Re: Microclimates and survivability

[Guest guest]

A big challenge is getting the general public to understand the issues...

and these issues are complex.

One question is for society to decide how much a primary care doc should

be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

population salaries????) and for each service we provide. $1500/month of

student loans at the age 40 with daughter to enter college in 4 yrs

changes my needs ... but if I had no kids and no student loans my personal

financial needs would be very different ... but I don't think the general

population really understands that most docs today go into big debt and

don't start really making money until they are 30 yrs old (at least) a

good number of years later than other professionals so the financial

picture is odd.

Another question is that without big, very big, powers-that-be, there

ain't nothing important going to happen. I don't mean to bring up politics

and do not mean to offend, but the current administration uses sound bites

great and has a good portion of the masses supporting their " ideas " but

the true policies again and again seem to prop up the industries and large

businesses of America. Great case for us would be Medicare Part D and how

the insurance industry and pharmaceutical companies are making a killing

while only a small percentage of the general population save money and

doctors' offices had to do more work without reimbursement... but I

digress...

The point I'm trying to make is that any change needs big-time

government/industry support and right now we are years (decades?) from any

reasonable conditions that will allow that.

Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to simply

love what I do, do it as well as possible, basically stand proud by

Gordon's definition, remain aware of the changing tides and be nimble

enough to do well while serving as a good example for others. And I

appreciate this list because it's helping me be able to do those things.

.... but I too will add my voice to Gordon's statment for reform (even if I

don't think it'll ever happen).

Tim

> One of the shocking discoveries on our network is the degree of

> regional variation.

> It is very evident that some environments are so difficult as to make

> it extremely unlikely that any practice can survive without

> subsidy. We see subsidy from hospitals, from within the practice (e.g.

> " Robin Hood " types or doing a lucrative side business).

> One wonders if there are microclimates where IMPs - in spite of doing

> everything right - would fail to survive due to a combination of

> financial factors.

>

> I suspect that Southern CA is one such place. Cost of living is very

> high and average reimbursement is very low.

> We must explore innovations in financing so that IMPs can survive

> anywhere. While we work on payment reform, some will experiment in their

> own ways.

>

> I could hold my head up in public if:

> I've done all humanly possible to shave costs to the bone

> I do my share of work for uninsured and Gov't contracts

> I deliver on the principles of patient-centered collaborative care

>

> Then I could say " I've done all I can, and there still exists a gap

> that is unsupportable in my region due to extraordinary:

> malpractice

> cost of living

> reimbursement

> I add my voice to those crying out for health care financing reform to

> free me from having to charge more for certain activities. These

> benefits should be available to all as a right. Until we as a

> country are willing to do this hard work, I'll continue to do the best I

> can. " Gordon

>

> At 08:04 AM 10/13/2006, you wrote:

>

>>So, you are going to be a cash only style of practice (ie, no

>>insurances)? Otherwise, I would think a " registration fee " would be a

>> violation of your contracts. California sounds like a whole other

>> planet from where I practice in central Ohio because people here would

>> laugh & walk right out the door if I requested a similar

>> " registration fee " here!

>>

>>

>>

>>

[Guest guest]

A big challenge is getting the general public to understand the issues...

and these issues are complex.

One question is for society to decide how much a primary care doc should

be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

population salaries????) and for each service we provide. $1500/month of

student loans at the age 40 with daughter to enter college in 4 yrs

changes my needs ... but if I had no kids and no student loans my personal

financial needs would be very different ... but I don't think the general

population really understands that most docs today go into big debt and

don't start really making money until they are 30 yrs old (at least) a

good number of years later than other professionals so the financial

picture is odd.

Another question is that without big, very big, powers-that-be, there

ain't nothing important going to happen. I don't mean to bring up politics

and do not mean to offend, but the current administration uses sound bites

great and has a good portion of the masses supporting their " ideas " but

the true policies again and again seem to prop up the industries and large

businesses of America. Great case for us would be Medicare Part D and how

the insurance industry and pharmaceutical companies are making a killing

while only a small percentage of the general population save money and

doctors' offices had to do more work without reimbursement... but I

digress...

