DoctorSH thoughts on the practice transition away from third parties

Cash Transition- Jan-June 2010

2010-08-15T16:24:00.004-04:00

Cash Transition stats by popular request

I have been asked by many colleagues on Sermo, as well as followers of this blog to post further stats of my practice transition away from third parties.

So here goes....

First some history:

Back in 2007, I was getting fed up with the third party control of healthcare. I had a "normal" heavily HMO and managed care family practice. I was exploring options that I would enjoy more. My daughter thinks I am a good cook, but my back can not handle being on my feet for too long, so becoming a chef was out of the picture.

I had a few other options to remain in family practice.

1) Continue as is, as a solo family practice doc.

2) Join a large family practice group without walls, where the group would share a taxpayer-id and other management resources, and would handle all the contracts with the third parties. Advantages included increased fees from third parties. Disadvantages included having to toe the line of the group practice. As I do not always play well with others, I did not choose this option.

3) I also explored converting my practice to a concierge model. This also had many advantages including a guaranteed salary for three years, less patients seen per day, and no dealings with third parties. Disadvantages included the high membership fees for patients that would scare off 95% of my practice, and possibly brand me as a "country club doctor". While sticks and stones can break my bones, but names can never hurt me, I decided against Concierge as I had developed many strong relationships with my patients and I truly did not want to abandon them, or make my fees out of their reach.

So I then did what I usually always do. I made up my own business model that best fit my own personal healthcare philosophy.

I decided to transition away from all third parties other than Traditional Medicare in January 2008. I also offered prepaid yearly Wellness options, some with no copays, others with small copays, as well as also allowing regular self-pay fee for service. In 2009, I moved all my Wellness Plans to no copays. My Wellness Plan fees average about 30-35% of a Concierge practice. Please make note that I do not offer Concierge services, so I do not charge Concierge fees. There is a Concierge physician in my area who does offer these services and I have referred patients to his practice who are looking for that type of service.

OK.

Enough history..

Here are some stats.

2010- Wellness Plan-Self Pay- Traditional Medicare
2007- Normal Third party dominated practice

1st two quarters 2010 revenues are now 4% higher than 2007
1st two quarters 2010 expenses are down 23% from 2007. They would be down more, but my type of practice requires more to be budgeted for marketing. The payroll expense, not including my salary is down 40% from 2007. If you do not deal with referrals, nor deal with medical billing, and see about half as many patients per day, the staff requirements drop!!

1st two quarters 2010 patient visits are just under half of those seen in 2007, so $/patient in 2010 ($126) is just under double 2007 ($64).

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Now for what I find interesting.

I calculate percetage revenues from three different categories;
1) Wellness Plans
2) Self-pay or fee for service each visit
3) Traditional Medicare and balance billing secondary insurances

Here are the percentages for each 1st two quarters 2010 for 2007---2010.

Wellness Plans:
2007 0%, 2008 43%, 2009 53%, 2010 56%

Self-Pay
2007 20%, 2008 23%, 2009 32%, 2010 32%

Medicare-secondary insurance-(third party hmo's, ppo's in 2007 only):
2007 79%, 2008 32%, 2009 15%, 2010 12%
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More interesting tidbits:

Revenues per patient visit for 1st two quarters 2010 by type of payer:

Medicare $80.89

Self-Pay (payment-at-time-of-service) $114.10

Wellness Plans (Yearly Retainer) $162.39

My conclusion: For all the docs that think that a zero copay retainer style patient will overutilize your services, I say:

1) They won't, as my practice proves

and

2) Who cares if the revenues per visit double Medicare, while allowing you more time to spend with each patient, building up trust and the doctor-patient relationship once again!!!

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Other interesting tidbits about my practice.

I presently average about 11-12 patient visits per day.

My 1st two quarters 2010 medical billing costs are about 30% of 2007.

I share office space with my spouse, who is a psychiatrist. We share one full-time employee. We have no other staff. We do not need a referral coordinator, nor a medical receptionist. We have a voicemail system. Many patients have my cell phone number for urgent or emergent situations. They have never abused that privilege.

For me, this practice style has been a no brainer, and I do not forsee myself going back to third parties. I will probably end up dropping Medicare participation within the next few years, or sooner dependent upon how bad Obamacare actually turns out.

I hope this post has fueled some thought.

I welcome any comments.

Cash Transition stats by popular request

2010-04-23T22:28:00.003-04:00

I have been asked by many colleagues on Sermo, as well as followers of this blog to post further stats of my practice transition away from third parties.

So here goes....

First some history:

Back in 2007, I was getting fed up with the third party control of healthcare. I had a "normal" heavily HMO and managed care family practice. I was exploring options that I would enjoy more. My daughter thinks I am a good cook, but my back can not handle being on my feet for too long, so becoming a chef was out of the picture.

I had a few other options to remain in family practice.

1) Continue as is, as a solo family practice doc.

2) Join a large family practice group without walls, where the group would share a taxpayer-id and other management resources, and would handle all the contracts with the third parties. Advantages included increased fees from third parties. Disadvantages included having to toe the line of the group practice. As I do not always play well with others, I did not choose this option.

3) I also explored converting my practice to a concierge model. This also had many advantages including a guaranteed salary for three years, less patients seen per day, and no dealings with third parties. Disadvantages included the high membership fees for patients that would scare off 95% of my practice, and possibly brand me as a "country club doctor". While sticks and stones can break my bones, but names can never hurt me, I decided against Concierge as I had developed many strong relationships with my patients and I truly did not want to abandon them, or make my fees out of their reach.

So I then did what I usually always do. I made up my own business model that best fit my own personal healthcare philosophy.

I decided to transition away from all third parties other than Traditional Medicare in January 2008. I also offered prepaid yearly Wellness options, some with no copays, others with small copays, as well as also allowing regular self-pay fee for service. In 2009, I moved all my Wellness Plans to no copays. My Wellness Plan fees average about 30-35% of a Concierge practice. Please make note that I do not offer Concierge services, so I do not charge Concierge fees. There is a Concierge physician in my area who does offer these services and I have referred patients to his practice who are looking for that type of service.

OK.

Enough history..

Here are some stats.

2010- Wellness Plan-Self Pay- Traditional Medicare
2007- Normal Third party dominated practice

1st quarter 2010 revenues are now equal to 2007
1st quarter 2010 expenses are down slightly from 2007. They would be down more, but my type of practice requires more to be budgeted for marketing.

1st quarter 2010 patient visits are just under half of those seen in 2007, so $/patient in 2010 ($125) is over double 2007 ($61).

Now for what I find interesting.

I calculate percetage revenues from three different categories;
1) Wellness Plans
2) Self-pay or fee for service each visit
3) Traditional Medicare and balance billing secondary insurances

Here are the percentages for each 1st quarter period for 2007---2010.

Wellness Plans:
2007 0%, 2008 43%, 2009 53%, 2010 60%

Self-Pay
2007 20%, 2008 23%, 2009 32%, 2010 28%

Medicare-secondary insurance-(third party hmo's, ppo's in 2007 only):
2007 79%, 2008 32%, 2009 15%, 2010 11%

----------------------------

Other interesting tidbits about my practice.

I presently average about 12-15 patient visits per day.

My 2010 medical billing costs are about 25% of 2007.

I share office space with my spouse, who is a psychiatrist. We share one full-time employee. We have no other staff. We do not need a referral coordinator, nor a medical receptionist. We have a voicemail system. Many patients have my cell phone number for urgent or emergent situations. They have never abused that privilege.

For me, this practice style has been a no brainer, and I do not forsee myself going back to third parties. I will probably end up dropping Medicare participation within the next few years, or sooner dependent upon how bad Obamacare actually turns out.

I hope this post has fueled some thought.

I welcome any comments.

Medicare- Should we still participate?

2010-03-26T20:37:00.007-04:00

As you may know, at least those of you who have followed my blog, my practice is free of third parties, other than Traditional Medicare. My reasons were many, but one of the main reasons was that Medicare did not put burdensome rules and regulations between me and my patients.

If I need an MRI, I give my patient a prescription. No referral or precertification necessary. So I did not see a reason to stop participation with Medicare, especially as Medicare, in my area of New Jersey, is actually a better payor than other insurers.

But now, we are being threatened with a 21% fee schedule reduction for Medicare. While it may or may not occur, I am getting pretty tired of all the b.llsh.t. There will come a point, and it may be soon, that Medicare, in my office, will no longer be accepted. Medicare accounts for about 15-20% of revenues. If I withdrew participation, I would probably keep about 30-40% of my Medicare patients, similar to the percentage of patients I retained when I terminated other insurers. If other docs stop taking Medicare as well, I would probably retain more. Revenues from "Medicare patients" would probably remain neutral.

Every practice needs to make a decision for themselves. But if you want my advice, and since you are reading this blog, you at least want to read my advice, it is to make plans to opt out of Medicare, as well as all your other insurers as well. Start acting like any other small business, and market your product directly to your customers, who happen to be your patients.

Physicians are responsible for the healthcare mess we are in. We allowed ourselves to be drawn into the third party system, with the hope of growing our practices. We hoped that the third party system would change our incomes for the better.

So I have a question for you.

Just how is all that hope and change working out for you?

Start planning your escape from the third party system. If you are a specialist, who relies on big ticket procedures, start trimming your overhead, and bring your fees to an affordable level, that still allows you to profit. If you are in primary care, it should be an easier adjustment, as primary care usually has less big ticket items. I dropped my practice overhead by 50% when I made the transition. As I had no business background prior to starting my practice in 1998, yet I was able to develop a healthcare business model that works, there is no reason why you can not!

And for all the docs on salary at hospitals or in academia, who do not feel threatened by Obamacare, what will happen to you, and to your salaries, when your hospital system can not afford to stay in business due to lower "reimbursements"? The first place they will go to make up for the cuts will be your salaries or your jobs.

So the physician community must get together, to take back control of our profession, and move it away from third party control, whether from government or insurers. Start your plans to drop Medicare, along with all the third parties, before it is too late!

Letter to NJ Governor Chris Christie

2010-03-26T20:34:00.000-04:00

March 26, 2010

Living in New Jersey, we have a new governor, who actually happens to be a republican in a very liberal state. He was elected, he states, to get rid of corruption and to balance a state budget that is billions in debt, without raising taxes, and to make the state an easier place to do business. My fear is that he has focused too much on budget cuts, while not fully researching how Obamacare affects healthcare for New Jersey residents.

I have written a letter to Governor Christie, emailed on Friday, March 26th, 2010, a copy of which is shown below.

