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A keystroke or two opens the door to hundreds of sites on many practice areas - a generous representation of what today's practitioners need to know. Regardless of the specialization, these sections offer in-depth industry info, news, technical support and business tools geared to keeping physicians professionals conversant and current in their disciplines.

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• Growing Farm-Fresh Physicians
  

  By Mara Knaub

  In a time of national doctor shortages, Yuma Regional Medical Center is taking steps to “grow farm-fresh family physicians.”

  Six newly graduated physicians – five women and one man – will begin their postgraduate training on July 1, kicking off a new era at the hospital.

  The first residency program at YRMC will focus on family medicine, with Dr. James Lenhart at the helm. Recently recruited from Las Vegas, Lenhart is considered a national leader in the field.

  Dr. Edward Paul will lead the overall Graduate Medical Education program. Paul previously served as program director of the Family Medicine Residency program at the University of Arizona.

  “On the one hand, this is the culmination of a 10-year process to bring the ethos of teaching hospital status to our community,” noted Dr. Stewart M. Hamilton, who retired last year as YRMC chief medical officer.

  “And on the other, the start of a journey that will help recruit new blood to the medical staff and help maintain the high standard of medical care that is provided within their ranks.”

  The three-year residency program will put the trainees on their last leg to becoming family physicians and board certified.

  “These young doctors have graduated from college, they have graduated from medical school. This residency will be their last step to being able to go out on their own and practice,” Lenhart said.

  Addressing shortages

  Hospital officials started with family medicine because of the lack of primary care physicians, and in particular, family physicians. They hope to expand into internal medicine and other specialties.

  Lenhart hopes that some of the residents will stay in Yuma after their training. “Data shows where residents do their residency is likely where they will practice.”

  On average, about 50 percent will stay in the same community, meaning that three graduates will likely stay in Yuma.

  “We will be growing our own farm-fresh physicians and ensuring a continuous pipeline of family medicine physicians,” Lenhart said.

  A “continuous pipeline” would also address turnover, as doctors relocate, retire or move into non-patient care fields, he noted.

  Rural Arizona in particularly is experiencing a shortage in doctors. “In fact, we already have less than half the average number of physicians per capita than the rest of the nation,” Hamilton pointed out.

  ‘No small task’

  Hamilton explained that “it is no small task to enter the field of graduate medical education. In fact, it has been 10 years since the first possibilities were discussed in then-CEO Bob Olsen’s office. Since then, there have been many discussions, meetings and documents generated.”

  Once the hospital gave the go-ahead last year, program leaders had to obtain accreditation and federal funding.

  Then came multiple visits from medical students interested in completing their postgraduate studies here and finally “the match” – a computerized process whereby student and hospital rank each other based on interest.

  The “painstaking” process to find matches started last August, Lenhart said.

  The hospital received 800 applicants, interviewed 46 and ranked 33 before whittling it down to the six residents.

  The candidates were ranked beyond academics, test scores and advanced degrees. The ability to speak both English and Spanish ranked high on the list.

  “Four of the six are fully bilingual. We’re very excited about that,” Lenhart said.

  ‘Bumps in the road’

  Paul and Lenhart also looked at life experiences and “bumps in the road” that could have “matured and cultivated them into much better people,” he said.

  They looked at their volunteer record.

  “Did they serve in the Peace Corps? Did they serve the underserved? Did they volunteer at a research mice lab or at a homeless shelter? A homeless shelter got more points because it shows dedication to service, humanness. We were looking for caring, compassionate people,” Lenhart explained.

  “We’ve very proud of how it played out. We think we got an outstanding group.”

  Just the fact that they applied to a new program showed them to be risk-takers, he added.

  “Some wouldn’t even apply here. It’s a brand-new program, and Yuma is not what some consider city life.”

  On the other hand, some applicants liked that it would be a brand new program and they would have seniority. Some liked the “down-home community” feel of the city.

  Change in culture

  Lenhart expects the program will “change the culture” of YRMC as he believes the residents will challenge all doctors to improve.

  Fresh out of medical school and the university environment, the residents will know the latest techniques and research that they can share with and inspire doctors who have been practicing for several years now.

  “It will make everybody step up to the plate,” Lenhart said.

  He noted that the program will teach the residents that “health care goes beyond the domain of the physicians’ office. We all have a responsibility to be citizens.” The trainees will be encouraged to volunteer in the community.

  The program will also address bedside manners.

  “There will be an emphasis on the delivery of a personal, literally ‘hands-on’ type of health care, and good ‘bedside manners’ will be actively taught,” Hamilton said.

  “While the theory of bedside manners can be taught in a classroom setting, there is no better way to learn for many of us than to see such care being delivered.”

  In addition, teaching hospitals attract qualified physicians interested in teaching, something that Hamilton believes will prove valuable in recruitment efforts.

