Obamacare and Bernie Madoff

Obamacare and Bernie Madoff

December 29, 2009

Obamacare and Bernie Madoff

Sorry again about another healthcare reform related newsletter, but I get mildly agitated when people not in the healthcare field, especially politicians, try to tell me how to do my job.

We all have heard about Bernie Madoff, and his, how can I say it, not exactly stellar accounting. Bernie Madoff by way of his ponzi scheme, led what may soon be known as the second biggest swindle in the nation. The first will be either the Senates or House of Representatives healthcare reform bills, which if either of them becomes law, will forever be known as the ObaMadoff healthcare plan.

Understand that our politicians do not play by the same rules that ordinary citizens abide by. We put money in the bank, and can only withdrawal what we have. On the other hand, our politicians, both democrat and republican, spend our money, and more than we have.

Oh, but they can raise more money to pay for all their pet programs you say.

You are correct.

But the politicians do not earn money like we do.

They raise money in a few ways.

1) They increase the taxes we have to pay.
2) They borrow money from other countries and ask we, the taxpayers to pay the interest.
3) They turn on the printing presses and print more money, diluting the worth of the dollar and making our money less valuable.

In other words, they spend our hard earned money like there is a never-ending supply!

So what does this have to do with healthcare?

I'll tell you.

Our country is deep in debt, due to all the money spent by our politicians over the past four decades. At last count, our country is over 12 trillion dollars in debt, not counting current and future entitlement obligations. So now, our politicians want us to go further in debt and add a new entitlement to reform the healthcare system, and they will raise the money to finance these reforms in the three ways mentioned above.

So how does this differ from what you and I do to access healthcare?

1) To pay for healthcare, we as individuals have to work and earn income. We can not collect tax money from others to pay for our care.
2) We can borrow money from banks and credit cards, but we are held individually responsible for our debt. Our politicians are not responsible for the debt they place our country in. We are, along with our children and grandchildren.
3) I think we would go to jail if we had a printing press printing money we did not earn. So why does our government get away with it?

This healthcare reform is not the change we believed we were getting during the 2008 presidential campaign.

Let us take a look at the president's healthcare campaign promises and how they have changed by looking at the present healthcare bills, their costs and how they are paid for.

House Bill:

Who is covered?

It is estimated that about 94% of legal residents under the age of 65 will be covered. Presently about 83% are covered. There will still be about 24 million people under the age of 65 not insured, with an estimated 8 million of those being illegal immigrants.

Cost:

871 Billion dollars over ten years. That is $871,000,000,000 dollars. That's alot of zeroes.

How It's Paid For:

Fees or taxes on the following: Insurance companies, pharmaceutical manufacturers, medical device manufacturers, medicare payroll tax increase on income over $200,000 for individuals, or $250,000 for couples, 10% sales tax on tanning salons, excise tax on high cost insurance plans, and fees for employers whose workers receive government subsidies. I am certain there are more fees and taxes still hidden in the bill that have not yet been discovered.

Cuts to Medicare and Medicaid

Fines on people who fail to purchase coverage.

Senate Bill:

Who is covered?

About 96% of legal residents under the age of 65, leaving an estimated 18 million people under the age of 65 not insured, with an estimated 8 million of those being illegal immigrants.

Cost: 1.2 trillion dollars over 10 years. That is $1,200,000,000,000 dollars. That's even more zeroes.

How It's Paid For:

Taxes on the following: New income taxes on single people making more than $500,000/year and couples making more than $1 million dollars a year, an estimated $20 billion from new taxes on medical device makers, limiting contributions to flexible healthcare spending accounts. As with the House bill, I am certain there are more fees and taxes still hidden in the bill that have not yet been discovered.

Cuts of more than $400 Billion to Medicare and Medicaid.

Fines on individuals and employers who do not obtain health insurance coverage.
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OK, so that is a synopsis, and definitely not the whole enchilada. But let me start breaking this down to what it means for you and how it differs from the 2008 promises made by the president during the 2008 presidential election campaign.

Promise #1 : No Individual Mandate

In both of the above bills, there is an individual mandate for insurance coverage or a fine is imposed. And as we still do not know the extent of government subsidies to help purchase insurance, it appears that many individuals will be coerced or forced by the government to purchase coverage that they may not want, or face the wrath of government fines. In essence, the government wants to pass a law forcing individuals to purchase something against their will.

Promise #2 : Complete Transparency

Need I actually go into this one?

Candidate Obama promised that health care deliberations with Congress and special interests would be transparent to the extreme. To quote candidate Obama: "That's what I will do in bringing all parties together, not negotiating behind closed doors, but bringing all parties together, and broadcasting those negotiations on C-SPAN so that the American people can see what the choices are," Mr. Obama said during his Jan. 31, 2008 debate with Clinton. "Because part of what we have to do is enlist the American people in this process. And overcoming the special interests and the lobbyists who -- Senator Clinton is right. They will resist anything that we try to do."

OK.I had my TIVO set up as a season pass to record all healthcare negotiations on C-SPAN. Funny thing. Nothing recorded. I called TIVO and asked what the problem was with their service. I found out it was not TIVO. There were not any negotiations broadcast on C-SPAN.

So what actually occured? Politics as usual, but on steroids. Both bills have been written along party lines, with mucho mucho special interests involved. These special interests do not represent you. They represent their corporations and their businesses. Now in a free market capitalistic economy, that is fair game. But were'nt we promised transparency and an overcoming of the special interests???

Promise #3 : Lower Premiums by $2,500 for a Family of Four

For this one, I'll believe it when I see it. I am pretty good at math, but not an accountant or mathematician. But to add 20-30 million more people into health insurance, and at the same time lower the cost of insurance premiums, you need to be a magician, not a mathematician.

Now back to who is covered, the cost and how it is paid for.

If we go midway between both the House and Senate bills, we will still be left with about 14 million uninsured, at a cost of over a trillion dollars over ten years, paid for by cuts to Medicare and Medicaid and large taxes on many segments of the healthcare industry and individuals. The healthcare industry segments will end up passing along the increased taxes as higher costs to you.

As employers and individuals, who, unlike the federal government can not print money, will pay higher taxes, and they will have less money in their budgets to expand their businesses and hire more workers. So the trickle down effect of higher taxes ends up costing everyone, not just those who pay the taxes, while still leaving about 20 million people uninsured.

Question 1: If you are unemployed, do you prefer being forced to purchase health insurance, or do you prefer to get help finding a job?

Question 2: With cuts to Medicare and Medicaid, and more people enrolled in these programs, how do we improve care for individuals with these two government plans?

Now, I will attempt to do some math.

Assuming midway between the House and Senate plan, we add 34 million people to the health insurance rolls. The taxes and fines start in year one, while the insurance coverage does not start until years 4 through 6. I will estimate 6 years of insurance coverage for 34 million people at a cost of 1 trillion dollars. That comes out to about $5,000 per year for insurance coverage for each individual, or just under $420 per month. The premiums I pay now are much less than that, and I am not mandated by any government to purchase it!

Question 3: Is the healthcare reform debate about doing what is right, or more about politics?

I'll let you answer that one.

Call your Senator and congressmen and tell them to put a halt to this healthcare reform debacle before it is too late. The legislation currently before Congress was crafted more out of political desperation and not the needs and desires of the large majority of the American people.

One thing I have learned from this debate is that elections do mean something and they do have consequences. Sometimes good, sometimes not.

My hope is that these reforms get stopped, and we reboot the debate and start over. First step, follow the president's campaign guidelines for reforming the healthcare system with true transparency, and a lack of special interests at the table. The table should consists of patient's and healthcare providers and the reforms should focus on individuals and not politics. We can then reform the system one step at a time and move in a direction that helps everyone without adding any costs to the system.

DoctorSH

I Love Capitation

Yea that's right.

I love capitation. But I do it a wee bit different from my colleagues.

You see, my colleagues accept capitation from a third party. You know the Aetna's, Blue Cross, and Cigna's of the world. If I left any other third parties out, I am not sorry ;) My colleagues sign 50-plus page contracts that they do not read, that give the third parties authority and power. Seems a little like the 2000+ page congressional healthcare reform package that is supposed to improve patient care. Well at least both of the above contracts accomplish the same goal. More bureaucracy, longer waits for care, and declining fee schedules.

So why do I love capitation?

The answer is fairly simple. I am capitated to my patients. I have a cash practice that offers yearly retainer options, or payment at time of service for those that do not want a retainer. The retainer options can be paid all upfront, or with a downpayment and monthly checking account autopay. This monthly autopay is essentially a capitation for my services. My services are spelled out in a two-page contract that I drew up, with a little help from my attorney. There are no hidden clauses, no HEDI's audits, or chart reviews.

