Musings of a newly minted Direct Care IMP Practice

[Guest guest]

I just wanted to share some musings with the list serve this weekend. This post is my thinking after ten years in practice, which have included: two years in a traditional private primary care practice, where I delivered babies, first-assisted with surgeries, and had no home life to speak of. I then moved on to four years of urgent care, then spent one year in a community clinic with a designation as a rural health care site, then opened an IMP that took all insurance, then, after three years, stopped contracting with all insurance this August and now charge what I consider to be a modest membership fee.

I feel I have gone through many stages: Overwhelmed, cautious, and angry (VERY angry at times), then back to overwhelmed and angry (this is a bad combination). I am now in a state of acceptance and constant striving, as opposed to personal beating, to improve myself and my services to my patients. (Who knows how long THIS will last? Grin).

I am once again in love with family medicine. I love how the specialty of family medicine does not discriminate based on age, sex or disease process. I love our emphasis on prevention, as well as the ability to care for those who are ill or have chronic disease processes. What amazing training I received! What incredible tools we have! What great things we can do when given the time to use our training and tools!!! (I am in no way intending to discredit or offend those in other disciplines. I just wanted to share why I choose family medicine to direct my career.) I had a new patient the other day thank me " for my obvious interest in her health. " She had never had a doctor that had behaved as if her health were more important than getting on to the next patient behind door #2.

As far as the financial aspect of my career choice goes, at this point, I am only just slightly annoyed that I have now become accustomed to shopping at the thrift stores for my children's clothing. If those of us in practice now can make it possible for additional bright medical students to choose primary care and actually make a decent living, fund their retirement, and, at the same time, have a happy home life, I will consider my current sacrifices well worthwhile.

At this moment, as a full time solo family physician who is the sole support of her family of four, I have a happy home life, and I am feeling truly valued by my patients, as well as receiving monetary payment by at least 90% of them. I did not buy a house that I could not afford, so my children's home is in no danger of foreclosure. My retirement took a massive hit, as did most individuals who have been doing the right thing and saving for the future. I will now be unable to retire when I wanted to, so I am going to make my professional life as rewarding as I possibly can in the sense of " right livelihood. " Right livelihood is a concept that is very dear to me. It means choosing a professional path or " job " that is fulfilling to both mind and soul, and does not impede my personal spiritual growth.

That is truly where my thinking is at this point. I currently do not believe that I will ever be financially rewarded for my chosen path. I have spoken several times with Knope, MD, the author of " Concierge Medicine. A New System to Get the Best Healthcare. " He is truly remarkable, and I have read his book at least three times. I still learn new things with each reading. (I have actually highlighted sections of his book--I have not used a highlighter since med school!) He gently told me in person once that my " Mother Theresa Gene " was slightly overactive and that would be one of my most formidable challenges in pursuing a direct care model of payment. (I found it fascinating that he used Mother Theresa to explain this to me, as she is one of my heroes. I am not Catholic, but " Come Be My Light, " a collection of her memoirs and letters, reveals a woman of exceptional conviction and seemingly unending inner strength, two qualities I deeply admire.)

Understanding how to assign financial value to my work as a physician is very, VERY difficult for me. I have chosen not to charge large fees for my services. I am currently financially surviving. I am hopeful that as I sign up more patients and pay off my ridiculous start up loan (It will be paid off the end of 2009), I will gently move to a more comfortable position where I can once again save for retirement (under my mattress? Grin.) and be able to help fund my children's higher education pursuits. Honestly, I would be positively giddy if I could make $150,000 a year.

I would love to read some discussion on how do we place an actual monetary value on what we do as primary care physicians. I feel like I have been waiting for " someone else, " either the government, my professional societies--anyone but me--to assign a reasonable value to what I do for a living.

I currently have 319 patients signed up for one of my two plans. About 300 of those are signed up to pay the true full amount. I have let my previous establihed patients pay their membership fee for the lower cost plan in quarterly payments ($75 for 3 months of access.) I will not be letting any new patients pay anything less than the full $300 at the time they sign up. When I first opened my new payment model to new patients, I had several drug seekers/dealers come in, find out I would not support their habit/livelihood (I will treat pain, but I will not be a narcotics supplier), and leave, only paying $25 for one month's access and $110 for their visit, or skipping out all together without paying anything. This was a waste of my time, so now my receptionist informs every caller that the $300 is due prior to the visit and a minimum of $50 dollars is due prior to the first appointment with me. I now also offer free 15 minute " meet and greet " appointments that have been helpful in screening out this particular population.