  “(As the) physician shortage rises to a crescendo in the U.S.A., YRMC and Yuma will stand out as a beacon, haven, oasis and jewel of health care in the Southwestern desert while other communities and hospitals will struggle and living standards fall for lack of medical care,” he said.

  Source: Yuma Sun, May 9, 2013 (http://www.yumasun.com)

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• Study Demonstrates Value of Practice Supports During PCMH Transition Process
  

  By James Arvantes

  Small and solo primary care practices are more likely to achieve improvements in efficiency and quality of care, as well as cost savings, when transitioning to the patient-centered medical home (PCMH) model if they have access to care-management services and other key practice support during the transition process. That’s according to a new study conducted by researchers at the University of Connecticut’s Health Center (UCHC) and published in a recent online edition of the Journal of General Internal Medicine.

  The study evaluated 32 primary care practices during a two-year period and randomized them into two groups: an intervention and a control group. The intervention group, made up of 18 physician-led primary care practices, received a three-part support package that included practice redesign support, embedded care managers and a revised payment plan to help them achieve PCMH recognition status. It also included per-member, per-month pay-for-performance incentives. The remaining 14 control-group practices received only yearly payments for participating in the study.

  All of the physician practices participated with EmblemHealth, a health insurance plan in New York that provided the support package for the intervention practices. The size of the practices varied from solo to medium-sized practices with as many as 10 physicians.

  The study found that the intervention practices achieved statistically significant improvements in two of 11 quality indicators: hypertension control and breast cancer screenings, as well as in one of 10 efficiency indicators: reduced emergency department (ED) visits. Practices without support failed to achieve significant improvements. “For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial,” according to the study.

  Judith Fifield, Ph.D., director of the TRIPP Center at UCHC, is convinced that the study has enormous policy implications. “Providing these kinds of supports will enhance the ability of practices to make the transition (to the PCMH model) and to show quality and efficiency improvements in a short time frame,” said Fifield, who also serves as a professor of family medicine at UCHC.

  Within the intervention practices, hypertension control increased 23 percent, and breast cancer screenings improved by 3.5 percent. Moreover, the intervention practices saw a drop of 3.8 fewer ED visits per physician per year, which corresponds to savings of $1,900 per physician per year.

  Still, said the study authors, “Despite these improvements, we did not observe significant cost savings, and ED costs continued to rise over time, even with the significant reduction in visits observed.” They attributed this “to the rising cost of ED visits reported by EmblemHealth and the relatively modest reduction in ED visits.”

  On the other hand, said the study, although not dramatic, the savings achieved have a cumulative effect, which could result in significant cost savings in certain circumstances. For example, although the fewer number of ED visits in the intervention group was modest, it would be substantial when applied to a large number of physicians.

  “For instance, if panels were similar in size and complexity across the 142,000 in-network physicians in EmblemHealth’s Group Health Incorporated plan, a supported PCMH transition across all physicians would be expected to save $270 million each year from ED visit reductions alone,” said the study.

  Fifield also pointed out that primary care practices in the study provided care to a general adult population rather than a specialty population, such as high-risk elderly patients. As a result, the savings and cost improvements achieved by the intervention practices are modest compared to what likely could be achieved in practices with high-cost patients.

  The UCHC researcher speculated that case management was the single biggest factor in driving cost and quality improvements. For example, the case managers worked with hypertensive patients on a regular basis and helped them adhere to their medication and food regimens, which played a major role in improving hypertension control rates, Fifield said. “This study points to the improvements that can result from care management and coordination. The changes could probably be larger with more intensive efforts.”

  The findings represent the second part of a two-part study. The first part of the study, which also was published in the Journal of General Internal Medicine, showed that small and solo practices can achieve PCMH status within a relatively short time with practice redesign support, embedded care managers and a revised payment plan to help them achieve PCMH recognition status.

  In fact, most of the supported practices in the earlier study became recognized medical homes within a year when given access to these practice support features, the study found.

  Source: AAFP News Now, April 26, 2013 (http://www.aafp.org)

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• Rising Costs, Regulation Turn Solo Doctors Into Endangered Species
  

  By Tom Kisken

  Ted Hole knows he’s a dinosaur.

  In an age of electronic records, the 63-year-old family practice doctor from Ventura tracks hundreds of patients in paper files that layer shelves and weigh down filing cabinets.

  Doctors in the large health care systems that may be the future of medicine employ administrators to deal with an avalanche of federal regulations and insurance mandates. Hole tapes a paper note to walls. “No injections on same day as visit,” it reads.

  At a time when solo-practice doctors face odds that would scare an inveterate gambler, Hole is more solo than most. On days when his only employee — a nurse who has worked with him for 30 years — is out, Hole answers the phone. But it won’t stop ringing. Patients are waiting. Insurance companies need paperwork. So Hole offers a white lie.

  He tells callers the doctor can’t come to the phone. He’s too busy.

  More than half of the nation’s doctors worked in solo or independent practices 13 years ago, according to estimates from the Accenture consulting firm. The consultants predict that number will fall to 36 percent by the end of this year, with the decline driven by the cost of running a business.

