Wednesday, February 2, 2011

The proposal of ACOG for health care liability reform and my ideas

This is an excerpt from an email that I received from ACOG today
I support these ideas in order to make the system more FAIR and transparent.

"Statute of limitations of 3 years after manifestation or 1 year after discovery of injury.
Lawsuits for minors under 6 must commence within 3 years of manifestation or prior to the 8th birthday.

Limits noneconomic damages to $250,000.

Allows punitive damages only if: (1) the claimant proves a clear and convincing standard; and (2) compensatory damages are awarded. 

Limits punitive damages to $250,000 or 2 times the amount of economic damages.
Allows periodic payments of future damage awards over $50,000.

Allows the court to restrict the payment of attorney contingency fees.
Allows introduction of collateral source benefits into evidence.

Does not preempt state law that provides greater protections.

Adopts a "fair share" model, where each defendant would only be liable for those damages attributable to their fault, thus eliminating the incentive to pursue "deep pocket" parties."

End of quote. Her a few comments from me:

Limiting NONeconomic damages is essential. Few lay people understand this. WE are not talking about capping the economic damages, nobody wants to take away the compensation for loss of income, the compensation for medical bills etc.
What we do not like is the "NON"-economic damages, the so called "pain and suffering". Pain and suffering is subjective. As soon as someone knows that he or she can make millions, he or she will experience much more pain and suffering. Believe me, if I was a plaintiff in court, I would suffer a tremendous amount - if millions are at stake. Slip and fall and become a millionaire - what a way to fulfill the American dream! Have postopertive bleeding and become a millionaire - wow! Have repeat surgery and become a millionaire!.
But, people in general are not that sneaky or sleazy. The prospect of gaining (or should we say gaming for) millions in "non-economic damages" or "pain and siuffering" is what drives attorneys. this is where they can make the big bucks, this is where they can rake in the doe, this is what pays for a yacht, for a new mansion and more, this is what turns an attorney into a "rainmaker" for his firm and what advances his career. The millions gained in malpractice suits is what is advertised in TV commercials "XXX millions gained for our clients" - sure, sure "for our clients" - and a 40% share goes into our pockets. They always forget to mention that in their ads.

Southern Florida, Miami, where liability insurance is abusively expensive and consequently many ObGyns do not carry any malpractice insurance, is a great example of what drives malpra tice suits. Once attorneys know that they cannot sue the deep pockets of insurance companies and there is no chance someone will fork over millions to plaintiff attorneys - lawsuits are .....just not done. The usual answer of an attorney to a plaintiff looking for a lawsuit against an ObGyn that has no liability insurance and no millions in personal assets is "Sorry, you do not have a case". Nobody sues a homeless person, nobody sues a poor person.
THAT is the current liability system.

FACT: Remove the prospect of making millions and professional liability suddenly becomes inattractive to attorneys.
this is the true reason why we have an unfair system, where some get "lottery agins" and most stay on the outside and do not get compensated.

I would go much further than ACOG.
I propose "Patient's Comp" - something equal to "Workman's Comp". A patient is injured during medical treatment or due to lack of - he or she submits the case to a committee, which decides based on the facts, based on actual damage and then compensates based on economic loss in a broader sense. Done. No involvement of attorneys required. The money for compensation is paid by a fund, to which physicians and hospitals contribute - in a similar fashion as they now pay liability premiums. This removes the witchhunt like persecution of physicians, the guilt and shame and emotional unease on both sides (patient and physician), it increases open detection and discussion of mistakes and consequently fixing of errors. It makes compensation of injured patients not only much easier, but also much faster - it takes months instead of years!

Why do we not have such a system?
Why do we not apply to medicine what already has worked for the manufacturing industry for decades?
Because the manufacturing industry has better paid, higher paid lobbyists and pushed it through against the financial interests of attorneys! Physicians have not spent enough money on lobbying, that's why.
Malpractice attorneys would lose the chance of making millions and millions, in some caases even billions.
That's why. Follow the money!

We need "Patient's Comp"

Tuesday, February 1, 2011

A ray of hope - Obamacare might be declared illegal

I could hardly believe my ears yesterday when I heard of of the decision of a federal judge in Florida that it is unconstitutional to force citicens to purchase health care contracts. The government might as well force us to spend money on gym memberships, on guns, on whatever your pet peeve might be. The government cannot not mandate what we purchase! What a reasonable position.
And no, the comparison with car insurance is flawed. We do not have to buy a car, buying a car is our choice. Once we have one, we have to operate it so that nobody gets hurt and we have to prepare for instances where we may accidentially hurt someone.
We do not chose to have a body! We are born with it. It is not a matter of choice as is the purchase of a car. A health insuracne is more about maintenance and disaster protection as compared to insurance against harm we may cause others and liability protection - which are the reasons we purchase car insurance.
Very nice touch also to quote Obama (by memory, may not be exact) "We cannot mandate health insurance or we might as well eliminate homelessness by mandating that everybody buys a house" Thank you for this insight, Mr. President! Thank you!
And wonderful also the statement that the insurance mandate is so central to the new health care reform law that the whole law has to be dumped.
I very much hope the Supreme Court decides along the lines of this ruling.

It is just my opinion, the opinion of a dumb little doctor, that it would have been much better to limit the reform to a simple few rules such as
"no lifetime maximum in payments"
"disregard preexisting conditions"
That would have been quite anough!

And I have to say - RESPECT, Americans! You really love your freedom. This lawsuit alone showed me more than anything else in the last 16 years I have lived in this country that American truly value their freedom. I had given up hope and thought that the giant USA had become complacent and weak and was ready to be domesticated by the present administration, by closet socialists and their "useful idiots". But, stop, wait, Americans are not ready to be converted into docile sheep in a high-tax, high-obedience herd where "paying taxes is patriotic" and being different and not conforming with the general rules is illegal. You will not be sheeps herded by the government - no Sir! You are still serious about the one true fundamental - freedom!
My hat off to you Americans!

Thursday, March 18, 2010

The Physicians' Declaration of Independence

- by Richard Amerling, M.D., New York, NY, April 2009

"When in the Course of human events, it becomes necessary for one Profession to dissolve the Financial Arrangements which have connected them with Medicare, Medicaid, assorted Health Maintenance Organizations, and diverse Third Party Payers and to assume among the other Professions of the Earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of Mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident: that the Physician's primary responsibility is toward the Patient; that to assure the sanctity of this relationship, payment for service should be decided between Physician and Patient, and that, as in all transactions in a free society, this payment be mutually agreeable.

Only such a Financial Arrangement will guarantee the highest level of Commitment and Service of the Physician to the Patient, restrain Outside Influence on Decision-Making, and assure that all information be kept strictly confidential.

When a Third Party dictates payment for the Physician's service, it exercises effective control over the Decision-Making of the Physician, which may not always be in the best interest of the Patient. The Third Party then intrudes heavily into the sacred Patient-Physician relationship and demands to inspect the Medical Record in a self-serving attempt to satisfy itself that its money is being spent in accordance with its own pre-ordained accounting principles.

The Financial Arrangements between Physicians and the Third Parties have become so destructive to the Patient-Physician relationship, and to the Medical Profession as a whole, that it is the Right, and Obligation, of the Members of the Profession to abolish them. Prudence will dictate that arrangements long established should not be changed for light and transient causes; and accordingly all experience has shown, that Physicians are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations evinces a design to reduce them under absolute Despotism, it is their Right; it is their Duty, to throw off such arrangements, and to provide new Guards for their future security.

Such has been the patient sufferance of this Profession; and such is now the necessity that constrains them to alter their former Financial Arrangements. The history of the present system is a history of repeated injuries and usurpations, all having in direct effect the establishment of an absolute Tyranny over the Medical Profession. To prove this, let Facts be submitted to a candid world.

