February 20, 2008
We near the end of February, nearly two months into the transition of my practice. Many of my patients, peers, friends and family have asked how the transition is going. So far, so good. The goals I have set for my practice are being met.
Please allow me to list a few of these:
1. Same day appointments- If you are not feeling well and need an appointment, the last thing you need to hear from your doctor’s office is that they can schedule you in three days. That just does not work! We have always offered same or next day appointments, and now if you call our office before noon on a workday, you will be offered a same day appointment. My father was also a family physician in a solo practice. He would always tell me, “Make sure you get patients into your office when they are sick, because if you wait a few days they may not be sick anymore.” I have followed my father’s advice.
2. Longer appointment times- When my office participated with health insurance companies, the large overhead expense forced us to try to see more patients per day. This would often cut into the length of time available per patient. Average appointment time prior to my transition was 12-15 minutes. Now we are scheduling for at least 20-minute appointment times, and longer for Wellness exams and physicals. My goal is that each patient gets the time they need for a full and comprehensive evaluation.
3. Less waiting time- With longer appointment times, I have finally been able to run on schedule. No one is perfect, but I have been doing a much better job of seeing patients at their scheduled appointment times. Another side benefit is less crowded waiting rooms and less time in the waiting room. In fact I am considering canceling some of my magazine subscriptions as no one is finding time to read them.
4. Creating a medical home for my patients- When contracted with health insurance companies my office staff and I would usually spend 4-6 hours per day on bureaucratic paperwork, referrals, precertifications and other health insurance nonsense that should have no place in our healthcare system. Well, no longer!! We now have time to serve as your sounding board to medical advice and treatment rendered by other caregivers and specialists. My office staff also has the time to help with the facilitation and coordination of your healthcare. This includes scheduling diagnostic tests and also referring and scheduling appointments with specialists.
I would like to restate my practice mission statement, as the words below are the standard of care that my office pursues.
To provide outstanding family medical care to our patients with a focus on comprehensive wellness and prevention.
To inform you of healthcare options that your health insurance carrier may not want you to obtain or know about.
To be an advocate for your medical care without regards to the health insurance bureaucracy.
Where patients go to be treated as a person and not as a commodity.
Where patients go to have a Physician who listens carefully and respects what the patient has to say and encourages the patient to say what is on their mind.
To give patients the ability to see their own Doctor and to make appointments without unreasonable waits.
To provide this care with an open mind, and to make your healthcare a team effort between Dr. Horvitz, his office staff, and you, the individual.
I appreciate the trust and confidence that my patients have shown in me. I take my job and my profession very seriously and I strive to treat every patient as I would want to be treated myself, and as I would treat my own family. I will always do my best to make every office visit or phone conversation worthy of your time.
If you have any suggestions or comments on how I can make my practice work better for you, please call or email. I will be happy to hear from you!
Steven Horvitz, D.O.
Founder Institute for Medical Wellness
Wednesday, February 20, 2008
Sunday, February 17, 2008
The Dumbing down of our profession
Thirty years ago our patients paid directly for our services. Those with health insurance sent in claims to their insurance for reimbursement. Health insurance at that time was true insurance. Reimbursement was for expensive medical bills, not for routine care. It covered large and catastrophic medical expenses. It is different today. People are enrolled in health plans that pay for routine medical care and expect that care to be paid for by these plans for a small cost. When physicians willingly contracted with these plans, so began the dumbing down of our noble profession.
Twenty years ago we were called physicians and the people we treated we referred to as our patients, family, friends and neighbors. What are they referred to as today?
· Covered lives
· Health Care Consumer
· Capitated life
· “Name the Insurer” patient
· HMO patient
· PPO patient
With our entry into managed care we gave up the management rights of our profession and handed it over to corporate CEO’s of the health insurance industry. These corporate CEO’s have managed to increase year to year revenues and profits on the backs of physicians, hospitals, patients, and employers. Profits of the health insurance industry is in the billions year to year and continues to increase while payments to those that provide the medical care decreases.
How much money is spent on the insurance infrastructure that does not go into patient care?
If we were to take half of these profits and unneeded infrastructure out of the equation, could we put it towards better use?
Lets see some of what this insurance infrastructure has created by looking at an entire new medical vocabulary.