I do what I can to improve the health of my patient's without any third party intruder in the exam room. I average 10-15 patient visits a day, instead of 25+ when I went by the name of "healthcare provider" instead of doctor or physician. That is actually pretty funny. When I was a kid, and people asked what I wanted to be when I grew up, I didn't say, "I want to be a healthcare provider." I think, no, I am positive, I said I wanted to be a doctor!

In essence, I am a physician (doctor) who loves being capitated to my practice.

DoctorSH

I'll be back!!

After recently being a part of a CME on practice transitions away from third parties, I will need to resume my transition posts.

I will be able to present end of year numbers on my transition sometime in January 2010.

If I find the time, I will also work on a second year 3rd quarter update before the end of the year.

As for now, I am on vacation in Florida, glued to the tv, watching to see whether the House of MisRepresentatives will pass the extremely liberal government takeover of healthcare.

As many of you know, we need healthcare reform, but not a government takeover!!!

Maybe, at some point, our elected government representatives will decide to ask independent physicians how to reform the system, instead of political and bureaucratic pseudo physician organizations, such as those that sold themselves out to a government takeover!

That's all for now !!

Keep on the lookout for updates.

DoctorSH

Healthcare Reform - Is it Gloom and Doom for Seniors?

Healthcare Reform - Is it Gloom and Doom for Seniors?

I apologize in advance if the purpose of this newsletter is once again reform, but with the daily debates in Washington about overhauling the healthcare system, I feel I have no choice.

Let me be clear.

Our healthcare system needs reform, but the reform must start at home and not in Washington. I founded the Institute For Medical Wellness because the present third party insurance, government and corporate dominance of our healthcare system is unsustainable and detrimental to high quality patient-centered care. I removed myself from the system to be able to provide the patient-centered care that you deserve, not the care that a insurance or government bureaucrat feels you are worth. The present reform bills in Washington, both House and Senate, are focused not on improving care, but on controlling costs by putting more roadblocks into obtaining medical care. These reform proposals aim to incrementally and permanently move individuals and businesses into a government controlled system. This has already been tried in Massachusetts and Tennessee and has not worked, with the costs of the programs and waiting time for medical care both rising exponentially. When government medical costs rise, taxes rise and rationing of care soon follows. In a freer market based system, where individuals have more control of their healthcare decisions and dollars, medical costs and waiting times decrease as medical innovation increases. As costs decrease, care becomes more affordable and accessible to all. Look to the car industry. The cost of a new car today is about the cost of a new car a decade ago. This is not due to government intervention, but due to free market economics. On the other hand, Medicare and Medicaid , both government programs that fix costs, thereby not a free market, have had tremendous costs increases.

At the present time, I participate in Traditional Medicare. But the reform proposals aim to change the Medicare system, and not in a way that is good for patient care. When I stopped participating in insurance plans, some of the plans paid me better than Medicare, some worse. I did not risk my practice due to payments from insurers being too low. I dropped the insurers because they were meddling in the care that I needed to provide. Presently Medicare does not have these roadblocks. Under the present reform proposals, that will all change, and I truly fear for the medical care of seniors. Senior citizens will bear the biggest brunt of the reform due to cuts to Medicare of half a trillion dollars over the next ten years. These cuts will happen even though Medicare enrollment is expected to increase by 30% as the "Baby Boomers" become eligible. So how do we improve care, cut the budget to pay for this care, all while having people enrolled in this care increase by 30%? We can not! The math just does not add up!!

No, you have it wrong doc.

That is not what the reform bill is all about.

We will all get access to better healthcare.

Sorry, but that is just political rhetoric. One of the OBama administrations healthcare advisors, Zeke Emmanuel, has written extensively that the elderly should get less care, especially for incurable illnesses such as dementia, because, they "no longer contribute to society." The following is a quote from Dr Emmanuel:

"An obvious example is not guaranteeing health services to patients with dementia. A less obvious example Is is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason."

Sorry Mom and Dad.

Sorry Grandma and Grandpa.

It was nice knowing you !!

Sorry children. You do not deserve the chance to learn to read and reason!!

I am sorry, but this is not reform, and is not the type of healthcare I expect from our country! This is a planned political medical power grab and medical rationing by the government. Any other conclusions or statements to the contrary is rhetoric, outright lies and deceptions.

There are better ways that benefit individuals and business of all size to better afford medical care, while keeping medical freedoms. Some proposals I agree with are listed below:

1) Allow individuals and small businesses to band together to negotiate better rates with insurance companies.
2) Allow insurance companies to sell policies across state lines. This will increase cost competition and hopefully end state mandates that lead to higher insurance rates.
3) Allow individuals the same tax deductibility for health insurance and healthcare that businesses now enjoy.
4) Decrease defensive medical costs by passing tort reform. Many doctors order tests that may be unnecessary for fear of getting sued. Patient's truly injured by medical malpractice will still be able to sue for damages, but the frivolous lawsuits must be ended.
5) We need more HSA's, (Health Savings Accounts), tied to higher deductible or catastrophic insurance policies. These policies are much, much cheaper than present policies, allow tax free savings for medical care, and protect from medical bankruptcies. It also puts the power of the healthcare decision making and the power of the healthcare dollar back in the hands of the patient, and away from insurers and government bureaucrats.
6) End pre-existing condition clauses in health insurance.
7) Make health insurance portable and not tied to employment. If individuals are allowed to band together as a group to negotiate better insurance rates, why do we need employers to do it for us? Allow employers to give employees, as part of their compensation package, tax free money to purchase their own coverage, if they do not like the coverage offered by their employer. If the government wants to help, they can cover part of the costs of coverage if an individual is between jobs.

There are many other suggestions for reform, the key point in reform is to allow the power of healthcare to remain with the individual, and not a government or third party. If the present reform package becomes law, I truly fear for the health of our country! We need reform that will restore the doctor-patient relationship as the predominant factor in healthcare!! Ask yourself, "Who do you trust to help you make healthcare decisions? Your doctor or Washington politicians??

If you care about healthcare choice and healthcare freedom, I strongly urge that you visit the following website, http://www.defendyourhealthcare.us/ , which contains more in-depth information on the present reform proposals. Please do not be left on the sideline, or say it is too late to stop these reforms. You may agree or disagree with the views on the above website, but you need to be informed, and make certain that your political representatives hear from you!

DoctorSH

You call that Healthcare Reform???

July 21, 2009

We are all hearing alot of hubbub about healthcare reform.

This is too important a topic, so let me speak on this subject for just a moment.

First a little background. I grew up in my father's medical office, back in the 70's when an office visit was $8 and when you paid your bill, you left with a smile and a lollypop. I watched these interactions with patient's. I saw trust and confidence that the doctor-patient interaction was always all about the patient. There were no third party intermediaries.

Fast-forward to 2009. The healthcare system has changed. Some have said the sytem has been stolen by special interests. Physicians and hospitals, in agreeing to work with government and private insurance plans, have all but given up control of the healthcare system. When in the 70's, medical decisions were made by the doctor and the patient, now these decisions need to go through bureaucratic entanglements that place your medical care outside the scope of your physcian. The doctor-patient interaction has now become the doctor-insurer-bureaucrat-actuary-patient interaction.

For example:

If you need an MRI, it is no longer as simple as getting a doctor's prescription, making the appointment and getting it done. Now, the MRI "request" has to be pre-authorized by your insurance plan. You can not make the appointment until this pre-authorization has occured. This pre-authorization is just one set of guidelines that slow down the acquisition of care, and in many cases deny it altogether. Your insurance plan is not examining you, yet is somehow is able to deny you care your doctor wants you to have!

If you need a prescription medication that is not generic, most likely it will not be "On Formulary". This means that you have no coverage for this medication and your insurer will offer to switch to a cheaper drug, all to save money for the insurance plan. What if using an alternative insurance approved medicine does not work, and you end up worse, or even needing hospitalization? Saving money is wonderful, if it is effective and in the best interests of each individual patient. But these rules are not for patient's benefit, but for the benefit of the power holding the dollar, in this case, the insurance plan.

Insurance companies AND government regulators are playing doctor with your health. They have power and control over how your healthcare dollar is spent. Your insurer's goal is to make a profit off of your insurance premiums and to spend as little as possible, even if it means delaying or denying care. The government's goal is to spend as little as possible and meddle in your healthcare decisions to attain that objective. Now, I have no problem with saving money. There is a lot of waste in healthcare. But this waste began when the third parties, the government and health insurers inserted themselves into the medical decision making process. If our system is ever to change for the better, we need these third parties out of our exam rooms. We need health insurance to once again be insurance, that covers large bills, or catastrophic costs, so medical illness will never cause one to lose their home. We do not need them in our exam rooms telling doctors and patient's what tests to run or what treatment to prescribe.