The Tyranny began during the Second World War, when Companies, suffering under Wage and Price Controls, were forced to lure workers by offering Health Insurance Benefits. This benefit, in lieu of cash, received favorable tax treatment and was allowed to continue after the War, even with the removal of the Wage and Price Controls. This system created a strong incentive to use Medical Care and set the stage for massive Cost Inflation.

Slowly, insurance changed into payment for all Medical Expenses, minus a small and shrinking Deductible, which led to further Inflation, and a call to control costs.

The Government decreed that Employers must offer Employees the option of a Health Maintenance Organiz-ation. Thus were born the HMOs: Private Insurance Entities designed to ration Medical Care for their Members. These Organizations received Tax-favored treatment that allowed them to survive in spite of their horrendously flawed concept.

The Government, in 1965, in its Infinite Wisdom and going far beyond its Powers as set out in the Constitution, decreed that the Poor and the Elderly should receive Health Benefits funded by the Taxpayer. Thus came into existence Medicaid and Medicare. Medicaid, from the Conception, paid Physicians such a lowly wage that few participated, thereby creating a Two-Tiered System. Medicare payments to Physicians were initially fair and reasonable, and many Physicians participated in Medicare. Both Systems flooded the Medical Marketplace with Money, which fueled Inflation even more.

Alarmed by the Medical Cost Inflation that it had engendered, the Government set out to restrain costs, principally by limiting fees to Physicians. These Price Controls had the effect of increasing Medical Inflation, as Volume of Services went up, and Quality went down.

With each new round of Controls, Regulations and Paperwork multiplied many fold. This caused Physicians great Anguish, and took more time away from the Patients, with attendant loss of Quality and increase in Medical Inflation.

Government policies continued to favor the HMO, in the hope they would tame Inflation. These Organizations skimmed Money off the Premiums as Profit, but which they called "Savings." They spent less on Medical Care by denying or limiting access to Specialists, Procedures, Hospitals, and High Technology. Since this strategy mostly delayed care, it was ultimately more expensive. Thus did the Premiums again start to rise.

The HMOs paid the Physician by Capitation; Physicians could stay profitable by having large numbers of Capitated Patients, which they would see rarely, if at all! There were other Financial Incentives to Physicians to limit their Patients' access to Tertiary Care. These incentives set Patient against Physician, thus destroying this Sacred Trust.

Remuneration for Physician services by the Government and the HMOs has dwindled to the point of Unprofitability and has compelled the Bankruptcy of increasing numbers of Practices, and the search for Other Sources of Income by Physicians. No other Profession in the United States is denied the ability to raise fees to cover increasing costs of doing Business.

The Government, becoming increasingly desperate that all its strategies to control costs had failed (because they themselves were the cause of Cost Inflation!) resorted to Criminal Prosecutions of Individual Physicians and Hospitals for alleged Fraud. The Regulations being so Arcane and Vague, a simple Billing Error could be interpreted as Fraud. Most of those so pursued, being financially unable to defend themselves, simply capitulated and paid Huge Sums to the Government. Some were imprisoned.

The Government passed a Massive Bill called HIPAA, which forced Doctors and Hospitals to spend billions to comply, with absolutely no positive impact on Patient Care.

The Government passed a law called SGR which automatically lowers Physician Payment when total spending and volume increase, virtually assuring a downward spiral in Payments.

The Government and HMOs now conspire to limit fees to Physicians by a diabolical machine known as "Payment for Performance," based on "Practice Guidelines." In addition to insulting our Ethic, this system will close the circle between the Central Payment for Care and the Central Prescription of Care. Thus do we completely lose our Professional Autonomy.
In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A System whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a Free Profession.

We, therefore, the undersigned Physicians of the United States of America, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name of our Patients solemnly publish and declare, that we will withdraw our participation in all above-described Third Party Payment Systems. Henceforth and Forever, we shall agree to provide our services directly to our Patients, and be compensated directly by them, in accordance with the ancient customs of our Profession.

As has always been true of our Profession, our charges will be adjusted to reflect the Patients' ability to render payment. Nothing prevents any patient from purchasing and using Insurance. The Patients' medical interactions with us will remain completely confidential. We pledge the highest level of Service and Dedication to their Well-Being.

And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

- Richard Amerling, M.D., New York, NY, April 2009

Please sign this declaration on the website of the AAPS! Thank you!

Saturday, January 2, 2010

SIMPD Has a Better Idea

Begin quote;

"Thomas W. LaGrelius, MD, FAAFP

President’s Address

Delivered May 5, 2008 at SIMPD annual meeting, Las Vegas, Nevada

Good morning SIMPD members and friends! Welcome to SIMPD’s fifth annual meeting here at the beautiful Venetian Hotel in Las Vegas. It’s great to be here with the most independent doctors around. We in SIMPD have lifted a page from managed care and created instead a network of unmanageable doctors, except by our patients. And our movement is growing.

Have you wandered through this place? I’ve been to Venice, Italy, but Venice, Las Vegas may be almost as grand. I hope you all have some fun here, see some shows and not lose too much money.

While you are here, connect with and comparing notes with your colleagues in direct practice from around the country. At this meeting you will find happy doctors who love their practices and know they are doing the best work of their lives. Our doctors take excellent, personalized care of their fewer patients, not just run past thousands of them on a mad dash from room to room to room.

Our attitude toward the practice of medicine is quite a bit different from the attitudes of our colleagues back home that are not in direct practice. Many of them are depressed and disillusioned. Some tell their children not to become physicians. Some look for ways to retire early or use their medical training to switch into non health care or even anti-health care occupations. (Being Medical Director of an HMO comes to mind here.)

We know better. We know the practice of medicine is exciting, rewarding and enjoyable.

I hope this meeting provides you with sessions that inform, inspire and assist you in your own practice goals. That is our purpose. Please fill out our program evaluation forms and tell us how we are doing.

How many of you are at your first SIMPD meeting?

When we first organized we called ourselves “The American Society of Concierge Physicians”.

How many of you were here for that first meeting in Denver in 2004?

By the time of our second meeting in Dallas in 2005 our name had been changed to SIMPD. How many were there?

How about the third in 2006 in Chicago where we spent so much money to hear Tommy Thompson talk, and maybe it was worth it. There were some bumps in the road for SIMPD after that, but we made it through.

Our fourth meeting in 2007 was delayed half a year, because of the bumps, until only six months ago in Washington DC, where Chris Ewin turned over the gavel to me after spending 18 months as president smoothing out the bumps. How many were there?

And here we are in Las Vegas for number five. We are young and small and the organization still struggles to provide services and better benefits to our membership, but a lot of folks outside of our movement are now asking about us who did not before know or care that we existed. Venture capitalists approach us with intriguing ideas to rapidly expand the numbers of direct practice doctors with their capital. The media call fairly often putting SIMPD’s name and web site in the public’s eye and thus bringing patients to you our members. Politicians too now wonder and ask if what we do could really be the solution to our gathering health care perfect storm almost everyone sees on the horizon.

I missed the first meeting in Denver but have attended all the rest. What I learned at my first SIMPD meeting in Dallas allowed me to launch my own direct concierge practice later that year. Without SIMPD my practice would be very different than it is today, and perhaps much less successful. The doctors I met in Dallas that first meeting were an inspiration. SIMPD promises to be an inspiration to all of our profession throughout the nation. SIMPD is a visionary organization. We know that doctors need to work directly for the right people, their patients and not for government, health plans or employers.

Until recently it was unusual to find a doctor present in the room where business people and politicians discussed their plans for our future. We were the forgotten victims of their well meaning but misguided schemes to reorganize health care. But now we are here at the same time and in the same place where dozens of other groups are dealing with all aspects of consumer directed health care. What an opportunity to show them our vision of the future.

I want to thank Transmarx and its CEO Skip Brickly for the hard work developing this meeting and making sure we are here participating with and connecting with business leaders in consumer health. Our thanks also to Walt Tudor our very effective day to day administrator, and all the other members of Transmarx’s excellent staff. Take advantage of this opportunity. Look around at all the meetings and investigate all the sponsor booths here. Talk to the business people here and teach them what needs to happen to save American medicine. Make sure they know that there is now a doctor in the room discussing the future of doctors and patients and not just waiting for the next hammer to drop on our heads.