· Provider
· In-network provider
· Out-of-network provider
· PCP – (primary care provider)
· Physician extenders
· Prescriber
· PBM’s – (Pharmacy Benefit Managers)
· Formularies
· Tier 1, 2 or 3 medications
· Generic equivalent
· Managed Care
· Capitation
· Copay
· Precertification
· Preauthorization
· Insurance referral
· Utilization review
· Quality Assurance
· Incentivize
· Pay for performance
· Third party payer
· Contractual adjustment
· Assignment
· Claims
· Payers
· DRG’s
· Universal Healthcare
· HIPPA
Did any of these words appear in any medical dictionary prior to managed care?
Do you evaluate any patients in your office without using one of the words listed above?
My father was a family doctor prior to managed care. Had he been alive today, but in a twenty year time bubble, he would not understand the mess we have gotten ourselves into. He would say, “Just treat your patient’s well and to the best of your ability, and you will have a good career, a good business and a good reputation in your community.”
How many of our medical offices today are run with my fathers thoughts in mind?
Instead we have reacted to this insurance system quagmire in many ways.
· We try to see more and more patients each day.
· We hire more clerical and billing staff to handle intrusive rules and regulations.
· We go to seminars that attempt to teach us cost-effective healthcare.
· We hire physician extenders.
Does any of the above help with patient care?
Can we really evaluate and treat our patients in the 8-10 minutes we give ourselves?
So we hire medical assistants, billing managers, office managers and health care consultants to help run our practice.
They all help in the day to day operations of our practice, but how much of their time is actually spent with patients, and how much time is spent pushing papers, or on the phone with an insurer, etc?
We go to seminars that tell us to use electronic billing, to buy an electronic medical record, to organize our office to comply with all the insurers and governments rules and regulations. Does any of this help in our evaluations of our patients?
They tell us how to see more patients per day, and how if we only stay open every weekend and five nights a week, that our practices will thrive. But I for one, enjoy my work, but I work to live, not live to work!
Nurse practitioners and physicians assistants are hired to medically evaluate our overflow of patients. Is this a good for our profession? Are we allowing physician extenders to become commonplace in our healthcare system? If we hire them, are we not giving our blessing that they can do our jobs as well as we can? In essence we are hiring our own replacements.
Big business has also reacted to high healthcare costs. Walk in clinics staffed by nurse practitioners and physician assistants are growing quickly. Walmart clinics, and Minute Clinics are in direct competition with family practitioners. They are treating the bread and butter illnesses of our patients, which accounts for a nice percentage of most offices revenues. Do we accept these clinics as inevitable, or do we devise a strategy to compete?
Can we compete?
Do we have the will to save ourselves?
Can we enlist any group to help?
Who will understand the most?
Who needs us the most?
Who is closest to us?
· Lawyers?
· Insurance industry?
· Politicians?
· Hospitals?
· Universities?
· Media?
· Congress?
· President?
· Governor?
· Democratic or Republican party?
Can you find ONE in the list that has any interest in helping our profession get out of this mess and make a better system?
Our patients are the one group that we must get on our side. This will not happen if all we do is complain, without offering solutions for high quality and affordable healthcare. We can abandon all third party payers but we must not abandon our patients. We can and must reform our healthcare system by returning the pricing power to the physician, cutting out the middleman, and return to the primacy/centrality of the doctor-patient relationship. It is a trend we as a profession must set by example.
With the presidential election approaching, and the candidates all proposing fixes to healthcare, setting an example with a unified front must not be a dream, but a reality. All of these have factored into the dumbing down of our profession in our eyes, our patients eyes and the government eyes. If we are to survive as a profession, we need to take control back. We must act to set the rules before we lose control of our profession forever.
Steven Horvitz, D.O.
Founder of The Institute for Medical Wellness
Twenty years ago we were called physicians and the people we treated we referred to as our patients, family, friends and neighbors. What are they referred to as today?
· Covered lives
· Health Care Consumer
· Capitated life
· “Name the Insurer” patient
· HMO patient
· PPO patient
With our entry into managed care we gave up the management rights of our profession and handed it over to corporate CEO’s of the health insurance industry. These corporate CEO’s have managed to increase year to year revenues and profits on the backs of physicians, hospitals, patients, and employers. Profits of the health insurance industry is in the billions year to year and continues to increase while payments to those that provide the medical care decreases.
How much money is spent on the insurance infrastructure that does not go into patient care?
If we were to take half of these profits and unneeded infrastructure out of the equation, could we put it towards better use?
Lets see some of what this insurance infrastructure has created by looking at an entire new medical vocabulary.