The supermajority of doctor's are for reform of the present system. We want to get back to where decisions are made solely between doctor's and patient's. While I can not speak for all doctor's, I can speak for myself. In fact I did it with my pen and my feet 2 years ago, when I terminated my contracts with insurers, and founded The Institute For Medical Wellness. This was the only way I knew to be able to work solely for you, without any third party intruder. Many more doctor's are now starting to follow my lead.

You may have heard that the AMA (American Medical Association) has given their support to the present healthcare bill going through committees in Congress. Let me make it known that I have never been a member of the AMA, and I do NOT support the present bills. These bills give more power to bureaucrats, and less to patients and doctors and will only make the system worse and more costly. The AMA, unfortunately, is a political organization, that does not necessarily represent doctor's, but actually represents it's own corporation. The AMA makes millions of dollars selling and licensing medical coding books to sell to doctor's and hospitals. These coding books contribute to the massive overhead of the present third party system. So any reformed system that continues this coding system, will benefit the AMA's corporation, thus their apparent support of the present reforms being de bated. Physician's have finally wised up and are quitting the AMA in droves. A recent poll on Sermo, a doctor's only website, has over 94% of physicians against the present healthcare reform package. So when you hear in the media that doctors are for the present reform package, it is untrue. The AMA does not speak for nor represent physicians.

If healthcare reform is to work, patient's and physicians must unite. If healthcare reform is to work, the power of the healthcare dollar needs to be returned to individuals. Health insurance must once again be insurance, and not healthplans with thousands of strings attached. Patient's must have choices in insurance and physicians. Third party involvement in the exam room must end! Unfortunately, the present reform bills want the opposite, less patient choice, more third party bureaucracy, and decreased patient-physician autonomy. Too much power of the healthcare dollar in the hands of any third party, whether it be an insurer or government agency will harm our system beyond repair.

There is a better way, and it is why in 2008 I started The Institute For Medical Wellness. We act as your personal health advocate, not that of your insurance company. You receive personalized, individualized care without regards to any third party. We are an independent practice committed to offering the absolute best care- without compromise.

Please go to my blog at http://click.icptrack.com/icp/relay.php?r=6529843&msgid=158418&act=LD0W&c=201613&admin=0&destination=http%3A%2F%2Fdrhorvitz.blogspot.com%2F and comment in the comment section. Healthcare reform needs a true and open dialogue to occur, without politics involved!

DoctorSH

July 15, 2009

It's the middle of the summer.

Whoopee!!

It is also wednesday, and my day off. I am relaxing watching TIVO. I have to admit I am a news junkie and watching Neil Cavuto review the new government healthcare plan that is being proposed. It is ridiculous!!! There are so many barriers between the doctor and the patient that will make healthcare impossible to deliver efficiently and effectively.

If a government run plan comes to fruition, my practice style may fluorish.

Why?

If we add 40 million new "insured" patients to the "system", where will they all go? Primary care will be overcrowded even worse than now.

So will more people get fed up and pay a modest retainer fee to my practice for quicker, more efficient care? That is my hope!!

If you disagree, let me know!!

As for June 2009, it was the second best revenue month of the year. But so far, in july, the summer slowdown has begun and I expect lower revenues.

A Good Trend

Middle of June tends to be a slow time. Weather is getting warmer. Lots of graduations and proms. No one has time for their health. So its a good time to catch up on other work.
But no one told my patients about the middle of June.

Today I saw 14 patients.
1 new patient joined a wellness plan.
1 other joined himself and his wife into my wellness plan.

I have decided that patient's like to know they have a ceiling on their medical bills, at least in my office ;)

But I have had a good trend over the past 30 days that I hope bodes well for the future.

Over the past 30 days, of which I worked 17 days, I had 27 patients sign up for a wellness plan.
Stil nowhere near the 1000 I hope to eventually have, but:

Of the 27,

10 were renewals

3 were new members, but prior to were existing patients

and

14 were totally new to my practice

Of the totally new patients,
3 were referred by a local pharmacist,
3 from an acupuncturist
4 were referred by other patients
2 by my wife
and 2 from advertisements.

Most admitted to checking out my website before scheduling and joining.

So hopefully, marketing and word of mouth are starting to take hold. My practice can only grow by maintaining my existing patients, but as important, bringing in new!

Wellness Growth

I run a small solo and independent family practice office.

I took the initaive in 2008 to decontaminate my practice from the pests that make up third party insurers. I knew that initially I would take a hit, but that word of mouth would again grow my practice. I do not like to be out of control. That includes the growth of my patient base. As many who have been following this blog know, my practice consists of the following:

1. Wellness Plans- prepaid or yearly contracts with monthly auto-debits
2. Traditional Medicare
3. Self-pay with payment at time of service

As mentioned in previous posts, my expenses have gone down, my available time to spend with patient's has gone up, and being a doctor is once again enjoyable. But unmanaged growth can change that. My goal is not to build a huge practice with large staff and overhead expenses. Thus managed growth is the key and it appears to be happening without any further change in my practice style.

My goal is to have between 600-1000 active patient's in my practice. I would like to have 60-75% in my prepaid wellness plans. These plans allow my overhead expenses to remain low.

Comparing June 2008 to June 2009:

There is an increase of 19% in Wellness plan patient's.

20% of 2009 wellness patient's are totally new to my practice.

7% of 2009 wellness patient's switched from self-pay to this plan.

When I opened my practice in 1998, it took a few years for the word of mouth to make me busy. That appears to be happening now, but I am not looking to be "busy" with bureaucratic and government insurance regulations, but instead busy on direct patient care.

So far, I am on goal. I only hope that "Government healthcare reform" does not push me off course. That would be a bad thing for our profession and even worse for our patient's.

DoctorSH

May 2009 stats

May 2009 has been an interesting month.



I will present some stats that I find interesting.



Patients seen for the month of May 167.

New patients to practice 10%

Wellness patients 39%

Selfpay patients 42%

Medicare patients 19%

Average $/patient for May $123.61

Average $/patient for 2009 $100.69



Numbers are only as good as the interpretation. To understand their meaning you must understand my practice. I participate with no insurers other than traditional Medicare. I offer fee for service and wellness plans with either a full prepay or auto-monthly debit option. Advantages to full pay are obvious. Total payment upfront helps the monthly numbers, but each further visit during the year brings in no further revenue. The auto-pay monthly debit does little for the monthly numbers, but works similar to capitation, WITHOUT the insurance middleman. For adults 24 and over the autodebit is $45/month, much higher than traditional HMO capitation.



What I find interesting is watching the % of revenues that comes in each month from the auto-debit option. As the contracts last for a minimum of one year, this will continue to grow each month. In january the percentage revenues was 2%, and now in May is up to 9%. At this pace I may be up to about 20% by years end.



As always, it is important to continue to sign up new wellness patients. At present revenues from full prepay wellness patients averages 35%. So a bad month in new sign-ups would not be a good sign.

Interesting Discussion with a patient

I had an interesting discussion with a patient yesterday. She works as a schoolteacher at an elementary school one mile from my office. She and her family have been with my practice for about 8 years and have referred many new patients to my office. Surprisingly, over the past 2-3 months, I have seen and heard very little from her. She came in yesterday to discuss some health issues and to "feel me out" on whether my new wellness plans were right for her and her family.

Her daughter is about to graduate from high school and has gotten accepted to a very prestigious college. Unfortunately, prestigious colleges come with a high price tag. She told me she had to watch her pennies a bit more, and was upset at my new pricing structure. In fact, she and her daughter had a few visits at another local doc who accepted insurance. Yet she came back in for a visit and to talk.

The question is not why she tried another doctor. That is purely a financial motive. The question is why did she come back?

1) Trust
2) Value
3) Excellent Doctor-Patient Relationship
4) Long history with family

She not only came back, but re-enrolled in the wellness plan, with the auto-monthly bank debit option. She threatened that I would "lose money" on her as she would come in more frequently. I laughed and smiled, and said "Bring it on, That does not scare me. That is my job!!"

Pearl of the day:

Trust and Value are extremely important in any doctor-patient relationship. With a cash practice, with no third party intruders, it is easier to build and maintain!!