So, where is American medicine and where is it going?

Modern medical science has made incredible strides in the advance of medicine, but our systems to finance its delivery are falling apart and actually damaging the critical doctor patient relationship.

You have all heard the litany of health care financing problems facing us today. It is said we spend too much money and get too little for it compared with other countries. But I submit that the individual citizens of the wealthiest and freest country on earth MUST have the right to spend more of their own money on maintaining the most valuable asset they have, their own good health. And it is our job to make sure they are really getting their money’s worth.

There are 47 million uninsured. Some say this is a crisis, but there are also 253 million insured Americans whose health plans and whose doctors working under the thumb of those health plans often serve them very poorly. Their doctors are working for the wrong master and in the wrong practice design.

We link 60% of health insurance to our conflicted employers creating gigantic problems for patients and employers that threaten not only health care, but our entire economy. This system is the last vestige of the 19th century “company store”, long ago abolished in every other sphere of human need. Our employers do not buy our food or housing or clothing. They pay us wages and we choose what and how much we want to buy as free Americans must.

Medicare, now covering 15% of Americans, is insolvent and will soon have a trillion dollar annual deficit. Yet some, like Michael Moore, suggest we make Medicare universal, as if that would solve our problems. SIMPD members know that expanding a failed system like Medicare to 100% of Americans will only cause a universal catastrophic failure with a ten trillion dollar annual deficit. We have a better idea.

One proposed solution, P4P (pay for performance) is a joke as administered by government, health plans and employers. Through this idea, health professionals are paid for more paperwork rather than for delivering care, and while our colleagues stare at the papers and the computer screens, medical errors kill 100,000 Americans a year because they do not look at their patients. In this election year, every politician has his or her proposed solution to our difficulties. Most are extremely unlikely to work. Again, we have a better idea.

Our goal is an error free practice, and we come very close to that goal. We have the time and the voluntarily given funds we need to improve the odds of getting to that goal. Because, there is a limit to how many patients a primary care doctor can care for safely and thoroughly, and it is a lot less than three thousand. It is probably less than 1000. It has been estimated that caring properly for 2000 to 3000 patients, the way we do for our more limited panels of patients, would require the primary care doctor to work 18 hour days six days a week. Some have questioned the ethics of concierge medicine. But is it ethical to take on a task one knows cannot be done safely?

In a recent Wall Street Journal op-ed, Dr. Jonathan Kellerman, a popular author and clinical professor of pediatrics and psychology at USC compared modern health plans and Medicare to the Mafia. He convincingly described their premiums as equivalent to payments to a protection racket. He accuses the health plans as being worse than a Mafia protection racket because they not only take money and deliver no value back, but then go further and interfere with the business of medicine to the detriment of both patients and doctors after taking their protection payment. Not even the Mafia goes that far. He makes the argument that less insurance rather than more is the solution to the health care financing plaguing our country. And though real insurance for high cost illness is important, we agree with Dr. Kellerman when it comes to basic health care. Americans should buy it directly and eliminate the meddlesome and costly middle man. That my friends is a much better idea.

The only payer that really values our services today is the patient, but most doctors don’t work for the patient. Last month I spoke to Dr. Katherine Atkinson, a family physician near Boston. The Washington Post had just published an article about her practice. She has a one year waiting list to get into her popular and excellent practice. After getting in for a first visit there is a nine month wait to set up a complete physical examination. She loses $20 a visit on each Medicare patient, but does not turn them away. She works very long hours, approaching those 18 hour days I mentioned. No one should work that hard, but that’s what it takes. Those of us who have tried to do it know it is true.

Nearby to Dr. Atkinson there is no doubt an excellent orthopedic surgeon who also works hard, but there is no one year wait to get into his practice. He earns $400,000 per year. Katherine Atkinson earns $110,000 per year and cannot afford to replace her aging automobile.

It is not that we begrudge the orthopedist or the cardiologist or the interventional radiologist their better pay, they too took a cut, albeit smaller, in real dollars in the last few decades. What we are saying is that the economics of medicine drive students to these specialties and away from the primary care dream most of them had at the beginning of their educations.

We are also saying is that good primary care medical homes reduce hospitalizations 60-85% resulting in huge hospital and high tech care savings. We are also saying is that any society that devalues primary care and attempts to run its health care primarily with specialists and a few overworked primary care doctors doing little more than mass triage will never control its costs or improve its quality of care no matter how many electronic medical record systems and pay for performance programs the third parties demand. If that society also believes health care is an inalienable right to be paid for by other people’s money, it will also go bankrupt.

We must work directly for that patient. That is the only way to restore balance. We must convince society that health care is not a right, but a service and a product that must be paid for, ideally by the consumer of the service/product in a free and transparent market. The consequences for our profession and for our nation of not doing so will be catastrophic.

There is another way. If we had 500,000 primary care doctors each providing a medical home for and average of 600 patients as I and many of you here do, guess what. Every single American could have such a direct practice medical home. Do the math. Half a million times 600 is 300,000,000! Imagine that. We would eliminate medical homelessness, cut hospital days at least 60%, save billions and billions of dollars and prolong and improve our lives. We have the answer to our American health care crisis right here in this room. We have a better idea.

Then we could still have 400,000 sub specialists who would be busy doing half the high tech care they do today. The other half would be prevented and much of it actually managed in the medical home instead of being fragmented into multiple consultant’s offices as we see so often today.

Doctors should apologize for allowing the current situation to exist. We allowed others to control health care economics and run it like Enron and the DMV. Physicians and patients must lead the way to solutions, and that is what SIMPD members are doing throughout the land. We are leading the way to a better idea and a better day for ourselves and our patients. In a way this is a return to the practice designs of our youth. It is in some ways a return to the Marcus Welby kind of practice some of us actually remember.

I grew up in Seattle, the birth place of concierge medicine, in a middle class neighborhood long before Medicare, Medicaid, PPOs, or HMOs were invented. Yet we all had excellent, affordable health care. Our family physician Russell Anderson provided us his home phone number, made house calls, saw us the same day when ill in an unhurried well equipped office with little or no waiting. He became my role model and remains so today. I even build my office from a mind’s eye blue print of his.

His was the equivalent of a modern, “medical home” such as SIMPD members provide. My practice is a “medical home” as are most of yours. What most Americans lack today is not insurance, but that primary care “medical home” with a doctor they can access 24/7 who coordinates all their care. A doctor they can see the same day, on time. A doctor who will care for them in the hospital. A doctor who hands them his cell phone number. A doctor who will spent thirty minutes seeing them in an office visit till their last question is answered. How many Americans today have such a doctor? Our patients do and they now number at least one million. Our goal should be to make that 300 million. That is another very good idea.

Russell Anderson’s practice was also a “direct practice” like ours. He had direct professional, direct prompt access and direct financial relationships with his patients. It was a direct practice, medical home like mine and many of yours, but unlike us he had a lot of company. Almost all his colleagues practiced that way in direct professional and financial relationships with their patients. They were accessible, affordable and affable because they worked for and were responsible to us, not for and to third parties.

Back then emergency rooms were quiet and saw only real emergencies. There was not a six hour wait behind a line of people with colds. We called our doctor instead, and he acted.

And, we were completely uninsured. So were most of our neighbors.

Back then there were 150 million Americans without health insurance, not just 47 million. And we amounted to 90% of the then US population, not just 15%. Being uninsured was the norm. And those who had illness insurance had it only for hospitalization, never for doctor’s fees or basic outpatient care. The uninsured were respected consumers of health services, not problems and opportunities for politicians.