· Provider
· In-network provider
· Out-of-network provider
· PCP – (primary care provider)
· Physician extenders
· Prescriber
· PBM’s – (Pharmacy Benefit Managers)
· Formularies
· Tier 1, 2 or 3 medications
· Generic equivalent
· Managed Care
· Capitation
· Copay
· Precertification
· Preauthorization
· Insurance referral
· Utilization review
· Quality Assurance
· Incentivize
· Pay for performance
· Third party payer
· Contractual adjustment
· Assignment
· Claims
· Payers
· DRG’s
· Universal Healthcare
· HIPPA
Did any of these words appear in any medical dictionary prior to managed care?
Do you evaluate any patients in your office without using one of the words listed above?
My father was a family doctor prior to managed care. Had he been alive today, but in a twenty year time bubble, he would not understand the mess we have gotten ourselves into. He would say, “Just treat your patient’s well and to the best of your ability, and you will have a good career, a good business and a good reputation in your community.”
How many of our medical offices today are run with my fathers thoughts in mind?
Instead we have reacted to this insurance system quagmire in many ways.
· We try to see more and more patients each day.
· We hire more clerical and billing staff to handle intrusive rules and regulations.
· We go to seminars that attempt to teach us cost-effective healthcare.
· We hire physician extenders.
Does any of the above help with patient care?
Can we really evaluate and treat our patients in the 8-10 minutes we give ourselves?
So we hire medical assistants, billing managers, office managers and health care consultants to help run our practice.
They all help in the day to day operations of our practice, but how much of their time is actually spent with patients, and how much time is spent pushing papers, or on the phone with an insurer, etc?
We go to seminars that tell us to use electronic billing, to buy an electronic medical record, to organize our office to comply with all the insurers and governments rules and regulations. Does any of this help in our evaluations of our patients?
They tell us how to see more patients per day, and how if we only stay open every weekend and five nights a week, that our practices will thrive. But I for one, enjoy my work, but I work to live, not live to work!
Nurse practitioners and physicians assistants are hired to medically evaluate our overflow of patients. Is this a good for our profession? Are we allowing physician extenders to become commonplace in our healthcare system? If we hire them, are we not giving our blessing that they can do our jobs as well as we can? In essence we are hiring our own replacements.
Big business has also reacted to high healthcare costs. Walk in clinics staffed by nurse practitioners and physician assistants are growing quickly. Walmart clinics, and Minute Clinics are in direct competition with family practitioners. They are treating the bread and butter illnesses of our patients, which accounts for a nice percentage of most offices revenues. Do we accept these clinics as inevitable, or do we devise a strategy to compete?
Can we compete?
Do we have the will to save ourselves?
Can we enlist any group to help?
Who will understand the most?
Who needs us the most?
Who is closest to us?
· Lawyers?
· Insurance industry?
· Politicians?
· Hospitals?
· Universities?
· Media?
· Congress?
· President?
· Governor?
· Democratic or Republican party?
Can you find ONE in the list that has any interest in helping our profession get out of this mess and make a better system?
Our patients are the one group that we must get on our side. This will not happen if all we do is complain, without offering solutions for high quality and affordable healthcare. We can abandon all third party payers but we must not abandon our patients. We can and must reform our healthcare system by returning the pricing power to the physician, cutting out the middleman, and return to the primacy/centrality of the doctor-patient relationship. It is a trend we as a profession must set by example.
With the presidential election approaching, and the candidates all proposing fixes to healthcare, setting an example with a unified front must not be a dream, but a reality. All of these have factored into the dumbing down of our profession in our eyes, our patients eyes and the government eyes. If we are to survive as a profession, we need to take control back. We must act to set the rules before we lose control of our profession forever.
Steven Horvitz, D.O.
Founder of The Institute for Medical Wellness
Friday, February 15, 2008
Interesting question from Medicare patient
In my practice I accept no insurance other than Medicare. Today I had a Medicare patient whose family left my practice due to insurance issues. This patient, I shall call Rose, was very happy that I was not only able to give her a same day appointment, but also her boyfriend. She thought the new practice model was wonderful and that she hoped I would start to see a large number of seniors on Medicare.