My goal is to eventually have 400 paying patients and not to have more than 500. (If you want to learn more about how I have things set up, you can visit my website: mountainviewmd.com ).

I am striving to be a nice mixture of our wonderful L. Gordon , MD, + Knope, MD + a healthy serving of , MD. I will never achieve Mother Theresa. I am committed to the ideals of the IMP movement, but I am also trying to find a payment situation that will allow me to uphold these ideals and not go crazy (with rules, regulations, coding etc), as well as broke, in the process. I also want to serve my community as best I can and provide some form of role model for future healthcare providers.

Hope this offered any helpful information to the readers. It helped me tease some things out in my mind.

Mountain View Family HealthCare, P.C.

Durango, CO

Opened IMP June 2005

Severed all insurance contracts, opted out of Medicare, and changed to direct care model August 2008.

[Guest guest]

and fellow list-serve "pals",

I have been a long-time lurker and occasional participant in this discussion group, and I wanted to provide an update on my life path.

I'm a family physician, practicing in North Palm Beach, Florida. I did my residency training in Rhode Island, and stayed there 14 years, in private practice. "Suffering from" a terrific reputation but finding myself working harder and harder and earning less and less (sound familiar?), I took an opportunity to join a hospital backed primary care practice in Palm Beach County. I became a salaried physician, with incentive bonuses, and was frankly, quite content. In the summer of 2001, Tenant Health Care took over our previously "nonprofit Hospital system", and quickly decided they did not want to "own" physician practices.

So in January, 2002, I reentered the brutal battleground of primary care medicine and all the crappy reimbursement which followed. By the end of 2003, I realized that practicing medicine in a fashion that was comfortable for me (giving patient's the time they needed, having same-day availability and accessibility) was not a financially viable model in the current reimbursement system. In January, 2004, I initiated a "voluntary administrative fee", initially $125 per patient, explaining to the patients all of the reasons I needed to do this. There was actually fairly good response to the voluntary fee (close to 50%), and this did help keep the doors open.

I continued with this voluntary fee approach from 2004 through 2008, with gradual increases, in 2008 at $225 ($35 if under 25).

As this year progressed, I realized my balance sheet was showing more and more red ink, and I was foregoing taking home a paycheck in the interests of continuing to pay my rent!

After dodging the bullet since 2004 (actually, a case could be stated that I've dodged it since 1993 when I left Rhode Island), I had reached a point where morphing my practice into a "concierge practice" became what I viewed as the only solution to maintaining a viable medical practice and my own sanity.

As I was awash in red ink, I came in contact with a relatively new concierge management group, ModernMed, and was immediately impressed by their business model as well as their "corporate culture". That isn't to say I didn't have a tremendous amount of ambivalence about the necessity of jettisoning many of my established patients in the pursuit of a more compact 500 patient panel, but, at 58 yrs of age, I felt this was a move I needed to do, or just go ahead and lock the front door, and look for a job at the VA.

Of course, following in a long family tradition of having dismal timing, I announced to my patients that I was doing this the exact week that the bottom fell out of the economy! I am pleased to say that even with this bad timing, I have reached my projections for this point in time.

I have great admiration for the IMP model, but for a variety of circumstances, including a long-term lease on a very large space, I have not been able to make that move. Over the past six weeks since my "start up", I have felt a tremendous amount of relief, that comes with a better sense of having control over my patient's health information as well as my own existence. Clearly there is no dollar value that can be placed on this, but at the end of the day I feel much more content.

Ira G. Warshaw, M.D.

a ModernMed Practice1216 U.S. Highway #1North Palm Beach, FL 33408Office: (561)626-1000Fax: (561)626-3007www.modernmed.com/warshaw

Ira G. Warshaw, M.D.2611 Embassy DriveWest Palm Beach, FL 33401Home: (561)689-5161Fax: (561)689-5163

To: Sent: Saturday, December 13, 2008 1:43:05 PMSubject: Musings of a newly minted Direct Care IMP Practice

I just wanted to share some musings with the list serve this weekend. This post is my thinking after ten years in practice, which have included: two years in a traditional private primary care practice, where I delivered babies, first-assisted with surgeries, and had no home life to speak of. I then moved on to four years of urgent care, then spent one year in a community clinic with a designation as a rural health care site, then opened an IMP that took all insurance, then, after three years, stopped contracting with all insurance this August and now charge what I consider to be a modest membership fee.