-----------------------------------------------------------------------------

To: Chris Christie (R-NJ), Governor

I urge you to take all available actions to protect New Jersey from a federal government takeover of healthcare. Such actions include filing a lawsuit against potentially unconstitutional provisions and securing New Jersey's ability to opt out of federal mandates. More than a dozen states have already filed such lawsuits challenging the individual mandate and Medicaid provisions in the bill. The Medicaid provisions alone will likely cost New Jersey billions of tax dollars we cannot afford.

I urge you to direct your Attorney General, Paula Dow, to join with these other states in doing everything possible to protect my rights to make my own health care choices, and also to protect physicians, so that they can offer the best care possible, without government or insurance interference.

As an independent family physician, I would welcome you to come to my medical office, which has given up all insurance contracts, other than Medicare. You will find that cost-effective high quality care occurs to a greater extent when the insurance companies and the government stay out of healthcare decisions.

I urge you to not repeat the same mistakes that other politicians have made, by listening only to your political appointees. To get a real view of healthcare today, you need to talk to independent physicians, without ties to hospitals or other institutions. Only then can you get enough data to formulate a real-world opinion on the state of healthcare in New Jersey.

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OK.

So let's take a vote.

What response will I get?

A: Form letter
B: None
C: Real response by letter or email
D: Governor Christie acceptance to visit my office

My hope is for choice D, while I expect choice A.

The Day After

2010-03-24T20:31:00.005-04:00

The Day After Obamacare became law.

To anyone reading this blog.

With Obamacare now law, the days of private practice in a third-party dominated system are just about over. If you choose to continue to participate with Medicare, and private insurance payers, you better get real lean, or join a group practice, or even work for a hospital system.

The problem with all the above options are they do not work for the independent minded docs. I did not go into medicine to work for someone else. I went into medicine for the independence.

So I will state again, the days of private practice in a third-party dominated system are just about over.

But......

You can still get out of the third party system, make your office lean and efficient, and work directly with your patients. Work for a single payer system, where the single payer is the patient.

I have been away for awhile, concentrating on other issues. My practice is slowly growing, while my office expenses are slowly being whittled down further. It is amazing at all the fluff offices spend on, that we really do not need.

Start thinking like a businessperson, and remember the customer is always right in a business transaction, not a healthcare decision. Cater to individuals, and prove you are worthy of more than a $10 copay.

There will end up being a two-tiered system this decade. It will consist of the government run large practices and hospital systems, with all their largesse and accompanying overhead, overcrowding, and long waits.

And there will be the remaining independent practices, who cater to no one but their patients. Independent practices that offer cost effective quality care in a timely manner.

So everyone, make your decision , and live with it. Otherwise stop complaining about Obamacare and either get on board, or jump off like I did, and chart your own course!!

I would post more on this blog, if I got any feedback or comments. I do not feel like anyone is listening so the posts have trickled.

BTW, I started a new blog, Healthscare101blog, which can be found here. Let me know what you think.

Institute For Medical Wellness State of the Practice for 2010

2010-01-02T21:47:00.001-05:00

January 2, 2010
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This is an excerpt from an email newsletter sent to my patient's on the date above. It was met with many smiles, chuckles and approval. I am hearing more from my community how they admire the new practice style, and the growth in new patient's is starting to accelerate. My hope is that this is the year we truly turn the corner, and that other docs get off their a--es and consider returning to treating patient's and not insurances.
=========================================

Institute For Medical Wellness State of the Practice for 2010

I know.

Kind of corny.

But why should only our presidents and governors have all the fun!

Besides, what I write below is factual and truthful, unlike most political speeches, regardless of party, and this state of the practice newsletter will be given without the use of a teleprompter ;)

So here goes.....

My fellow Americans, Wellness Plan members, patients, newsletter subscribers, and anyone and everyone else interested in achieving better health and wellness, I am happy to bring to you the The Institute For Medical Wellness State of The Practice 2010.

Two years ago, in 2008, I was elected, um, scratch that, I founded the Institute For Medical Wellness to provide healthcare like it used to be, without insurance, government, or other third party intrusion. While the transition has been a true learning experience, by the response I have received from my patient's and the community, it is one I have never regretted. I am happy to report that by bypassing the traditional third party route of healthcare, and instead dealing directly with you, we have been able to drastically decrease our overall operating budget, which allows us to continue to offer and expand our services at truly low costs. I am also happy to report that we are not 12 trillion dollars in debt and our budget is fully balanced. Take that Washington, D.C. and Trenton!!

I would now like to share with you some of the proud accomplishments since our founding in 2008.

*Same day appointments are the standard, with new patient visits available same or next day
*60 minute Wellness exams focusing on wellness and illness prevention
*Zero copay Traditional Wellness Plans- a much less expensive version of Concierge or Boutique practices, and now available with monthly payment options
*Greater than 90% of Wellness Plan patient's continue to re-enroll year to year.
*20% growth of patient's enrolled in our Traditional Wellness Plan
*Welcoming back of many patient's who returned to our practice after leaving during our 2008 transition, after they sampled traditional third party healthcare delivery
*Expanding Wellness network affiliates- from Naturopathy to Fitness, Massage and Acupuncture, more choices are now available.
*Increasing number of subscribers to our free email newsletter

My professional objective in founding The Institute For Medical Wellness is to offer the absolute best care - without compromise, and to serve as your primary advocate for health and wellness by combining holistic care and traditional old-fashioned values with true modern day medical expertise. My primary goal is to make certain that our attention is solely focused on YOU, not your insurance or some government bureaucrat.

In today's economy, providing this type of healthcare can be challenging. Many businesses are reducing services to cut expenses. But I have always been a contrarian, so at The Institute For Medical Wellness, I take a different approach. I prefer to expand and make more services available, some of which I will mention below.

1) New more easily individualized Wellness Programs. Last year, in my eagerness to offer many different wellness programs, the choices became a bit confusing, even to me. So starting in 2010, wellness programs will be re-organized in a friendlier way. The Institute For Medical Wellness network affiliates will now be offering individual A-La-Health and wellness programs, which can be purchased separately, or better yet, added to our Traditional Wellness Plan. If added to our Traditional Wellness Plan, you will also receive 20% off all supplements purchased from our office.

2) Our new Healthy Weight Program is now available. This physician supervised weight management programs main focus is on achieving a healthier weight, curbing hunger, while achieving optimum nutrition. It is ideal for treating diet related disorders including high blood pressure, diabetes, obesity, high cholesterol, among many others.

Each individualized program will consist of:
-
Full initial evaluation by Dr Horvitz- medical and diet history, review of labwork to determine your metabolic needs, initial measurements and goal setting.
--Follow-up to review labs and start on program.
---An individualized starter package of nutritional supplements geared to your medical history.
----Monthly supplies of Dream protein
-----Twice-monthly office visits to check on your progress and make any necessary adjustments.

*Big discount if combined with our Traditional Wellness Plan.
*Discount of $75 if combined with our 8-Hour Optimum Results personal training program. *Discounts also available for partners joining together.
*Healthy Weight Programs offered are for 3, 6 and 12 months.

For more information please visit our website here.

3) Nutritional and dietary supplements available at the Institute For Medical Wellness

Nutritional supplements have become a bigger part of The Institute For Medical Wellness. This is not due solely to my health and wellness beliefs, but more to the demands of my patient's. The nutritional supplement industry is not regulated as strictly as pharmaceuticals and there are thousands of supplements available at stores and thru the internet. This is both good and bad. The good is in the greater innovation and less expense in bringing a product to market. The bad is there are less mechanisms in place that make sure you are truly getting what you are purchasing. So at The Institute For Medical Wellness, we only carry supplements from very reputable manufacturers who have put their products through very strict procedures to be certain that you get what you buy. If you want more proof, most of the products we sell have been or are presently being used by myself or my family. Click here for a list of the different supplements we have available. Also note that discounts are available with certain A-La-Health programs.

4) Genetic testing for Breast cancer, Ovarian cancer , Colon cancer and Melanoma are now available at The Institute For Medical Wellness. I have teamed up with Myriad Genetics and Laboratories, a company designed to help patients and healthcare professionals understand how genetic testing can help identify individuals at risk for hereditary cancer.

There are ways to reduce your risk or overcome cancer in your lifetime. If cancer runs in your family, hereditary cancer testing may be an important step for you. Click on this link and take the quiz to see if testing is right for you.

5) Medical Records

Keeping an accurate medical record is one important part of your care. Back in 2004, ahead of most physician practices, I transitioned from paper to electronic health records. While it occasionally makes me pull out what little remaining hair I have, electronic health records also have many positives. One is their ease of access. When we had paper records, the time involved to keep them updated was very costly, both in time and materials. Not as much with electronic records. So we can now offer Wellness Plan patients one digital copy of your medical records per year for personal use if securely emailed as a pdf file. If you prefer a hard copy on a CD, a fee of $15 is required. For all other patients, the fee is $15 for a digital copy and $25 for a hard copy on CD. Please note, fees are different if records are required for legal, transfer or insurance requests.

6) Telephone consults now available

While many patient's take it for granted that doctor's will prescribe treatment over the phone, it is not always good sound medical practice, nor the best for patient care. But many patient's in my practice have strongly requested these consults. Thus, I am adding phone consultations to the services I offer, in the hope that when used in the proper circumstances will be of benefit to you. Phone consultations simply consists of phone time spent with you evaluating your health complaints, and prescribing treatment. For example, if you are feeling ill, but stuck at work or home, you can arrange a phone consultation.

The following fees will be charged dependent upon the time spent on consultation or if treatment is ordered or prescribed:

5 minutes or less without treatment prescribed = No charge
10 minutes or less with treatment prescribed = $45
11-15 minutes with treatment prescribed = $75
Any consultation that would require more than 15 minutes requires an on-office evaluation.

If you are seen in the office for the same illness within one week of your phone consult, you will receive $25 off your in-office follow-up.

Phone consultations will most often be used to evaluate and treat recurrent illnesses such as sinusitis or urinary tract infections. This service is not available to new patient's, nor to any condition Dr Horvitz feels requires an in-office evaluation.

To schedule a phone consult, please call our office at 856-231-0590. A valid credit card or a bank debit arrangement is needed for this service.

These fees are not applicable for the following:

* Quick follow-up phone conversations about a recent office evaluation.
* Wellness plan members, as these services are already included as part of your plan.
* As Medicare rules are vague on telephone consults, this service is not available to Traditional Medicare patients.
* Routine requests such as pharmacy refills, appointments or non-physician requests.

7) Help with insurance reimbursement We realize that medical billing can be very frustrating, which is one of the many reasons my office stopped working with insurers. But just as medical billing is frustrating to my office, it can be equally frustrating to my patient's awaiting insurance reimbursement. So in 2010, we will now be submitting paid office charges to your insurance to help you with reimbursement. For this process to run smoothly, please make sure we have an updated copy of the front and back of your health insurance cards, as well as your signed authorization.