It struck me that my message of participating with no insurers other than Medicare may not have been fully explained nor comprehended by my patients. Some patients may have left my practice thinking I was only treating Medicare patients. In fact Rose wanted to know whether her family could return to my practice. I needed to have a 5 minute fce to face discussion with Rose and explain my practice was open to patients ages 6 and above. The only caveat being I will bill Medicare but no other insurance for payment. A light then went off in Rose's head and she said she would talk to her family.
I also explained to Rose that I was not hoping for a large Medicare practice, but was very happy with the percentage of Medicare patients that I have. I did not want to be beholden to any insurer, whether government or private. Rose also informed me that her family went to another doctors office and was not happy. This is not good for the other doctor or Rose's family, but it follows my logic of treating patients and not their insurance, of taking the necessary time with each patient, and of not running your office like a cattle mill where the best doctor is the one who sees the most patients for the day. A doctor can see less patients and still earn a good living. I am on pace to see 250 patients this month, which is about 20% off of my amount seen in February 2007. But my revenues so far for the month are 33% higher than in the similar period of 2007.
I gave up capitation checks for Wellness patients. So far the Wellness patients brought in much more revenue than capitation ever did. However I do not know if this will continue throughout the year as my established patients come through the new practice style. I believe I will eventually need to bring in new Wellness patients to the practice to continue the increased revenue. I am preparing a marketing strategy for just that. If anyone reading this blog has any helpful tips for marketing, please speak up.
Steven Horvitz, D.O.
It struck me that my message of participating with no insurers other than Medicare may not have been fully explained nor comprehended by my patients. Some patients may have left my practice thinking I was only treating Medicare patients. In fact Rose wanted to know whether her family could return to my practice. I needed to have a 5 minute fce to face discussion with Rose and explain my practice was open to patients ages 6 and above. The only caveat being I will bill Medicare but no other insurance for payment. A light then went off in Rose's head and she said she would talk to her family.
I also explained to Rose that I was not hoping for a large Medicare practice, but was very happy with the percentage of Medicare patients that I have. I did not want to be beholden to any insurer, whether government or private. Rose also informed me that her family went to another doctors office and was not happy. This is not good for the other doctor or Rose's family, but it follows my logic of treating patients and not their insurance, of taking the necessary time with each patient, and of not running your office like a cattle mill where the best doctor is the one who sees the most patients for the day. A doctor can see less patients and still earn a good living. I am on pace to see 250 patients this month, which is about 20% off of my amount seen in February 2007. But my revenues so far for the month are 33% higher than in the similar period of 2007.
I gave up capitation checks for Wellness patients. So far the Wellness patients brought in much more revenue than capitation ever did. However I do not know if this will continue throughout the year as my established patients come through the new practice style. I believe I will eventually need to bring in new Wellness patients to the practice to continue the increased revenue. I am preparing a marketing strategy for just that. If anyone reading this blog has any helpful tips for marketing, please speak up.
Steven Horvitz, D.O.
Thursday, February 14, 2008
Dr. Steven Horvitz's practice transition
This is a letter I will be posting on my patients blogsite and my website. It gives an idea of what direction I am going with my practice. I also hope to add my thought processes as the transition to a cash practice continues. Hopefully putting these thoughts down in electronic print will help me and other physicians in their quest to get back to the roots of medical care, without the third party interference.
------------------------------------------------------------------------------------------------
When I started my family medical practice in 1998, the majority of patient visits and hence the revenues that came into my office was for sick care. At the time, it was what my patients and the public were demanding and what I was glad to provide. But today, with the baby boomer generation getting older, and healthcare costs skyrocketing, demand has increased for medical programs to help patients stay well.
But physicians today are forced to practice under an outmoded system that rewards frequent, extensive and expensive medical care for the very sick, but does not reward for the teaching and teamwork that goes toward prevention of illness. The government in its wisdom, throws more and more money into this system which gets worse year by year. The tremendous amount of government regulations and insurance industry greed and profits has doomed our healthcare system. The present healthcare scenario will not survive as is. The government can not save it. The health insurance industry can not save it. Only patients and physicians first taking individual responsibility, and then forming a partnership in their medical care can.
In January 2008 I started my transition towards a practice that is more patient centered and patient focused. I terminated my contracts with all health insurers except Medicare. With this practice conversion, I am now able to:
1. Improve access to medical care by offering same and next day appointments.
2. Improve communication with patients through longer appointment times, easier telephone access, and internet communication via email and our new and improved website.
3. Help patients to be better managers of their care via stronger coordination of the healthcare services they obtain outside my office. Many physicians are so busy seeing 30+ patients per day that they do not have the time for this coordination of medical care. In my new practice model, We Do!!