We bought health services directly with little financial strain, just as we bought more expensive things like housing and food and cars. Today in contrast almost everything we buy in health care is funneled through insurance. Money and time is thus wasted while most doctors and patients have endless battles with insurance coverage, rules and bureaucracy for basic, relatively inexpensive care. Often it is easier, and a lot more satisfying, to care for the uninsured.

Our crisis is not really one of un-insurance. It is instead a crisis of “medical homelessness”. That “medical homelessness” is the result of insurance perversions having destroyed the free market in health care necessary to create value sensitive consumers and service oriented doctors. There are too many “third parties” meddling in basic health care.

So in America, doctors are working for the wrong employer. SIMPD doctors work for the right employer. We work for each and every individual consumer of medical services. We offer direct practice medical homes. That my friends, is the good idea SIMPD is all about.

In addition to concierge practices, cash practices with low prices now exist to serve patients and the service can be excellent. SIMPD member Dr. Robert S. Berry, a former emergency room doctor in Tennessee, runs such a practice called “PATMOS, named after the Greek Island where St. John worked and wrote, but also meaning “Payment At TiMe Of Service”. Dr. Berry has been widely recognized, appeared on 20/20 and the Geraldo show and testified before Congress. He was one of the first modern, excellent cash doctors to the uninsured but is no longer alone. His practice design is growing.

And another cash design, SimpleCare which was started in the Pacific North West by SIMPD member Dr. Vern Cherwatenko is another fine example. SIMPD is also the professional society for such cash doctors.

Outstanding, “concierge”, medical home preventive medicine and primary care including all needed treatments at that care level can be bought directly for $100-500 per month in a fee for care practice such as that operated by SIMPD member and founder John Blanchard in Michigan and SIMPD immediate past president Chris Ewin in Ft. Worth Texas and SIMPD member and author Dr. Steven Knope whose new book “Concierge Medicine” is now in the book stores and for sale here. Such retainer care can be purchased for less than most Americans spend on cell phones and cable connections. It costs far less than the amounts spend on food and a fraction of the amount spent on housing. SIMPD is the professional society for such monthly retainer fee for care doctors.

Another SIMPD member and former president, Dr. Garrison Bliss in Seattle just opened the second of seven new Qliance clinics, each with several doctors and nurse practitioners, aimed at caring for lower income Americans and the uninsured. Patients who join pay $39 to $74 a month age adjusted. For that fee they get 100% of all the primary medical care they can use, 24/7 direct access to their personal doctor, same day or next day on time appointments, regular check ups and a lot more. Not one cent of insurance money, government money or charity funds are used in his clinics. The care is paid for directly and entirely by the patients through their monthly fee, bypassing the expensive and meddlesome middlemen. SIMPD is the professional society for such retainer doctors to the uninsured.

Many SIMPD members, me included, offer fee for insurance non-covered services direct practice medical homes. We still bill patients and some insurance companies for covered services, but 75-80% of practice revenue is from a monthly or annual fee for services NOT covered by insurance. The best known national franchise practice with this design is the MDVIP network with some 200 quality doctors. We welcome its member doctors here today. We too offer same or next day appointment, 24/7 direct access, high levels of service and affordable wellness and illness care. Again, these practices provide the same excellent direct medical home environment for patients as do the fee for care practices. SIMPD is the professional society for such fee-for non-covered services direct practice doctors.

Both former SIMPD president Garrison Bliss and SIMPD member and Director Marcy Zwelling are independently negotiating with a major carriers to provide patients wrap around coverage for high-tech and hospital services our primary care doctors oversee but cannot provide alone. These insurance companies can be our friends. They can “get it” and understand what is needed and what is NOT needed.

This coverage will have rock bottom premiums because our patients use less hospital time and less high tech care. Published data, from MDVIP, suggests that such direct practice medical homes can radically reduce medical errors and cut high tech care by over 60%. That translates to better health, saved lives and lower cost. It can no longer be claimed that direct practice doctors do not deliver better health care. We do. And SIMPD must develop reporting tools to prove as MDVIP has done that the care delivered by all our members is better.

This is care like Russell Anderson used to give my family and friends. It is the care all Americans should have, could have and will have if our ideas prevail.

Think about it. There are 900,000 physicians in America. Six hundred thousand of them are sub specialists and their numbers are growing. Three hundred thousand of them are primary care doctors and their numbers are shrinking. It used to be the other way around. When we were children the vast majority of doctors did primary care. Most pre-med students enter college still assume they will do primary care. Why did the outcome change?

Well, one reason is of course that high tech care is much more complex, but that is not the major reason. There is a huge shortage of primary care doctors and a relative glut of sub specialists as we all know. Why does the market not correct this imbalance? The reason is simple. The current third party driven payment systems pay sub-specialists about $400,000 per year for their services while they pay primary care doctors about $150,000 a year for their services. We need to equalize that pay to restore the previous balance that once allowed medical homes to exist all over American. How do we do that? We do it through SIMPD direct practices.

Now, charity for those in need is not optional to us and SIMPD members do more than the average amount of it, but patients who are not in need of charity should take care of their own expenses. That is part of being a free American and it should not be that hard to do. Even with today’s massively inflated, quadrupled prices the average American consumes only $250,000 worth of health care in a lifetime. He consumes $400,000 worth of food.

Furthermore, 20% of patients consume 80% of the care. The healthier eighty percent spend much less, perhaps $50,000 in a lifetime or $100 a month. That is an affordable lifetime expense for most of us. The unaffordable excess risk that infrequently befalls a few of us must be insured. That is what insurance is good at. It is in fact the ONLY thing insurance is good at.

So, can we fix health care? Is there the political will to fix it? Can we defeat the vested interests holding back progress? What criteria should we use to sort through, accept and reject, the various ideas thrown our way?

We need to gradually get people back to buying their own basic care with their own money completely outside the public and private insurance systems. SIMPD will be part of that gradual change. Another part of it is tax free health savings accounts and high deductible personally owned insurance that some of you may already have. Non existent five years ago, today at least six million of Americans use health savings plans. My family does. So do two of my employees. Do yours? Even Medicare now offers such a plan.

We must change health insurance, public and private, so that it covers only expensive chronic disease and catastrophes, not basic care. All but the poorest Americans, who do need a charitable safety net, should buy that basic care through a primary care “direct practice medical home” or through a direct cash practice. With the savings we could easily afford the charity care the poorest Americans need. SIMPD’s goal is to see that day come.

Under our current arrangement primary care medicine is on life support. Most students refuse to enter the field. We must convince 50% of our medical students to enter primary care. Less than 8% went down that path last year. That has to change because primary care is the backbone of medicine. Until we eliminate medical homelessness and make primary care the best kind of practice to enjoy and thrive in as a doctor, nothing else will work very well.

Government does have a role. Insurance, real insurance, once purchased must not be cancelable or up ratable just because of illness. It must be purchased in advance of need. We need strong tax incentives that encourage almost everyone to buy that coverage in advance of need. Creating that playing field is the role of government in a free society. So is encouraging and incentivizing patients to join a direct practice medical home like ours. That is why each of you needs to get involved in organized medicine and politics in your local community. You need to be the voices that stand out and shout our message from the roof tops. And they are beginning to listen to our better idea.

We must means test government programs and promote private charity as better and less costly solutions. Charity care, public or private, must go only to those in real need, and bluntly, most of us and most of our patients do not need other people’s money to pay for routine care.

Health care is different from other critical human needs like food, housing and shelter, which are actually more expensive. Illness is unexpected, confusing, terrifying. It strikes randomly and unevenly. Only recently have we found effective tools to battle and prevent it. We naturally want all humanity to have equal access to those new and effective tools, and in our zeal to accomplish that we forgot that free markets are the best way, the only way, to achieve that goal.

Can we do it? I don’t know. SIMPD has put itself in a position to have a more audible voice in the national debate. Keep the objectives of direct practice primary care medical homes for all paid for directly by the patient, an open transparent market and consumer controlled financing in mind with every action you take. My fear is that health care may crash and burn before the rest of America wakes up and rebuilds it. I hope it is not too late.