DoctorSH

It's been a few weeks

It's been a few weeks since my last post. Daily posting can get cumbersome after a while, but I am back!! I have realized that looking at daily numbers does not give a good overview of my practice transition. It is similar to a dieter checking the scale before and after each meal. Just too much information. So I will continue posting, but at a slightly decreased frequency.

Since April 20th, I have worked 10 days and the following occured:

patients seen 102
New patients 4
Wellness Patients 42
Selfpay 39
Medicare 17

26 Wellness Plan enrollments
21 were renewals
5 previously selfpay patients enrolled.
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The wellness plan enrollments alone almost pay my overhead. So the goal, as always, is to increase this part of the practice. I am presently researching additions to my plans that would encompass more dietary, holistic, cardiac and corporate versions. As the 2008 to 2009 wellness plan renewal rates are over 80%, with some patients just delaying coming in to renew, the concept is working. Now the object is to get to 1000 active patients and close the panel and become a doctor first and only, instead of a doctor , businessman, and marketer. The best run medical practice is one that grows from word of mouth with very little marketing. But it takes a few years to get to the level where this will occur. Until that time, I will continue to actively market my practice, my ideas, and my views on patient care. I will try to attract the type of patient that wants my style.

I have another blog that I write for my patients. The patient response has been terrific. In fact, half of my patient visits end with the statement, "Doc, keep sending me those email newsletters you write." It has been the most productive practice builder and goodwill generator of my career.

It can be found at http://drhorvitz.blogspot.com/

DoctorSH

Institute For Medical Wellness Vision

I write an email newsletter to my practice. The contact I keep with my patient's , even when they do not need my services has proven very valuable and has continued to build on the trust in the physician-patient relationship. Below is an email just released to my practice. While my practice does not fit into everyone's ideal, continuing to explain why my system is better for them is priceless.
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April 27, 2009

I have often been asked how and why I developed The Institute For Medical Wellness.

So here goes.

It all came down to following my vision of what makes a true Family Physician and developing a practice with this mission. This vision has been shaped and reshaped over the past 18 years. Upon graduation from medical school in 1991, and completing an internship and residency in Family Practice in 1994, I felt very well trained to begin my career. My first four years were spent working for another family physician with two offices. One was based in Cherry Hill and the other in North Camden. During those years I matured alot as an individual and as a physician. I learned that being a physician is not just about diagnosis and treatments. It is about building relationships based on trust and mutual respect.

My goal since childhood has always been to have a private practice. So in 1998 I started my own solo private practice in Moorestown. At the time I was told by a majority of physicians that I would never succeed. The prevailing thought in 1998 was that independent medical practices were too risky. In 1998, hospitals were buying up independent practices and physicians became employees of large hospital orgaizations. Well, if you do not know me well yet, I have my own views, many of them contrarian. I do not believe that the majority opinion is always correct. I also do not always play well with others, so an independent practice was my best career decision and I have never looked back and never regretted it.

Now starting a practice from scratch was not easy, but it was the right thing for me. It was slow the first year, but by the second and third year, things were moving along nicely. I was busy enough to be happy, but not so busy that I couldn't take the time necessary for each patient, as well as have enough time for my own family. Health insurance companies were strong, but they were not yet planting themselves between me and my patient's. But year after year insurance companies started requiring more and more bureaucratic nonsense in order for the proper delivery of care. Back in 2004-5 I stopped participating with 2 health plans due to their nonsense. My practice grew nonetheless. But again, each year brought more bureaucratic and governmental regulations that hindered the proper delivery of care. Referalls, preauthorizations, precertifications, electronic billing, HIPPA, and many others were not part of running an efficient and effective medical office when I started medical school. But this is what happens when Big Business and Big Government takes control of your healthcare.

In 2007, I was at a crossroads. My career goal was not to be the richest or poorest physician, but to be the best physician I could be. I explored two opportunities. One would have meant joining a large group practice that would deal with all the bureaucratic nonsense for me. The other was to convert my practice to a Concierge model. Both had many advantages, but also came with one big disadvantage, that being loss of control of how my practice is run. And as I stated before, I do not play well with others. So I needed another direction. I needed a practice model that fit my views of proper patient care and yet still remain viable in the community. So I brainstormed and put together the vision of The Institute For Medical Wellness. Special thanks to my wife, my daughter Nori, and great friend Ivy for all your help with bringing a name to my vision.

So in January 2008, The Institute For Medical Wellness was born and has been growing and evolving every day. It has not been all smooth sailing, and I have hit some bumps along the way, but overall I am moving in the right direction. Being in practice for 18 years, I have become more realistic in my views on medical care. I have learned that traditional medical care does not have all the answers. So while I received a traditional medical school education, my views now also include holistic approaches. In the treatment or prevention of illness, we need first to do it safely and effectively. I do not like to order tests just to order tests. I do not prescribe medications just for the sake of medications or expediency. I do not like calling in a prescription over the phone without a proper evaluation. That is not the best care I can provide. When I do prescribe medications or order tests, it will be the least amount necessary to do the job right. More is not necessarily better when it comes to medical treatment. My views are also that most disease can be classified as mild, moderate or severe. A holistic approach may work very well for prevention of disease as well as for mild disease. But when we get to moderate to severe disease, a traditional approach may be necessary. That being said, nothing makes me happier than lowering medication use by way of a healthier and more holistic lifestyle. Treatment without medications is always the number one goal.

So it is now the Spring of 2009. The Institute For Medical Wellness is 16 months old and is still in its infancy. But like all infants learning to walk, our legs are getting stronger each day. We are learning what our patients want and expect and are doing our best to accomodate in the safest and most effective way possible. The most frequent question has been about offering a closer integration of holistic approaches to treatment. So in future newsletters I will be introducing some holistic integrations available to improve your overall health and wellness. Many of our affiliates listed on my wellness network page will become more visible and available for your care.

So please stay tuned and be certain that The Institute For Medical Wellness is focused not on Big Business or Big Government, but instead on each and every individual who steps through our door. Our focus has always and will always be focused on you!

Steven Horvitz, D.O.
Board Certified Family Medicine
Founder of The Institute for Medical Wellness
128 Borton Landing Road, Suite Two
Moorestown, NJ 08057
Phone: 856-231-0590
Fax: 856-294-0311

For more information about Dr. Horvitz and The Institute for Medical Wellness, please click here.

To view upcoming Wellness Network Events, please click here.

Spring Break is finally over

Last week was Spring Break. It seemed like half the town was away. Now I know some docs who love it when the office is slow. But they are usually either salaried, or heavy into capitation. I like to be busy, but not rushed.

So last week had 43 patients through the office with 1 wellness plan renewal.
overall for the week,

14 wellness , 8 medicare, and 21 selfpay.

For the year the percentage patient visits is as follows:

37% wellness, 23% Medicare, 39% Selfpay

this is pretty close to what I expected at 40-20-40.

I hope as the year drags on to make it to 50-15-35, and each year have the wellness portion get larger.

For those reading this blog, please send in comments, questions or suggestions. I hope to learn as much from you as hopefully you are from me!

DoctorSH

Should I continue this blog??

I have been writing this blog for awhile now. My purpose is to record the good and the bad of my practice transition and to open up the discussion among other primary care docs.

I have taken a break recently as I have been busy with other items at work.

I would like to know if I should continue.

If you feel this blog is useful and think I should continue please respond as such by leaving a comment. If I get enough comments I will do my best to continue.

If there are other issues or questions about the transition please post those as well.

DoctorSH

Pre holiday week

Geared up for Passover and The Easter weekend.

In 3 workdays, had 40 patient visits, one workday to go in the week. Might be slow for the Easter and Passover holidays.

Overall 4 renewals of wellness plans, 1 new patient to the practice who joined a plan, and others have given me feedback that they are preparing to renew.

Through the first quarter, compared to last year, 2/3 have renewed their wellness plans, 5% did not renew but stayed in the practice as self pay, and the others we have not heard from yet. My assumption is that half will renew, of the other half most will switch to selfpay. A few of these are kids who switched due to leaving for college.

The revenues are on par with the average for the first three months. As long as the renewal rate stays at 2/3 or greater and we continue to bring new patient's in, the practice will grow. Unless Obama socializes our profession, and then we are all screwed!

DoctorSH

April 2nd, 2009

I did not add to this blog yesterday, April 1st, as I was in a deep contemplation about whether to sell my practice to a local hospital. They offered me about $500,000 and a guaranteed salary of half that to help market my program to other docs in the area, as long as we would continue to utilize their hospital for admissions. I had a long talk with my wife and we decided to turn down their offer. More on the reasons later.