  A 2012 survey from the Association of American Medical Colleges showed one in 100 of the nation’s medical school graduates planned a solo-practice career. More than six in 10 wanted to work in medical groups, in partnerships with hospitals or at a university.

  Some observers contend solo doctors will survive. They say the old-school physicians who pride themselves on medical autonomy and their bond with patients will find ways to deal with administrative burdens, federal reform and changes in the way they’re paid.

  Others say the tar pits are waiting.

  “They don’t have a future, not in the new health care paradigm” said Jim Lott, executive vice president of the Hospital Association of Southern California. He contends the only private-practice doctors who will survive are those who partner with hospitals and medical groups or reject insurance altogether and accept cash only.

  “The others are just in denial and have their heads in the sand,” he said.

  SCARY PROPOSITION

  Hole’s office is decorated with muted blue wallpaper. It hasn’t changed since he took over the office 21 years ago.

  Every morning, Hole arrives at 7 a.m. to do paperwork. He calls it “parasitic drag” as part of a rant against insurance companies and nonstop government regulation.

  “Insurance companies are getting more aggressive in trying to control the medications to treat patients. The goal is obviously to maintain their profit margin,” he said one morning as he scrambled for the insurance forms to continue a prescription for an asthma patient. The request was ultimately denied.

  Years ago, he would make hospital rounds every morning to see his patients. Reductions in insurance reimbursement for hospital care and the reliance of hospitals on their own doctors curtailed that practice. Now his practice revolves around his office, on the corner of a modest sprawl of medical suites sandwiched by two hospitals on Loma Vista Road in Ventura. When his patients call, they don’t need to use their names. Hole has treated some of them for so long he knows their voices.

  Marlene Reinhart, who is 81, has been seeing him since 1992. She remembers how he met her at the hospital when nerve problems in her mouth made her feel as if her head was going to explode.

  “He came when I needed him,” she said, trying to explain how well they know each other. “He can tell when I’m feeling low about something. He can tell when I’m elated about something. He can read me.”

  She winced at the notion that his practice — that solo doctors — may be obsolete.

  “How long is it going to be where I have to go to the other kind of system, where I’m just a number, where the doctor looks at me and doesn’t even know who I am?” she said. “I find that very scary.”

  PERFECT STORM

  Reimbursements already have been pushed down by large companies that control the insurance market and send patients to medical practices. The Affordable Care Act provides incentives for doctors to join new networks — accountable care organizations — in which they work in sync with other doctors, hospitals and insurance companies.

  Bonuses are paid when the accountable care organizations reach goals for improving quality of care and reducing health care costs, which increase with unnecessary care and hospital visits. The concept is that though doctors may make less initially, the bonuses will offset the loss.

  The government is also paying as much as $63,750 over six years to doctors who have installed high-priced computer systems and are meeting government standards for using electronic medical records. But a price that can reach into five figures or higher and a transition that can cost practices more money scares away many solo doctors.

  Other pressures include the rising administrative burden of running a business and the availability of jobs in medical groups in which doctors have time to lead lives outside work.

  “It’s kind of like the perfect storm,” said Troy Fowler, of the Merritt Hawkins physician recruiting firm. “Many physicians are saying, ‘I’m seeing more patients than I ever did. I’m working longer hours and making less money.’”

  Some large health systems have bought out smaller practices in a nationwide trend. In Ventura County, clinic systems ranging from Kaiser Permanente to the Ventura County Health Care Agency have opened new facilities or renovated old ones.

  A foundation linked to St. John’s hospitals in Oxnard and Camarillo has started a group of primary-care doctors. The hospitals are also teaming up with a coalition of more than 250 local doctors in a partnership designed to grow into an accountable care organization.

  LEARNING TO ADAPT

  Extinction is not a foregone conclusion. Dylan Roby, a health policy professor at UCLA, noted that solo-practice doctors have been adapting to changes in insurance and reimbursement for 20 years.

  They will survive by joining loosely formed networks that allow them to integrate with hospitals and specialists but maintain some autonomy, Roby said. He predicted others will form concierge practices where patients pay for care not through insurance coverage but through regularly paid membership fees.

  “I don’t think private-practice doctors will have to go away,” he said. “I just think they’ll have to adapt.”

  Doctors worry that if they don’t join a group or an affordable-care organization, large insurance companies won’t contract with them, said Dr. Jim Hornstein, a solo-practice physician in Ventura.

  Hornstein has no immediate plans to join a new network or to dramatically alter a 25-year-old practice in which his duties include checking supplies of office toilet paper. He’ll keep his overhead low, maintain a staff that handles administrative duties and focus on caring for his patients.

  His confidence in survival is driven in part by Obamacare provisions that are expected to provide coverage to 32 million Americans nationwide and 40,000 people in Ventura County.

  “There’s going to be plenty of people to go around to fill up all of our practices,” he said.

