June 7, 1937
“I am profoundly sorry that we could not attend the exercises today, for such are the fortunes of those that chose the Profession to which you aspire. Your life shall be never entirely your own, but there will be many things that will make you forget the hardships, and your heart happy for the good that you will do for humanity…”
That was 1937, a letter given to my grandfather, George Legg M.D., who was graduating from Muhlenberg College. He had been accepted to Hahnemann University Medical School. It was written by J. Harris Brown, M.D., a close family friend.
Fast forward 78 years. What Dr. Brown said in his letter is still similar for most doctors. The hardships have stayed the same and changed. The exhaustive training, long hours, incredible stress, as we are morphed into caregivers for human beings, has remained constant through the decades; but now there are more hardships beyond just caring for this precious thing called life. I wonder what Dr. Brown and Dr. Legg would think of the state of affairs now as we continue to work to do “good for humanity” despite it all.
I am a Primary Care Physician. I take care of the Primary part, the Family part. We are the cheapest care out there. If given time with the patient, we can keep them out of the ER/hospital as best as we can. Oh, but wait, I have to meet my billing goals if I am an employed doctor (thank God I am not but I still have overhead). I have to see 25 patients today…. no time to keep them out of the ER. Can you say RVU (Relative Value Unit-the basis of employed physicians’ pay)??? I am willing to have my life not be my own, but only for my patients and no one else.
None of us can see a patient in 7 minutes, and do a really thorough job, I don’t care how smart we are. Unless it is a mosquito bite, of course. For one copay, patients want all of their five issues addressed in one visit, and rightly so for what they are paying for healthcare in 2015. Hmmmm…that allows 1.4 minutes per issue.
“I know you will make good George; It’s Hard; It’s Tough; It’s Dull; It’s Bright; but in the end success will crown your efforts, for you have the stuff in you…”
Success—now that’s interesting. In 1937 the success of a physician was defined by their ability to help their patients and earn a living. Although Dr. Legg passed away before I was born, I was told by his colleagues whom I met, that graduating doctors in that time were told to expect to do 20% of their work on a charity basis. What?? Not charge the patient who cannot afford it? Or better yet, trade services? No way!!! I was told Dr. Legg had a patient paint his house who could not afford to pay for his gallbladder removal. Wow, would love to do that! Now success is defined by insurance companies and hospitals measuring productivity and quality through programs that track diagnosis codes, generic prescribing, ER visits, hospitalizations, referrals to specialists and the costs of one specialist over another. Forget being able to tell a patient to not worry about today’s visit because they lost their job. Never happen. None of us are permitted to give “professional courtesy” to our fellow health care workers anymore, it violates the insurance contracts. Do plumbers fix each others’ toilets for free? If I don’t want to charge a patient for a service I am trained to provide, that should be my prerogative. Family doctors will get thrown a few extra bucks ($3-$9/visit) for playing the “game” by the insurers’ rules. That extra will DEFINITELY help pay down those student loans faster! I lost “points” with a carrier for referring to a group for a screening procedure that “cost more than the other group.” Aren’t the insurers setting the fee schedules? I’m seriously being held responsible for that? We are rated against our peers by one carrier. Who are these “peers?” I have asked many times, no answer. It’s like going into battle and not knowing your opponent. Then the rating measures by another carrier change mid rating period and we are not notified until the rating period is over. Who wants to play that game by those rules? No rules, no game. This is human life we are dealing with. It follows no rules, no measures. It is not a commodity nor black or white. How dare they? That could be my mother, my husband, my son, my 3rd grade teacher. And all in the name of profits, stock dividends. Non-profit, really?????? I feel like some of my patients who work for Amazon and get paid on how many orders they fill in their shift…..can’t stop to eat or go to the bathroom. Is that the “stuff in you” to which Doc Brown refers? I don’t think so. Doctors Brown and Legg would probably not believe their eyes were they here today. Is this the “success that crowns our efforts?” I want to lay my head on my pillow at night and know I did the best job I could that day for my patients, not for the insurance companies. That is my success.