Thus far, I have been able to turn the healthcare system upside down, by engaging patients in this team concept of wellness and prevention. I tell all my patients, “ Put your effort into true health wellness and prevention, and I will treat your illnesses for a discount, without any health insurer or third party interference.” My patients who have teamed with me for their healthcare needs by enrolling in my wellness plans, get discounted fees, usually equal to or less than their insurance copay for all their sick care at my office. I am no longer restrained by health insurer contracts what I can offer and what I can advise. By terminating my relationships with the health insurers, I can again become my patients #1 advocate in their care.
One of the nicest comments I ever received was in 1991, from a fellow medical school student who happened to be a patient in my fathers family medical practice in Philadelphia. He told me the main reason he went to medical school was because of the personal connection and trust he and his family received in their medical care from my father while growing up. This trust shaped this students life and career aspirations. Do people still have this same sense of trust in their doctors today?
Sometimes moving forward is not the answer. Sometimes we need to look backwards, to a system that worked in the past. To a system where you picked your doctor based on quality and trust and not by looking at an insurance directory filled with names of physicians you do not know. My practice will move forward and grow by looking backwards. The basic qualities of the doctor-patient relationship will be emphasized again. My patients will choose my practice for the basic qualities of a true family physician such as expertise, sincerity, personal connections, and trust.
I look forward to 2008 and all the challenges that it brings. I value each and every individual in my practice and hope to continue to offer the best family medical care possible.
Steven Horvitz, D.O.
------------------------------------------------------------------------------------------------
When I started my family medical practice in 1998, the majority of patient visits and hence the revenues that came into my office was for sick care. At the time, it was what my patients and the public were demanding and what I was glad to provide. But today, with the baby boomer generation getting older, and healthcare costs skyrocketing, demand has increased for medical programs to help patients stay well.
But physicians today are forced to practice under an outmoded system that rewards frequent, extensive and expensive medical care for the very sick, but does not reward for the teaching and teamwork that goes toward prevention of illness. The government in its wisdom, throws more and more money into this system which gets worse year by year. The tremendous amount of government regulations and insurance industry greed and profits has doomed our healthcare system. The present healthcare scenario will not survive as is. The government can not save it. The health insurance industry can not save it. Only patients and physicians first taking individual responsibility, and then forming a partnership in their medical care can.
In January 2008 I started my transition towards a practice that is more patient centered and patient focused. I terminated my contracts with all health insurers except Medicare. With this practice conversion, I am now able to:
1. Improve access to medical care by offering same and next day appointments.
2. Improve communication with patients through longer appointment times, easier telephone access, and internet communication via email and our new and improved website.
3. Help patients to be better managers of their care via stronger coordination of the healthcare services they obtain outside my office. Many physicians are so busy seeing 30+ patients per day that they do not have the time for this coordination of medical care. In my new practice model, We Do!!
Thus far, I have been able to turn the healthcare system upside down, by engaging patients in this team concept of wellness and prevention. I tell all my patients, “ Put your effort into true health wellness and prevention, and I will treat your illnesses for a discount, without any health insurer or third party interference.” My patients who have teamed with me for their healthcare needs by enrolling in my wellness plans, get discounted fees, usually equal to or less than their insurance copay for all their sick care at my office. I am no longer restrained by health insurer contracts what I can offer and what I can advise. By terminating my relationships with the health insurers, I can again become my patients #1 advocate in their care.
One of the nicest comments I ever received was in 1991, from a fellow medical school student who happened to be a patient in my fathers family medical practice in Philadelphia. He told me the main reason he went to medical school was because of the personal connection and trust he and his family received in their medical care from my father while growing up. This trust shaped this students life and career aspirations. Do people still have this same sense of trust in their doctors today?
Sometimes moving forward is not the answer. Sometimes we need to look backwards, to a system that worked in the past. To a system where you picked your doctor based on quality and trust and not by looking at an insurance directory filled with names of physicians you do not know. My practice will move forward and grow by looking backwards. The basic qualities of the doctor-patient relationship will be emphasized again. My patients will choose my practice for the basic qualities of a true family physician such as expertise, sincerity, personal connections, and trust.
I look forward to 2008 and all the challenges that it brings. I value each and every individual in my practice and hope to continue to offer the best family medical care possible.
Steven Horvitz, D.O.
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