  Other doctors are already changing. After 13 years as an independent pediatrician in Oxnard, Dr. Imelda De Forest said her costs kept rising and her income kept falling. So she joined 10 other doctors in a Ventura medical group.

  She believes money will determine whether solo doctors will survive.

  “The bottom line is who can afford it,” she said.

  LOSS OF INNOVATION

  Private-practice doctors worry medicine controlled by groups means they’ll lose autonomy. They think their patients will be less like family and more like widgets on an assembly line.

  They worry about a health care system that increasingly ties reimbursement to care called evidence-based. The label means medications and other treatments match standards verified by research.

  The result is doctors have fewer choices in treatment, said Dr. Geoffrey Drew, a solo-practice physician from Thousand Oaks. Doctors won’t find ways to deal with mystery illnesses because they won’t be allowed to try.

  Drew’s answer to the pressures is succinct. He’s retiring. At 65, he plans to work as a mission doctor in his native South Africa.

  “With all of these bureaucrats looking over our shoulders, innovation and modification is going to be virtually impossible,” he said. “ … It’s going to cause medicine to be stifled and stagnant.”

  But if solo doctors worry about what is being lost, many others focus on what is gained. They note that health care reform emphasizes the importance of dealing with chronic illnesses and keeping people out of hospitals and emergency rooms.

  Integrated care means doctors work together to figure out what a patient needs without repeat appointments or duplicated tests, said Dr. Paul Phinney, president of the California Medical Association and a pediatrician affiliated with Kaiser Permanente.

  If a patient comes to a primary-care doctor with a mysterious mole, a medical assistant can take a digital photo and send it to a dermatologist. The doctors can confer on a speaker phone while the patient listens. In one visit, the doctors can decide on the best treatment.

  “That makes the care of the patient not only more convenient but more cost-effective,” he said.

  Phinney thinks integration can improve care.

  “It’s not going to be Marcus Welby anymore,” he said, referring to the 1970s television doctor. “It’s going to be something new and different.”

  OLD-SCHOOL DOC

  Hole came to Ventura 37 years ago in the same year Jimmy Carter was elected president. He learned to be a family doctor in Ventura County Medical Center’s residency program, working 80 hours a week.

  If he was 26 again, if he had to choose again, he wouldn’t go into medicine. He worries the focus is moving from care for the patient to the process of how care is delivered.

  His goal is to survive for a few more years. Then he’ll retire.

  “It makes me really sad,” Hole said, “because I know one day that I’m going to get taken care of in this system, and it’s not going to be the way it was in the past.”

  Source: Ventura County Star, April 6, 2013 (http://www.vcstar.com)

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• The Days Of The Solo Medical Practice Are Waning, But Some See Positive Aspects In The Changes
  

  By Carolyn Kimmel, Body and Mind staff

  “The days of physicians coming out of medical school and hanging out their own shingle to practice medicine are over,’’ said Dr. C. Richard Schott

  Dr. Scott Setzer knew when he chose to become a family doctor, he wasn’t going to make the money a specialist would, but that was OK.

  He didn’t go into medicine to make money – although, of course, that would be nice.

  Mainly he just loved the idea of building relationships with people in a way that could really make a difference in their health and quality of life.

  But in his traditional practice, he started seeing the business aspects interfering more and more.

  “I found myself spending a disproportionate amount of time on billing and coding, arguing with insurance companies over why I prescribed the drug I did rather than a cheaper one, trying to demonstrate ‘meaningful use’ of electronic patient records in order to receive an incentive,” said Setzer, who said he has watched the nature of primary care change since he began practicing here in 1997.

  As Setzer experience first-hand, the business side of doctoring is changing. The number of solo practitioners who are members of the American Academy of Family Physicians fell from 44 percent in 1986 to 18 percent in 2008.

  Moving forward, doctors are either joining health systems or hospitals or turning, as Setzer did, to what has been called “concierge medicine,’’ where patients pay a fee that ensures them access and gives the physician financial breathing room to schedule longer visits.

  “The days of physicians coming out of medical school and hanging out their own shingle to practice medicine are over,’’ said Dr. C. Richard Schott, president of the Pennsylvania Medical Society.

  “Doctors coming out of medical school today aren’t considering that and there’s very little training for how to run your own business,” Schott said. “The economics of practice, regardless of which venue you choose – solo practitioner or employed physician – are quite different than 10 to 15 years ago.”

  The benefits of being part of a hospital or health system

  More than 60 percent of doctors age 40 and younger are employed by a hospital, physician group or other entity, according to a survey done last year by The Physicians Foundation, which sent more than 630,000 email questionnaires to doctors and received 13,575 responses. Merrit-Hawkins, a physician search firm that assisted in the survey, reported that only 1 percent of their search assignments last year were for solo physicians compared to 22 percent in 2004.

  But the move away from solo practitioners does have positive aspects Schott said.

