Saturday, October 30, 2010

Dismantling the Cottage Industry

Last week I went to see a doctor about an EHR. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed “two and a half” days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene’s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn’t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Dr. Greene collects 99.6% of his charges and he never used a collection agency and he never will. Wait a minute…. This is impossible. Insurers deny payments all the time and they certainly don’t pay what you bill out. Not to mention that patients are not very quick to pay either. How can you collect 99.6% of charges? How about allowables and adjustments and writeoffs and all other administrative nightmares that are part and parcel of a medical practice? Dr. Greene walked out of the kitchen and returned with a piece of paper he picked up at the front desk: his fee schedule.

Dr. Greene’s fee schedule was neatly typed on a letter sized pink sheet of paper and carefully encased in a clear plastic protecting sleeve. The fee schedule contained about fifteen procedure codes, mostly E&M codes for various office visits. He doesn’t do any procedures in the office and if he does an “EKG or some other simple thing”, he doesn’t charge separately for it. The fee schedule had two columns for each code; the Medicare allowed fee and the actual fee he charges all his patients. I had to look several times at the column headings to understand – Dr. Greene charges less than Medicare is willing to pay him. For the most common visits, he charges a lot less than Medicare will pay. He bills these lower charges out to Medicare, to all private insurers and to his cash patients. Why????

Dr. Greene was laughing and Mrs. Green was smiling at my total lack of understanding. I guess city folks are not so bright after all. For Dr. Greene this is a matter of principle. It is an entire philosophy. This is about fairness and honesty. His patients are his neighbors and he knows all too well that most cannot afford to pay the Medicare deductibles. He charges what people can pay and he makes it simple, straightforward and fair. His fee schedule is displayed at the front desk. In return, his patients pay their bills promptly. Fairness in small communities is usually reciprocated. Medicare and commercial payers, probably assuming he is mad, are quickly paying his claims just like a quarterback quickly snaps the ball to avoid a challenge. That’s how you get 99.6% of your charges collected with very little overhead. And, no, he is not at all interested in changing things. He is making a very nice living, thank you.

Dr. Greene wants an EHR. Why? Because he wants to receive lab results electronically from the little hospital down the street, and because he wants to use templates. Templates??? You mean you want to click on boxes instead of writing those beautiful golden notes? He thinks a dozen or so customized templates would make him more efficient and allow him more time with his patients and perhaps he can go home a bit earlier too. He wants to send prescriptions to pharmacies and not have to write down the medication list each time. No, he doesn’t want to create documentation for higher billing codes. And he doesn’t want to be left behind. Dr. Greene, unlike some of his colleagues in town, has no plans of running away and retiring early in the face of new challenges. He will get an EHR and he will exchange clinical information and he will advance with the times. He will be exploring quality improvements and medical homes and even accountable care organizations. Dr. Greene knows that EHRs slow you down and are well positioned for improvement, but he also knows that his grown children, who are themselves physicians, will expect an electronic office if and when they return to their hometown to continue the tradition. There was a faraway dreamy look in his eyes now. Lunch hour was over and there was one patient in the waiting room.

For all the pundits and the health economics experts, and for the political activists on either side, who are actively trying to dismantle our health care cottage industry and reconstitute its remains into large corporations of efficiently employed physicians, this is what you are attempting to dismantle - Dr. Greene, and the thousands of others like him who practice medicine four to five hours away from a major airport beyond miles and miles of cow pastures and fields of corn.


  1. Margalit, for someone whom I've come to admire as a self described cat/dog, this post is far more antagonistic than your usual.

    Dr.Greene probably should continue his cottage practice in the country, but that doesn't mean it's the best future model for the city.

    I believe one of the lessons we're learning from medical home implementations to-date is exactly how difficult the process and cultural changes are to accomplish. I don't see how these processes can be scaled in today's small practice cottage industry.


  2. It wasn't meant to be antagonistic, Vince. It's just stark reality and I felt physically ill when I walked out of that clinic. I just had to write about it.

    I don't know how he can continue practicing the way he does now if the rules of the game are changed. I don't know how to separate the city model from the country model if reimbursements are to change.
    I somehow think we owe it to ourselves to find a solution that will allow these country docs to exist and I think technology, being the great equalizer, is the answer. Perhaps virtual networks of independent country docs (and city docs) can work as well as big medical groups. Perhaps the new reimbursement model can bring into account such virtual arrangements.
    You have much more expertise at this. I'm sure something can be done.
    I just don't want these docs to be forgotten or dismissed from future arrangements.

  3. We need more Dr. Greene's (pseudonym notwithstanding), to step up into leadership! A truly great post, Margalit, and a must see, imj. Tweeted today via @2healthguru.

    Fairness and honesty driving practice level decisions up to and including pricing and collection practices - what a concept!


  4. Antagonistic? Physically ill?

    I thought this post was a warm description of a good doctor doing things the right way. Caring, compassionate, hasn't let the bureaucrats intrude, he's managed to preserve the physician patient relationship. He spends his time practicing medicine, not being a little minion/paper-slave. And he manages to make a good living this way!

    I'm confused by your responses. You seem sympathetic towards him — you felt ill. From fear that this will disappear, perhaps?

  5. I felt ill because we are about to destroy what he stands for, callously, inadvertently as another "unintended consequence" of our collective rush towards "economies of scale", and there is nothing I can do to stop this juggernaut....
    My honest doctor is in harm's way and he is happily going about doing the right thing.....

  6. Thank you Gregg.

    There are many, many more like this physician, "busy seeing patients". Unfortunately, leadership lies elsewhere....

  7. Oh, I see. Thanks for clarifying.

    His solution should be to opt out of medicare and all insurance and go cash only. And keep notes on his Macbook Air, with someone setting up a simple system for him. No e-prescribing. :)

  8. @pacificpsyhc

    > His solution should be

    Sounds to me like that's what YOUR solution should be. Why should it be his? Because you say so?