DoctorSH

End of month, End of quarter

It's the end of the month and quarter.

Before I get to numbers, it has been an aggravating tech couple of days. My website had been down for 3-4 days. My webmaster had the hosting switched from one server to his, and it took 3-4 days to switch and "propogate". Of course this happened as soon as I sent out an email newsletter to my patients that included links to my site that they could not get to!!! Great timing!!!!!!!!!!!

Next tech hassle is my EMR. I use soapware. I have been happy with it for 4 years, but over the past 6 months, since their frequent upgrades to become C-CHIT certified, there have been many bugs and glitches, and their tech support has been lacking. I am contemplating making a switch to another vendor if the switch itself does not become another nightmare!

My third tech hassle is that along with my website, my email is also down, now for 4 days. I am being promised it will be back up by tomorrow, but that is the same promise I have heard for the past few days.

Pearl of the day: Technology can be wonderful, but when it does not work it becomes a nightmare.

What will happen next? Hopefully not that April fools worm that might hit tomorrow!

The numbers..................

Pts seen for the 1st quarter of 2009: 590
Average $/patient for the 1st quarter of 2009 $95.53


Pts seen for the 1st quarter of 2008: 570
(if I remove leftover 2007 insurance patients from the total)

Average $/patient for the 1st quarter of 2008: $89.19
(when old(2007) insurance $ removed)

So by switching to a zero copay wellness option, with more money upfront, it seems that I have had a slightly higher patient volume and better $/patient. This may decrease if I do not continue to sign up new wellness patients each month. Of these patients, just over 1/3 are on the monthly autobank draft option that keeps monthly revenue flow coming in. About 25% of the 2009 wellness patients are new to my practice, whereas 95% of 2008 were established patients. About 15% of the new wellness plan patients were self pay in 2008. I have had a few patients switch back to selfpay, almost always the result of either a job loss, or less need for medical care. The new patients and the switch-in patients outnumber the 2008 wellness patient's who went elsewhere for their care in 2009.

The breakdown in patient visits for the first quarter 2009:

Selfpay 39%, Wellness 37%, Medicare 24%

The breakdown in patient visits for the first quarter 2008:

Selfpay 56%, Wellness 22%, Medicare 22%

So the selfpay decreased by 17%, wellness increased by 15%, medicare down 2%
Now part of the wellness relative increase is due to some 2008 patients whose old plans are still in effcet for part of 2009. January 2008 started with zero plan members and it took a few months to increase the wellness patient volume.

My ultimate goal is for Wellness to be about 60%, Selfpay 25%, Medicare 15%. At this breakdown, overhead and collections will be even lower than at present.

Expenses for 2009 are lower than 2008 by about 10% and from 2007 by about 35%.
The revenues have not made up the difference yet, as my take home is still lower.
But the joy of going to the office and just being a doctor, and working for my patient's and not any third party is a pleasure.

My hope is that the revenues increase with slightly more volume. In my set up, if I get 800 active patients, with 600 in wellness plans, averaging about $425 per year per wellness patient, that would bring in $255,000. Selfpay patients would be about 50 visits per month averaging another $48,000 per year. Medicare would be another 25 visits per month averaging another $21,000 per year.

Total hopeful revenues would be about $325,000 per year, with expenses coming in at about $15,000 per month or $210,000. That would be profit of $124,000 per year, with a patient practice of about 800, and seeing about 12-18 patients per day, 4 days a week. If I want to work harder and work 5 or days a week, then increase the profit accordingly.

I welcome any thoughts.

DoctorSH

Monday 3-30-09

I saw 11 patients today.

3 Medicare.


3 Wellness- 1 renewed a husband-wife plan- prepaid for the year. I see the husband maybe 3x per year, the wife 6-8. It works out well for all involved.


5 Selfpay- 1 was a full physical in am, 1 was a fit in in the evening with palpitations.

One gentlemen came in with calf pain at 445PM. About 1 week ago he flew back from Hawaii, overall 12-13 hours on a plane. Since I have no need to rush through evaluations to get to the next patient, I called a radiologist friend to see if I could get a stat ultrasound-doppler r/o dvt. A radiologist appt after 5pm??? I made a few calls, scheduled the patient for 7pm and had the radiologist read the studies from home and call me on my cell phone with normal results. I called the patient on his cell phone. He had just left the radiology center and was pleased with the results, and I am sure pleased with the speed of his testing and treatment. Try getting this done with 5 patients in your waiting room complaining of long waits!! Two years ago this patient would have been sent to the ER. Not a fun place to be these days ; )


I also spent some time tidying up the office, helping prepare a room for the massage therapist who starts in 3 days. The room needed some work, but it looks pretty good. Just a few more touches needed.

Tomorrow or wednesday I'll try to post end of month and end of quarter numbers.

DoctorSH

Another saturday

A nice spring day.

It's saturday am. My wife and daughter are out for the morning. I am home relaxing catching up on emails. I do not have regular scheduled hours on weekends. I only live a few minutes from my office so I can go in to see a patient without messing up my day. But it still is nice to not get any calls.

The prior week was slow in patient's seen, but good for wellness plan signups. We had 39 patient visits, and 9 wellness plan sign-ups or renewals, including a few new to the practice and new to the plan. Revenues still allow take home pay, but still below the average for most family docs. But I would not trade the revenues for the freedom. And if all goes well, the revenues will increase each year. As it is still early in the transition, I find it easier to pay myself quarterly instead of monthly.

My new ad campaign continues in the local paper. Have had a few calls and have seen my website hits rise. It will take time, but it will happen. Why do I say that and why the confidence?

If you hear the compliments I receive from my patient's, not for any special medical skills, but instead for being a different kind of doctor, one who takes the time to listen, and one who does what is necessary, regardless of the outside powers that be, you would also be confident.

DoctorSH

Slow week so far but optimistic

I take Wednesday's off. But as I have alluded to in past posts, I was at the office today anyway, this time for 3 hours upgrading my EMR. I have used Soapware (www.soapware.com) since September 2004. At that time it was very inexpensive and easy to use. The cost has gone up slightly, but it is still inexpensive compared to other EMR's, and the new version is C-CHIT certified. For solo or small practices, it is worth a look.

The weather was sunny on Monday and Tuesday. It seems that nice weather days cause a slowdown in patient volume. I saw 9 patients both days. But of the 18 seen this week, 7 have signed up for the wellness plan, with another new patient tomorrow also expected to join. 2 of the renewals were not even seen. They just sent in a check for payment in full, and the memo section of the check was written "wellness plan". These 7 patients, with one more expected tomorrow represent at least $3,955 of revenues for the year.

Try this on for size.

• If I am able to grow the practice to 800 patients, with all in the wellness plan, that would be $395,500 in revenues.
• If each average 5 visits per year, that would be 4000 visits per year averaging just under $100 per visit.
• 4000 visits in 50 work weeks = 80 visits/week, or 20 per day in a four day work week.
• That would be 2.5 visits per hour, or about 25 minutes per visit. This is an average, some would be longer, others shorter.

If anyone reading this blog does not like these numbers, please tell me why?

This should be the future of primary care. But until more physicians utilize this system, and make it the standard, physicians will continue to be stuck in the inferior insurance mill style.

The main question about my system is whether I can grow it to 800 or more patients. It would be easy if the other docs in my area adopted a similar system. If this style became the main force in my community, I would have to turn people away. Revenues would be up, medical care would be non-rushed, costs would be controlled, the doctor-patient relationship would once again mean something, and residents would once again choose primary care as a specialty.

In other words, "Win,Win,Win, Win and Win!"

I just got a text message from one of my wellness patients, He faxed me some labs from another physician. He wants to chat about them. I can have him come to the office for a visit, but he has no copay, and it would take him away from his work. I'll check the efax from my laptop, and call him tonight. It's a nice thing not to worry about payment!!

DoctorSH

Communication and the toys we use

Isn't the weekend supposed to be for rest?

Not when you are trying to build a medical practice!!!

It started last night, after hours when I received two phone calls.

The first from a family I have treated for many years. Their son needs surgey on his finger on Tuesday, and needs a physical and clearance prior. He can not miss any more school, so in to the office I went today. Of course, while I was there, I checked out his older sisters broken toe, and renewed a prescription for his mother.

The second call I received last night was about the 8 year old girl who almost got "peed" on by my dog last week. She is just about over her flu, but broke out in an itchy rash on her face, elbows, and knees.

She was taking several OTC natural remedies. I had her parents take a

digital photo and email it to me. I then checked the picture and spoke to the mother. Mom sent me a text message this morning stating her daughter was fine today and all resolved.