I feel I have gone through many stages: Overwhelmed, cautious, and angry (VERY angry at times), then back to overwhelmed and angry (this is a bad combination) . I am now in a state of acceptance and constant striving, as opposed to personal beating, to improve myself and my services to my patients. (Who knows how long THIS will last? Grin).

I am once again in love with family medicine. I love how the specialty of family medicine does not discriminate based on age, sex or disease process. I love our emphasis on prevention, as well as the ability to care for those who are ill or have chronic disease processes. What amazing training I received! What incredible tools we have! What great things we can do when given the time to use our training and tools!!! (I am in no way intending to discredit or offend those in other disciplines. I just wanted to share why I choose family medicine to direct my career.) I had a new patient the other day thank me "for my obvious interest in her health." She had never had a doctor that had behaved as if her health were more important than getting on to the next patient behind door #2.

As far as the financial aspect of my career choice goes, at this point, I am only just slightly annoyed that I have now become accustomed to shopping at the thrift stores for my children's clothing. If those of us in practice now can make it possible for additional bright medical students to choose primary care and actually make a decent living, fund their retirement, and, at the same time, have a happy home life, I will consider my current sacrifices well worthwhile.

At this moment, as a full time solo family physician who is the sole support of her family of four, I have a happy home life, and I am feeling truly valued by my patients, as well as receiving monetary payment by at least 90% of them. I did not buy a house that I could not afford, so my children's home is in no danger of foreclosure. My retirement took a massive hit, as did most individuals who have been doing the right thing and saving for the future. I will now be unable to retire when I wanted to, so I am going to make my professional life as rewarding as I possibly can in the sense of "right livelihood." Right livelihood is a concept that is very dear to me. It means choosing a professional path or "job" that is fulfilling to both mind and soul, and does not impede my personal spiritual growth.

That is truly where my thinking is at this point. I currently do not believe that I will ever be financially rewarded for my chosen path. I have spoken several times with Knope, MD, the author of "Concierge Medicine. A New System to Get the Best Healthcare." He is truly remarkable, and I have read his book at least three times. I still learn new things with each reading. (I have actually highlighted sections of his book--I have not used a highlighter since med school!) He gently told me in person once that my "Mother Theresa Gene" was slightly overactive and that would be one of my most formidable challenges in pursuing a direct care model of payment. (I found it fascinating that he used Mother Theresa to explain this to me, as she is one of my heroes. I am not Catholic, but "Come Be My Light," a collection of her memoirs and letters, reveals a woman of exceptional

conviction and seemingly unending inner strength, two qualities I deeply admire.)

Understanding how to assign financial value to my work as a physician is very, VERY difficult for me. I have chosen not to charge large fees for my services. I am currently financially surviving. I am hopeful that as I sign up more patients and pay off my ridiculous start up loan (It will be paid off the end of 2009), I will gently move to a more comfortable position where I can once again save for retirement (under my mattress? Grin.) and be able to help fund my children's higher education pursuits. Honestly, I would be positively giddy if I could make $150,000 a year.

I would love to read some discussion on how do we place an actual monetary value on what we do as primary care physicians. I feel like I have been waiting for "someone else," either the government, my professional societies--anyone but me--to assign a reasonable value to what I do for a living.

I currently have 319 patients signed up for one of my two plans. About 300 of those are signed up to pay the true full amount. I have let my previous establihed patients pay their membership fee for the lower cost plan in quarterly payments ($75 for 3 months of access.) I will not be letting any new patients pay anything less than the full $300 at the time they sign up. When I first opened my new payment model to new patients, I had several drug seekers/dealers come in, find out I would not support their habit/livelihood (I will treat pain, but I will not be a narcotics supplier), and leave, only paying $25 for one month's access and $110 for their visit, or skipping out all together without paying anything. This was a waste of my time, so now my receptionist informs every caller that the $300 is due prior to the visit and a minimum of $50 dollars is due prior to the first appointment with me.

I now also offer free 15 minute "meet and greet" appointments that have been helpful in screening out this particular population.

My goal is to eventually have 400 paying patients and not to have more than 500. (If you want to learn more about how I have things set up, you can visit my website: mountainviewmd. com ).

I am striving to be a nice mixture of our wonderful L. Gordon , MD, + Knope, MD + a healthy serving of , MD. I will never achieve Mother Theresa. I am committed to the ideals of the IMP movement, but I am also trying to find a payment situation that will allow me to uphold these ideals and not go crazy (with rules, regulations, coding etc), as well as broke, in the process. I also want to serve my community as best I can and provide some form of role model for future healthcare providers.

