| EDWARD HARRIS President of the medical staff One Doctor's Solution |
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 Peter Van Etten, addressing a special meeting last month of deputy chiefs and the medical board at Stanford Hospital and Clinics, talked eloquently, but with foreboding, about the disintegration of health care services in California. [See related story]. One recurring theme, with variations, was how economic, cultural and political forces outside the control of physicians are driving health care and the payment system. But health care is a labyrinth, not a system (to quote Peter), and so please read on about how one of your colleagues, a general internist and one of our best clinical teachers on the voluntary clinical faculty at Stanford, has regained control of his life and practice (and can still pay his bills). Since childhood, our colleague wanted to be a physician, one who helped sick people get well. After medical school and residency, the dream of caring for patients was fulfilled, first at the Stanford medical Group and later in a Welch Road practice. But over the years, the need to achieve productivity standards began to erode his satisfaction and that of his patients. Ten minutes for her, 15 for him, when 30 for each was needed. Understandably, this led to frustration. Then several years ago, a group of his patients came to him. Their message was, "Let us retain you as our physician. You care for us and keep us as well as possible. We will pay you prospectively." He realized, of course, that if a doctor accepts private payment from a Medicare patient to deliver care, that physician cannot, from that day forward, bill Medicare for services given to any patient. And he also knew that California's Knox/Keene Act prohibits payment for diagnosis and treatment of disease prospectively unless the physician belongs to an HMO. So our colleague came up with this scenario:
Of course, the patients who retain our colleague as their personal physician have commercial insurance and/or Medicare to cover hospitalizations and specialty care. Many patients take policies that also offer benefits for prescription drugs and laboratory tests. For most patients, the arrangement remains affordable even when combining their retainer with basic insurance, often with a high deductible to save premium costs. Within this scenario, there is a requirement to charge for purely medical services, so he has chosen to charge a nominal fee, $10 to $15 per visit. The income from retainer fee covers his professional expenses and allows for achieving reasonable personal goals. Our internist colleague can now spend the amount of time with his patients that he needs. He can sit with longtime patients, like old friends, and be with them when illness is burdensome and death approaches and arrives. He can take time to teach, to read and to write. He needs only one office assistant because his practice now has virtually no paperwork, few insurance forms, and no Medicare forms! Not too surprisingly, our colleague reports feeling good again about being a doctor. How do our colleague's former patients - those not part of the group that retains him - feel: rejected, abandoned, glad to be rid of him, or simply indifferent? Some of these former patients have written letters to him, many with congratulations and wishes for his success, some expressing dismay, sadness, and a very few, with some resentment. We must hope that they are all content with the more typical practices of one of the other superb primary care physicians in our community. When you think about it, our colleague's new practice format is not so different, from the kind one hears and reads about occasionally in a small Midwestern or Southern town that gathers its collective resources to put together a package that can entice a young physician to come to the town to take care of the residents. Few of us can make the same decision as our colleague. But his model is hardly unprecedented, at least in overarching concept. Our colleague points out that many mainland Chinese physicians traditionally have been paid by their patients to keep them well. When they take sick and die, the Chinese doctor gets no more income. Our colleague has learned that if you are first in line, you can sometimes follow a dream. For our colleague the dream makes medical sense. And at least enough people agree to enable him to survive as an innovator. Perhaps it tells us that the conscientious practice of quality medicine will somehow offer a winning scenario. Perhaps this is just one of the first creative innovations that physicians can devise to reclaim control of their lives while delivering good service to those who are well, "worried-well" and sick. |
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Establish a system specifically designed to provide disease prevention and health
promotion services. The Knox-Keene act does not preclude prospective payment for
non-medical services. This practice was envisioned to include those time-intensive and
previously unremunerated health education services that he had always provided, as well as
a wider range of services to be developed.