8) Beginning January 1st, 2010, there will be a $25 charge added to your first office visit each calendar year, with a $40 maximum per family. The reasons for this fee is as follows.
-
Upgrading our medical records systems due to the stricter government regulations concerning these systems.
--Increased insurance submission costs. This charge will hopefully be more than offset by any insurance reimbursement you receive by having your paid office visit fees submitted electronically to your insurer.
---Complying with the government's new privacy payment plan law due to take effect in 2010.

*Please note that this fee is not applicable if you are enrolled in our Traditional Wellness Plan or for Traditional Medicare patients.
*This fee is applicable irrespective of whether you have insurance coverage.

9) The Institute For Medical Wellness can now be found on Twitter at http://twitter.com/IMWHorvitz

I anticipate utilizing twitter for notification of office updates including interesting health, medical and wellness information, availability of flu vaccine, and inclement weather closings. Don't worry, you will not be tweeted about what I ate for lunch today, although I can say, it was probably low in processed carbohydrates, very filling, and very tasty ; )

I would like to thank everyone for their confidence in my professional abilities and referrals of new patient's to the practice as well as to the Wellness Plans. If you are presently in the Traditional Wellness Plan, and refer a new patient to this plan, you will receive 1 month added on to your plan for the first referral, and two months added on for every other new patient you refer. Just my way of saying Thank You for your confidence!!

It is always nice to get good feedback. Good feedback tells me that I am definitely moving in the right direction! So please check out the recent patient testimonials sent to our office.

My New Years Resolution is that you allow The Institute For Medical Wellness to help you make 2010 a healthy and prosperous year!!

This concludes the Institute For Medical Wellness State of The Practice 2010 newsletter. I will now leave the stage quickly, and you will not hear the media pundits restating over and over again what you have just read. Anyhow, it does not matter to me what others say about The Institute For Medical Wellness. As my primary goal is your individual health, the only one that matters when you are in my office, is YOU!!!

To Good Health and a prosperous 2010!!

DoctorSH

Obamacare and Bernie Madoff

2009-12-29T21:37:00.003-05:00

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

2009-11-16T12:15:00.005-05:00

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!!

2009-11-07T12:07:00.004-05:00

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?

2009-07-26T19:57:00.004-04:00

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???

2009-07-21T20:49:00.003-04:00

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

2009-07-15T17:57:00.002-04:00

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

2009-06-15T19:46:00.002-04:00

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

2009-06-07T08:48:00.003-04:00

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:

Wellness Plans- prepaid or yearly contracts with monthly auto-debits
Traditional Medicare
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

2009-05-29T20:35:00.003-04:00

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

2009-05-16T16:02:00.003-04:00

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

2009-05-09T10:30:00.003-04:00

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.
----------------------------------------------
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

2009-04-27T09:27:00.003-04:00

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.
----------------------------------------------------------------------------

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

2009-04-20T21:15:00.003-04:00

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??

2009-04-17T21:06:00.003-04:00

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

2009-04-09T15:56:00.003-04:00

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

2009-04-02T21:01:00.003-04:00

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

2009-03-31T20:32:00.006-04:00

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

2009-03-30T20:29:00.004-04:00

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

2009-03-28T09:07:00.006-04:00

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

2009-03-25T19:41:00.004-04:00

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

2009-03-21T15:16:00.009-04:00

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

2009-03-20T17:42:00.003-04:00

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

2009-03-19T21:31:00.010-04:00

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

2009-03-18T21:02:00.007-04:00

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

2009-03-17T17:21:00.003-04:00

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

2009-03-14T20:37:00.005-04:00

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

2009-03-13T17:24:00.005-04:00

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

2009-03-12T22:12:00.004-04:00

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 !!

2009-03-11T20:47:00.004-04:00

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

2009-03-10T17:52:00.002-04:00

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

2009-03-09T21:02:00.003-04:00

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

2009-03-08T13:46:00.004-04:00

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

2009-03-07T15:10:00.008-05:00

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

2009-03-06T17:51:00.003-05:00

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

2009-03-05T18:48:00.003-05:00

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

2009-03-03T14:06:00.010-05:00

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

2009-03-02T12:52:00.003-05:00

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!!

2009-03-01T19:55:00.006-05:00

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.

End of the week and end of the month

2009-02-27T21:56:00.004-05:00

Nothing beats a friday.

Had a busy two days. Busy these days equaled 15 patients on both thursday and friday.

Stats:

3 new patients

3 renewed their wellness plan

1 established patient enrolled in a wellness plan

1 new patient enrolled in a wellness plan- this patient is presently uninsured, but his father sees the value of a primary care doc to join a monthly payment plan.

The month ended with increased revenues over January. If I take out old insurance money for Jan-Feb08, then Jan-Feb 09 shows a slight increase. Now with the larger upfront wellness plan payments, and zero copays for the rest of the year, this may decrease as the year moves forward. So I will need to continue to bring in new wellness plan patients. About 40% of my wellness plan patients are paying by ACH, autodebit from bank account, which will keep the cash flow a little more regular.

The month ends and I am encouraged. It does not take many new patient's to increase revenues, and I hope to enroll 25 wellness patient's a month. The first two months brought in 57.

The first two months of the year also breaks down as follows:

40% of patient volume is Wellness patient's
40% of patient volume is Self-pay
20% of patient volume is Medicare

I like this breakdown, and would like to increase the wellness portion to 50% by the end of the year. We'll see what happens, so keep lurking.

If anyone is reading this blog and has any comments, questions, or words of wisdom, please use the comment section. I can use all the ideas you may have!!

DoctorSH

Tuesday February 24, 2009

2009-02-24T17:43:00.002-05:00

Tuesday, my second favorite day of the workweek. Try to guess my favorite day??

Normal day at the office, busy in the am, slower after lunch.

11 patients today. seems slow, but as the practice grows, and it is growing, I will look back and wish I had the free time. But I like slow, controlled growth. It avoids overextending myself and avoids mistakes.

2 new patients were seen today. One was the wife of a recent new wellness patient. She was not sure if she wanted to sign up for the retainer, but she set up a followup before she left. I think she respected the fact that I had plenty of time to spend with her at her initial appointment, about 45 minutes.

The other new patient is the daughter of a wellness plan member. She came in with her mother, who I have not seen since 2007. I had sent out mailers to some of my previous patients to inform them of the change in the wellness plans to zero copay about 1 month ago. The mailers must have worked, as the mother signed up for my family retainer at $100/month. It is for a family of 5, but last year I saw the father 3 times, the mother 0, and her kids are rarely sick. The pricing point will work both for me and for the family.

One other patient came in today who I have not seen in over a year. He came in specifically because he resents the insurance system and does not trust doctors that participate. He wanted a true independent medical opinion. Although my opinion was no different than the ER docs opinion he saw 4 days prior, he was still appreciative of the time.

Today my system has worked as I hoped.

Win for the patient and Win for my office!!

DoctorSH

Tell me why, I don't like Mondays!!

2009-02-23T21:08:00.002-05:00

Monday February 23, 2009

Nother first day of the week. Slow morning but picked up in the afternoon-evening.
It is 910PM, and I am waiting for my wife to finish with her last patient. I have been here since 845 this morning.

On a practice note,
The office saw 15 patients, 2 newly referred from a naturopathic doctor.
9 were selfpay or Medicare, and 6 were Wellness plan patients. So the revenues seemed down, but today I use the ACH monthly autodebit for 6 patients. So far this month, we are on par with last years revenues.

I am still waiting for an ad spec for promotion and marketing. Hopefully anyday now.

DoctorSH

I love Fridays!!!

2009-02-20T16:48:00.005-05:00

I love fridays!!

The end of the week, with a two day weekend of freedom. But if it is the usual weekend, I will be at the office for at least 1-2 patients. All part of being there for the patient's when they need it, not when it is "convenient".

Spoke to an advertising rep at a local paper. I have them working on an ad campaign that stresses the differences in my style of practice from other docs in the area. For an ad campaign to work, new patient's must have a reason to go outside their insurance to pay extra for my care. The ad campaign is definitely a work in progress.

This week went well.

Saw 60 patients, as compared to to 39 the previous week and 48 the week prior.
Revenues for February are almost 50% higher to date than January. And only 20% lower than this time in 2008, but 2008 included old insurance money.

I am presently waiting for the last patient to get to the office. She called at 3:30Pm and wanted to be seen for an inflamed eye. Problem is, it would take her at leat 90 minutes to get to the office. Her and her husband joined my Wellness Plan back in March, and are due to renew next month. Makes the decision whether to stay an easy one.

Do what it takes to be succesful !!

Be available and be a good listener!!!

February 17, 2009

2009-02-17T17:53:00.001-05:00

2-17-09

Average day at the office. Saw 11 patients. On the business side, one uninsured patient signed up for my Zero copay wellness plan, with a monthly payment of $45. She felt it was cheap for what she was getting and allowed her to budget her money accordingly. If she paid full price for the same service , it would cost her more than double, and she would probably refrain from the service. The Wellness Plan includes a full one hour physical exam, EKG, spirometry, review of labs, and review of full personal and family medical history, while creating a game plan for health, wellness and prevention. All done without any third party intervention and at a cost most can afford, if they choose.

Part of what I like about my new system is that the time constraints have been removed. Case in point where this is helpful: I have an unfortunate patient just diagnosed a few days ago with Liver Cancer with probable mets to the lung. When he called yesterday to schedule to review his recent hospital stay, my medical assistant was able to schedule him for 40 minutes. His son, also a patient in the practice, came along for the visit. I had plenty of time in my schedule to review the hospital chart with the patient and help to coordinate his future care. This would have been very difficult a few years ago, when anything over 15 minutes per patient would have caused a hardship.

One of the joys I have in Family Practice is the building of trust and relationships with patients and their families. When a patient refers their family member, it is one of the nicest compliments I can get. Unfortunately, in the case I mentioned earlier, this can also be one of the sorrows of family practice. Seeing how bad medical news affects other patients, especially family members, can be very trying.

DoctorSH

February 16, 2009

2009-02-16T19:21:00.002-05:00

2-16-09

Monday, the dreaded first day of the week. It starts at 9am and ends around 8PM. But today, the schedule was front loaded, with most patient's seen in the am. I actually ended seeing patient's at 6:30PM, giving me enough time to make call backs, recheck some documentation, and actually sit for 10 minutes and eat dinner. A nice change from a few years ago.

I saw 22 patients today. A busy day for now, but will probably be the average in a few years. But without the hassle of billing insurance, it was a pleasure. Two patients renewed their wellness plan agreement today without even being seen. I find that it is the trust between myself and my patient's that makes the system work. As long as I keep the patient-centered approach, without the bullsh.t, the practice should continue to grow.

