What I learned from Bennie the Brit

My first major purchase in life was a new, British, racing green,1968 MGB/GT. It cost $3,225, and after a down payment, it was paid off in 36 monthly drafts of $60.69. I remember that, to the penny. While a truly inferior automobile at any price, it was a source of great pride, for its lines and the rumble of its engine. It was also a frequent visitor to the shop, and a financial hemorrhage.

The warranty period was over all too soon, and on the first visit for repairs on my own nickel, I was shocked, shocked, to discover that I was charged for two hours of shop work when the mechanic spent only one hour under the hood.

“Why this extortionate fee?” I demanded of Bennie, the rotund and dapper little man with a pencil mustache and English accent who had sold me the car.

“Well,” he replied (my memory being, in this case, approximate), “you must recognize that this is an exceptionally talented mechanic. A normally talented mechanic, according to a survey conducted by British Leyland Motors, takes two hours to perform this particular operation. Should we punish this chap simply for the crime of being skilled?”

That introduction into the philosophy of Adam Smith left me speechless. Because, of course, he was right.

The official philosophy of Marxism was “from each according to his ability, to each according to his need.” Given the inexorable law of human nature, this led to the old joke in communist Russia: “I pretend to work, and the State pretends to pay me.”

This might be a pretty good description of some hospital-owned family physicians, at least according to the stories I hear from patients defecting from their practices. Routine physicals not available for eight months? No more than one problem per office visit?

Now I have to make a confession. Although I am an avowed capitalist, I was really slow to apply the lesson of Bennie the Brit when it came to my own practice. My excuse is that I’m not instinctively entrepreneurial, and the health care system is an oligopoly, not a free market. When I started practice in 1986, there were no guides to tell me what E/M code to charge – in fact, the term E/M wasn’t invented yet. So I asked around, and the consensus seemed to be that an office visit was a 99213, no matter how many problems you solved.

Except for Pap smears. Those were 99214, because that was what the local OB/GYNs charged. I was too dumb to ask why, and Blue Cross never challenged my charges. So I thought I must be doing something right. Now I know that they charged 99214 because their Pap was "special."

My goal was to imitate the Cooper Clinic physical, only cheap. Giving value was the part of capitalism that I understood at that point. Then the era of full capitation hit, and giving value was the precisely right formula; I got the same results as my peers for a lot less money, or better results for the same money (same thing, really) and took home bonuses amounting to 30 percent of my total income for several years.

Then the greed of Big Cigar HMOs cost us the confidence of the public, who assumed we were shorting them services when we didn’t order CT scans for muscle-contraction headaches. My income regressed toward the mean.

All this time, mind you, my practice style hadn’t changed. I pounced on hyperlipidemia like Holmes on Moriarity. Adult-onset diabetes was the rat to my rat catcher. I only hired RNs, and since I tried to follow the same algorithm with every patient, they did a lot of the work before I got into the room. Since patients got the same story every time, they didn’t get confused; and, though they rarely followed my “therapeutic lifestyle changes,” they did come to believe that I was informed, concerned and worthy of their trust. So they took the pills I prescribed.

When I worked for the U.S. Army, 12 patients a day was an exhausting load. Six years in the emergency room cured me of that bad habit. Early in my private practice, I found that 25 patients per day was not only conceivable but comfortable, when my staff became an extension of myself. Now the challenge is to see how many problems we can address in 10 or 15 minutes.

But I was still charging 99213 for these complex encounters. The scales fell from my eyes when I read a classic FPM article, “How to Get All the 99214s You Deserve.” A terrific follow-up to that was just published: “Coding From the Bottom Up."

Once I started getting all the 99214s I deserved, my charges rose by 30 percent over a four-year period. (It took four years to change my charging habits; such was the depth of my rut.) And all of that, dear reader, went directly to my bottom line – because it didn’t raise my overhead one dime to change a code.

And that was how I learned the lesson – better late than never – of Bennie the Brit. I was the skilled mechanic who was charging like a normal mechanic. If there is any low-hanging fruit in this blog, which is dedicated to proving that FPs can compete with specialists financially, this is it.

As for the more difficult issue – how to become a skilled mechanic – that’s a story for another day.

Sideline: If you’d like to get in on a continuing conversation between me and the physician who practically invented HMOs while serving as a member of the U.S. Congress, here’s the link.

Posted at 01:50PM Dec 15, 2008 by Doug Iliff  |  Comments[3]