Thursday, October 04, 2012

Musings: An Interview with Dr Rob

Dr Rob Lamberts, one of my very favorite med-bloggers, is making a major career change. He'll still be doctorin', of course, but in a new practice, based on a cutting-edge model of health care delivery. If you've never read any of his work, I heartily recommend that you do so.

After his residency at Indiana University in 1994, Dr Rob went into private practice with another physician (who subsequently went to Africa to do missions work). Their practice was initially owned by a hospital, but by 1996 they'd decided that it was better to leave and do "their own thing."

InsureBlog: What made you decide to chuck it all and re-boot?

Dr Lamberts: I had been frustrated as the other doctors in the practice grew more and more resistant to change. The more partners we had, the more inertia we gained. Since I am not a person to sit still when I think there are solutions to problems, I found it increasingly difficult to stay put because of others' personalities. This created conflict, which led to me looking at my options. Going solo in a practice that dealt with the insurance game and had the same limitations as the old practice was not a good solution for me, so when I found the Direct Primary Care (DPC) model it really appealed to me. In the end, my (now former) partners and I saw this as an irreparable split between us and the decision to split was mutual. They have worked it out so I don't have to draw a paycheck for up to 6 months, which gives me time to build my new practice right. They also gave me access to my patients to tell them about the new practice, which is a really generous thing on their part.

IB: You've mentioned that you may have patients that can't (or won't) follow you to your new practice, can you expand on that?

RL: The DPC model is one in which the patient pays the doctor directly for their care, usually in the form of a monthly "subscription," plus or minus a fee for visits. DPC usually limits the size of the patient pool as well, so I will only be able to take 1/3 of my total patient population even if all wanted to come (I had between 3 and 4 thousand patients in my old practice and will limit it to around 1000). Plus there is the fact that some patients are not going to be willing to pay what they see as an extra fee for care they already could get. Since nobody else in the area is doing this, the only way I can show that the value of the service will be worth the cost is to make it work. Some people will trust me in this, while others won't.

IB: I know a lot of practices are being gobbled up by hospitals eager to grow their ACO's [ed: Accountable Care Organizations]. Was this ever an option for you?

RL: Not really. If we were able to work out our differences in the old practice I would have been part of a primary care ACO that is being formed by a local IPA (group of independent primary care physicians who have allied together to do this). Primary care is quite independent in Augusta, and has recently done quite well in organizing and working together for their best interest (without risking collusion, despite what the hospitals may say). I could be part of an ACO in that setting if I wanted. In truth, however, I have grown less and less enamored with these models, as they are more driven by data and processes built around meeting care standards than they are built around good patient care.

We had been working on "Patient Centered Medical Home" in our practice, and I found that it was anything but patient-centered; it was data-centered, and took my attention away from the patients. Finally, I simply don't think the hospitals are the means to truly affect meaningful change in health care. They are the businesses that have been built on over-spending on health care, on unnecessary procedures, and on consumption of medical resources. The goal of most hospitals for my patients is 180 degrees from mine: their financial gain is built on people getting procedures, going to the ER, and being hospitalized, while mine is to help them avoid all of the above. [Continued below the fold]

IB: You mention at your site that you're adopting the "Direct Care Model." Can you explain how that works?

RL: DPC is basically a lower-cost concierge practice, but one that doesn't accept insurance at all. The payment goes directly from the patient to the doctor. My spin on it will be to use the freedom I have from removing the red tape of medicine (by dropping Medicare, Medicaid, and not accepting insurance) and build something that is radically patient-centered. Patients will pay a monthly fee (I am planning on it being around $50/month) and get access to my services.

Since I am not collecting copays (it makes no business sense to do so, as most of my income comes from the subscription and it makes billing far more complicated), I have no motivation to make people come in for care. I believe about 75% of my office visits in the old office could have been handled without forcing the patient to come in to be seen, so I am building my system so that it's easy for people to get information they need to handle their problems - either through direct contact with me (via phone or email) or resources I've made available to my subscribing patients. I also want to aggressively go after the patients who don't contact me, making sure their care is up to date and giving them a regular care plan as to the care they are due for, what's been done, and when upcoming care is due.

IB: Your new practice won't be accepting insurance. I'm curious how you'll determine pricing, what (if any) transparency do you envision?

RL: I am trying to find a price-point that will be attractive to patients and will pay me a good salary without working me too hard. I didn't like the typical "concierge" practice fees, as they excluded the majority of my patients. My intent is to say "This is what you will pay, and this is what you will get for what you pay," which is something very few doctors are even allowed to say. I am developing a list of deliverables that will come from paying the monthly fee, so I want to be absolutely transparent in this process.

IB: Kelley also wondered how are you going to ensure HIPAA regulations on patient confidentiality if you have notes posted on-line?

RL: I will use HIPAA secure software (leaning toward Avado now) which will give patients access without crossing the HIPAA line. How they handle that information (like accessing it on a public computer or printing it out) is not any different from what they did with lab results I mailed them. I don't see HIPAA as a big hurdle, in truth.

Thanks so much for your time and insights, Dr Rob, and our best wishes for your continued success.
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