practice, every family has been given a loose-leaf notebook with educational materials and dividers to organize their health information. They get copies of all their lab and x-ray reports, and my handwritten progress note sheets include a punched NCR copy for them to file away. Do they do it? Some do, some don’t. I don’t check. But I send them a message from the start: This is your health, and I expect you to be the lead partner in this relationship.
At the other end of the spectrum in our town is a pediatrician, an excellent and dedicated clinician and a nice person. She fosters dependency in her patients to a degree I would not have thought humanly possible. When I see her in her car, she is on her cell phone. She was evicted from her group practice because she didn’t produce her overhead, and her partners couldn’t tolerate taking calls from her patients. (She doesn’t have a family).
Do I encourage patient self-care and independence because it is more profitable, and lets me sleep at night? Only God knows. I do know this: The biggest health care crisis involves the American lifestyle, not coverage for the uninsured.
And I’m not going to be there to help my patients make good choices at the grocery store, the restaurant or the refrigerator. It’s on them, and I think we’d better get that straight.
Big Brother will be watching!
As I was driving home from the airport Wednesday morning I heard an enlightening interview on NPR, my default radio station.
Massachusetts, under then-governor and future Republican presidential candidate Mitt Romney, implemented the nation’s first full-court press toward insuring everybody. Now they’re having trouble paying for it. Imagine that! Who woulda thunk? So Congress is watching closely.
“The first thing they decided – unanimously and right off the bat – was that the current way of paying doctors, hospitals and other medical providers has got to go," reports Richard Knox. "… Massachusetts is going to try to kill off fee-for-service.”
Massachusetts policymakers want to replace it with "global payment" – paying groups of health care providers a flat yearly fee for each patient they cover. "Global means it's for all services," says Dr. Rick Lopez, chief physician executive of Atrius Health, one of Massachusetts' biggest doctor groups. "It includes when the patient comes in to see the physician, hospitalization, pharmacy, skilled nursing facilities, home care services – the whole spectrum."
Gee, that sounds a whole lot like “full capitation,” doesn’t it? That means they’re going back to “gatekeepers,” aren’t they? Remember how much fun that was? The calls in the middle of the night for permission to patronize the ER for belly pain? Patients questioning our integrity and commitment to them, rather than our income?
Ah, but this time it will be different! The problem in the 1990s was that there was no way to track, identify, prosecute and execute the bad apples in the primary care specialties. But now there IS a way! Read this carefully:
"To avoid a repeat of that experience, advocates of global payment say health providers will have to be watched closely. 'You need someone monitoring this,' says Nancy Kane of the Harvard School of Public Health. 'You can't just walk away because you've set the limit.' Kane is a health care finance expert who also served on the recent Massachusetts Payment Reform Commission. She says there are ways these days to prevent stinting on care. 'There's a lot of quality measuring that can go on now that didn't used to be available,' she says. 'We now have electronic medical records. It's easier to monitor what's going on. So I think the whole reporting system and the intention to maintain a monitoring infrastructure is all critical to avoiding the bad days of managed care.'"
Academics and bureaucrats love terms like “monitoring infrastructure.” That’s an Orwellian term for “Big Brother Is Watching You.” It sounds so easy, and so painless. But, of course, the Devil is in the details.
And, of course, there's the problem of the surgeon who examined my nurse for five minutes, sent me a three-page dictation, and charged for a top-dollar consultation physical. The system Massachusetts is heading toward will punish the honest, and reward the liars. Next step: Every encounter will be filmed by a hidden camera, and stored on government servers.
Until I heard the italicized comment above, I thought my friends in the blogosphere – who viewed the EMR as a plot by insurance companies to deny care – might be a bit paranoid. Mea culpa. They were right all along.
Dr. David Kibbe, who is as close as it comes to a guru in FP-IT, penned a great opinion piece in the latest Family Practice Management. He advocates plug-and-play modularity for components of the electronic medical record. Rather than a single vendor providing a comprehensive program at an extortionate price, with the separate elements always lagging the latest innovations in the marketplace, these elements should be disintegrated.
As Paul Nutting wrote in his initital assessment of the National Demonstration Project, “[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connection, evidence at the point of care, disease registries, and interactive Web portals without an EMR.”
To which I say, “Amen.”
Dr. Kibbe goes on to describe the ugly political state in which the Academy is trapped. (It essentially backed the wrong horse in the Derby, and now there's no winning ticket to cash.) Big vendors are fighting tooth-and-nail to slow the shift to plug-and-play modularity – that is, the same way you can buy separate applications, cheap, for your iPhone. They succeeded in getting the Feds, as part of their incentive program to adopt EMRs, to mandate comprehensive applications from single vendors.
This is an old, and familiar, political game. This is how we continued to subsidize tobacco farmers while we stigmatized tobacco users. This is how we continue to subsidize corn farmers while Americans are fattening on fructose-flavored soft drinks. This is why politicians should be banned from certain activities.
The fundamental problem, of course, is that we are led by politicians. They’re not bad people. They’re just different than those of us who would rather deal with chronic fatigue syndrome than collaborative back-scratching.
I suppose it’s my own fault – me, and tens of thousands like me. I never liked committee meetings. I liked patients. Mea culpa, mea maximal culpa.
Family (physician) values
I know I’m fakin’ it. I’m not really makin’ it. This feeling of fakin’ it – I still haven’t shaken it. – Simon and Garfunkel
Bill James is a world-renowned baseball analyst. After laboring for years in near-obscurity, his views are now near-gospel in many professional circles.