The point I'm trying to make is that any change needs big-time

government/industry support and right now we are years (decades?) from any

reasonable conditions that will allow that.

Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to simply

love what I do, do it as well as possible, basically stand proud by

Gordon's definition, remain aware of the changing tides and be nimble

enough to do well while serving as a good example for others. And I

appreciate this list because it's helping me be able to do those things.

.... but I too will add my voice to Gordon's statment for reform (even if I

don't think it'll ever happen).

Tim

> One of the shocking discoveries on our network is the degree of

> regional variation.

> It is very evident that some environments are so difficult as to make

> it extremely unlikely that any practice can survive without

> subsidy. We see subsidy from hospitals, from within the practice (e.g.

> " Robin Hood " types or doing a lucrative side business).

> One wonders if there are microclimates where IMPs - in spite of doing

> everything right - would fail to survive due to a combination of

> financial factors.

>

> I suspect that Southern CA is one such place. Cost of living is very

> high and average reimbursement is very low.

> We must explore innovations in financing so that IMPs can survive

> anywhere. While we work on payment reform, some will experiment in their

> own ways.

>

> I could hold my head up in public if:

> I've done all humanly possible to shave costs to the bone

> I do my share of work for uninsured and Gov't contracts

> I deliver on the principles of patient-centered collaborative care

>

> Then I could say " I've done all I can, and there still exists a gap

> that is unsupportable in my region due to extraordinary:

> malpractice

> cost of living

> reimbursement

> I add my voice to those crying out for health care financing reform to

> free me from having to charge more for certain activities. These

> benefits should be available to all as a right. Until we as a

> country are willing to do this hard work, I'll continue to do the best I

> can. " Gordon

>

> At 08:04 AM 10/13/2006, you wrote:

>

>>So, you are going to be a cash only style of practice (ie, no

>>insurances)? Otherwise, I would think a " registration fee " would be a

>> violation of your contracts. California sounds like a whole other

>> planet from where I practice in central Ohio because people here would

>> laugh & walk right out the door if I requested a similar

>> " registration fee " here!

>>

>>

>>

>>

[Guest guest]

A big challenge is getting the general public to understand the issues...

and these issues are complex.

One question is for society to decide how much a primary care doc should

be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

population salaries????) and for each service we provide. $1500/month of

student loans at the age 40 with daughter to enter college in 4 yrs

changes my needs ... but if I had no kids and no student loans my personal

financial needs would be very different ... but I don't think the general

population really understands that most docs today go into big debt and

don't start really making money until they are 30 yrs old (at least) a

good number of years later than other professionals so the financial

picture is odd.

Another question is that without big, very big, powers-that-be, there

ain't nothing important going to happen. I don't mean to bring up politics

and do not mean to offend, but the current administration uses sound bites

great and has a good portion of the masses supporting their " ideas " but

the true policies again and again seem to prop up the industries and large

businesses of America. Great case for us would be Medicare Part D and how

the insurance industry and pharmaceutical companies are making a killing

while only a small percentage of the general population save money and

doctors' offices had to do more work without reimbursement... but I

digress...

The point I'm trying to make is that any change needs big-time

government/industry support and right now we are years (decades?) from any

reasonable conditions that will allow that.

Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to simply

love what I do, do it as well as possible, basically stand proud by

Gordon's definition, remain aware of the changing tides and be nimble

enough to do well while serving as a good example for others. And I

appreciate this list because it's helping me be able to do those things.

.... but I too will add my voice to Gordon's statment for reform (even if I

don't think it'll ever happen).

Tim

> One of the shocking discoveries on our network is the degree of

> regional variation.

> It is very evident that some environments are so difficult as to make

> it extremely unlikely that any practice can survive without

> subsidy. We see subsidy from hospitals, from within the practice (e.g.

> " Robin Hood " types or doing a lucrative side business).

> One wonders if there are microclimates where IMPs - in spite of doing

> everything right - would fail to survive due to a combination of

> financial factors.

>

> I suspect that Southern CA is one such place. Cost of living is very

> high and average reimbursement is very low.

> We must explore innovations in financing so that IMPs can survive

> anywhere. While we work on payment reform, some will experiment in their

> own ways.

