FP as an art

[dancote]

Hello,
My dream has been to be a rural family doctor. I am from northern Michigan and would like to live and work up here. The past year I have been shadowing with 5 diff. FP docs and what I've seen is not what I'd expected. Each patient visit is so short there seems to only be time to deal with symptoms and that means adjusting and dishing out meds 90+ percent of the time. There seems to be no time to really look at the patients problems and hardly a chance to discover the CAUSE of the illness.
One of the doctors had been practicing for over 30 years and told me that with the short 15 minute visits the 'art' of healing has been lost.
I would still like to go to D.O. school and be a FP, but are there any ways around this trend or will we lose more and more of the personal side of medicine? Are there doctors forming clinics which address the needs of patients interested in in healing and not just suppressing symptoms? I've heard the Naturopathic doctors are favored in parts of Canada for this reason alone. What is the future of the doctor/patient relationship?

-Sorry for so many questions!!!

-Dan Cote'

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[edfig99]

unfortunately it's not just FP - it's all fields of medicine. With the industrialization of medicine (which is not going to disappear) art is no longer necessary. communication is necessary inasmuch as a way to prevent lawsuits, but medicine right now is ultimately it about coming down to the bottom line. chances are the FPs are seeing that many patients because they are enrolled in multiple plans that give them crappy reimbursement so in order to 'break even' or even net positive, they have to do more work. it sucks.

there is a way you can do what you want to do - but it may involve you living a life of poverty. you don't HAVE to sign up with HMOs, medicaid and medicare and can be a cash only fee for service. then you can charge what you want (within reason) and spend as much or as little time as you want with a patient. you have to be willing to be the best doctor you want to be, and sometimes that doesn't parallel making money.

maybe i'm just being cynical.

 

[PACtoDOC]

I have a close friend who refused to enroll in HMO's out of residency and even started his own practice. He was literally making less than 50 K a year for the first year and slowly climbed the ladder of success to make well over 500K per year now. He is cash and PPO only and he does not file insurance for the patient. He spends a great deal of time with patients, averaging 20 minutes actually face to face or so, and works from 7:30 to 7:00 PM. If her actually worked normal hours he would still make double the average doctor. He only works that long because patients truly need him in the small town he lives in. He often sees patients with HMO insurance who come to him and pay full price for an office visit cash off their insurance!!

 

[dr.smurf]

do you think he regreted that at first? i mean i was thinking maybe start out taking many hmo's and slowly wean out the ones with the lowest reimbursement and then eventually maybe all hmos. any thoughts? i mean you would be building up your practice and when you reached the numbers quit taking hmo's. but, this also seems very unfair to your pts too! ???

so let me get this straight. he takes ppo's but its up to the patient to file and do the paperwork. so essentially he doesnt take a copay..he takes the entire amount and the pt gets the money from his/her ins co. ??

thanks for the info...its nice to hear that that kind of practice does make it!

 

[edfig99]

if you start your own practice for the ground up, it's not atypical to not make any money the first few years -- you have to establish a patient base, and most doctors aren't trained well in practice management coming out of residency so you have to learn the coding, billing forms, etc. making 50k (if that's net) is possibly not bad depending on how much overhead there is. it's nice to hear how well your friend has done since then.

in terms of dr. smurf's question regarding PPOs - it's not uncommon to have the patient submit their own claims. they'll get reimbursed according to the terms of the PPO - for example, if it's an in network person, they'll get reimbursed full. if it's out of network, then they'll likely get reimbursed 70 or 80% until they meet their deductible.

in terms of building your practice and then dropping plans -- it actually puts everyone in an awkward predicament. on the one hand, they may wish to continue with you as their physician, however, if they are paying for insurance (employer) and can't afford your rates then you lose that patient and everyone else under their plan. I knew one physician that was taking HMOs for a while, got tired of it all, and then dropped every single one of them. a few patients stayed because they could afford him, but he ended up losing a lot of business and almost had to start from the ground up again and this was a practice that had been around for 10 or 15 years. it's almost better not to make bedfellow's with the plans since it really doesn't seem to help you much. building up a successful practice is a matter of providing niche services and great advertising.

 

[PACtoDOC]

Capitation is not too bad a deal for a practice if you limit the % of patients you have that are cap'd. 30% is a good number. Its like rolling the dice though. We used to get somewhere around 200 bucks per year per patient on our panel that were cap'd, and we actually got paid about 1.50 on the dollar of services provided. So thus, it meant that we did as well with our cap'd patient as we did our cash and PPO patients. But you have to manage them well and unfortunately you have to look to the front of the chart and see who is cap'd in order to limit costs on these patients the best you can. As bad as it may sound, in an IPA with cap'd patients it does the doctor a service to prescribe cheaper medications of practical, because pharmaceuticals are usually also part of the bottom line for the IPA. And bonuses get paid to physicians based on bottom line quarterly numbers. I actually left my first job because the doctor I worked for routinely withheld services to IPA patients that he would have not thought twice about doing for a cash or PPO patient. He was a great businessman but I felt there was an ethical issue in doing this. But my next practice did not treat any patient differently based on insurance and we still did just as well. I think I will take a certain amount of HMO's at first just because I feel it is a way to attract patients to your practice. Then later many patients might even be willing to change their insurance to stay with me, and honestly, I think serving HMO patients is almost like doing charity work and I like to feel I am helping all kinds. If you limit yourself to cash and high paying PPO's you will start to see that your population of patients is not as diverse. My goal as an FP will be do make 120K my first year, 200K within a year or two, and hire an awesome PA in my 3rd year and train them for a couple years. Then I will make them a full partner and pay them well, and hopefully the PA can be making 6 figs and add an extra 50K for myself!! As a PA my quarterly collections averaged about 120K but I was working my butt off and seeing about 150 patients a week average all year. I did a ton of procedures that paid real well. A simple hemorrhoidectomy pays like 300 bucks!!!