  “You are seeing movement away from a volume-driven reimbursement system towards something that is more value-based,’’ Schott said. “Traditionally, doctors haven’t paid attention to cost. These changes cause doctors to look at the appropriateness of what they order vs. cost.”

  There are definite positives for doctors who are employed by a hospital or health system, said Schott, a suburban Philadelphia cardiologist who used to be in solo practice.

  “They enjoy the fact that a hospital gets reimbursed substantially more from Medicare and private insurance than a doctor doing the same thing in his own office would get,’’ Schott said. “Employers can offer salaries and benefits that exceed anything a doctor could make in private practice.”

  Richard LaVanture, senior vice president and chief strategic officer at Holy Spirit Hospital in Camp Hill, said working in a hospital or as part of a health system allows doctors to spend more time focused on patient care. As part of a larger organization, doctors don’t have to worry about core services such as billing, coding and documenting, technology support and marketing, he said.

  “In this perfect storm of health reform mandates, the economy, high-deductible insurance plans and a diminishing workforce as baby boomers are aging, the trend away from solo physicians, especially in specialty areas like cardiology and oncology, is definitely increasing,” LaVanture said. “And now that perfect storm is making its way into primary care as well.”

  It’s a win for patients as well, who enjoy more focused attention of a physician who isn’t worried with running a business and a higher level of care coordination with available services within the larger health system, LaVanture said.

  “Doctors do give up full independence, but what they gain is substantial,” he said.

  Not all doctors are happy about the changes they are seeing, however.

  The Physicians Foundation report found three quarters of physicians are somewhat or very pessimistic about the future of their profession. It noted that those in the field longer had a dimmer view as opposed to a generally more positive outlook among younger physicians. The report also found that more than 50 percent of physicians surveyed said they planned to cut back on patients, work part-time, switch to concierge medicine, retire or take other steps that would reduce patient access to their services.

  A different model for solo practice

  Dr. Christine Cassel-Mackley, who owns Brownstone Dermatology Associates in Hummelstown, used to work for a medical center but opted to open to her own business to gain back time with her children, now 7 and 9.

  The only reason she can afford to fly solo is elective cosmetic work, which clients pay for out of pocket, she said.

  “About a third of what I do is cosmetic work,” she said. “I could definitely see it becoming difficult to be on your own if you didn’t have that option.”

  While she loves the flexibility of her schedule, she said, “There are business aspects I’ve had to learn and there is a lot of fear going out on your own – you don’t know if you’ll have enough patients and be successful.”

  Setzer knows that fear well – he faced it head on when he decided to leave the traditional family practice of which he was part owner and open his own concierge practice in October 2011.

  “It was a huge decision for me to leave my patients of 14 years, but the way I rationalized that is that I was losing those relationships anyway because of the way I was forced to practice,” said Setzer, who describes his Lemoyne practice as “relationship-based continuity of care.”

  Yes, he’s a solo practitioner, but not in the traditional vein. Patients pay $2,000 annually to have 24/7 access to Setzer and the guarantee that when they call the office, they will be seen that day or the next. In the office, patients get hour-long appointments; two and a half hours is allotted for annual physicals. There are no co-pays and no costs for in-office testing.

  “This is really my passion – the synthesis of the science, the people stuff, the good feeling you get when you really help people,” he said.

  Setzer was pleasantly surprised by how easy it was to build his patient base – he passed 200 patients at the eight-month mark, about half of whom followed him from his other practice. He is currently expanding his office space and adding an aesthetician and leasing space to massage therapists.

  Concierge medicine is sometimes criticized as being healthcare for the wealthy, and Setzer acknowledges it can be expensive. He offers a discounted price of $1,200 for children ages 10 to 25 to help defray cost for a family.

  Setzer doesn’t participate with insurance, but upon request, patients can get a summary of services to submit on their own. Often, though, claims are refused because he doesn’t assign a dollar value to services.

  He said he would like to see employers offer to subsidize concierge care for their employees and insists they would reap benefit in healthier employees who are enjoying a higher level of care.

  Patients have his cell phone number and his email address. If a patient can’t get into the office, Setzer is happy to swing by the house for a home visit.

  “In truth, people have such good access to me that they don’t call me much after hours. I’ve only been woken up twice in the middle of the night,” he said. “Part of it is, we have a relationship and they value that. This is how old-fashioned medicine is practiced. When there’s a personal connection, it’s better.”

  Source: Penn Live, The Patriot-News, Central Pennsylvania, March 17, 2013 (http://www.pennlive.com)

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• Care By the Hour
  

  Glorieta Doctor Cuts Insurance System Out Of Patient Care

  Dr. Willard Dean of Glorieta does not accept insurance and charges by the hour, or by the minute via phone.

  By Phaedra Haywood

  Glorieta physician Willard Dean doesn’t accept insurance, and he doesn’t have a flat fee for an office visit. Instead, he charges by the hour in person and by the minute over the phone. Still, patients say one of their favorite things about him is that he spends time with them.