After I finished with the preop physical, I checked the fax and some lab results.

Don't ever do this on a weekend if you want to get home. I received lab results on an octogenarian with CHF whose potassium has risen to 6.1. I am co-managing her case with a cardiologist. So I called the cardio and left a message on his cellphone voicemail. Then after 15 minutes, I sent him a text message. He returned my call 5 minutes later. He had just landed in Vegas for a conference that his wife needed to attend. We spoke for about 10 minutes and then I called the pateint with further instructions. This is a solo cardiologist who knows each of his patient's very well, and he communicates with me at length. He is always available to talk about any patient, whether it is his or not!

The fax machine resulted in an ER report of a 21yo patient who was found to have SVT. He was treated and sent home for cardiology follow-up. I have treated his family for over 10 years and have a good rapport with them. I called his mother on her cell to see if I could speed up the process of a cardiologist appointment. Mom was appreciative for the call!

Pearl of the day: When starting or transitioning a practice, be available, even on your days off, and do not be afraid to use new communication tools like cell phones, email, digital pix, and text messaging. Your patient's appreciate the effort!

Slow but promising

Slow day today. Only saw 8 patients. But brought in over $1100.

How can that be??

1 new patient for a full physical with tests.
1 patient renewed their wellness plan- paid in full.
4 other self pay patients- 1 of which will be returning next week to join the wellness plan, and possibly add her 2 kids.

1 patient with a bad back and lingering depression scheduled a 15 minute phone session and paid prior to with a credit card. This is something that I need to consider. Phone sessions for established patients, with a credit card or bank account debit set up. Less stress at the office for the routine and follow-up care. I may need to send out a patient survey on the need for this service. Wellness plan patients already get this service as part of their plan. But if I added a $25 yearly charge per patient, $50 per family for "phone care", with a possible $25 charge per phone session, it could really bring up revenues. The truly sick would be told to come in for evaluation.

DoctorSH

Jeckyl and Hyde patients

Normal day today.

Had about a dozen patients.

But same days seem like old movies. One movie I only saw bits and pieces of was Dr. Jeckyl and Mr. Hyde. I knew one was good and the other evil. I googled their names to find out which was which.

I am getting better at knowing which patient's in my practice are Jeckyl's and which are Hyde's.

An example below:

Jeckyl:

One new patient referred from her boyfriend who is already a patient in my practice. She was not happy with her previous doctor. She felt he did not listen to anyone but himself. At the beginning of the visit she was subdued. By the end of the visit, she asked if we had a form to get her old records transferred to my practice. She paid my full fee. She was not yet interested in a wellness plan. She felt she received good value for her money. So I had a talk with my medical assistant. It went like this:

ME: " Did the new patient have any problems with the fee?

MA: " No she did not. And in all the time I have been working here, no one has complained about your fees. They just pull out their checkbook or credit card and hand over payment."

ME: " It makes me wonder why I have kept fees so low. I should have raised them a long time ago!"

MA: "Let me know when you do, so I can ask for that raise ;) "

===================

HYDE:

This is different from the husband and wife who called up for refills on some meds. The wife also asked me to call in an antibiotic for a "sinus infection". This is the same couple who I saw in January, and left without paying, a combined $200 bill. So I had my MA call them back and tell them they need to send in payment, and if they need to pay it out over time, include a timeline they feel can work. Their answer was that they never received a bill from me. Well, if I was on the phone I might have lost it. When this couple was in my office in January, they came with no intention of paying. I did not find this out until they were about to leave. My assumption was they would put down some payment and pay the rest out over a few months. When they said they could not pay anything, they were given the full bill before they left. They were being disingenous to say the least about payment.

====================

I learn something new every day.

If I feel a patient will be non-compliant with payment, have an entitlement attitude towards my office, or just be plain untrustworthy, they will not be scheduled again. This is not being mean. This is not allowing myself or my office staff be taken advantage of or enabling of bad behaviour. And yes, lying or twisting the truth about payment for my medical services is BAD behaviour.

DoctorSH

Urine, Fit him in, a Baby Shower and T-cubed

Wed March 18th, 2009

My day off.

What did I do today?

Worked out in the am. Had some "me" time.

Then I went to the office to see 2 patients.

The first was a new 8 year-old girl with the flu. Her parents and 2 grandparents are already in my practice, as selfpay patients. Very nice people and very understanding. Why do I say that?

Well.......

URINE:

My wife and I bring my dog to work with us. A cute 20lb poodle named Ellie. Ellie usually stays with my wife or with my medical assistant, usually hoping to get fed. But my wife was shopping at Target, so Ellie just roamed around the office greeting everyone. Well as I was almost finished with the 8 year old, Ellie comes into the room to say hello. Ellie acted like she wanted to get closer to the patient so I allowed her to get up on the exam table. Ellie then proceeded to squat and urinate on the exam table, inches away from the 8 year old. Thank goodness for table paper!! As I saw the squatting, I grabbed Ellie and put her on the floor and had my medical assisstant take her for a quick walk outside. The 8 year old and her mother, instead of being horrified, were laughing it up. It is nice to have patient's who are real people!!

FIT HIM IN:

The other patient is an owner of a small business that is downsizing. He has an HMO insurance via his wife's employer. He called his "primary", but they could not see him until next week. He did not want to wait, so we "fit him in". He had an abcess and early cellulitis on his right thigh. I called a surgeon I have referred to for years and they "fit him in" 2 hours later. I charged him only for a minimal visit, 99212 for those who still code, as I did an evaluation, but no real treatment. I also gave him a break as I treat his wife and mother-in-law.

A BABY SHOWER:

Some nice happenings today. A surprise baby shower for one of my medical assistants. My new part-time medical assistant took charge and planned the surprise shower which we had at the office at lunchtime. today. My other part-timer was there along with a former employee, my wife, and in-laws. One nice thing about a small office is we can do little things like this. It keeps the office happy and running smoothly.

T-CUBED:

After work today, while driving with my wife to go food shopping, I received a call from one of my wellness patients. She was sick for a day, but felt this was not her normal sickness. I was able to get info on the phone to help her, and asked that she text me her pharmacy phone number. I use a treo cellphone that enables me to make calls by tapping the phone number contained in the text message. After calling in an RX to the pharmacy, I replied to her text that the rx was called in and that she should schedule an appointment in 2 days if she is not getting better.

As part of my wellness plan, she has no copay. I would not receive any revenues by seeing her in the office. She also lives about 1 hour away. In the olden days, I would have requested she come into the office right away for evaluation. So it would have cost her 2 hours of drivetime on the NJ turnpike, while feeling really ill. Not a pleasant thought! The wellness plan allowed me not to worry about getting paid, but instead to focus on my patient's health.

So what does T-cubed stand for:

T-cubed = Telephone + Treatment + Texting

T-cubed allowed me to treat a patient efficiently and quickly, and we were both happy with the process. No insurance or government regulation to get in the way!!

DoctorSH

This and That

THIS:

Monday and Tuesday- the 16th and 17th of March- St Patty's Day.

24 people the past few days, 3 new patients, 1 renewal of a wellness plan.
A medicare check brought the revenues to January levels.

Hired a massage therapist. Part-time independent contractor to work 2 days a week.
Will be sending out email marketing tomorrow.
Plan is to put together a full introductory wellness package for patient's to try, and maybe at a discounted rate. After the discount, patient's can work out their own deal , but hopefully they will find the services valuable.

THAT:

In between patients, I had 3 pharmaceutical reps sitting in my waiting room. 2 were together, the odd pairing of the rep with the manager. You know how it goes, the rep actually tries to show he knows how to sell the product, while the manager sits and daydreams about how nice it is to not be stuck behind a desk somewhere. Actually, they all should be thankful they still have jobs. With the economy going south, generic price wars, and a new presidential administration calling for changes in the healthcare system, the pharmaceutical industry should be really worried.

But back to the waiting room. The rep who represented medicine X, started to "teach" me about when would be an appropriate time to use medicine X. Usually I just ignore their speeches, but when he started telling me how medicine X now is a tier 2 drug on formulary with so and so insurance plan, instead of tier 3, I abruptly stopped his speech.

I told him the following;

"Nothing personal, but if your industry does not stop bowing to the government and insurance companies, you are digging your own grave. You have enough competition with generics being so cheap, a downward economy, and a new federal administration that will presumably make it even worse, but you continue to dig yourself deeper, by detailing physicians about how we should prescribe medicine X to people with this or that coverage.

What about people with different coverage?

What about people with no coverage?

Why the different pricing for insurers and individuals?