I played, and played well. Rated on top by constantly re-writing office policies, updating them to stay on top of the “quality programs.” The only quality I saw was the quality of my paper shredder hanging on for dear life, the quality of my ability to maneuver around an unseen opponent improve, and the quality of my office staff meetings improve in creative thinking techniques. We rated #1 for 4 years over many other primary care offices with one insurance program in The Lehigh Valley. Yes, the “quality” of our efforts was crowned by “success.” What the hell was I doing? In 7-10 minutes per patient? Really? I was not resting too well on that pillow at night.
D…..P….C…..Direct Primary Care. I watched it and digested it for a year. Sounded too good to be true. Simplistic in design and returned decision making to being between the doctor and the patient. Ridiculously affordable monthly fees based on age. A smaller number of patients in the practice. All medical information is PRIVATE—no data mining of diagnosis codes for risk pooling by “you know who.” No insurance, no co-pays, no deductibles, no DENIALS of care!! A 30-60 minute same day/next day appointment to address all of a patient’s concerns in one sitting? Unlimited visits with no co-pay? Ahhhh…did I die and go to heaven? An EMR (Electronic Medical Record) with a blank progress note for me to write an old fashioned progress note, no clicking boxes to prove to insurance I am not over billing for the extra 3 bucks they held back because I prescribed one extra brand medication last quarter even though it was medically necessary (the insurance company could have cared less that this particular med was to help reverse a pre-cancerous condition-REAL STORY). I’d rather look and talk to the patient than click on the computer. The medical students don’t know how to hand write a full progress note. Ho hum. I am teaching them. Now I will teach them on a completely blank progress note; they will learn to rely on themselves not a template.
DPC is spreading like the swine flu did in 2009, but it is not deadly. Some are saying it is going to save health care. It is like the Billy Joel song, “We Didn’t Start the Fire,” we didn’t. Who did, and how did it get to this point? Rising premiums, ridiculous out of pocket expenses through deductibles, co-pays, exponentially inflated charges for services. DPC is less than a gym membership, your cell phone bill, or trip to Target. People spend more money on their pets (including myself, love my furry friends)! The patient will get TIME, ACCESS and COMPREHENSIVE CARE. Everything in the office is covered with the monthly membership fee, ie., EKG’s, spirometry, mininebs, lesion removal, sutures, and more. It will be between us, it will be efficient and relaxed. They can reach me directly after hours on my phone, email, text, Skype. No answering service. Stay the heck out of that ER, call me instead!!
Wait, DPC patients can get wholesale prices for what? This is what: radiology (MRI, CT, U/S, x-ray) and laboratory (around $2.00 for a CBC-normally over $60.00). Wholesale medications will be dispensed from the office. Remember when we left our doctor’s office with a little white envelope with our antibiotic in it? $2.00 for 10 days of Amoxicillin? Really? Pinch me, I am dreaming?? Just like Dr. Brown and Dr. Legg used to do. And the most amazing part is that all of the above and the monthly membership fee can be applied to an HSA, HRA, FSA with PRE-TAX dollars. What? I may not hit my deductible with AFTER TAX dollars this year? But Dr. Corba, my medical care is “free” after that… oh no it’s not. Think of what happens when you get in a car accident. You pay your deductible and your premium goes up because insurance companies are in the business of keeping their money. Paradigm shift.
Small employers are joining the movement around the country that is saving thousands for the little guy who employs less than 50. This new model can help larger companies too. DPC provides a huge value to these companies if they provide the employees with a HDHP. By saving money to employers, it may allow the employees to get a raise, may permit the hiring of another worker, or the employer may offer to pay for the monthly DPC membership fee or match an HSA contribution. It is a beautiful world when your workers can get to their PCP anytime and stay as healthy as possible, miss less work and have it cost less.
I am converting my practice as of January 2016 to DPC and can’t wait to take even better care of my patients than I do now, make it more of a value at a far lower cost and never again let insurance dictate how I do my job. I am actually going to save the insurers money, they just don’t know it yet!
“…may you hear much that will make others happy for your knowledge, and your heart proud that you were able to know.”
Thank you Dr. Brown for the epiphany, light bulb moment, clarity. Thank you Dr. Legg for being my inspiration and guiding light. It shouldn’t be as hard as it’s become for any of us, patients or physicians. After all, the care of one human life is an art that can’t be timed, quantified, or restricted.
George E. Legg’s granddaughter
Kimberly Legg Corba, D.O.