  “Most other doctors, you go in and you are in and out so quickly,” said Joanie Wagoner, a 59-year-old piano technician who has used Dr. Dean as her primary care physician for the past 25 years. “Bill Dean takes his time. Sometimes he Xeroxes an article so you can take the info with you. Not like other doctors, where you feel so rushed.”

  Dean said he charges $120 per hour (or $2 per minute over the phone), but his prices are somewhat flexible.

  “With a new patient, I quote $120 per hour,” he said, “and a first visit is sometimes longer. So I know in their mind they are going to be ready for $120 per hour.”

  If the case is complex or will require him to do additional research, Dean said, he charges the patient for the full hour. But if the visit is routine, Dean said he often ends up charging a little less.

  “Sometimes we spend time socializing or talking about politics or philosophy, and I won’t charge for that,” he said. “Then, when I come in on the lower end, they are surprised or pleased. They come away happy. My system of pricing is flexible, and part of that is the nature of the medicine I do, and my philosophy of not being a materialistic-type in terms of more is better or having to have new cars all the time or whatever. Most of the time, if I get any complaints at all, it’s patients telling me I don’t charge enough. Sometimes they will write me a check for more than I tell them, which is a nice stroke. It’s a little bit different, obviously, than the managed-care model that most physicians are practicing under.”

  Dean, 67, said that the three years he spent at Texas Chiropractic College before attending medical school at the American University of the Caribbean was where he was first exposed to the ideas that led him to become the kind of doctor he is today — one who combines alternative and traditional therapies to treat patients.

  “It really turned me on to the benefits of natural therapeutic or alternative healing,” he said.

  When the doctor and his late wife initially moved to Santa Fe, they started a holistic healing center, which accepted insurance and treated patients with alternative modalities such as acupuncture and hypnosis. But, Dean said, dealing with so many different practitioners under one roof was “kind of like herding cats. The overhead was high, there were more headaches, and I wasn’t really making much more than if I was doing it solo.”

  Disbanding the center and going it alone was what led him to adopt the fee system he’s used for the past 20-plus years.

  One of the reasons he doesn’t take insurance, Dean said, is because if he did, he’d have to hire someone to do all the paperwork that comes along with it.

  “As soon as you hire even one employee, you open up a whole can of worms,” he said. “You have to charge more because you have to pay for their salary and comply with OSHA regulations and etc., etc., etc. It changes the dynamics considerably.”

  Dean said his way of doing business might seem quaint, but rejecting the bureaucracy associated with the health-insurance machine is a burgeoning trend in his profession.

  “Physicians across the country are really by and large a burned-out group,” he said, “dealing with insurance problems all the time, and a lot of times people will have insurance that requires pre-authorization for a CT scan or MRI. So the doctor has to spend time on the phone going through a long tree of options and authorization numbers. It’s an immense amount of paperwork for the average physician, which makes their day a living hell.

  “A lot of doctors are stepping outside the system because they are fed up with dealing with bureaucrats. It doesn’t make sense to have someone who doesn’t have medical training making a decision about if someone deserves to have surgery.”

  “Some [physicians] like myself have gone back to a general practice, some are just seeing indigent patients and accepting eggs and chickens in barter. There is an overall trend to find some way of making a reasonable living helping people and having a love of medicine, instead of being a semi-bureaucrat and trying to game the system.”

  While many physicians are moving toward a “boutique” form of medicine, where they sell subscriptions to a finite group of patients who pay monthly fees for unlimited access to doctors, Dean said his method is more in keeping with his philosophy that medical care should be offered at a reasonable cost so patients won’t hesitate to get treatment.

  As for insurance, Dean’s not against it, and says it makes sense for people diagnosed with chronic diseases (such as diabetes, or heart or lung disease) who need regular lab work and medication.

  But, he said, people who live a relatively healthy lifestyle and don’t have a family history of genetic ailments such as breast cancer should consider other options, such as having only catastrophic medical coverage or depositing money into a health savings account.

  “I would rather have people spend the money they’d be spending on insurance premiums on things like going to Ten Thousand Waves and getting massages and taking good trips, vacations, things that promote health or well-being, as opposed to insurance premiums, which just cause stress by and large.”

  SOURCE: Santa Fe New Mexican, March 11, 2013 (http://www.santafenewmexican.com)

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• There's a Doctor in the House
  

  It’s a new-old idea: Physicians who don’t make you come to them—they come to you

  By Rita Rubin

  On a sunny, early fall afternoon, the navigation system in Dr. Amy Schiffman’s crossover SUV guides her to the contemporary-style home of an elderly widow in Chevy Chase.

  “How’s our lady doing?” Schiffman asks the certified nursing assistant who answers the door.

  Schiffman follows the nursing assistant to the master bedroom, where the lady in question is stretched out under a plaid blanket on a king-size bed plump with pillows and scattered with newspapers and magazines.

  “Do you remember who I am?” Schiffman asks her patient, who is 85 and suffers from dementia.

