A Country Doctor Writes:

I love medicine. I love being a doctor. I thrive on making diagnoses and treating disease. I find deep satisfaction in educating and empowering patients.

But, as I have said many times, I am a problem solver and not a bookkeeper.

Doctors today are required to do more and more EMR data entry in more and more stilted ways with less and less team support. All the while we are under pressure to be both productive in terms of patient volume and comprehensive in terms of both disease management and an ever increasing burden of public health that really shouldn’t require a medical degree at all.

We have become bottlenecks in the flow of information. Our electronic inboxes exist so that our EMRs can document exactly when we saw a test result and what we did about it. This creates a tight bookkeeping workflow but ignores the fact that we can’t be in two places at the same time: We are scheduled to see patients all day long, so our inboxes fill up with unsorted data, unseen by the nurses and medical assistants, who used to help prioritize incoming data before the EMRs changed all that.

I have finally made the decision to move away from working in this unsafe, unsustainable and wholly unsatisfying way. I am transitioning away from traditional fee-for-service Family Medicine.

I will be the lead physician in the entire state of Maine for a new kind of practice that eliminates the hamster wheel of counting face-to-face encounters. I will personally and through supervision be responsible for the care of a fairly small number of complex, high risk Medicare, and later Medicaid, patients. My organization will be paid per member per month. This will avoid unnecessary visits, and it will make it practical to use remote monitoring, phone calls, video visits, and any other means of communication to stay in touch with my patients.

The foundation is house calls. I loved doing house calls when I worked full-time in Bucksport many years ago. These days house calls are viewed as not very profitable because by the time you drive to somebody’s house and see them and then drive back to the office, you could have seen two or three people in the office. But with the capitated payment model, a house call will teach you a lot about how the patient lives, and what their circumstances are, and that will help you make better decisions for their future care.

I will document my process of getting to this decision and my progress in entering this new type of practice on my Substack in a post category titled PROGRESS NOTES. This is a learning experience for me and a growing experience. My patients will be those in managed Medicare, also called “Medicare Advantage”. I already have many patients with that type of insurance, and many of them are very complex. It has been difficult to give them everything they need because in the traditional type of clinic I work in, we don’t get paid more when we spend more time with the patient. Any visit is paid the same, so there is no financial reward for being comprehensive, except some minor bonuses for the practice when quality standards are met.

I have been skeptical of managed Medicare, in part because they are stingy with authorizing and paying for CT scans when I think my patient has cancer, but in terms of outcomes for chronic diseases, the statistics are clear, because of the extra support managed Medicare provides, patients with that type of insurance have better outcomes. One insurer, WellCare, even sends people healthy food through a program called Mom’s Meals.

In “PROGRESS NOTES“ I will document what I am learning and what I experience in this new phase of my clinical career. Please join me.

https://acdw.substack.com/