We all know the insurers profit from prescription plans. Their formularies are not based on efficacy, but more on cost and profit. Your industry has taken a huge public opinion drop because the public knows you are not looking out for them. The system needs to be fixed, but it will never happen as long as your industry is seen to be in bed with the insurers. You need to stop making deals with all insurers. This will put an end to formularies and the b.llsh.t preauth nonsense that goes with it. One price for everyone, and a reduced price at that. Get rid of the middlemen, and have a price-point that will be profitable, to keep research and development thriving, and people employed. If insurers want to pay for prescriptions, let them reimburse the patient separately, but keep them out of the doctor-patient-pharmacy loop. It only adds cost and wastes time."

So I finished my little speech, and the three reps looked up and at first were afraid to talk. Finally, the third rep, a woman, decided to try and argue about how much it costs to bring a drug to market, etc, etc. I agreed, but that argument has nothing to do with the insurance-government middleman. She then said how they "voluntarily" signed the pharma code about gifts to doctor's office. The new "code" was signed to hopefully deter the feds from passing laws that would have greater restrictions on gifts. Boo Hoo. My patent's now have to use bank pens instead of drug sponsored pens. What a shame!! As if a free pen makes me write for a drug. Give me a break. But I am sure that politicians never, ever, ever help their lobbyists by passing laws that help them with ......

So back to my speech:

"The more your industry continues down this path, the worse it will get, and you will all be looking for a new job soon. I just heard Pfizer laid off 10 of the 14 reps that were in my area. You don't think you will be next? Your industry leadership needs a new direction. Now have a nice rest of your day, and be sure to go sit in your car and write down everything I just said and pass it on to your higher ups! If they want some advice, have them call me. I'll be glad to talk to them, For $500 per hour! "

Well, that felt good, and now its time for lunch.

Can you believe I actually had to buy my own sandwich today.

No drug rep lunch today ;)

DoctorSH

Availability

Saturday, the day after Friday the 13th.

Office is closed. But I still went in and evaluated 3 patients.

1 new, 1 established self pay, 1 established wellness.

All three were thankful I came in on my day off. In fact the wellness patient called at 10am , and I was already going to the office at 11am, His words at the end of the visit,

"I am happy and impressed! I called on a day off, was met and treated at the office in an hour, and as part of the wellness plan I don't have to pay for the visit! "

Even though I do not have routine hours on Wednesdays or weekends, I am still available when needed. It is not that big a deal to go to the office for an hour or so when a patient is in need. It builds loyalty and grows a practice.

DoctorSH

The end of the week and Jan-Feb analysis

Friday ended.

It was definitely not thursday. Had 6 patients thru the office.

One gentlemen came in for his wellness physical. With my open scheduling, he called yesterday, and we performed the exam today. Spent about one hour with him, performed an ekg, spirometry, reviewed labs, full exam, and chit-chatted about other things. It's called having time to get to know your patient's, building trust and loyalty, and being a true family physician.

Ended up with 46 patients for the week. It would be nice to have them spread evenly throughout the week, but now that would not be realistic, would it?

I have some numbers for the first 2 months of 2009 for analysis:

400 total patient encounters

154 selfpay ---- avg $77 per encounter
152 in wellness plan---- avg $126 per encounter
94 Medicare---- avg $85 per encounter

An encounter is any patient that is in the office to see myself or the medical assistant, even if just for venipuncture, a B12 shot, or quick nurse vitals. If they were seen and paid something, it counts as an encounter.

So the selfpay and medicare $/encounter underestimate the avg amount that physician visits would generate.

The wellness plan average may decrease if I fail to continue to enroll new patients in the program, but will stay the same or increase if my marketing and other word of mouth generates a buzz.

If you still take insurance, let me know what your average $/encounter is with your payers for comparison. Also we should calculate the extra overhead involved in collections, and the third party bureaucratic machine. My way is not for everyone, but it is a nice way to do business and provide medical care.

Oh, and by the way, my patients all call me doctor, not provider!!

I found the definition of provider in the new AMA dictionary.

provider: an evil word that came from the third party intruders when they took over healthcare. The dumbing down of physicians who provide care while chaining themselves to bad contracts.

DoctorSH

It has been an eclectic week so far

After the slowest day of the year on tuesday, I had 19 patients through my office today. Most of my time was spent with patient's, very little on other matters. It felt good!!!

Of the 19, 6 were Medicare, 6 were wellness plan, and 7 were selfpay.

3 New wellness plan enrollees today.

1 was a renewal from last year, 1 was already a patient, but enrolled this year as she wants to work more on prevention, and 1 was new to the practice. Interestingly, this last patient recently moved from California, and wanted to work with a doc who has the time to listen, and also who will not nickle and dime her with office visits. When she saw the wellness plan, with the monthly auto-pay option, she signed right after our visit was over.

I may have said this before, but I think the zero copay option to the wellness plan along with the monthly autopay option is attracting more patients, especially the uninsured, and those with high deductible policies. In fact, one wellness patient came in tonight, just for 2 rxs, and informed me as soon as he gets his hsa funded, within the month, he will be enrolling his family in the plan, instead of just himself. This is what I hoped to be able to do, enroll more families!!

This last patient also switched, at my suggestion, into an HSA with a $5000 deductible for his family. His previous family premiums were $1500/month with $10 copays. He now pays only $700/month. Thats $9,600 in premiums savings a year. His $5000 deductible is self funded but is tax deductible, which saves him another 28-31%. So his savings by being in an HSA , even if he uses all his deductible is about $6000 a year. And his wellness plan will come directly out of his HSA and count towards his deductible.

If we can somehow get more HSA plans in to the mainstream, my style of practice will thrive!!

DoctorSH

I should have been a Veterinarian !!

My day off. I took my dog to the vet for her annual checkup. 30 minutes and $175 later, I was driving home. They did not ask to see my insurance. They did not ask for a copay. They did not ask for an insurance referral. All they asked was for payment in full at the end of the visit. Cash, check or credit card please, Ka-ching!!!

The $175 breaks down as:

$50 for the exam
$61 for 3 vaccines
$48 for blood and stool test
$16 for a flea-tic collar

So if we look at it more closely, the bill is actually reasonable. And it was one stop shopping. Pretty convenient!!

Now let's compare to a managed care practice for humans.

You show up at the office and are asked for your insurance card prior to anything else. Once the insurance is verified, you wait to be called back to the exam room. If you need blood tests, the office must first check to see what lab your insurance participates with and whether the tests will be covered. Then you may be given a labslip to get the tests performed at a capitated laboratory.
Then you must wait 3-5 days for most test results.

Vaccines can be given. But with the insurer changing the rules frequently, the doctor does not know if he will get paid. If not, good luck getting paid afterwards by the patient. As for medications and treatments, you need to give a prescription for patient's to get filled at a local pharmacy, or a mail order pharmacy, which can take a few weeks to obtain.

After all this, the patient pays a copay, averaging $20-25. Then the doctor's office must submit a claim to the insurance company and hope to get paid within the next month or two, and not for the full amount, but a discounted rate.

It may just be me, but it sounds much easier and more efficient at the vet's office!!

And you wonder why I transitioned out of third party contracts!!

DoctorSH

Slow day

Tuesdays are usually slow. Today wins the award for slowest of the year.

Only had 5 people through the office, however one established patient paid for the wellness plan without being seen. Also had a new self-pay patient as well. While I saw 1/3 of the volume of the previous day, the revenues were still 2/3 . Still making a profit even with only 5 patient's today. Try that with insurers.

I am off tomorrow. But thursday already looks busier with 11 patient's scheduled, with 2 potential wellness plan enrollments.

On slow days, you need to make good use of your time. My spare time was spent partially with the patient's I evaluated today, an extra 5-10 minutes goes a long way for goodwill, and the rest was spent negotiating for a mortgage refinancing for my home. With interest rates so low, the few hours I spent could have a huge return on the time investment.

DoctorSH

Annoying day

Ever have one of those annoying days?

Mondays are tough enough, but you walk into your office, find out your medical assistant is late. She walks in 2 minutes before the first patient.

Then my first patient complains about his bill, $90 for an office visit that lasted 30 minutes + a labdraw. The next patient was a no show. The 11am new patient also no showed.

I like to start off Mondays on a good note, and when patients No Show, it kind of ticks me off. It shows lack of respect, and a lack of true value. I track all no shows in my emr, and I have stopped scheduling repeat no show-ers.

Overall we had 16 patients thru the office today.

1 wellness plan renewal from last year.
1 new wellness plan for a child. This child is on medicaid, but the mother, who joined last week, has trouble getting in to her pediatricians office quickly. My assumption is the quick availability in my office is valuable.