While 22 patient's were seen today, tomorrows schedule has 6 so far. It will end up double that, but I still need to grow the practice with new patient's, especially in the zero copay wellness plans. I am working on an advertising plan, and hoping for more word-of-mouth and referrals from within.

While I do not participate with third parties, most of my patients still rely on these insurers for payment of testing. Today a patient with thyroiditis by laboratory studies was denied precertification for a thyroid scan. The patient has been hospitalized twice so far, once with new onset atrial fibrillation. It truly makes sense that some insurance wonk can make a decision on the worthwhileness of a test when they have never seen, spoken to, nor examined the patient. These third parties are the downfall of the medical system. They really need to be removed!!

DoctorSH

The Week Ahead

2009-02-15T15:25:00.003-05:00

It is sunday. I get to sit and relax, my laptop at the ready, with a news show on in the background. Tomorrow is the start of a new week. Tomorrow is also President's day. Schools are closed. Many other businesses are also closed. My office is open!

Tomorrow being a national holiday means that it will be a busier day than normal. But that is a good thing. An empty office is not one that will remain viable in today's healthcare system. But that is not the subject of today's blog post, which is the week ahead.

As many of you already know, I transitioned my practice away from third parties in January 2008. I made some good decisions and some that were not so good. But as I own my solo private practice, I can remedy and change on a dime. One aspect of my practice that my transition has allowed is the accomodation of same day appointments. My motto is that if a patient calls in the morning, we will do our best to offer an appointment for same day. But to follow through with this pledge, I need to control my schedule. This is done by keeping my open hours appropriate for the amount of patient's in my practice. At present this allows my workdays to be Mondays, Tuesdays, Thursdays and Fridays.

As of today, this coming week has 20 scheduled appointments. This bodes well for the week as a good week in my practice system is 50-60 patients per week. Now most are frontloaded with 13 patients on Monday, so the busiest day of the week will also be the first day of the week, and also the day that sets the tone for the remainder of the week.

DoctorSH

A new direction

2009-02-14T14:55:00.000-05:00

My transition blog will now move in a new direction. I will be focusing on daily, weekly, monthly events in the continuing transition of my practice. I will not be focusing on any one area, but as changes occur in my day-to-day practice, I will post on the blog. I encourage anyone reading or lurking to post comments. As I learn more and more from my patient's every day, I hope to expand my knowledge, both professionally and academically through the insights of others.

DoctorSH

2008 Transition- Year end results

2009-01-10T18:56:00.005-05:00

December 2008 transition to Cash Only + Medicare

Solo physician, suburban practice, large HMO penetration.
Conversion to cash practice, Medicare, Selfpay and Wellness-Retainer model at affordable market based prices.

--------------------------------------------------------------------------------------------
Comparisons given below are percentages comparing Jan-Dec 2007 to January-Dec 2008.

Patient Volume decreased by 43%.

New patients seen decreased by 49%

$ per patient seen Increased by 18%

Revenues decreased by 30%.
Expenses decreased by 20%.

In 2008, my practice had multiple payment options for patients.
These range from Selfpay, to Medicare, to Wellness and Retainer options.

The breakdown in patient visits is as follows:

Selfpay 50%

Wellness/Retainer 25%

Medicare/Insurers 25%

The breakdown in % revenues per patient class is as follows:

Selfpay 50%

Welness/Retainer 32.5%

Medicare/Insurers 17.5%

$ per patient visit is as follows:

Selfpay $83
Wellness/Retainer $104

Medicare $61

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Analysis:

Wellness Plan:

Averaged out to $104 per patient visit, 41% higher then Medicare, and 20% higher than selfpay. A good percentage of revenues came in from Wellness Plan fees, which is upfront money. In 2008 most plans were $200-300 upfront with $25 copays per visit. As many patients joined early in the year, the numbers were higher in the first quarter. To level out the revenues for 2009, I have started a monthly payment plan through Bank-ACH. This would help with patient budgeting and allow marketing to small businesses, and individuals with FSA's, HSA's and high deductible insurance plans. I am combining the Wellness and Retainer options for 2009. Info on this option can be found on my website. My job for 09 is to market my office to new Wellness patients throughout the year, whereas in 08 I only marketed within my practice. The new Wellness Plans will have no copay, but a higher upfront cost. This will save time at check-in and check-out by between 5-10 minutes per patient. Multiply that by 15 patients and that is 1-2 hours a day of time saved from paperwork, and instead used for patient care.Selfpay: averaging $83 per visit, lower than Wellness Plans, but 26% higher than Medicare. It is $19 more per visit than I received last year, or a relative increase of 23%. I have more time open in my schedule to fit in these patients, as I am not seeing the $10 copays or capitated patients. I hired a new part-time medical assistant who also works at an HMO dominated office. She is amazed that my patient's expect to pay for my services. At the HMO-dominated office, the patient's often get nasty and refuse to pay their copays. I have found that HMO patient's value their doctor's office by the cost of the copay. The lower the copay, the less value they place on their care, and the more entitled they become. Medicare: averaging $61 per visit: This is low as it includes office visits for venipuncture, B12 injections etc. Even if this number goes up to $75 per visit, it is still much lower than the selfpay, and a pittance compared to Wellness Plans. With Medicare payments from the government expected to drop, continued participation in Medicare is not guaranteed.

--------------------------------------------------------------------------------------------Other Good Effects:

Expenses have gone way down.
Overall expenses are down 20%.

My medical billing expenses have been slashed 66%.

I have eliminated one medical assistant during my day hours, and went from two to one medical assistants during evening hours.
My payroll expenses have been slashed by about 33%.My supply costs have also decreased by 33%.

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I have had a good number of patients leave my practice due to the dropping of insurance. Some have been nice about it and understanding, and some have been downright rude and insulting. So be it, I do not take it personally. Each patient may make their own decision. I am still available to anyone, they just have to be willing to pay me directly for my services, which are priced at an extremely reasonable rate.The feedback I have received from the patients who have remained has been terrific. While they wish they could pay me less, they have all been happy with the type of non-hurried care they receive. They can get appointments same day. We have time to help them coordinate their care with specialists. All things that were difficult or impossible in the old-insurance driven model.
My goal is to get to about 1000 active patients in my practice, instead of the average of 2500 in my community. If I can get 50% and up in the wellness plans, my revenues will be higher, and patient care will be much improved. Hopefully the addition of a monthly or quarterly payment option along with the results of marketing my practice will continue the successful transition.

TPBG- Third Party Bypass Grafts- The time has come!!!!

2008-07-16T20:10:00.003-04:00

TPBG- Third Party Bypass Grafts- The time has come!!!!

It is time to take Washington out of the equation.

Here is an analogy: Lets just perform a CABG on our present healthcare system, but change the name to TPBG, Third Party Bypass Graft. Leave the diseased portions in place, and just bypass them. The diseased portion will soon cease to function.

Make a route around the diseased portion that is wide open for better patient care and less regulations. Our patients will start moving to the wide open patent system very quickly when they see the medical care is better, easier, and in most cases less expensive.

The past twenty years, we have been trying to treat our present system medically, and all that has happened is that it has gotten sicker. Those that wish to continue to try to treat the problems with letters to Washington, or negotiating contracts with third parties will just be swept up into the diseased portion or evil atherosclerotic plaque. We do not have a pill that will reverse this plaque and defeat the third parties other than to decide to make them irrelevant.

We are overdue for a TPBG. I for one have bypassed the system and am very happy, and will be even happier next year as my practice continues to grow. Ever since my TPBG, I have more time for my patients and my family, and no longer have the morbidity associated with all the third party nonsense. And the beauty of it is, I did not need a knife or a hospital stay for my TPBG. All I needed was a pen and a stamp. I wrote a letter to terminate my third party contracts, put postage on the letter, and sent it away. No morbidity, no referrals, no billing staff, less office staff, and more time to spend with the patients to give better care.

Its like I always hoped I would practice my profession!

1ST 6 month transition to cash practice

2008-07-07T14:16:00.004-04:00

January-June 2008 transition to Cash Only + Medicare Solo physician, suburban practice, large HMO penetration. Conversion to cash practice, Medicare, Selfpay and Wellness-Retainer model at affordable market based prices. January and February’s numbers contained some old insurance money and is included in percentages given. Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks. But February and March had little if any old insurance money and was very low compared to January. April-June had Medicare secondary insurance money only, otherwise all revenues were direct from patients.

-------------------------------------------------------------------------------------------------
Comparisons given below are percentages comparing Jan-June 2008 to January-June 2007.

Patient Volume decreased by 41%.
New patients seen decreased by 55%
$ per patient seen Increased by 69%
Revenues remained the same. The revenues dipped in the second quarter. This is due to the majority of my established patients joining my Wellness programs in the first quarter.

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More Analysis:

$ per patient visit for 1st quarter 2007 was $64.43
$ per patient visit for 1st quarter 2008 was $108.00.

My practice has multiple payment options for patients. These range from selfpay, to Medicare, to Wellness and retainer options. More info on how these options differ can be found by clicking here. The breakdown in patient visits is as follows:

Selfpay 48%

Wellness 23%

Medicare 20%

Old Insurance-Ancillary 7% and dropping

Retainer 2%

The breakdown in % revenues per patient visits is as follows:

Wellness 33%

Selfpay 33%

Old Insurance-Ancillary 21% and dropping

Medicare 11%

Retainer 2%

$ per patient visit is as follows:

Wellness $165.00

Retainer $158.00

Selfpay $87.00

Medicare $61.00

- ------------------------------------------------------------------------------------------------
Further analysis:

Wellness Plan: A good percentage of revenues came in from Wellness Plan fees, which is upfront money. This skewed the numbers higher at the beginning of the year. The numbers, averaging $165 per patient visit, are now coming into the range that I expected and are still almost double the average of selfpay patients. My job is to market my office to new Wellness patients throughout the year. If I do not get these new Wellness patients, the revenues will slow. I am also looking into a monthly payment plan for the Wellness program, which would run between $25-30 a month, instead of a lump sum upfront. This would help with patient budgeting and allow marketing to small businesses. A physician who has already made this system work can be found by clicking here.

Selfpay: averaging $87 per visit. That is $23 more per visit than I received last year, or a relative increase of 35%. Also I have more time open in my schedule to fit in these patients, as I am not seeing the $10 copays or capitated patients.

Medicare: averaging $61 per visit: This is low as it includes office visits for venipuncture, B12 injections etc. Even if this number goes up to $65 per visit, it is still much lower than the selfpay, and a pittance compared to Wellness and Retainer. With Medicare payments from the government expected to drop, continued participation in Medicare is not guaranteed.

Retainer: averaging $158 per visit. This is 45% better than selfpay, but only a small percentage of my practice. As with the Wellness Plan I may allow a monthly or quarterly payment plan. It is really nice to see a retainer patient and know that I can be a doctor and not worry about what everything costs in relation to their treatment.