We will not solve health care with employer or government based universal first dollar prepaid health plans advocated by some. We will destroy it. Likewise, we must not copy the failed systems of Europe and Canada. We must solve health care in a unique American way.

Winston Churchill said that Americans can be depended upon to do the right thing after trying every other possible alternative first. We have tried or observed the shortcomings of every other possible alternative already. Let us try elevating the individual to his proper role of self reliance when possible, using true charity only when necessary, to care for ourselves optimally, while preserving our national identity.

It is the patient’s health care, but he who pays the piper calls the tune.

Tom LaGrelius, MD, FAAFP

President, Society for Innovative Medical Practice Design

Owner, Skypark Preferred Family Care"

End quote

Capitalism for Doctors

Begin quote:

"Capitalism for Doctors
by Nicholas Provenzo (May 16, 2003)

The following is an excerpt of an address given by CAC Chairman Nicholas Provenzo to the Colorado Medical Society on May 4, 2003.

Ladies and Gentlemen, Good Morning. I thank you for your kind attention this morning and I thank the staff and directors of the Colorado Medical Society for providing me the opportunity to speak with you about the injustice you face under antitrust.

The theme of this weekend's conference is "Physicians are Not Criminals." I applaud you for having the courage to say it, especially face to face with those in our government whose actions against you indicate that they believe all too differently.

I, for one, would like to take the sentiment that physicians are not criminals one step further: I say physicians are heroes. There is a clear correlation between the work of physicians in providing healthcare and the health, comfort, and quality of life of their patients. Your dedication and professionalism has brought good health to our people in a way unprecedented in human history. I believe it is truly a shame that we as a people do not take more time to contemplate the greatness of your professional achievements and the means by which you achieve them.

Yet for all your virtues and the benefits you bring to your patents, you are under attack. As Chris Unrein said yesterday, so powerful and vicious is this attack that one of your own peers was unable to bring himself to speak of it before you this weekend. He said that to talk of it made him more physically ill than he could bear. Truly contemplate that, because such is the nature of the attacks made against you today.

You are told that by exercising your economic self-interest as a group with others in your profession, you represent a coercive threat to your patients that must be prevented by the full weight of the law. You are told that you must justify every increase in fees you seek by proving to someone ignorant of your profession a direct benefit to your patients, as if the continued patronage of your patients was not justification enough. You are warned that if you speak to others about the prices you negotiate, in as innocent a venue as a golf club, or here, this weekend, that act could be held against you in an antitrust proceeding--this in a nation that has enshrined the principle of individual rights, free association and free speech in its most sacred of foundational documents.

So at root, you face a conflict between your rights and the rights of consumers. I hold (and this holding is critical) that in a free market, there is no such conflict. But before this can be made clear, because it is far from self evident, we must go for a little walk that this morning I'll call "Capitalism for Doctors in the Time They Give Me."

When I was in college, I started a summer business that I named "Value for Value Services." I washed windows. Armed with my squeegee and my bucket, "Value for Value Services" was the way that I described my relationship with my customers. I charged as much I believed the market would bear, no matter how badly people needed clean windows, and my customers talked me down as much as they could, no matter how badly I needed the money for school. When we agreed on the exchange, I gave them the value I provided in trade for the monetary value they gave me. Each side could refuse the other, but if an exchange was agreed upon, each side benefited from the transaction. If anyone felt ill used, they only had themselves to blame. Sometimes I made great money washing easy houses, and sometimes I got stuck with a lot more work than I bargained for. And yes, I asked my other window washing buddies what they charged their customers. Over time, I got pretty good judging both the market and the work involved, and I was ultimately able to pay for a year of school with my selfishly sought-after profits.

As I alluded to before, you are in the business of providing the value of health and wellness to your patents. How much do you seek in payment for the services you provide? Your attendance at the conference would seem to say this much: you seek as much as the market will bear and not any less. From my conversations with you, you want a government that respects your right to profit from your work.

Why? Because you know that the pursuit of your economic self-interest is not robbing your patents, or exploiting them--it is simply you exercising your right to the best remuneration you can bargain for in exchange for the services you provide. Profit is not evil. It is nothing more than return on investment after expenses, and the justification for it is nothing less than your right to pursue your own happiness by your own work. I should not have to say to men and women who have endured the rigors of medical school and are dedicated to promoting human life that you have a moral right to profit from your work. Yet as we saw yesterday, when we heard to the government's side of the antitrust debate, that I do.

As much as I oppose the antitrust mission of the Department of Justice, Federal Trade Commission and state antitrust enforcers--as much as they make me physically sick--I'll give the representatives they sent to us yesterday their due. They told us in no uncertain terms what they believed their mandate against you to be. As assistant director Jeffrey Brennan of the FTC indicated yesterday, his mandate, and the mandate of all antitrust enforcers is to protect "consumers."

But what is a consumer, and how are his rights different than those of a producer? Let us define our terms. A producer is someone who creates. He puts his mind to the question of human existence in as many different ways as there are people, and he shapes the materials nature provides him and his own knowledge in a way that benefits human life. You are physician-producers. I produce the value of a rational defense of the principle of individual rights. Others produce homes, entertainment, make cars, raise children, or even serve as sources of spiritual inspiration; so and so on.

Contrast this with a "consumer" A consumer qua consumer (and don't be shocked by this--please hear me out) is a parasite. A consumer consumes, and if we believe that words have meaning, he does nothing else. You wouldn't hesitate a minute to cut out a parasite if it threatened the life of one of your patents. I do not hesitate to cut out a parasite when it threatens you.

I hold that everyone in the free market is a producer, or someone who has the fruits of someone else's productivity bestowed upon him. Accordingly, I hold that to understand the principle that animates the free market, it is inappropriate to look at the people in the market as either producers or consumers. I'm not a producer from 9 to 5 and a consumer the rest of the day. Neither are you. We are all producers who seek trade with other producers on mutually agreed upon terms, to mutual advantage.

Understanding that the market is made up of producers--that is, Bill Gates, you, me, your patients, and anyone else who is productive--will help us as we now define the rights of producers.

The proper principle to guide all economic and political relationships is the principle of individual rights. And to you, I say this: In the field of economic relationships, the principle of individual rights is as important to us all as the scientific method is important in your work as doctors. And just as their are charlatans in medicine who claim that the horn of a rhinoceros is a good cure for disease, there are charlatans in the law that claim that antitrust is good for the free market.

Yet I hold that the principle of individual rights says this: We have a right to our life, and the right to take the action necessary to advance it. We have a right to our individual freedom, which means that we as individuals have the right to take the steps necessary to secure our own ends, unshackled by the whims of others. When producers come together to form a market (because there could never be a market of true consumers), we all meet as free and equals entities, whether we meet as individuals, as a labor union negotiating with a multi-national corporation, or any other such combination or so-called "conspiracy." Whatever our size or numbers, we meet as traders, and each of us has a right to pursue his own self-interest, even if it results in higher prices, or no trade at all. "Restraint of Trade" implies a right to trade. Yet no one has a right to the unearned.

Yet it is the unearned the government antitrust enforces seek in the name of the rights of "consumers." Now drawing back to the question that faces us this weekend, we must ask, as far as a true consumer goes, by what right does the productive efforts of others fall to him?

Under the antitrust laws, their need is sufficient right alone. Under antitrust, we do not have individual rights, but consumers' rights. And that is why, while assistant director Brennan was flying on a plane so he could tell you that he is "here to help" by enforcing the federal antitrust laws, the regulatory agency he works for announced that it was breaking up an association of doctors in New Mexico for having had the audacity to negotiate as a group with a government-created monopsony affectionately known as an HMO.

What assistant director Brennan truly provides is "charity" for consumers, of the government mandated kind. His agency demands that doctors accept less payment for their services than they would accept if they were free to do something as simple as talk to their peers. Add a host of other businesses and professions under their yoke--from Microsoft to ice cream manufacturers to computer chip makers--and you have modem day antitrust enforcement.

