By Dave Chase
First Posted at Forbes on 5/23/2013
Dr. Rob Lamberts is an entertaining and informative writer who has been chronicling his departure from a traditional practice where his time was increasingly spent with billing codes, rather than patients. In his latest installment, he describes how well it’s working.
It feels dangerous to write this, but…my practice seems to be working. I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning. I don’t know why I wrote that.
Knowing Rob, I’m not surprised that it’s working. It’s well planned/earned. He goes on…
But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.
Slowly, but surely, a movement is rising that has growing momentum. I’ve written about it in the pieces below.
- The Marcus Welby/Steve Jobs Solution to the Medicaid-driven State & County Budget Crisis
- The Hot Spotters Sequel: Population Health Heroes
- IBM Unleashes “Primary Care Spring”
- “David Clause” in Obamacare Ready to Slay the Healthcare Cost Beast
- Health Insurance’s $4.4 Billion Bunker Buster
Nonetheless, there are always going to be critics. Some even think it’s not right (some even calling it unethical) to do what he’s doing. Let me share a story one other Direct Primary Care doctor told me about why he shifted away from a 7-minute “productivity” driven, volume-based, referral-generating model. He’s now free to practice medicine the way he was trained rather than a “system” our distorted reimbursement model has created. That “system” is best described as a Gordian Knot designed by Rube Goldberg. Unfortunately, doing some minor tweaks to it won’t get the job done. As Dr. Rushika Fernandopulle says, “You can’t put wings on cars and call them airplanes. You need to rebuild the model from the ground up.”
I asked him why he made what some perceive as a risky move. I’ll paraphrase his words below…
“I couldn’t sleep well at night when I was in the hamster wheel model answering more to productivity goals and billing/coding than my patients. I felt the medicine I was practicing was bordering on unethical as I was only using 40% of my medical training. Why? When I was meeting with a patient, my medical knowledge and intuition would generate a set of questions I wanted to ask the patient to get at the root cause of the condition. However, there would be a battle in my head knowing that if I asked this or that question, it would initiate a series of conversations and questions that would be very productive from a problem-solving perspective. However, that “productive” discussion would blow my so-called productivity goals out the window.”
I’ve had the privilege over the last few years to spend time with the leaders of many of the most acclaimed new delivery models that I call the “Triple Aim Champs” as they are light years ahead in improving outcomes, reducing costs and improving the patient experience. [See links above for more on those organization.] There are two common threads:
- They are pre-paid allowing them to spend time with patients. Pre-payment has many forms — direct primary care, Medicare Advantage, Indian Health Service, etc. As one said “pre-payment is freedom – not risk.” These doctors know how to doctor so they don’t see it as risky and their results bear that out.
- They have had to develop much of their own information technology. Naturally, the mainstream established vendor solutions are optimized for the old, volume-driven model where the “patient” (from a technology perspective) is a vessel for billing codes and not a valued member of the care team.
As William Gibson said, “The future is here. It’s just unevenly distributed.” With the success of physicians such as Rob Lamberts, it won’t be long before it moves mainstream. Working for your patients rather than insurance companies can be freeing. With primary care, that is an option. After all, we don’t pull out our State Farm card for a visit to the auto mechanic. Why would we do the equivalent in medicine unless we like paying a 40% insurance bureaucracy tax for what can easily be paid directly for less than the cost of a daily latte?
Dr. Rob Lamberts