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I have had a good number of patients leave my practice due to the dropping of insurance. Some have been nice about it and understanding, and some have been downright rude and insulting. So be it, I do not take it personally. Each patient may make their own decision. I am still available to anyone who wants my services, they just have to be willing to pay me directly for my services, which are priced at an extremely reasonable rate.The feedback I have received from the patients who have remained has been terrific. While they wish they could pay me less, they have all been happy with the type of non-hurried care they receive. They can get appointments same day. We have time to help them coordinate their care with specialists. All things that were difficult or impossible in the old-insurance driven model.

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Other Good Effects:

Expenses have gone down.
My medical billing expenses have been slashed by at least 50%.
I have eliminated one medical assistant during my day hours, and went from two to one medical assistants during evening hours. My payroll expenses have been slashed by about 30%.
My supply costs have also decreased by 20%.
I have spent more on marketing the new practice style, but overall my expenses are down about 12% compared to 2007.
For other good effects for my patients please see my blog post of 2-20-2008.

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My goal is to get to about 1000 patients in my practice, instead of the average of 2500 in my community. If I can get 50% and up in the wellness and retainer plans, my revenues will be higher, and patient care will be much improved. Hopefully the addition of a monthly or quarterly payment option along with the results of marketing my practice will continue the successful transition.

Medisave: A Blend of Government funded healthcare in a privately controlled fund

2008-06-12T21:25:00.001-04:00

Medisave: A Blend of Government funded healthcare in a privately controlled fund

Much of today’s debate about healthcare reform revolves around two distinctly differing viewpoints. On one side we have the call for a government takeover of the present system, with new insurance mandates, continued insurance management and regulation, and higher taxes. On the other side we have the call for an end to government regulation, an opening up of the free market, and the end of the insurance industry's undue authority and oppressive control over healthcare processes, without any new taxes.

Is there a way to bring the two sides together?

Let’s look at some numbers:

Estimated population of the United States is 300 million.

Estimated direct government contribution to healthcare spending in 840 billion dollars.

That is about $2,800 a year per person.

Is there a way to spend that money more efficiently?

Here is my proposal:

Individually owned Medisave accounts for all United States citizens from birth.
With no added taxes from the government, the $2,800 can be used to purchase a catastrophic high deductible insurance policy that would also cover the first $500-1,000 per year of preventive coverage for well exams, Pap smears, childhood vaccines, etc.
These Medisave accounts would be individually owned and controlled and could be managed by banks or other brokerage service centers. To cover the costs of the deductible, patients and employers could voluntarily contribute to the accounts. For the unemployed, there could be more charity care and other tax deductible accounts set up. Means testing would also be on the table for those truly in need. Any money remaining in the Medisave accounts at the end of the year would roll over for the following year.
Hopefully money would be saved in these accounts to fully cover any future year deductible. Family members can use a portion of their excess Medisave dollars for other family members or for charity to others in need.

The Medisave accounts would be paid for by the same taxes present today. However these monies would need to be separated from the government’s general fund to avoid having any of the funds spent on other programs. With the accounts controlled by individuals, it would bring an end to government lobbyists and special interests.

Tort reform would also need to be enacted to lower the costs of defensive medicine. A fair system is beyond the scope of this article.

Lets look at the positives of this plan:

1) Lowers employer costs greatly. Employees could get more in salary as a result. Also insurance is fully portable, and not dependent on employment, only upon citizenship. Non-citizens can buy into the plan at much lower costs than today’s insurance premiums.
2) Ends Medicare and Medicaid and all the government regulations and price controls and replaces them with individually controlled and owned policies.
3) No price controls. The free market would set the costs. Competition would open up and be fierce to increase innovation and decrease costs. Look at all the mini-clinics opening up as lower cost alternatives as an example of true free market competition.
4) Citizens can opt out of the plan, but what would be the advantage?
5) If individuals want to buy a Medigap policy for their deductibles, they may buy one on the open market.
6) Insurance companies would stay in business but would have to change they way they operate. They would no longer be in the business of healthcare, but back solely in the business of insurance.

This proposal would cover every United States Citizen and be funded by the government in the form of Medisave withholding deductions from paychecks. This would replace the Medicare withholding. The percentage needed can be calculated by a group of budget economists. It would be budget neutral as no new funds would be needed.

Medicare and Medicaid would end along with the regulations. Patients would have open access to any doctor or health care provider they choose in the free market. Payment would be direct from their Medisave accounts at the time of service or as agreed upon between patient and the doctor or provider. There would be no third party involved to increase costs or intrude upon the doctor-patient relationship. And most importantly, those with medical expertise and genuine interest in our patients' health will once again have absolute control.

An Open Letter from America's Physicians

2008-06-03T21:25:00.001-04:00

Dr Steven Horvitz- Reading between the lines: Healthcare Information you can trust!

In the first half of 2008, I have been involved in a grass roots campaign with other doctor's across the nation whose goal is to reform the healthcare system and to restore the doctor-patient relationship to make healthcare once again affordable for all. Written below is a letter that I helped to create along with six other doctors. We are presently acquiring physician signatures so that we can present our thoughts on the problems that face our healthcare system and how we can best solve them.

We presently have over 3,200 physician signatures with more each and every day.

I ask for your opinions on healthcare today and on the letter as it is written. The physician community truly wants to partner with the American public to create and better system.

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An Open Letter from America's Physicians

Dear Fellow Americans,

For decades the United States has led the world in healthcare. We have enjoyed the finest hospitals, medical schools, research, technology, and resources. Unfortunately, our healthcare system has lost focus to the point where patient well-being is placed after politics, profits, and special interests. Healthcare costs are on the rise and patients have lost their freedom of choice. These trends are hurting our economy and compromising the doctor-patient relationship. As a result, it has become difficult for physicians to deliver the best possible care.

Our heavily fragmented healthcare system has made it very difficult for you, the American public, to get the care you need. As your physicians, we want to partner with you to address the critical defects of the system as outlined below:

You are paying a lot for healthcare and not receiving enough in return. Your insurance premiums continue to increase while your healthcare options are dwindling. Gatekeepers, insurance networks, and restrictive regulations limit your choice of doctors and your access to care.

You have been made dependent on complicated and expensive health insurance plans. Employers are forced to take money out of your paycheck to purchase health coverage. If you lose your job, you are left with no safety net and the money you have paid for health coverage vanishes.

The time you spend with your physician has become remarkably brief due to regulatory hurdles requiring doctors to spend more time on documentation than with you.

We believe the following factors have made our current healthcare system unsustainable:

The insurance industry's undue authority and oppressive control over healthcare processes

Excessive and misguided government regulation

The practice of defensive medicine in response to a harmful and costly legal environment

We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients' health have absolute control. This letter is merely a summary of the most important problems in our current system. We believe that by partnering with the public we can start to demand real change and formulate practical solutions.

We invite you, our patients, friends, neighbors, and employers to unite with us at this important time in the history of healthcare in the United States. Together, we can guarantee our nation a healthier tomorrow.

Please talk to your doctor about this letter and visit http://www.sermo.com/doctor... for more information.

Respectfully,

The Undersigned U.S. Physicians

The Clock is Ticking. My response to a blog post on HealthBeat

2008-05-12T18:47:00.004-04:00

The Clock is Ticking. My response to a blog post on HealthBeat.

The link to the above original post on Healthbeat is found next: http://www.healthbeatblog.org/2008/05/the-clock-is-ti.html

I have copied it below with my comments in red.