But notice that the antitrust enforcers are never honest enough to refer to themselves "charity enforcers." Instead, they make the oft-repeated and lofty claim that they are "protecting competition," a value they have determined to be the "bedrock of our economy" as we were told yesterday.

Yet contrary to popular misperception, competition is not the bedrock of our economy, but only an after product of the free market. In a free market, producers trade with one another by voluntary means. A businessman associates with whomever he chooses, shares information with whomever he chooses, "colludes" with whomever he chooses, and no one has a right to question otherwise. All that said, he still can not evade the fact even the prospect of potential competition and substitutes compels him to check his prices--and those businessmen that fail to do so lose ultimately economic power. Market power can only sustained by those businessmen who effectively supply their customers with goods and services, not those who act against them.

The only institution in America that can truly restrain competition in a way that threatens us is an institution not of economic power, but of political power. Only the government, the same people who brought us the US Postal Service, can outlaw competition. And as Andy Dolan adroitly recognized yesterday, when the government created Medicare, it created a powerful price signalizing institution that the other powerful government-created institutions, the HMO's, have slavishly followed. You doctors seek nothing more than to negotiate with these government-created HMO's on equal terms, and for this, the government has sent its antitrust dogs upon you.

You do not deserve this. It is said we need to educate the Bureau of Competition about the problems doctors face. I say, (and I say this knowing all the political hurdles such an endeavor must overcome): we instead need to abolish the Bureau of Competition and the FTC. It's no longer time to see how we can fit within their system--we need to free ourselves from their system outright. We need to starve it of its funding. We need to take away its legislative mandate and kill it. Millions for defense--but not one cent in tribute. We need to affirm once and for all that producers have rights, and free, unfettered markets are the only means by which these rights are truly protected. Let the government regulators get physically ill over their government-granted livelihoods being taken away from them, but not one more doctor.

Now I want to put my remarks in some context. I wager that what I say to you today in your defense will be more controversial among many of your peers that what those who regulate your lives with impunity said yesterday. I deliberately name my principles up-front because this is the stage we are at in defending the rights of producers against the attacks made against them. When I accepted this invitation, I asked myself what is the most important thing you as victims of antitrust do not know about the assault waged against you. It is not technical minutia--as much as that has its place. It is the fundamental principles that drive antitrust, and the antidote against them. That is your doctor's tool kit. If I was only able to convey this to you in the most limited sense, you are infinitely better armed that you were before.

The founder's application of the principle of individual rights to America created the greatest nation in the history of humankind. As the recipients of this legacy; we should demand a more perfect application of these principles to our relationships. The great John Hancock, signer of the Declaration of Independence and financier of the revolution has this Latin phrase engraved on his tombstone: "Obsta Principiis" --"Resist the first encroachments." Antitrust has been around for 113 years. It is not too early to start resisting this unjust encroachment.

Nicholas Provenzo is founder and Chairman of the Center for the Advancement of Capitalism."

end of quote

Health Care Reform - where we are now

I am reproducing a letter by Dr. Thomas Lagrelius, which I received today. It represents what I think of our present state of health care reform, I could not have said it better. I may add that the most important two issues of Health Care reform for me personally have NOT been addressed in this reform.

My absolute "must include" reform issues are

1. Tort reform. We should have something analogous to "Workman's Comp". It could be named "Patient's Comp". Patients who suffer an injury during medical care would apply, be examined by an expert committee and compensated according to preset tables. Fair, fast and feasible. Why? Defensive medicine costs 100-200 billions (yes, with a B) each year! Want to reduce costs? Start here.

2. Balance Billing for physicians everywhere for all patients. Not for hospitals. This is the only way physicians will be able to survive the downgrading of our income that seems to an obligatory part or at least result of any kind of "reform". We are independent professional, we have worked very hard to get where we are, we have paid our dues, and we most definitely have earned the right to bill what we consider adequate for our time and experience. We need balance billing. And until then, I recommend to opt out of any contract that does not allow you this basic professional freedom.

Here is the copy of the letter. Emphasis was added by me.

Begin quote:

"Dear Hal:

You are correct about it being far from over! There is still a chance that some Senator will balk after getting an ear full from his constituents over the holiday break so we should keep the pressure up on them.

Even if it passes, this is my take. The single payer advocate Left in Congress built a straw man, the insurance company based guaranteed issue, community rated, insurance exchange thing with all kinds of rules and regs knowing it would be very expensive and entirely unworkable, and intentionally so. They expected to have the "public option" also in the bill. They rightly assumed that straw man would collapse and all would flow into the public option, i.e. "single payer". They got the bill through only by bribing lots of Congress members making Obama, Reid and Pelosi look like the worst smoke filled back room politicians since Mayor Daley or Tammany Hall.

But the Senate screwed them and took out the public option! We can thank Lieberman for that I guess. (I always did like Lieberman and he could still change his mind on the final vote.)

So they are left with the straw man with nothing to default to when it fails.

Everyone knows it sucks. Howard Dean and John McCain both agree for different reasons that the bill should be scrapped and they should start over again. Sixty percent of Americans don't like it while only 30% approve of it in the polls. Insurance will now cost much more, at least double, and most of the uninsured will still be uninsured because there are no teeth in the individual insurance mandate and the bill does not include half the uninsured anyway. In the end nobody will bet better care, nobody will save money and nobody will be happy.

And where are the doctors to do primary care on which the whole thing depends? No place. They are quiting. Even the Mayo Clinic is testing opting out of Medicare in some of its locations while direct practice continues to grow exponentially and students shun primary in droves. Taxes will go way up immediately while the "benefits" if there are any won't start for years under the front loading provisions pretending to make it look cost neutral at first. The voters will feel the pain immediately and get nothing out of it now or later.

Thousands of doctors will quit the AMA and seniors will quit AARP in even greater numbers. Current projections are that the Dems will lose this year's congressional election worse than they did in 1994 so the public option is dead along with the Dem. majority. Obama approval rating is now minus 18% down from plus 35% when he took office (strong approval minus strong disapproval on Rasmussen likely voters. Check the graph:

What a mess for Obama who sits in the sun in Hawaii looking remote and inept. He is seen as soft on terrorism, ineffective on the economy and inadequate to the job. The bloom is definitely off the Obama rose.

Laws have been repealed in the past before they went into effect. In 1989 the Medicare Catastrophic Coverage Act was repealed in less than one year and before taking effect due to a senior revolt.

It could happen again. Let's make it happen! We should throw our support behind the non-conflicted organizations that support physician and patient freedom, like Docs 4 Patient Care, SIMPD and AAPS, pull our support from conflicted ones like the AMA and AARP and make it happen for doctors and patients seeking freedom.

Tom LaGrelius, MD, FAAFP"

End of Quote

Saturday, December 19, 2009

Letter to my fellow Physicians

The annual Medicare pay cut, based on the seriously flawed SGR (sustainable growth rate) formula has been a topic of great discussion every year. This year it was part of the discussion of the new health care bill. While most Americans are against a Medicare pay cut for physicians, one prominent House Democrat would prefer to let the Medicare cuts happen. "I'm inclined to do nothing," Rep. Pete Stark, D-Calif., told Congress Daily in December of last year.
"My colleagues, my staff say, 'Oh, dear, the doctors would all drop Medicare.' I don't believe it. I don't believe that doctors are willing to give up half their income."

Well, Mr.Stark, the doctors are going to drop Medicare and more third party payers - and here is the step-to-step plan on how to do it.

Simple Action Plan

We have been working more and more for less and less. We are being suffocated by ever increasing regulations, which usually turn out just to be new tricks to pay us less (e.g P4P). Many primary care colleagues are at the edge of viability of their practices. The demand for physicians is said to go up, some even talk about a "physician shortage", yet, in contrast to the most basic economical rules, our reimbursements continue to go down. We have lost 60-70% of our earning power since the 80's, a unique situation without precedent.

