Thursday, January 30, 2014

Is Solo Private Practice Obsolete?

Driven from every corner of the earth, freedom of thought and the right to private judgment in matters of conscience direct their course to this happy country as their last asylum.

Samuel Adams (1722-1803), Speech, 1776

Is solo private practice obsolete? 
Is it feasible in this age of nearly universal  3rd party payment, government intrusion, mandatory compliance , required documentation of every doctor-patient encounter, and constant  calls for coordinated team care ?  

These are the questions I  pose in this blog post.     

And they are the questions I’ve been asking myself  as I prepare for a talk before the Association of American Physicians and Surgeons (AAPS).    

My answer is:  Yes, it is possible to conduct a solo private in this technological age. Ironically, disruptive computer innovations make it feasible.

APPS defends private practice. It believes the doctor-patient relationship is a confidential one-on-one private matter.  AAPS  maintains the patient should pay the doctor directly at the point and time of care.  The doctor and the patient should agree upon the fee, not the government or some other 3rd party.   And lastly, when government and other 3rd parties, intervene, the intervention destroys the relationship and threatens the future of private practice.

Is this belief system realistic? 
Not in  3rd party eyes.   They argue for the collective and individual patient good,  data is necessary to judge health care “value”-  the best outcomes for  money expended.  They insist health care has become so complicated and sophisticated only a team of professionals,  using experts’ guidelines based on population studies,  acting in concert, deploying  the latest data, can offer optimal  care.   

In short, in  the words of Edward Deming (1900-1993), American statistician and quality control guru, “In God we trust, all others use data.”

This is a persuasive argument, and I do not disagree with it.    But there are other sides to it -  loss of personal privacy,  limitations of personal choices,  restrictions of  individual clinical judgment, release of personal data for all the world to see,  desiccated  dehumanization of  the patient-physician relationship,   and physician demoralization.    

Physicians often go into medicine with the belief that their experience and their knowledge of the patient in face-to-face encounters gives them the right  to do what they think is best for the patient,  without having  to justify their actions through endless paperwork, countless  phone and online calls asking permission to order a test or do a procedure, and being second-guessed at every turn.

This belief system has produced a movement towards return to individual practices.    This return is  a reaction against  becoming employees of large organizations,  of spending 25% of their time on paperwork,  of being judged and paid for data on “value” and “performance,” and of sacrificing their independence for the benefit of organizations, 3rd parties,  and the collective good of the “system.”
In a larger sense, what physicians are doing is decentralizing n in an age of  centralization and consolidation.   

Returning  to individual private practices is a difficult thing to do. It requires giving up revenue streams from 3rd parties, losing  loyal patients who depend on 3rd party payment,  taking financing risks,  entering  into a brave new world of individual care rather than coordinated care, listening to  critics harping and moralizing  that   it is the wrong thing to do because it creates a two-tier system  between those able to pay and those unable to pay for physician services.

But thousands of  physicians are  doing it. They are  downsizing into solo  direct-pay practices.  They are doing it  with the help of the Internet. They are shedding the need of large staffs  necessary to deal with the documentation, regulations, restrictions, and hassles that accompany 3rd party payment.  

 In the words of Clayton Christensen and his colleagues at Harvard Business School,

 “Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. If the natural process of disruption is allowed to proceed, the result will be higher quality, lower cost, more convenient health care for everyone.”

Either alone, or with help of s nurse practitionesr, physician assistants, or other medical assistants,  and with routine  and imaginative use of the computer,  including email communication,  physicians are now able to practice in  smaller,  more personal,  more patient-friendly settings.

Here, in a previous blog post,  is how I described the process of disruptive innovation, decentralization, and individualization works 

Gordon Moore, MD, a family doc, working alone, but on the faculty of the Institute of Health Improvement, has come up with and implemented,  this Wild and Crazy Idea - that One Doc Working Alone in One Room, with no support staff and nothing but a computer with Internet access to keep him company, can revolutionize solo practice, by making it more productive, profitable, and fun.

Sure, I know it sounds crazy.  But he backed and documented  the theory and work of his practice in a medical journal article, “Going Solo: One Doc,  One Room, One Year Later.”

In one year, he did the following:  

Maintained open access scheduling, meaning he saw patients on the day they called; took his own call, reduced other access barriers, developed deep and personal relationships with his patients by spending 30 minutes with each one of them; reduced his patient load  from 25 to 30 to 12 patients each day; operated without support staff, in one room of 150 square feet, averaged $65 per patient visit, and expected to take home $155,000 a year

Thanks to a lean IT system and low overhead. He did this with high patient satisfaction rates,
and a high percent of quality goals met. He built his unorthodox practiceon these four basic principles:

1) Access. Patients have unlimited access to the care
and information they need when they need it.

2) Interaction. Interaction between the patient and care team is deep and personal.

3) Reliability. The system exhibits high reliability in that it provides all and only the care known to be effective.

4) Vitality. The practice has vitality: happy employees, a spirit of innovation, and financial viability.

Along the way as he practiced these principles, he developed and articulated these philosophical axioms.

Interaction is not the price we pay to submit a claim.It is the essence of what we do.”
Tweet:   With imaginative computer use,  it is possible  to run a profitable, productive solo practice satisfying to practitioner and patient alike.

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