May 12, 2008
The Clock Is Ticking
After being re-elected in 2004, President Bush began touting an ambitious social policy platform, the so-called "ownership society." Part of this agenda was a strong push for high-deductible health plans (HDHPs) coupled with health savings accounts (HSAs)—tax-free savings accounts to pay for health care expenses.
Like so much else that the Bush Administration attempted (author’s- Niko Karvounis- bias), the ownership society flopped (author’s - Niko Karvounis bias),, in large part because it called for the privatization of Social Security (which failed due to Democratic party disagreements, not to any failure of the Bush administration). With this failure (author’s - Niko Karvounis- bias),, HDHPs and HSAs fell out of the public spotlight. To the casual observer, the question of whether or not health care reform should move in this direction seemed to have been put to rest.
But even though they are no longer in the political spotlight, HDHPs and HSAs are actually thriving—and in fact penetrating our health care system at a relatively brisk rate (The result of free market forces at work). This is problematic (the authors - Niko Karvounis - opinion only). Not only are HDHP/HSA plans poor policy, but their proliferation also weakens the political viability of the health care reform we really need (the authors - Niko Karvounis -opinion only, not a fact).
Here are the numbers: at the end of last month, the Associated Press reported that the number of Americans enrolled in HDHP/HSA plans has nearly doubled (free market forces at work) from 2006 estimates, to around 6 million. Admittedly (by whom?), these plans still have a long way to go before they become a force to be reckoned with. America’s Health Insurance Plans estimate that enrollment in HDHP/HSA plans comprises just 3.4 percent of the private insurance market in the U.S., and in March, Employee Benefit Research Institute (EBRI) estimates that 42 percent of people who have HDHPs and are eligible for HSAs don’t even use the accounts (that is because it is up to the individual, not the government or the the employer. Its called individual responsibility).
Nevertheless, a doubling of enrollees over two years is nothing to scoff at (I agree). And while national rates of enrollment are still meager, the picture’s somewhat different at the state level. The AP reports that in Minnesota, the state with the highest percentage of HDHP enrollees, "about 9.2 percent of the state's total enrollment in private health insurance comes through high-deductible plans. Following closely behind [are] Louisiana, [at] 9 percent and the District of Columbia, [with] 8.7 percent."
State governments are also beginning to turn to HDHPs and HSAs as models for reform. Last week, Georgia passed a law—with the support of Newt Gingrich—that will give insurers $146 million in tax breaks for selling HSA plans (While I like HSA’s, I don’t understand the need for tax breaks to health insurance companies to sell them.). In Indiana, Health Affairs reports that HSAs are being coupled with Medicaid to provide high-deductible health insurance to low-income citizens. (Maybe a way for the Medicaid population to save for their future medical needs, as we do not expect individuals to remain on Medicaid their entire lives. Sort of like Welfare reform signed into law by Bill Clinton.)
In practice, the HSS/HDHP combination makes little sense for families poor enough to qualify for on Medicaid. The $1,100 deductible is more money that most impoverished families have lying around, and the requirement that they contribute 2 percent to 5 percent of their income to the HSA each month ignores the fact that families on Medicaid live paycheck to paycheck and often run out of groceries before the end of the month. (Scare tactic. Please prove that claim) They don’t have a 2 percent to 5 percent cushion to deposit in an HSA. (Not much to disagree on here, but some form of means testing and a way for each individual to save for the future to get off public assistance would be helpful. All income classes would agree with that.)
Yet while Bush was unable to broadly institutionalize HDHPs and HSAs in one stroke Social Security (which failed due to Democratic party disagreements, not to any failure of Bush administration)., it's clear that the two still have made major inroads into our health care system—and into policymakers’ thinking on reform (free market acting on its own!). With so much activity surrounding HDHP/HSA plans, projections for growth are optimistic: the U.S. Treasury Department estimates that there will be 14 million HSA policies in place across the U.S. by 2010.
Despite this healthy forecast, HDHPs and HSAs aren’t the answer to America’s health care problems (again, the author’s – Niko Karvounis -opinion only, not a fact). As I’ve noted in the past, consumer-driven health plans require a lot of out-of-pocket spending (even in the Indiana Medicaid/HSA program, the annual deductible is a not-cheap $1,100). Big expenses at the point of service encourage patients to forego necessary care—including patients with chronic conditions, who often end up needing more costly and extensive catastrophic care down the line. With HDHPs, patients save now, and pay—a lot—later (Instead we have today’s system, where people get everything and then some, and paying little for it, but at much higher premiums, without better long-term medical outcomes. Wouldn’t you rather get a higher paycheck, then insurance you don’t use?)
HDHPs and HSAs also do little for the uninsured, since most families without health insurance are low-income won’t be able to afford health coverage that asks them to pay $4,000 out of pocket before their insurance kicks in (I would like to see true data on this one. Medicaid is available for the lowest income earners. Many of the others are uninsured by choice, not due to income. If affordable coverage was available, they might not be uninsured.) (In 2005, $4,000 was the average HDHP deductible for a family). No wonder EBRI found that in 2007 only 7 percent of people enrolled in HDHP with HSAs were uninsured before they got their current plan, and just 15 percent of those in HDHPs without HSAs had no insurance before enrolling. (And what percent of people today do NOT have insurance? Is it greater than 7-15%? The 2007 estimated population is just over 300 million. If we count 47 million as uninsured that is just over 15%- numbers seem the same to me!)
Asking people to pay more is not the way to expand health insurance to those without it—especially since the higher out-of-pocket spending of HDHPs is often coupled with increasingly expensive premiums. (Not even near as expensive as todays traditional plans) In April, the Minneapolis Star-Tribune reported the story of John Gruber, a 63 year-old man who has an HDHP/HSA plan and who has continually seen his health care costs increase. Even though Gruber’s medical bills have never exceeded his deductible, his insurer Blue Cross Blue Shield upped his monthly premium from $337.50 a month to $470.50 in 2007, a 39 percent increase. His annual deductible also increased from $3,500 in ’04 to $4,100 in ’07. (Why not give the example of the many individuals with insurance that never visit the doctor, have minimal to no healthcare costs. What is the cost savings in premiums and personal healthcare costs to them? What is the profit to the insurer? )
Gruber’s case is not unique: the Star-Tribune quotes Blue Cross Blue Shield as admitting that HDHP premiums are increasing just like those for traditional insurance plans. Patients are paying more out-of-pocket and more in premiums. And don’t count on HSA savings to soften the blow of high health care costs, which have been growing faster than investment returns. (As HSA savings grow year to year, patients will have money saved up for their deductibles, while the catastrophic costs will be covered by their plan. So the problem is ???)
The only folks who can really benefit from HDHPs and HSAs are high-income earners. When you have enough money to pay for your health care expenses, high-deductible plans aren’t a problem; and if you are wealthy, you also have more money to save, making HSAs more useful. (Class warfare at its finest). Finally, HSAs offer a way to permanently shelter you income. Like an IRA, or a 401-k, an HSA gives an employee a chance to squirrel away pre-tax dollars—you don’t pay any income tax on the money the year you put it into the tax shelter.
But with the HSA, the deal is even sweeter: when employees withdraw money from the HSA to cover medical expenses, they still don’t have to pay any taxes on the either the principal or the dividends and capital gains that have compounded over the years. Moreover, "medical expenses" include items often not covered by health insurance including contact lenses, in vitro fertilization, psychoanalysis and dental work. (Coverage for items not covered under todays insurance system- Sounds terrible to me ????? So the problem is??)
As a tax shelter, the HSA has no peer, at least for healthy, wealthy Americans. (No, it works for all Americans regardless of income) Today, a family with cash to spare can sock away up to $5,800 a year, tax-free, sign up for high-deductible policy that will cover catastrophes—and then pay for check-ups, flu shots, mammograms, eye exams and the occasional childhood accident out of a separate account. (That is called choice, and in a free society, choice is to be desired and not taken away)
Why not use the $5,800 in the HSA to cover the medical expenses? Because if you don’t touch the HSA you can carry it over to the next year, contribute another $5,800 and watch the account compound, tax-free, for decades. (And the problem with that is???)
As a gift from the government (actually a remarkably generous present from other,less fortunate taxpayers), the HSA can’t be beat. (How is money that individuals earned and saved, a gift from the government. The government did not work to earn the HSA-money, the individual did. It is not the governments money to take.) A family that tucks $5,800 into an HSA for 30 years, and earns 7 percent a year on their investments, will wind up with a nest egg worth well over half a million dollars—tax free. (And the problem there is??) You can then leave the HSA to a spouse, again without paying taxes. (If your spouse happens to be, say, 20 or 30 years younger than you are, he or she can look forward to continuing the family tradition of contributing to an HSA, and watching it grow, tax-free, for another few decades). (A spouse 20-30 years younger than you. Wow. All I can say is Way to Go!!!!)
A GAO report from last week suggests that families have caught on to the benefits of using HSAs as tax shelters. In 2005 contributions to HSAs totaled $754 million, more than double the $366 million in withdrawals (And the profits of the health insurance companies over that same time period dwarfs the 754 million. Where would you rather have the money saved? In the insurers bank accounts as profits, or in your own tax free medical-health savings account.) This disparity between what people put in and what people take out of HSAs suggests that there’s a certain degree of money hoarding at work, with folks taking advantage of the opportunity to stash big bucks away in a tax-free haven. This has nothing to do with promoting healthcare or a healthier America. (What you call hoarding, others call saving for the future, so as not to have to ask the government or their employer to pay their expenses.)
Given the advantages for the wealthy, it should come as no surprise that taxpayers with HSAs earn almost two-and-a-half times as much as the average American, with an average adjusted gross income of $139,000—compared to $57,000 for all other filers.
Besides the basic injustice of a health care policy that so explicitly favors the rich and the healthy, there’s another reason to be concerned over the high-income bias of HDHPs and HSAs. Maggie has written a lot about how meaningful, system-wide health care reform is going to require a high degree of unity, and she’s right (the author’s - Niko Karvounis - opinion, not fact). But HDHPs and HSAs undermine this unity by giving high-income Americans the opportunity to "check out" of health care reform. (Incorrect assumption. It gives all Americans with HSA’s the ability to put away money for their future healthcare, instead of giving it to insurance companies for profit.)
Think about it. HDHP/HSA plans are a sweet deal for the rich. They pay for care only when they need it—a risk that they can afford thanks to their deep pockets—and they have a new tax shelter to boot. How on Earth are we going to convince the rich to pay higher taxes to fund universal health care if they settle into this cushy situation? (Here is the author’s - Niko Karvounis -biased answer for healthcare reform. Have the rich pay for healthcare for all of America. Is that the American Way???)
Unfortunately, HDHPs and HSAs are indeed becoming the pet policy of high-income earners. According to a March Employee Benefits Research Institute/Commonwealth Fund report, 31 percent of households that held these plans had incomes of $100,000 in 2007—up from 22 percent in 2005. In contrast, just 19 percent of households with high-deductible plans made under $50,000 in 2007, down from 33 percent in 2005. The demographics of HDHP/HSA plans are becoming more uniformly high-income. (Meanwhile, there was little change in income distribution of people enrolled in traditional insurance). (That leaves 50% of households with HSA’s who earn between $50,000 and $100,000- Does not sound uniformly high-income to me!)
HDHPs and HSAs run the risk of dividing our commitment to health care reform by fragmenting interests—and not just for rich people (author’s - Niko Karvounis -opinion, not fact). Like high-income Americans, employers have a vested interest in exploiting HDHPs and HSAs. (Employers exploiting – interesting use of words!) In this case, the appeal lies in the offloading of responsibility. Premiums tend to be lower for HDHP plans than for traditional health insurance, which means that employers contribute less to them. Further, employers are not required to contribute to employees’ HSAs—and in fact there’s a legal limit to how much an employer can contribute if it chooses to do so.
This is good news for employers, who are eager to minimize their health care responsibilities. (I guess it matters whose responsibility healthcare is. I always assumed that healthcare was the responsibility of individuals and families, not employers or government. Why not ask employees if they prefer higher take home salaries or more expensive health insurance?) Indeed, the proportion of U.S. workers covered by employer-based coverage fell from 51.1 percent in 2000 to 48.8 percent in 2006. HDHP/HSA plans might be a happy surprise for the rich, but for employers, they are a long-awaited backdoor exit. So it’s no surprise that firms are increasingly offering HDHPs and HSAs to their employees. The Kaiser Family Foundation reports that in 2003 less than one percent of firms offered HDHP plans with HSAs; in 2007, the share rose to 4.2 percent. Once again, this is not a whopping number, but it’s a rapid increase. (Maybe its due to the high cost of traditional plans.)
Here we have the same problem that surrounds high-income earners: how do you get an interest group to think of the greater good once they catch wind of an immediate alternative that furthers their own self-interest? (Nice rationalization by class warfare! The greater good would be to bring down costs for healthcare, by having individuals assume some individual responsibility for the costs, with government creating a foundation to help those who most need it, not a one size fits all for those who do not!) Can we really expect employers to embrace health care reform that might require mandates or some form of employer-based coverage once they succeed in disengaging from health insurance? Once they’re out of the health care business (Excuse me, but how many employers are in the healthcare business? Does Home Depot sell healthcare? Does your local mom and pop grocery store sell healthcare?), it won’t be easy to pull them back in—even as an intermediary step to universal coverage. (There you have it. Universal coverage. It is not what everyone wants. And to force it by mandating everyone into a single system will just raise costs. Look at the Massachusetts state plan and the cost overruns. Look at all the mandates in Massachusetts. Imagine that on a nationwide scale.)
It’s important to note that neither high-income earners nor employers are officially "out"—at least, not yet. HDHPS and HSAs make up only a tiny part of our system. But as these policies continue to gain ground, the fracturing of health care interests will become more and more of a problem. Wealthy Americans and businesses are two of the most influential lobbies in U.S. politics, let alone health care. If they feel that their self-interest is being served without broader systemic change, then reform is going to be that much more of an uphill battle. (Reform and change are big words being used a lot this election cycle. But the words are not as important as the type of reforms and the type of change that is being proposed)
Ultimately, we should be concerned about HDHPs and HSAs not only because they’re bad policy—which they are—but also because they get in the way of good policy ( The author’s - Niko Karvounis -opinion only- not a fact). And we should get moving on meaningful, universally beneficial health care reform before it’s too late. (I agree on the need for reform of the healthcare system, but not the present author’s vision. We need reform that will bring down costs across the board, by opening up the free market to bring down costs and increase quality. It has worked in all other areas of our economy, it can work in the healthcare system.)
Posted by Niko Karvounis on May 12, 2008.