Patients perceive us as "rich", the media portrays us as making a most comfortable living in the top 5% of incomes.

The media also prefer to report on errors and scandals, on our weaknesses and failures rather than medical success.

For politicians we are part of the problem, not part of the solution. We have no friends in politics, since physicians only amount to 1% of voters. Americans in general consider us "rich" and "too expensive" and one congressman mentioned that "all health care problems would be solved if we could just get the doctors to be satisfied with 75,000 a year".

Insurances earn by not paying us or by delaying payments. They have successfully applied salami tactics for 20 years to reduce reimbursements.

The organisation that is meant to represent us, the AMA, has long bought into the status quo, has surrendered in every important issue and keeps busy tweaking minutia. The "solutions" the AMA offers are anemic and pathetic, and they lack the guts to confront the root problems.

We have no friends and we have no allies.

Nobody will help us. If we want change, we will have to do it ourselves. We have to remember that we are the ones with the knowledge, the skills and the expertise! We do not need anyone to diagnose and to treat. Those who have pushed themselves into the patient-physician relationship do not know medicine, and they are only able to harass us, because we have signed contracts allowing them to do so. Without us, they are nothing!

We have to remember that we have signed the contracts that allow them to withhold, deny, restrict, control, demand pre-authorization, delay and defraud us. We can cancel these contracts. And, with the coming "shortage of physicians" there is no better time. We have to remove the control of medicine from the third party payers. And we have to do it ourselves. Fortunately, this is not hard and may even be not just rewarding, but fun.

Here is a simple action plan. The actions complement each other, each strengthens the other. The plan is flexible, you can start wherever you want and you can go as far as you want. Going just a little step is good for you, going far helps your colleagues as well. the more physicians participate, the larger the impact on health care overall will be.

After putting our personal finances in order, we take a close look at our practice and see which third party payers (and yes, that incluides Medicaid and Medicare) are loosing propositions. We gradually, deliberately, smartly drop third party payers based on an economic analysis of our practices. This shrinks the networks of HMOs and reduces their power and market appeal. At the same time we unite into large groups working under one tax ID to bill together and negotiate together ("group practice without walls"). This increases our numbers and direct negotiation power with the remaining HMOs until we drop them too. At the same time we educate our patients about alternatives to HMOs, so that they favor more attractive options of insurance coverage, such as HSA, HRA, cooperatives, individual tax deductible health plans etc. We offer cash services at a very competitive price. We can do this since we would greatly benefit if we received the same amount of money in cash right from the patients - rather than from an HMO that pay us only after a lot of administration hoops, shenanigans, withholds and months of delay. "Carecredit" and other options may make it appealing to the patient. The more patients drop HMOs, the weaker they get. And finally, we talk to our colleagues about these issues to come to common concepts and understandings, to unite us. One of the possible ways to do this is sermo, the physician-only online community founded in Cambridge in 2006.

This is the plan:

1. Get your personal finances in order first

Consider a fee-only financial advisor. Fee-only advisers are paid by the hour and consequently have less of a conflict of interest than advisers who live on commission. Go over your personal finances, make a long term plan and a mid-range plan. Determine how much income you need as a minimum, what kind of drop of income you can afford while you drop HMOs, and for how long. Initially your income may decrease when you drop the low paying plans, although it does not have to.
Secondly, talk to your partner to get his or her agreement. While dropping HMOs may reduce your income initially, this is temporary and it will to a greatly improved quality of life in the long run. It is essential to have the support of your partner during this time.
Consider postponing larger purchases that put you in debt such as a new car, new home etc. Don't fall for the myth that "doctors are rich and can afford luxury". Living above your means will chain you to the third party payers. Limit your luxury purchases and spend wisely in general. Limit your monthly payments (new car, renovation of condo or house etc).

2. Streamline your practice finances

Sit down with your office manager, your accountant and/or your billing service. Write a business plan! The business plan should include your mission is and your financial goals. Write into the plan what you want to earn on a monthly and yearly basis. Look at your overhead. Based on your planned revenue and your overhead you can now calculate what you have to collect, what you have to earn for each visit and what you have to earn for your most common services. Note those figures. This is a standard business process that astonishingly is not done by many physicians.

Now make a spreadsheet with the ten most common procedures or services in your field. List what each third party payer reimburses you for these services. Calculate which payers will allow you to reach your business goal and which payers do not! Plan to drop the payers that do not allow you to reach your business goal! This is a crucial step.

You may also calculate what each third party payer contributes to your overall collections to help you with the decision about which payer to keep and which ones not to keep. Calculate the average payment for each visit from each payer. Consider the number of patients from each payer. Calculate the accounts receivable for each payer - as a fraction of the charges after 30 days and after 60 days. That informs you about their delays and denials, about the hassle and sleaze factor. Decide which third party payer makes no sense economically and also which payer gives you the most hassle.

3. Drop third party payers that threaten your financial viability

A colleague wrote the following: "I started with the lowest paying HMOs. It is a 2 year process. First I stop taking any new patients from that HMO. Then 1 year prior to dropping them, I will send out a letter to the patients with that insurance informing them that I will be dropping that insurance the following Jan. I send out this letter with the labs that I send to them prior to their physicals. They come in for their physical and they have the opportunity to ask me why I am dropping their plan. I inform them. I tell them which plans I will be taking and that they can still see me if they have out of network benefits. I would say that most patients change insurance or continue out of network with me."

Send certified return receipt cancellation letters to those third party payers that drag your practice down. It is likely not feasible to drop all third party payers at the same time. Start small, gain experiences, then drop more. Remember that you are not "abandoning patients", you are merely becoming an "out of network physician". You are supporting HSAs and high deductible insurances. You are moving your practice towards "consumer directed health care" or towards "cash medicine" or towards concierge medicine". Promote HSAs coupled with high deductible health plans (also called catastrophic coverage) to your patients by several means, such as those described in Neil Baum's book. We will talk about this more later.

The following two books are extraordinary useful and well written: "Think Business" by Owen Dahl, $69, a kind of mini-MBA for physicians written by a veteran of medical management, and "Marketing your medical practice" by Neil Baum, $89, a fantastic book by a successful urologist in private practice. And of course there is "Medical Economics" magazine....

Legal disclaimer: Do not coordinate this purely economical plan with your colleagues, since this might be misconstrued as a "conspiracy". In the past acting as a group to flex our muscle or to influence prices was deemed illegal for physicians, since it might "worsen patient access to health care" or "might increase prices" - something that actually never happened. This was ruled "illegal", since obviously the consumer is a higher priority than physician income or influence. This is a hidden compliment and an acknowledgment of our power.

Therefore do not write emails or letter about this using any other terms than "purely economical reasons" and "supporting consumer driven health care" and use only verbal communication in private places. And understand that this is NOT done to fix prices in any way, but to move the health care system to "consumer driven" - a system that offers maximum transparency, and uses market forces to deliver cost effective, affordable, high quality medicine to everybody. Consumer should call the shots and not the insurance, and therefore consumers should holds and control the money and not the insurances. That is why we are moving away from insurances, to empower consumers.
And we are obviously doing this based on purely economical thinking. We "think business", something that we have learned from just those HMOs - remember?

Should anyone threaten, bring up or even hint at us doing something "illegal" or "conspiring", go to the media and show how this person or entity wants to cheat the consumer and wants to prevent the consumer from being in charge! Consumer driven health care is the ultimate democratic health care system and should be supported by everybody! Nobody will dare object to our move in that direction!

Stop taking new patients 2 years prior to dropping the plan because it is often the case that many other doctors are dropping the same plan. You may have a rush of new HMO patients because the panel of that insurance is drying up. It is harder dropping an HMO which is 30% of your practice than 15%.

Inform the patients a year in advance because many insurance plans require the employee or employer to sign up for the following year 6 months or more before the end of the year.