Hope this offered any helpful information to the readers. It helped me tease some things out in my mind.

Mountain View Family HealthCare, P.C.

Durango, CO

Opened IMP June 2005

Severed all insurance contracts, opted out of Medicare, and changed to direct care model August 2008.

[Guest guest]

and fellow list-serve "pals",

I have been a long-time lurker and occasional participant in this discussion group, and I wanted to provide an update on my life path.

I'm a family physician, practicing in North Palm Beach, Florida. I did my residency training in Rhode Island, and stayed there 14 years, in private practice. "Suffering from" a terrific reputation but finding myself working harder and harder and earning less and less (sound familiar?), I took an opportunity to join a hospital backed primary care practice in Palm Beach County. I became a salaried physician, with incentive bonuses, and was frankly, quite content. In the summer of 2001, Tenant Health Care took over our previously "nonprofit Hospital system", and quickly decided they did not want to "own" physician practices.

So in January, 2002, I reentered the brutal battleground of primary care medicine and all the crappy reimbursement which followed. By the end of 2003, I realized that practicing medicine in a fashion that was comfortable for me (giving patient's the time they needed, having same-day availability and accessibility) was not a financially viable model in the current reimbursement system. In January, 2004, I initiated a "voluntary administrative fee", initially $125 per patient, explaining to the patients all of the reasons I needed to do this. There was actually fairly good response to the voluntary fee (close to 50%), and this did help keep the doors open.

I continued with this voluntary fee approach from 2004 through 2008, with gradual increases, in 2008 at $225 ($35 if under 25).

As this year progressed, I realized my balance sheet was showing more and more red ink, and I was foregoing taking home a paycheck in the interests of continuing to pay my rent!

After dodging the bullet since 2004 (actually, a case could be stated that I've dodged it since 1993 when I left Rhode Island), I had reached a point where morphing my practice into a "concierge practice" became what I viewed as the only solution to maintaining a viable medical practice and my own sanity.

As I was awash in red ink, I came in contact with a relatively new concierge management group, ModernMed, and was immediately impressed by their business model as well as their "corporate culture". That isn't to say I didn't have a tremendous amount of ambivalence about the necessity of jettisoning many of my established patients in the pursuit of a more compact 500 patient panel, but, at 58 yrs of age, I felt this was a move I needed to do, or just go ahead and lock the front door, and look for a job at the VA.

Of course, following in a long family tradition of having dismal timing, I announced to my patients that I was doing this the exact week that the bottom fell out of the economy! I am pleased to say that even with this bad timing, I have reached my projections for this point in time.

I have great admiration for the IMP model, but for a variety of circumstances, including a long-term lease on a very large space, I have not been able to make that move. Over the past six weeks since my "start up", I have felt a tremendous amount of relief, that comes with a better sense of having control over my patient's health information as well as my own existence. Clearly there is no dollar value that can be placed on this, but at the end of the day I feel much more content.

Ira G. Warshaw, M.D.

a ModernMed Practice1216 U.S. Highway #1North Palm Beach, FL 33408Office: (561)626-1000Fax: (561)626-3007www.modernmed.com/warshaw

Ira G. Warshaw, M.D.2611 Embassy DriveWest Palm Beach, FL 33401Home: (561)689-5161Fax: (561)689-5163

To: Sent: Saturday, December 13, 2008 1:43:05 PMSubject: Musings of a newly minted Direct Care IMP Practice

I just wanted to share some musings with the list serve this weekend. This post is my thinking after ten years in practice, which have included: two years in a traditional private primary care practice, where I delivered babies, first-assisted with surgeries, and had no home life to speak of. I then moved on to four years of urgent care, then spent one year in a community clinic with a designation as a rural health care site, then opened an IMP that took all insurance, then, after three years, stopped contracting with all insurance this August and now charge what I consider to be a modest membership fee.

I feel I have gone through many stages: Overwhelmed, cautious, and angry (VERY angry at times), then back to overwhelmed and angry (this is a bad combination) . I am now in a state of acceptance and constant striving, as opposed to personal beating, to improve myself and my services to my patients. (Who knows how long THIS will last? Grin).