The remarks appearing in red are by Steven Horvitz, D.O.

Healthcare Persecution

2008-04-28T22:13:00.005-04:00

“Things get worse for you only when you try to accommodate your persecutors”

This is a quote from a book I just finished, “The Charm School” by Nelson Demille.

Definition of persecution: Persecution is persistent mistreatment of an individual/group by another group. The most common forms are religious persecution, ethnic persecution, and political persecution, though there is naturally some overlap between these terms.

How does this relate to healthcare and the transition of my practice?

I will call it Healthcare persecution.

And it depends on who are your persecutors and what type of system you are working. I have heard some physicians complain and complain again about how patients are overly demanding and aggressive about their care. They want everything and they want it immediately. These physicians appear to consider patients as their persecutors.

Insurers have persecuted physicians by making managed care contracts more and more one-sided. No one is forcing physicians to sign these contracts. Yet, physicians over the past twenty years have persecuted themselves and their patients by continuing to participate with these managed care organizations.

A result has been that physicians gave up control of healthcare decisions without even blinking. Can anyone order a MRI without prior approval? Try to get a new pharmaceutical covered. Are we truly making decisions or just asking “Mommy May I?” Are our medical decisions being tainted by trying to avoid the managed care bureaucracy? Do you avoid ordering tests or medications that need managed care prior approval? Is that the type of care you went to medical school to learn? Is that the type of healthcare system you enjoy working in?

Our patients no longer feel that we are their advocates and that we do not have their best interests in mind. In today’s managed care environment, Can you blame them? Our patient’s want our help and want it unconditionally. They want the trust back in the doctor-patient relationship. But until we give up delegating healthcare decisions to insurers, we will not get the trust back.

Why did I stop participating with insurers?

“Things get worse for you only when you try to accommodate your persecutors”

Preparing yourselves for the transition away from third parties

2008-04-23T11:04:00.004-04:00

Preparing yourselves for the transition away from third parties:

I have been asked by other members of the physician community to write about my practice transition and the different feelings, thoughts and reactions I have had as well as those of my peers, patients and community.

A few necessary items to make the transition are listed below in no particular order:

Courage- I have learned that the path to success is not to always follow the crowd. Watch for patterns and trends and determine what you feel is sustainable and what areas are not.

Thick Skin- There will be many parties that will try to throw mud at you. Face it. A majority of the public does not like change!

Marketing Plan- Be prepared to lose a good portion of your practice. But a good marketing plan outlining the positive and valued aspects of your practice will help you to retain your existing patients while growing your practice with new.

Good communication skills- Goes hand in hand with good marketing. If you or your staff can not communicate the purposes of your transition, it will not succeed.

Savings or a spouse that works- Be prepared for a possible decrease in your revenues. It should increase as patients who desire your new style of practice join you, but how long it will take is not possible to predict.

Ability to stay within a budget- You had better have a firm grasp on your practices finances. Knowing where every dollar goes and being able to determine how much overhead you can cut to keep the practice going and to keep your income flowing is an absolute necessity.

Proactive and visionary- If you wait until everyone else is doing it, you will be left behind.

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Patient’s reactions:

Yelling and Screaming- There have actually been patients who have called up my office yelling and screaming that I no longer work with insurers. They do not understand the concept of a doctor-patient relationship without third party intrusion. I find that these are the patient’s who trust doctors the least.

Abandonment- Some patient’s feel abandoned. Again, you or your staff need to explain to all your practice that they are all still welcome, only that they will be responsible for payments as opposed to insurance.

Entitled- These are the patient’s who feel that they bought a product (insurance plan) that entitles them to free or low priced care.
"I already pay too much for insurance": Some patient’s, no matter how much they like you, feel that healthcare costs too much already by complaining about their insurance premium. It is a difficult concept for patient’s to understand but health insurance and healthcare are two different entities.

Excited and understanding: I like these patients. They understand the issues facing physicians, and they also value our services.

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Doctor’s in the community:

Inquisitive: I have had responses from other docs such as, "You are doing what?, I wish I had the courage to do that!, and "You’ll end up going back to insurers"

Watching from afar: These same docs are also watching from afar. Many pharmaceutical reps have taken questions from other docs in the community asking how my transition is going.

Eager to steal your patients: Soma, albeit a minority of doctors, actually badmouth me and my new practice style to patients who have transferred out. This is the part I do not understand and is one of the main reasons our profession has been taken over by the big business interests.

Trying to find the courage to be the next to transition: There is one other doctor in my community who has given up insurance and switched to a Concierge practice. In speaking with him, so far he is very happy, and he feels that he has his patients respect.

Respect: Whether other physicians approve or disapprove of my transition, I have earned their respect for making a bold move.
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My feelings through the transition:

Excitement: It is exciting to start over again. Now I have not totally started over as about 40-50% of my patients have remained in my practice. But it feels good for the ego when you find out that people do value your services and that you are not just another name in the insurance directory.

Pissed off at Insurance lies to patients: I get calls from patients who tell me that the insurance company will not cover testing if it is ordered by a non-participating doctor. Unless the patient is in a managed care setting, this is wrong and disingenuous on the part of the insurance industry. A good article on the above abuses can be found by following this link to an article entitled "The Health Insurance Mafia."

Fear: On the days when I see 6 patients instead of the 25 I would usually average, it can get depressing or fearful. But then the next day comes and I have 20 patients and the fear fades.

Boredom: What do I do with all the free time I have at the office when I am not seeing patients. Well so far, I have had all my paper charts scanned into electronic format, and all the paper and filing cabinets stored in a basement. I am cleaning out some exam rooms and decluttering the other office rooms. I am preparing to give some rooms a new look, new paint and more open airy feel. I have time to journal my thoughts on this transition by use of this blog, and also posting to SERMO, a physicians online community.

Like a doctor again: Imagine you are a primary doctor and you want to send a patient for some tests. You hand them a prescription and send them to your medical assistant who helps the patient schedule the test. No referrals needed. No time consuming bureaucratic waste, a happy patient who feels the office is truly helping them get through the maze of the healthcare system.
More time to spend with family and friends: The best part of the process so far. While I am a physician, I am first a husband, father, friend and neighbor.

Enjoyment of the challenge: Whenever I get bored, I look for a new challenge. I have found it. While my office is low in patient volume, it will increase within a few years, and I will look back on the boredom and wish I had some of it again.

More info on my office can be found on my website at http://www.drhorvitz.com/

Why did I choose to take the risk of alienating patients by refusing to work with insurance?

2008-04-12T15:32:00.000-04:00

I often post on Sermo, an online physicians community. I have been asked to comment on parts of my transition to a cash practice:

Why did I choose to take the risk of alienating patients by refusing to work with insurance?

Look closely at the question.

Risk? I look at it as being more risky to my patients, my practice and my profession if I continued to participate with insurers. My job, first and foremost is to my patients. I have mentioned in previous posts and blogs that my father was a family doc. He always put his patients first. “Treat your patients like you would want to be treated, or how you would want your family member treated. Always remember without patients, you have no practice and no career.” I have always practiced by these values. I do not worry about the finances of my practice when I am with a patient. If I do right by my patients and have their trust, there is no need to worry. The practice will do fine!

Alienating patients? I treat patients not their insurance. Every patient I have is an individual, not an insured member, and not a capitated life. If patients choose to leave my practice, it is their choice to leave. I have not discharged one patient from my practice. The patients who have chosen to remain value my practice and the care they receive. Those that do not value my services will go elsewhere. What is the old adage, “You get what you pay for?”

Refusing to work with insurance? I have never worked for insurance. I always work for my patients. Insurance just gets in the way. In the past , how did insurance help me to care for my patients?Oh yea, I remember how! With managing referrrals , preauths, precerts formularies, etc. All of those office tasks were very helpful to my patients and my practice. And the insurance premiums kept going lower and lower, right?????

1st quarter 2008 transition to cash practice

2008-04-05T20:51:00.002-04:00

January-March 2008 transition to Cash Only + Medicare Solo physician, suburban practice, large HMO penetration. Conversion to cash practice, Medicare, and Wellness-Retainer model at affordable market based prices. January and February’s numbers contained some old insurance money and is included in percentages given. Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks. But February and March had little if any old insurance money and was very low compared to January.
------------------------------------------------------------------------------------------------- Comparisons given below are percentages comparing Jan-March 2008 to January-March 2007.

Patient Volume decreased by 40%

New patients seen decreased by 50%

$ per patient seen DOUBLED

Revenues increased by 18%
------------------------------------------------------------------------------------------------ More Analysis:

$ per patient visit for 1st quarter 2007 was $63.40

$ per patient visit for 1st quarter 2008 was $128.00

My practice has multiple payment options for patients. These range from selfpay, to Medicare, to Wellness and retainer options. More info on how these options differ can be found by clicking here.

The breakdown is patient visits is as follows:

Selfpay 40%

Wellness 20%

Medicare 20%

Old Insurance-Ancillary 18% and dropping

Retainer 2%

The breakdown in % revenues per patient visits is as follows:

Wellness 35%

Selfpay 29%

OldInsurance-Ancillary 25% and dropping

Medicare 8% and slightly rising as we wait for money to come in and deductibles to be paid.

Retainer 3%

$ per patient visit is as follows:

Wellness $289

Retainer $244

Selfpay $95

Medicare $40 - but waiting on billing-collections-deductibles

Other-ancillary $38 - these are quick 5 minutes visits overseeing a Naturopathic doc.
------------------------------------------------------------------------------------------------ Further analysis: A good percentage of revenues came in from Wellness Plan fees, which is upfront money. This may skew the numbers at the beginning of the year. My job is to market my office to new Wellness patients throughout the year. If I do not get these new Wellness patients, the revenues will slow.

Selfpay averaging $95 per visit. That is $32 more per visit than I received last year, or a relative increase of 33%. Also I have more time open in my schedule to fit in these patients, as I am not seeing the $10 copays or capitated patients.