4. Join or create a "Group Practice Without Walls"

This is the solution when you are faced with one or two dominating HMOs in your area holding 40 plus percent market share, which makes it very hard to cancel their contracts. This is a good solution for colleagues who prefer to have someone else handle the business aspects of medicine and for those who prefer to be employed.

Group Practice Without Walls means the physician continues to practice in his/her own facility, yet is part of a group, just not under one roof. The group does marketing, billing and collections, sometimes, but by now means necessary, also staffing and management. All members have the same tax ID. This way a large number of apparently independently practicing physicians can represent themselves as one group, buy and negotiate as one group, with the obvious advantage of using your larger numbers. The laughter of HMOs about you will become a lot softer.

I have seen this work very well in South Florida, by a group of ObGyns, who prefer not to be named.

Joining this group gives an ObGyn reimbursements of about twice Medicare/Medicaid. For example: global fee for prenatal care, delivery and postpartum care yields $1538 from Medicaid, and group members receive about $3000. Same amount of work, probably even a lot less for a Non-Medicaid patient. Much better payment for group members. Members of the group work in their own private offices, with their own staff, own equipment and rooms, own clinical guidelines and decisions, own budget, own finances, own everything. Except: they bill together and negotiate together under one tax ID. They pay 5% of collections for billing. Codes are entered in the practice computer in the same way you enter information for a clearinghouse. Members pay an entrance fee of 25-50,000 for admission to the group and would have to pay an equal fee in case they left.

The group management will negotiate with the remaining HMOs and routinely fire the lowest paying third party payer. Expect reimbursements of 150 to 200% Medicare. These groups can be set up so that your practice is an LLC within the LLC of the mega group. Billing goes through one single entity, you can pool labs and technical services such as Xray, mammography, ultrasound, bone density, but also cosmetic services, such as botox, epilation, vein therapy etc

How do you set it up? You first spread the word among the best doctors and the key players in the area offering to join you. Then you retain an attorney experienced with formation of such as group. this is expensive, but worth it in the end. You must stand up to anti-trust scrutiny. Your ultimate goal is to attract enough doctors to reach enough critical to have negotiating power, but not as many to violate anti-trust laws. Consider staying under 50% of physicians in your specialty in the area. This may take several years, but is well worth it.

5. Get support from your patients

The transition towards consumer driven health care (and away from HMOs and third party payers) will be much easier with patient support. There is a profound lack of knowledge about consumer driven health care, high deductible insurance plans (HDHP) and Health Savings Accounts (HSA). Once we help our patients understand these issues, they will help us in the transition to more economic and more responsible care!

Learn: buy a HSA/HDHP for your own employees and your family. Browse the most educational and easiest to understand websites on HSAs. Summarize the info into a one half page note. Post this in your office, hand out leaflets to your patients, leave them in your waiting room, post it on your website, in your monthly newsletter, email it to friends and colleagues, drop in mailboxes of other docs in your hospital. Ask your hospital HR to offer them, give a talk at the hospital and at the local chamber of commerce. Write a blog. Create a Google Alert on "HSA". Read and lay out Regina Herzlinger's book "Who killed health care" in your waiting room.

Teach: Educate your patients that they might save 30-40% of coverage costs, that HSAs are funded with pre-tax dollars, that they own those dollars, that they roll over to the next year and may collect interest! Even Medicare has Medical Savings Accounts available during the current enrollment. A huge benefit -it eliminates the need for MediGap coverage. HSAs teach the patient accountability and are the only solution to ever increasing health care costs.

Act: Offer cash services for your patients with HSAs! Patients need to know what to do with their HSAs!! Post a list of prices for your 10-20 most common services. You could even post a comparison list with the prices of a local plumber, electrician etc for comparison - an eye-opener!

Direct patients to the cheaper HDHP providers that actually save money. Traditional HMOs may price these plans so that they become less attractive. Tell your patients that every bank can administer a HSA.

Links: AMA brochure...
US Treasury Dept...

Consumers for Health Care Choices is a national membership organization, chaired by a former president of the American Medical Association. /Greg Scanlen,, tel:301-606-7364

Politicians, blissfully unaware of true details of healthcare, may claim that consumers actually do not know enough about and are "not smart enough" and not "educated enough" and "too weak" or "need protection" from all the other players in health care - and that of course, the "government knows best" and has only the best intentions and the best advice for consumers.

"Hi, I am from the government and I am here to help you"

A well designed HSA can save 30-40% on total coverage costs, including the HSA contribution. Further, this contribution is not lost, but owned by the individual, is rolled over into the next year and may collect interest. For the 80+% of us who are basically healthy, HSAs are a great deal. For those that are chronically ill, it is a wash. Employers like HSAs because they save money for the employer. HSAs have proven to decrease costs. Taking all risk away from the patient leads to overuse of resources because it is a lot easier to spend the insurer's money than your own money.

The vast majority of transactions can occur with a debit or credit card at point of sale, no need to file a claim.
Currently, pre-tax HSA dollars can be spent according to IRS section 213(d) which defines healthcare broadly as anything therapeutic, including "alternative medicine" or chiropractic care, while cosmetic surgery is not an "allowable expense"

The opposition to HSAs takes several forms:
1. Only the well-off can afford them
2. People with HSAs will see them as just another investment scheme, and will avoid needed medical care (including essential screening) to "save" this retirement money.
3. We have 4 or 5 generations of consumers / patients in the US who don't have a clue how much their insurance / Medicare is really paying, and will be shocked back to the old ways when they get their bills.
4. Unless they are combined with a cash-for-care schedule of lower payments (less hassle, less paperwork, lower charge) there is not much advantage to having an HSA.
HSAs would actually work great in a "health care cooperative", where physicians AND their patients unite and truly work together to combat their common enemy, disease.
Big opposition will come from HMOs, since they have the most to loose. Pharma is lobbying for a "carve out" of drug costs from the HSA dollars. If patients know the actual cost of drugs, they will prefer generics and "Direct to consumer advertising" will tank.

Unfortunately, most physicians are not offering cash services. We all should post a list of our services for cash payers - independent to the fact if we take HMOs and or Medicare / Medicaid etc. Just good business sense. You inform the patient, you give them an option and you get them thinking in the right, this is what it costs....with all the ramifications, such as why is my insurance so expensive or so cheap, could I afford this on my own without insurance? and so on

Educate your patients about alternatives to insurance, mention HSAs and high deductible plans. The AMA has a leaflet on this.

Patients often think that we receive all the money they pay to their insurance. They assume we make millions. It often is an eye-opener that we receive about the same amount the HMOs keep for their administration (withholding and denying) and they are often very surprised to find out how little we get paid for services. It is incredible effective to create a list comparing our services point by point with with that of a electrician and plumber - and you will find that they come out ahead. This creates sympathy from the patients and the willingness to drop HMOs

6. Get support from your colleagues

Previously we had recommended to put your own finances in order to be able to survive for a while with less income, then approach your practice from a business point of view: first establish how much you want to earn, calculate what each payer has to pay for your most common services and then drop those HMOs that do not meet your business needs. When Jack Welsh was CEO of GE her routinely dropped the two least profitable lines of business. Do the same with third party payers. This is plain economic thinking, and obviously not a plan to boycott third party payers. Start or join a group practice without walls. Encourage patients to enroll in HDHP / HSAs instead of conventional HMOs. This saves our patients money, allows them to accrue savings tax free, while paving the road for cash practice for us.

The last component is to spread the word to as many physicians as possible! Encourage your colleagues to join Sermo, to join our discussion. This way we can learn form each other how to save the health care system. Let them participate and contribute to our discussions. Keep talking about health care reform, stay in touch, write a blog, read about the issue, email a summary of the plan to friends and colleagues, drop a flyer in mailboxes of your colleagues at the hospital. Just invite them to Sermo, the rest will follow!

Follow the plan for yourself and it will be very helpful. Tell your colleagues about it, spread the word and the effect will multiply