For four years we were contemporaries at the University of Kansas. He was the last Kansan drafted for the Vietnam War; my lottery number was 313, so I was safe. He went on to fame as a statistical genius; I passed on that internship at Sports Illustrated to attend med school.
C’est la vie. Look who gets to blog for Family Practice Management, Bill! Can you hear me now?
Bill once wrote, and no truer words have ever been writ: “One of the unwritten rules of economics is that it is impossible, truly impossible, to prevent the values of society from manifesting themselves in dollars and cents. This is, ultimately, the reasons why athletes are paid so much money.”
Allen Barra, writing in the Wall Street Journal, adds this: “It isn’t some vague indefinable ‘they’ who pays the players. It really isn’t even the owners. It’s you, or rather, it’s us. If we put our money where our mouths are and support cancer, AIDs or Down syndrome research and then buy our tickets with what’s left over, athletes and rock stars will actually be paid what we pretend they should be paid.
“The fault lies not in our All-Stars, but in ourselves.”
Since I’ve fallen into a rut of quotations, let's make it a little deeper by paraphrasing Lincoln: "Now we are engaged in a great civil war, testing whether that profession, or any profession so conceived and so dedicated, can long endure."
Week by week, we’re watching it play out in Washington. Will family medicine survive? We are met on a great battlefield of that war. It’s an ugly process. It’s unbelievably messy, and contentious. Winston Churchill said: "Democracy is the worst form of government, except for all those others."
For all its inconsistencies, sham, pretense, inefficiency and corruption, democracy always beats tyranny or oligarchy, just as free markets always beat central planning. Sometimes it takes a long time.
In the end, all you can control is what is under your own thumb. Society is going to get the health care it wants and deserves, and you are going to get the medical career you want and deserve.
Make no mistake: You are not a helpless pawn in an inscrutable system. Our situations are all different, but we have this in common: We are free moral agents, and our actions (but not our passions) will always have an effect.
Are you fakin’ it? Are you murmuring and complaining about the System, or the Man? Get off your keister, and make something happen!
How to manage media medicine
In a prescient letter to the Wall Street Journal, Homer Jack Moore, MD, responds to a previous article bemoaning the ignorance of the medical profession about fibromuscular dysphasia:
“Your report reminds me of yet one more reason why medical care in the U.S. is so vastly expensive with little extra gain in any actual outcomes. While the implication in this article that American doctors know little or nothing about this 'common' disease is terrific for newspaper circulation, it results in terrible practice of medicine. FMD was fully reviewed in the New England Journal of Medicine in 2004 (in a report co-authored by Dr. Jeffrey W. Olin, no less), and in multiple other medical journals since then. I know what it is. So do my colleagues.
“But never mind that. I can now full well expect a flood of anxious young women (and gentlemen, too, even though FMD is even more rare in men than women) in my office, being among them those afflicted with migraines, aches and pains, anxiety neurosis, depression and other of life's ills, who have all now become convinced that the doctor is a dolt; that indeed, all life's problems would have long been solved had just that right test been done. And they will demand, now, that these tests be done, paid for with other people's money, of course. And I, knowing full well that there is no particular advantage to even the smallest particle of risk of being at the wrong end of some lawyerly deposition inquiry, will give them exactly what they demand.
“Alas, the overwhelming majority of these people will still have only what they ever had: migraines, aches and pains, anxiety neurosis, depression and other of life's ills. But in the vanishing few that, lo, do turn out to have unsuspected FMD, my advice to them, for the most part, will be exactly the same as it ever was: Take an aspirin every day.”
Ever feel like Dr. Moore does? Me too.
I think, honestly, that medical writers are better than ever in my lifetime. Often I get tipped off to relevant scientific developments by reading their columns.
But then there are the cheap-shot artists just looking to make a buck. They start with a sob story, add a dash of factoids, and then bake into an epidemic. Usually an epidemic ignored by the medical establishment; something common. After all, a malady experienced by 1 out of 10,000 patients strikes 35,000 in America every year. Pretty common, right?
There are two ways to deal with this problem, to avoid wasting time playing whack-a-mole with patient questions.
My first effort, early in my career, was to browse the contents of magazines like Ladies Home Journal and Men’s Health in an attempt to stay abreast of the breaking misinformation. That didn’t last long. There was too much trash, and it was depressing.
Then I started my own information campaign. I wrote my own practice newsletter once a year – for an example, see the dig at Dr. Gott at the end of last year’s newsletter. When I read something egregious in the local newspaper, I wrote back for publication. When the Internet revolution came along, I steered patients to reliable sites.
Before too many years had passed, my patients viewed me as the authority to be reckoned with, not the hack in the magazine. I had gotten ahead of the information curve, at least in their minds. That doesn’t stop them from asking questions, but it does stop them from questioning my answers – most of the time.
Unless writing is excruciatingly painful for you, I think you will find this useful, and maybe fun. Start with the mini-lectures you give every day. We all have them. Why not write them down? Let your personality flow through.
One of the worst pieces of advice I got in medical school was to guard my ‘professionalism’ – which meant, act like a talking robot. Balderdash. We’re all unique, and the better patients get to know us, the better they’ll sort themselves into good matches with their primary physician.
The Academy has hundreds of patient information sheets available, but they’re pretty bland. Not bad, just safe and boring. The rule seems to be “don’t say anything that stands a remote chance of being misconstrued” – like they are written by a committee. And they often advise to consult your doctor for this, check with your doctor for that – for stuff, it seems to me, ordinary commonsense people usually handle without consultation, except maybe from Grandma. If I wanted to engender dependency, I’d become a Democrat.
Frankly, when I write an information sheet it is with the intention that they won’t consult their doctor. That’s how I get an uninterrupted night’s sleep.