Medicare averaging $40 per visit. This is skewed as I am waiting for payments to come in. But why should I have to wait? And why should I have to pay a billing specialist to get the money that I earned? Even if this number goes up to $65 per visit , it is still much lower than the selfpay, and a pittance compared to Wellness and Retainer.
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I have had a good number of patients leave my practice due to the dropping of insurance. Some have been nice about it and understanding, and some have been downright rude and insulting. So be it, i do not take it personally. Each patient may make their own decision. I am still available to anyone who wants my services, they just have to be willing to pay me directly for my services, which are priced at an extremely reasonable rate.
The feedback I have received from the patients who have remained has been terrific. While they wish they could pay me less, they have all been happy with the type of non-hurried care they recieve. They can get appointments same day. We have time to help them coordinate their care with specialists. All things that were difficult in the old-insurance driven model.
------------------------------------------------------------------------------------------------ Other Good Effects: Expenses have gone down. My medical billing expenses have been slashed by at least 75%. I have eliminated one medical assistant during my day hours, and went from two to one medical assistants during evening hours. I anticipate my payroll expenses to be slashed by about 25-30%. For other good effects for my patients please see my blog post of 2-20-2008.
------------------------------------------------------------------------------------------------ My goal is to get to about 1000 patients in my practice, instead of the average of 2500 in my community. If I can get 50% and up in the wellness and retainer plans, my revenues will be higher, and patient care will be much improved.

I call that a Win-Win!!!!

Leveraged Healthcare

2008-03-16T22:10:00.007-04:00

Healthcare in America is changing.

The past ten years the change has not been for the better.

Demand has increased.

Supply has shrunk.

Why is this?

Health insurance has given patients access to physicians for copayments as opposed to true market fees. This is leveraged care at its finest.

The demand for primary care has gone up exponentially. But the respect we receive as physicians has shrunk.

Could the low copays have anything to do with it?

Is this good for our system?

I say No!

The present system will fail soon.

A good analogy is todays housing market and the subprime mortgage debacle. Homeowners paid very little for homes they thought they could afford. But the housing bubble artificially inflated the value of their homes. When the bubble burst, and when interest rates went up, they could no longer afford payments on their mortgage.

Our present healthcare system. Patients pay copays (subprime mortgages) for their healthcare. Healthcare costs are artificially inflated due to large overhead caused by government and insurance mismanagement. Take away the large overhead and insurance intrusion and healthcare (mortgage payments) would again be affordable.

What will happen when the insurers and government can no longer keep up with the artificially high demand?

Will they continue on the present course of price fixing and burdensome regulations that only add to the cost of care?

We need an end to leveraged healthcare.

We need a system that brings the cost of healthcare down.

We need a system that would make health insurance once again insurance, and not prepaid leveraged healthplans.

Taking money out of the system, opening up the free markets, would once again make healthcare more affordable, and cost our patients and the government less. The uninsured would once again be able to afford insurance.

But we need to first remove leveraged payments from our system!

Solutions for our healthcare system

2008-03-09T14:13:00.003-04:00

March 9, 2008

For our follow-up to our initial open letter to America, we must continue with our patient focused concerns. We must also show that we can make changes to the present system that will increase affordable access to care for all, and cost our government less. It will also keep the present industries in business, but would necessitate a change in the way they do their business. We are the workforce in healthcare. We have the power to induce change if we remain united in our goals. This followup letter must show our continued unity with a focus on improving our healthcare system for all.

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We the Physicians of the United States of America, have taken an oath to serve the medical needs of you our patients. As written in our previous letter, the present system makes it more and more difficult. It is wasting billions of dollars a year, increases patient and doctor dissatisfaction, and ruins the needed trust in the doctor patient relationship.

It is time for a change. It is time our healthcare system returned to the principles of our founding fathers, of individual responsibility, where medical decisions are made solely by you and your doctor.

Here are my proposals:

Medicare:

Freeze spending at 2008 levels- this will help our federal government keep costs down and allow Medicare to continue for future generations, while taking up less of our nations GDP.

Allow doctors to balance bill patients above Medicare set rates. This allows doctors to keep up with their ever increasing overhead. This also allows doctors to remain open to treating Medicare patients. It also opens up Medicare to free market principles, which invariably will keep fees low and quality high.
Allow secondary medicare insurances to pay more than Medicare if fees rise. These secondary insurers can compete in the free market, which they are very good at.
End Medicare Advantage plans and the overregulation it causes.
Means-test Medicare deductibles according to patients tax filings. Higher deductibles for wealthier patients, lower for poorer.
Make preventative medical care for medicare recipients tax deductible.

Other Third Party Insurances:

End Third party insurance meddling and determination of care. This third party intrusion into medical care has done the opposite of its intentions while producing profits in the billions. These profits drain the system of much needed resources for medical care. The profits based on ever increasing premiums have made health insurance so unaffordable to many, i.e. 47 million uninsured.
End Insurance networks and give patients true choice in picking their doctors.
End Referrals, preauthorizations, pre-certifications, etc.
End insurance formularies, PBM’s which only serve to restrict and deny medications and increase profits for an unnecessary middleman.
Stop P4P before it starts.
Let the market decide the prices- lower cost alternatives will flourish!

End government mandates:

all people should have equal access to care, but not all people need the same care. Equal care for all means mediocre care for all. One size does not fit all.
Government should set up system of fair rules and then stay out of it. These rules should be enforced to go after the 1% of doctors, patients, and insurance companies breaking the rules, but leave the other 99% alone.
Increase individual responsibility.
Make healthcare insurance and payments tax deductible for individuals as well as employers. Employers should not be mandated to buy insurance for employees. But employers can compete for employees by joining co-ops for health insurance to allow their employees to purchase insurance policies based on individual needs. These policies become portable and individually owned regardless of employment status.

Increase availability of CDA’s and HSA’s.

This increases individual responsibility while decreasing entitlement attitude towards healthcare. It may even encourage health savings for the future.
Eliminate bankruptcies that allow discharge of medical debt. This increases individual responsibility and decreases use of our overcrowded emergency rooms. Primary care offices can provide cost effective care for non-emergent conditions.
End lobbyists power over medical care and decision making. Medical decisions need to be made by doctors-patients PERIOD, and guided by free market principles.

Tort Reform: Defensive medicine cost billions. My local yellow pages has over 130 pages of lawyer ads, and under 40 pages of physician ads. Why the discrepancy?

The present system allows for jackpot verdicts and is not sustainable. It is driving doctors out of business and into early retirement. A proper system is fair to all and does not increase the cost to all, for the benefit of the few who get jackpot verdicts.
Propose a medical courts system where we are judged by our peers and not by public sentiment. This will allow for proper damages. It will also force change in the system to deal with medical errors as they occur. The present system does not.

Big Pharma: Your public perception is at the lowest it has ever been, and your stock prices are following. You need to change the way you do business. The free market will help your industry immensely. But todays back door deals with insurance companies and the medication-formulary system does not work for the greater good of our nation. For people without insurance to pay inflated costs to make up for the lower cost to insured patients does not work and is not fair. The system needs to have a level playing field.

Immediately end DTC advertising.
Have full transparency in medical studies. Publish all studies, not just those that support your products. No more manipulation of data. If you do, you will be called to task on it! You do not want a continuation of the Vioxx lawsuits.
Stop dealing with third parties for pricing.
End pharmaceutical formularies.
With the cost savings, lower your prices to make your products affordable to all.

These are just my thoughts as a solo family physician. I am open to any and all options that we can add or subtract. But we need to focus on one common goal. What is best for our patients and sustainable for our nation.

Steven Horvitz, D.O.
Founder Institute for Medical Wellness

February Analysis of Cash Transition

2008-03-02T21:02:00.002-05:00

Results of first two months transition to Cash Only practice

February 2008:

1st two months – January-February 2008 transition to Cash Only + Medicare

Solo physician, suburban practice, large HMO penetration.

Conversion to cash practice, Medicare, and Wellness-Retainer model at affordable market based prices.

January and February’s numbers may not indicate future months as some old insurance money came in and is included in percentages given.

Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks.

But February’s old insurance money was very low as compared to January.
---------------------------------------------------------------------------------------------------------
Comparisons given below are percentages comparing Jan-Feb 2007 to January-Feb 2008.

I will try to post further months and quarterly data as it comes in.

Patient Volume decreased by 33% for Jan-Feb 2008

New patients seen decreased by 63% for Jan-Feb 2008

$ per patient seen increased by 204% for Jan-Feb 2008

Revenues increased by 73% for Jan-Feb 2008

Old insurance money should not take me thru further than March 2008. Feb 2008 revenues are consistent with Januarys with much less in old insurance income.

Ok All, Lets here the questions and comments!!

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The numbers posted above reflect my suburban solo family practice in a highly penetrated managed care location.

The numbers so far are very encouraging. However they may not indicate the future.
A large part of the initial revenues have been from established patients enrolling in my practices Wellness plans. The enrollment fees start at $200 per year. For more info on the wellness options please click here. In order to sustain the revenues and the increase in $/patient I must continue to enroll patients both new and old in these plans. I hope that March 2008 has equal numbers to the first two months, but April and on need to bring in new patients to the practice. I do intend to start a marketing plan shortly to bring in these new patients. I have had a few so far, and I believe word of mouth will spread to bring in these new patients as it always has in the past.

Why the optimism? The patients who have enrolled so far in the wellness plans have stated to me they are very happy with the product and feel the fees are very fair and reasonable. Also the service we have been able to provide with same day appointments and improved patient advocacy has been very well appreciated by my patients.

What are the problems so far?
The biggest problem so far has been patient’s not understanding that health insurance networks do not dictate who they can see for their medical care. They feel they are breaking rules if they go out of network. They do not understand that they can pay directly for an office visit without using insurance.
Some believe that as an out-of-network physician that they will not have coverage for prescriptions, or other care accessed outside my office if I prescribe it. These are all issues that I have found need a lot of hand holding and teaching of how the system truly works. Once I explain how nothing changes other than my fee, a light goes on in their heads and it becomes a decision of a few extra dollars per visit to see me.

Another problem is all the other doctors in my area who still take their insurance and are thus cheaper per visit than I. But, I have already had half a dozen patients return to my office due to the inability of these other offices to accommodate same day appointments for sick visits.

Other Good Effects:

Expenses have gone down. My medical billing expenses have been slashed by at least 75%.

I have eliminated one medical assistant during my day hours, and went from two to one medical assistant during evening hours. I anticipate my payroll expenses to be slashed by about 25-30%.
For other good effects for my patients please see my blog post of 2-20-2008.

Copy of letter to my patients 2-20-2008

2008-02-20T23:16:00.001-05:00

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

The Dumbing down of our profession

2008-02-17T20:12:00.004-05:00

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

Interesting question from Medicare patient

2008-02-15T17:22:00.000-05:00

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.

Dr. Steven Horvitz's practice transition

2008-02-14T23:42:00.000-05:00

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.

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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.