Wednesday, April 9, 2014

 A 63 Year Old St. Paul Internist's Soliloquy

The act of talking as if alone. A discourse by a person talking to himsel in order to disclose his innermost thoughts.

Soliloquy definition

This is not so much an interview but a soliloquy.  This was a conversation with a 63 year old,  solo internist, Donald Gehrig. He has an equivalent staff of 0.5 persons. He conducts a direct cash practice.  He’s been around the medical block for 34 years in St. Paul, Minnesota,  beginning as a member of a  small private medical  group and then as an employee of the large dominant health system.  For the last 15 years he has been in solo practice and for the last 2 ½ years, he has conducted a direct pay practice, seeing 4 to 6, sometimes,  8 patients,  a day. He has 2 assistants, both with him for 15 yrs.  One who now works one day a week, the other 3, 1/2 days a week. 

Dr. Gehrig sees the world through the eyes of a doctor  who wants to work for the patient, not the corporation, not the government.   He loves working with a broad spectrum of patients, with a wide divergence of income levels.  He often  talks to them about their families and their personal concerns. He  spends as much time with them as needed. He is their personal physician.

He  bemoans medicine’s decline  as a profession.  He  believes health corporations, private and public,  run the medical world, not doctors or patients’ with individual needs. He has a talent for the  memorable one-liner.   I found myself not asking questions but listening for an occasional pearl of wisdom to drop.

This is not a sequential interview.  This is a collection of excerpts intended to give a sense of the man and the medical scene as it now exists.

“ I’ve been in practice since 1980, in MN. In the 1990s, MNCare legislation, based on the promise of capitated ‘care’, was enacted  and forced most general internists to be bought out, leave the state, or quit. However, most of the capitated HMOs in the Twin Cities  died here, and across America in 1997 and 1998." 

"I felt then that these huge managed care organizations didn’t need to exist, yet today remain menacingly more in control and continue to exploit to foster their existence.  After capitation died, they didn’t like the idea of internists taking care of older folks, as they couldn’t make money on them from general internal medicine practices, with just the discounted, Government price fixed FFS care of the time." 

"Only 3 independent internist practices exist in St. Paul now, compared to 20 to 25,  20 years ago.  Most  of the remaining internists are indentured in  huge billion dollar medical corporations, one of which covers 11,ooo square miles. That’s not health care, in my opinion.  Health care is 80 square feet, in an exam room.”

“For last 2 ½ years I’ve been in a direct pay practice, not necessarily a concierge practice, which is typically more expensive. My practice is what I call ‘concierge care at non-concierge prices."

"I’ve opted out of Medicare B, the physician component, since January 2012, and decontracted from other carriers but for 2 small plans whose contracts end this year. I charge for my time as the needs and discussions always vary. I offer patients with chronic conditions,  like diabetes or needing predictable frequent visits like patients on warfarin, a monthly or yearly fee, a retainer, which works out to be a 15% to 20% discount over being charged per time. “

“Most of my patients, 60% to 65%, are Medicare age. They are very loyal and get it, they value me, not a plan. They come back! Some of them have been with me since I’ve started practice in 1980.”

“I also call this sort of practice, the Art of Small. I survive by keeping costs low and doing things simply. I have no coding or billing for my Medicare patients. In the Twin Cities, managed care has ruled the roost for decades."

"Most doctors who know me think I was crazy for doing this, and (including my wife) did not think I could carry it off, either starting a solo practice, in Nov 1999 or establishing a direct pay model in Jan 2012. I did need a banker with a sense of humor at the start and a trusting, although skeptical wife.  Starting these kind of practices, like any small business,  takes a true leap of faith,  kind of like jumping off a cliff in a fog; you don’t know where or how you’re going to land.”
“In the present system, we doctors have been made the fall guys-  the demonizable,  fee-for-service villains.  However, how is it that everything else in our society is paid for by fee-for-service, or fee for product?  Why  is it that the doctor working for patients is viewed as diabolical, unseemly or unethical? Patients don’t think so. Patients get it. Certainly, those who look down upon us,  don’t get it.  Patients come to me.  I take care of their medical problems,  swipe their card or write a check.  Period. Voila! Done. Transacted.”

“Nothing exits my office unless the patient wants me to send some information out.  It’s wonderful. It’s private. And it’s simple. I use a manual chart, supported electronically.  The chart stays in my office. I like interaction with each patients, not computer screens.  I like that each one  is different. I don’t have to make their outcomes conform to payer or Government protocols – that is not the practice of medicine.

I am their personal physician. I tell them, here’s my cell phone number.  Call me.  But patients  rarely need to call me.  In small practice dynamics, we tend to settle all their questions during our visit or during the day. And they can be seen the same day or tomorrow if they do call and should be seen.”

“The plans have been basically price-fixing us  under  various schemes with or without Government cues, across specialties,  and the physicians in this perverse and opaque system are clearly working for the 3rd party rather than the patient. We won’t ever have a single payer system, in my opinion. But we already have a single-pricer system, following these strong handed and price fixed plans, directly or indirectly dictated by those Government cues.”

“These very large managed care corporations and the huge health insurance cartels are becoming too big to fail and, like Wall St, probably too big to jail.”

 “ Big practices consist of machinations with 3rd parties,  where nothing easily gets settled, and chaos reigns.  Nobody seems to have a personal doctor.   I know.  I’ve been there. There’s was always a sense of agitation in these big clinics. Being big detracts from caring for each patient.”

“Where’s the system going?  I believe towards continued government ‘social fixing’ that never goes away with consequences that never go away and compound the problems even more. The code-masters have enslaved us with their codes.   Most probably, 5 to 10% of patients will be taken care of by doctors like me." 

"Politicians and their families, who exempt themselves from their own laws and formulated health plans, will likely continue to come to us, where they can get personal care. The rest will go to indentured doctors or Doctor extenders, governed by their corporate handlers."

"Doctors will be capitated,  or paid for performance guided by patient outcomes, largely beyond their bedside control. They’ll focus on outcomes and computer based, far away performance protocols  rather than patients,  and the patients will continue to be bewildered and their personal unique needs, less cared for. But the bosses will always have these same Drs controlled and exploited,  ready to be blamed…a perfect nightmare future, a future of deprofessionalization and Doctor -patient abuse.”

Tweet:  Dr. Donald Gehrig, a solo St. Paul internist, advocates direct pay practice, in which doctors work for patients,  not for anonymous 3rd private or public corporations.

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