The revenues for the day were actually good as we had a good number of selfpay patients.

So what started out annoying actually turned out ok.

Pearls for the day:

Don't let the ignorant (no show-ers) annoy you.

Show your value by being available, If a patient is sick and wants an appointment, get them in same day. They might not be sick tomorrow!

DoctorSH

Decisions do affect your future

It is a tough time to do anything in a medical practice these days.

I chose to be in control of my future and to do it my way, independent of intruders.

The way I see it, if any form of healthcare insurance reform occurs, there will be a huge shortage of primary care as all the newly covered start showing up in medical offices. This will either drive more patient's fed up with the "mill practices" to my office, or if physician's are forced into the system, there will be more than enough patient's to keep everyone busy.

But that is the problem. I do not want to be busy for the sake of being busy. I want to do the best job possible for those that ask for my help. A smaller practice size with more time allotted for each patient is the method that works best for me!

It is time that physician's start advocating for this type of care, as more time with patient's improves the care they receive.

DoctorSH

Talk is cheap

How many docs hate giving away free advice?

Shouldn't there be a system that rewards us for this sidewalk chatter or elevator conference?

The issue is our present payment system. We make our living evaluating patients in our offices or hospital and then send a bill, not to our patient, but usually to a third party go between. We can wait for months to be paid for our services, and during the wait our frustrations mount. There must be a better way as it seems we are working for free!

So what do we do??

About 2 years ago I came to a crossroads in my practice. I was getting busier, and not being able to spend as much time with each patient as I liked. Even though I was busier, my revenues were stagnant, and my expenses were rising. Not a great situation for the future. I belonged to a multi-specialty IPA that was quickly disintegrating, as specialists withdrew to form single specialty organizations. Many family docs in the IPA got together to see if we too, could convert to a single specialty of our own. The thinking was that if we got enough members, we would have the clout to battle the insurers for better contracts.

At the same time I was approached by a practice management company that offered to convert my office to a concierge retainer style practice. I went through the process of sending out surveys and was very close to joining this company. However the lack of being 100% in control of my own destiny made me decline the offer.

I decided to remain independent, because as I like to say, "I don't play well with others." But remaining independent was a guarantee for continued decreasing revenues , or I would have to see a greater volume of patient's. To me, that would be selling out my values for income. Many of the primary docs in the IPA joined another IPA that already had clout with the insurers. At this time, they are doing well financially, however with the possible changes in our healthcare system, I do not know if that model will be sustainable.

So I chose to terminate from third party contracts other than traditional medicare. I focused in the first year on retaining as many patient's as possible within a reduced self-pay fee and also the introduction of wellness and retainer plan options. I survived the first year. Percentage numbers have been previously reported on this blog. Now it is year two, and my focus is on retaining my first year patient's while starting to market to new. I have merged the wellness plan with the retainer option, so now I offer medicare, selfpay and retainer- with a monthly payment option. The retainer with monthly payment option has been popular so far, as there is no copay per visit. This has attracted many patient's with HSA's, FSA's and also the uninsured.

So what does this have to do with free advice. As more of my patient's transition into my retainer option, there is no such thing as free advice. As 2 minutes on the phone may negate a 20-30 minute office visit, and as I am being paid to be available, not per office visit, sidewalk chats are welcome.

It is nice to be able to help my patient's without worrying about getting paid, and without any third party in my mind. I am free to be a physician again!!

DoctorSH

A slow friday

Boring day today.

Only had 7 patients today. The weather thawed for the first time in over a week. The sun was out and the temp. hit 50. An apple a day does not keep the doctor away. But a warm sunny day after a week of miserable weather will keep the doctor away.

1 new wellness patient. This patient has a $3000 deductible and rarely goes to the doctor. But he felt $45/month was a good deal for my services.

I have 11 patients scheduled for monday.

Hopefuly next week will be busier.

DoctorSH

OBama's Healthcare Summitt

I worked today in my private office. I receive no outside funding. I work for myself and my patient's. I do not ask for any handouts or any special political favors.

Today was President OBama's healthcare summit.

My main question: How many physicians who own and operate their own private practice were included in the "summit" ?

Here I am trying to do what is right for the healthcare needs of my patient's. My practice is set up to be accessible and affordable. I keep overhead low and time with patient's high. I do this by avoiding any third party intrusion into the exam room. My fear is that Mr. OBama will try to jam down more third party intruders into the exam room, and as a result will dismantle the doctor-patient relationship even further. This will not be good for our country. My goal is to be able to provide family healthcare needs to any who want it at an affordable price. This may get difficult if the bureaucrats take over.

Todays stats:

15 patients- 12 in the am shift, 3 in the afternoon.

1 new patient who joined my wellness plan. this is the daughter of a current wellness patient, who is presently uninsured. She has medical issues she wants to address, some of which may be hereditary. As I treat her parents, and have an affordable monthly payment option, she had no hesitation in joining my office.

There is value in trust. More docs need to remember this!!

1 wellness patient renewed for the year.
Only 1 medicare patient today, and 7 selfpay.
If my 4 workdays were all like this, my revenues would be higher than when I participated with insurers.

My ad campaign starts next week. I will be running 4 consecutive ads, costing under $70 each, with bullet points that share my views on healthcare and how my practice differs from others.
I'll comment later in my return on investment (roi).

DoctorSH

The Day After The Snow

It is the day after a missed day at work due to snow.

The usual happened. 2 no shows in the morning. And then it hits. The phone starts ringing and we start filling up. All the afternoon slots were filled by lunchtime. Still could be no shows, but I can't worry about that.

Ended up with 13 patients today. 3 wellness renewals including the two I will mention soon. 1 patient returned after 2 years away, and when he found out I did not participate with his insurance, he didn't mind, he said it was worht it as I took almost 45 minutes with him for a short physical and talk session. I could not have done that 2 years ago. I would not have had the time.

A good feeling this morning. An 82 yo man, a patient in my practice for many years, renewed his and his wifes wellness plan for the year. They have a Medicare-HMO plan that would enable them to recieve care elsewhere, and at a much reduced cost. Instead , he paid today in full for the wellness plan on his credit card. His wife was only in my office twice last year, but he still wanted her on the plan, primarily to fix the costs for the year. This couple does not have a lotof money, and lives off of a fixed income. But they obviously value my services. They have trust that I am working solely for them.

On another note, I am looking to further the wellness part of the practice. I am in the process of hiring a massage therapist. I think this will add to the value that patient's receive from my office. The fee schedule has not been cemented yet, but patient's in my wellness plans will get a discount.

The goal of my practice is to be as third party free as possible, and be able to give truly valuable services to those who come to my office for care. The key to keeping patient's in this system is one word, trust!

DoctorSH

Monday, aka snowday

I woke up this morning and looked outside, and saw a blanket of white. I was informed last night that schools were closed for today. So should I go in to work or stay home?

The conditions were not terrible, but far from ideal. Winds and snow, and temps in the teens, with a wind chill in the single digits. So here is how I made my decision to close for the day.

• Only had 4 people scheduled for the am, 2 of which were for labwork only. None were urgent. I cancelled them out last night.
• I had no one scheduled for the afternoon-evening appointment slots. Now, on a normal day I average about a dozen call-in appointments on mondays. But with the weather, I did not expect too many, and there is always tuesday.
• My medical assistants are paid hourly. It would cost me more to pay them to work, then I would get in pay form the few patient's who braved the weather.
• By 1pm, I had 3 phone calls from patient's. 2 for UTI's , and 1 a question on blood pressure. So I am not exactly losing much in revenue for the day. And if previous years show a pattern, I will make up most of the revenues in added patients the next few days.

I'll post the next few days to see if my predictions come true.

DoctorSH

Its snowing!!

It's sunday evening, and it just started snowing. I used to enjoy the snow, when I was a salaried physician. A free day to sit on my sofa and watch the snow fall, play with my daughter in the snow, and laugh while watching my dog's hair turn white in the snow.


But now I have a solo practice. If I do not work, I do not get paid! That is not fair. But as I tell my daughter all the time, "Life is not fair!"

The forecast is for anywhere from 6-14 inches of snow. But it is a NorEaster, and they tend to be trouble. Doubly troubly is that mondays are my busiest day of the week.

Now as 40% of my revenues are prepaid wellness plan patient's, I have no revenue loss from this group. But the 20% Medicare and 40% selfpay patient's are another story. This is another reason why trying to get a larger percentage of wellness patient's would be beneficial.

DoctorSH

P.S. Let's hope the weather forecast is wrong.