  The woman appears mildly puzzled. “I remember,” she says, “but I don’t know why.”

  She sits up and swings her bare legs over the side of the bed. Schiffman and the nursing assistant, who cares for the woman during the day, are worried about her persistent, hacking cough. So Schiffman takes the stethoscope from around her neck to listen to her patient’s chest.

  “You don’t have happy lungs,” the doctor says.

  Schiffman clips a pulse oximeter to the woman’s index finger to measure her blood oxygen level. It’s 88 percent. Any lower and the woman will have to go on oxygen, Schiffman tells the nursing assistant.

  The patient dismisses the notion and assures Schiffman that her cough will go away. Still, the doctor will seek the advice of a lung specialist.

  Schiffman is among a handful of local physicians who are bringing new meaning to the phrase “there’s a doctor in the house.” They might seem like a throwback to a simpler time in medicine, but doctors who make house calls actually represent a growing trend, due in part to the aging population.

  The number of house calls paid for by Medicare has increased every year since 1999, when it was nearly 1.5 million, according to the American Academy of Home Care Physicians. In 2011, Medicare paid for just over 2.6 million house calls.

  “It is so much less expensive, and it is what patients want,” says Constance Row, executive director of the home care physicians group, which is based in Edgewood, Md.

  At the same time, an increasing number of concierge medicine practices are offering house calls to patients in wealthier parts of the country, such as Bethesda, Row says. These people are willing to pay out of pocket for the convenience.

  From the time she launched her practice in May 2011 until this past fall, Schiffman made more than 1,500 house calls throughout Montgomery County and Washington, D.C. Virtually all of them were Medicare patients, but she has a handful of private-pay patients, too.

  “It’s about rediscovering medicine,” says Schiffman, who had spent most of her career as an emergency room doctor with fancy high-tech medical machinery at her fingertips and a battalion of medical specialists at her beck and call.

  These days, her goal is to keep patients out of the emergency room. Her equipment fits inside an L.L. Bean “boat and tote” bag personalized with “Dr. Amy” in blue embroidery, and she does as much as she can in patients’ homes without bringing in other health care professionals. Schiffman says Medicare pays her about $210 for a house call to a “complicated” patient. She charges $300 and up for her private-pay patients.

  A Bethesda resident, Schiffman originally made the switch to have more control over her schedule and her practice. She’s married to an OB-GYN and the mother of two elementary school-age children. “I wanted to do my own thing,” she says.

  So she Googled “house calls” and hit upon the MedStar Washington Hospital Center Medical House Call Program, which was created in 1999 to serve elderly patients who live near the hospital. She tried it out by accompanying Dr. George Taler, a geriatrician who co-directs the program, for a couple of days. “He looked at me and said, ‘Amy, you can do this.’ “

  Now “I’m part social worker, I’m part doctor, I’m part family caregiver for those who have no family,” says the 43-year-old Schiffman, who grew up in Durham, N.C., the daughter of two Duke University psychologists. “I want to solve the hardest problems, and I can’t think of doing that any other way.”

  Like Schiffman, Bethesda resident Dr. Susan Miller began making house calls so she could set her own schedule. After completing a geriatric fellowship at George Washington University in 1990, Miller had a typical office practice in Friendship Heights and Chevy Chase, Md. But in 1998 she closed the office in order to give her more flexibility for her children and doctor-husband, and began doing house calls and nursing home visits exclusively.

  On a house call, Miller can check to see whether a patient has food in the refrigerator or an excessive number of pill bottles in the medicine cabinet.

  Also like Schiffman, Miller accepts Medicare. But because Medicare doesn’t reimburse for travel time, she began to concentrate six years ago on nursing home visits, and her house call practice dwindled to about a dozen patients.

  “I was so glad when Amy [Schiffman] actually started seeing patients, because I was turning patients down all around,” she says.

  About a year ago, Miller became a consultant for Encompass Meds, a doctor-owned, Bethesda-based company that manages home care for elderly patients, and started making more house calls. An empty nester at 56, Miller says she “can afford to work a little bit harder” now.

  Miller likes having the support of the Encompass Meds team, which includes a dietitian and social worker. A medical technician accompanies her on calls, so while she’s talking with the caregiver, the tech can perform tasks such as checking the patient’s list of medications. Encompass Meds charges patients a one-time fee of $450. Then Medicare pays her for each house call.

  Because of traffic, Miller tends only to see patients in Bethesda, Potomac, Kensington and Chevy Chase. She also provides in-home hospice care through the Jewish Social Service Agency.

  Dr. Steve Simmons knew since age 4 that he was destined to become a physician. The Gaithersburg resident couldn’t, however, imagine the dissatisfaction he’d encounter when he actually began practicing medicine.

  With financial pressures to squeeze as many patients as possible into a day, primary care “was an impossible job to do well and sleep at night,” Simmons says.