I am once again in love with family medicine. I love how the specialty of family medicine does not discriminate based on age, sex or disease process. I love our emphasis on prevention, as well as the ability to care for those who are ill or have chronic disease processes. What amazing training I received! What incredible tools we have! What great things we can do when given the time to use our training and tools!!! (I am in no way intending to discredit or offend those in other disciplines. I just wanted to share why I choose family medicine to direct my career.) I had a new patient the other day thank me "for my obvious interest in her health." She had never had a doctor that had behaved as if her health were more important than getting on to the next patient behind door #2.

As far as the financial aspect of my career choice goes, at this point, I am only just slightly annoyed that I have now become accustomed to shopping at the thrift stores for my children's clothing. If those of us in practice now can make it possible for additional bright medical students to choose primary care and actually make a decent living, fund their retirement, and, at the same time, have a happy home life, I will consider my current sacrifices well worthwhile.

At this moment, as a full time solo family physician who is the sole support of her family of four, I have a happy home life, and I am feeling truly valued by my patients, as well as receiving monetary payment by at least 90% of them. I did not buy a house that I could not afford, so my children's home is in no danger of foreclosure. My retirement took a massive hit, as did most individuals who have been doing the right thing and saving for the future. I will now be unable to retire when I wanted to, so I am going to make my professional life as rewarding as I possibly can in the sense of "right livelihood." Right livelihood is a concept that is very dear to me. It means choosing a professional path or "job" that is fulfilling to both mind and soul, and does not impede my personal spiritual growth.

That is truly where my thinking is at this point. I currently do not believe that I will ever be financially rewarded for my chosen path. I have spoken several times with Knope, MD, the author of "Concierge Medicine. A New System to Get the Best Healthcare." He is truly remarkable, and I have read his book at least three times. I still learn new things with each reading. (I have actually highlighted sections of his book--I have not used a highlighter since med school!) He gently told me in person once that my "Mother Theresa Gene" was slightly overactive and that would be one of my most formidable challenges in pursuing a direct care model of payment. (I found it fascinating that he used Mother Theresa to explain this to me, as she is one of my heroes. I am not Catholic, but "Come Be My Light," a collection of her memoirs and letters, reveals a woman of exceptional

conviction and seemingly unending inner strength, two qualities I deeply admire.)

Understanding how to assign financial value to my work as a physician is very, VERY difficult for me. I have chosen not to charge large fees for my services. I am currently financially surviving. I am hopeful that as I sign up more patients and pay off my ridiculous start up loan (It will be paid off the end of 2009), I will gently move to a more comfortable position where I can once again save for retirement (under my mattress? Grin.) and be able to help fund my children's higher education pursuits. Honestly, I would be positively giddy if I could make $150,000 a year.

I would love to read some discussion on how do we place an actual monetary value on what we do as primary care physicians. I feel like I have been waiting for "someone else," either the government, my professional societies--anyone but me--to assign a reasonable value to what I do for a living.

I currently have 319 patients signed up for one of my two plans. About 300 of those are signed up to pay the true full amount. I have let my previous establihed patients pay their membership fee for the lower cost plan in quarterly payments ($75 for 3 months of access.) I will not be letting any new patients pay anything less than the full $300 at the time they sign up. When I first opened my new payment model to new patients, I had several drug seekers/dealers come in, find out I would not support their habit/livelihood (I will treat pain, but I will not be a narcotics supplier), and leave, only paying $25 for one month's access and $110 for their visit, or skipping out all together without paying anything. This was a waste of my time, so now my receptionist informs every caller that the $300 is due prior to the visit and a minimum of $50 dollars is due prior to the first appointment with me.

I now also offer free 15 minute "meet and greet" appointments that have been helpful in screening out this particular population.

My goal is to eventually have 400 paying patients and not to have more than 500. (If you want to learn more about how I have things set up, you can visit my website: mountainviewmd. com ).

I am striving to be a nice mixture of our wonderful L. Gordon , MD, + Knope, MD + a healthy serving of , MD. I will never achieve Mother Theresa. I am committed to the ideals of the IMP movement, but I am also trying to find a payment situation that will allow me to uphold these ideals and not go crazy (with rules, regulations, coding etc), as well as broke, in the process. I also want to serve my community as best I can and provide some form of role model for future healthcare providers.

Hope this offered any helpful information to the readers. It helped me tease some things out in my mind.

Mountain View Family HealthCare, P.C.

Durango, CO

Opened IMP June 2005

Severed all insurance contracts, opted out of Medicare, and changed to direct care model August 2008.