  He switched from internal medicine to urgent care medicine but still felt disgruntled, due in part to wrestling with insurance companies. On his 40th birthday, “I caught myself wishing I was 65 so I could quit practicing medicine.”

  He didn’t, of course, but in 2008 he joined DocTalker Family Medicine, a Vienna, Va.-based practice that offers house calls. Founded seven years earlier by family doctor Alan Dappen, DocTalker accepts neither Medicare nor private insurance. Simmons says that frees him and his colleagues to focus on the doctor/patient relationship.

  DocTalker charges new patients a one-time fee of $500. According to the practice’s website, DocTalker physicians charge $400 an hour or $33.50 for every five minutes. If patients can’t afford the entire cost, Simmons says, they might agree to pay $20 a month for years to cover it.

  Simmons, who is married to an emergency medicine doctor, empathizes with adult children who ask him to check on their elderly parents because they don’t live nearby. His parents live in Tennessee, and his 84-year-old father, a retired college professor who spoke many languages, has dementia. Simmons has been unable to find a doctor who will make house calls to see him.

  In Montgomery County, Northern Virginia and the District, the demand for house calls has been so great that Simmons went from occasional house calls when he first joined DocTalker to as many as six a day while also continuing to see patients at the office.

  House calls can reveal much more than what can be learned in an office visit, he says. “I get to see if the house is clean, if the person’s groomed, if there’s a fall risk. I see the complete picture when I go in the home.”

  No longer, Simmons says, does he dread going to work. “I get to get up every day and, for the first time, I get to do what I was meant to do.”

  Like Simmons, Dr. Stephen Kinney was tired of feeling rushed with patients. He worked as a family practice physician at a primary care clinic in Easton that was run by a corporation he declines to name.

  “You’ve got to see patients, more patients, more patients,” says Kinney, a North Carolina native who now lives in the District.

  In his mid-50s, he didn’t want to give up medicine, but he wanted to slow down. So in November 2011 he launched Metro Direct Care Medical in Chevy Chase. It’s just him and business partner Patrick Lodise, who drives Kinney to appointments in private homes and hotel rooms.

  Also like Simmons, Kinney accepts neither Medicare nor insurance. “I worked for a company that took every insurance known to mankind,” he says. “I spent 50 percent of my time on the phone arguing with insurance companies. That’s why I decided I’m going to do this on my own.”

  Kinney, who sees Montgomery County patients within the Beltway, calls himself “the MacGyver of house-call medicine,” referring to the television show that went off the air 20 years ago. MacGyver, a secret agent, was able to solve complex problems with the tools at hand.

  MacGyver’s tools included duct tape and a Swiss Army knife; Kinney, who focuses on patients 18 and older, can perform a variety of assessments in patients’ homes, testing for urinary tract infections, for example, with what he carries in his car.

  He doesn’t charge patients an upfront one-time fee and bills as little as $50 a visit for patients who live near him. A new patient visit typically is $150. “I had to undercut as a way to get patients,” he says.

  For now, Kinney supplements his income by working under contract in a medical practice office.

  “This is an experiment for me,” he says of Metro Direct Care Medical. “If it works, it works. If it doesn’t work, I’ve given it a good effort.”

  Dr. Leila Hall’s patients are at the other end of the age spectrum from her counterparts. The Bethesda pediatrician typically makes at least two house calls a week, usually to check on infants.

  “I’m very passionate about helping new moms do the right thing for their babies,” says the 37-year-old Hall, whose practice consists of herself and her mother, Marilee Hall, who sits at the front desk. “I didn’t want my new babies and my new moms to have to come into the office, where potentially there are germs.”

  Plus, she gets to see for herself whether the baby’s environment is safe.

  She’s also the go-to pediatrician in her east Bethesda neighborhood, happy to see sick children if their regular pediatrician’s office is closed. That way, Hall’s neighbors “don’t have to drag their kids to the emergency room.”

  Having an office practice that’s open while her 4-year-old son is in preschool and making house calls when needed is the perfect arrangement, Hall says. After all, most insurance plans don’t cover well-child visits in the home, she says, and kids need a lot of vaccines that must be kept refrigerated. When she makes a house call to a sick child, the parents pay the same co-payment they would at her office.

  “It’s such a comforting thing to know the doctor can come,” Hall says.

  As the mother of “virtual triplets,” Dalene Erickson agrees. The 47-year-old Bethesda resident grew her family through birth and adoption, so only about 10 months separate the oldest, 9, from the youngest, 8.

  Erickson works two jobs, running a day care center in her home and teaching ballroom dancing at night. Hall has “made many house calls to my house, usually because somebody’s sick,” she says. “I obviously cannot leave my job during the day.”

  Hall also has gone to Erickson’s house to administer flu vaccine. “She came right after school, so they didn’t have to miss any,” Erickson says, “and we didn’t have to sit in traffic and wait and wait and wait.”

  Source: BethesdaMagazine.com, February 2, 2013 (http://www.bethesdamagazine.com)

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