>

> I could hold my head up in public if:

> I've done all humanly possible to shave costs to the bone

> I do my share of work for uninsured and Gov't contracts

> I deliver on the principles of patient-centered collaborative care

>

> Then I could say " I've done all I can, and there still exists a gap

> that is unsupportable in my region due to extraordinary:

> malpractice

> cost of living

> reimbursement

> I add my voice to those crying out for health care financing reform to

> free me from having to charge more for certain activities. These

> benefits should be available to all as a right. Until we as a

> country are willing to do this hard work, I'll continue to do the best I

> can. " Gordon

>

> At 08:04 AM 10/13/2006, you wrote:

>

>>So, you are going to be a cash only style of practice (ie, no

>>insurances)? Otherwise, I would think a " registration fee " would be a

>> violation of your contracts. California sounds like a whole other

>> planet from where I practice in central Ohio because people here would

>> laugh & walk right out the door if I requested a similar

>> " registration fee " here!

>>

>>

>>

>>

[Guest guest]

Tim,

I think you are wrong on your assessment.

I think we are about 6 years or so from reform, and it is important to get in

during the planning stages (now) so our voices are heard later. Why will things

change in the next 5 years? If rates continue to increase like they are,

insurance will be $20,000/family/year which leaves a lot of middle class folks

with no insurance and a lot of businesses laying off

people (a big time economic crisis). Less people with insurance leads to higher

rates for those with and the situation gets worse exponentially. Add to it the question

of what to do with seniors when Medicare goes belly up in 2018, and the

situation is ripe for a revolution. Maybe I’m wrong, but I would bet a

lot of very influential people are looking for any possible solution to the

current problem (it’s just no one has really offered one yet). Enter the IMPs to provide the safety net.

Obviously, seeing the future is not anyone’s

strong point, but I would think whoever runs for president in 2012 had better

have health care as a primary agenda item or he/she will not be elected.

Re:

Microclimates and survivability

A big challenge is getting the general public to understand the

issues...

and these issues are complex.

One question is for society to decide how much a primary care doc should

be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

population salaries????) and for each service we provide. $1500/month of

student loans at the age 40 with daughter to enter college in 4 yrs

changes my needs ... but if I had no kids and no student loans my personal

financial needs would be very different ... but I don't think the general

population really understands that most docs today go into big debt and

don't start really making money until they are 30 yrs old (at least) a

good number of years later than other professionals so the financial

picture is odd.

Another question is that without big, very big, powers-that-be, there

ain't nothing important going to happen. I don't mean to bring up politics

and do not mean to offend, but the current administration uses sound bites

great and has a good portion of the masses supporting their " ideas "

but

the true policies again and again seem to prop up the industries and large

businesses of America. Great case for us would be Medicare Part D and how

the insurance industry and pharmaceutical companies are making a killing

while only a small percentage of the general population save money and

doctors' offices had to do more work without reimbursement... but I

digress...

The point I'm trying to make is that any change needs big-time

government/industry support and right now we are years (decades?) from any

reasonable conditions that will allow that.

Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to simply

love what I do, do it as well as possible, basically stand proud by

Gordon's definition, remain aware of the changing tides and be nimble

enough to do well while serving as a good example for others. And I

appreciate this list because it's helping me be able to do those things.

.... but I too will add my voice to Gordon's statment for reform (even if I

don't think it'll ever happen).

Tim

> One of the shocking discoveries on our network is the degree of

> regional variation.

> It is very evident that some environments are so difficult as to make

> it extremely unlikely that any practice can survive without

> subsidy. We see subsidy from hospitals, from within the practice (e.g.

> " Robin Hood " types or doing a lucrative side business).

> One wonders if there are microclimates where IMPs - in spite of doing

> everything right - would fail to survive due to a combination of

> financial factors.

>

> I suspect that Southern CA is one such place. Cost of living is very

> high and average reimbursement is very low.

> We must explore innovations in financing so that IMPs can survive

> anywhere. While we work on payment reform, some will experiment in their

> own ways.

>

> I could hold my head up in public if:

> I've done all humanly possible to shave costs to the bone

> I do my share of work for uninsured and Gov't contracts

> I deliver on the principles of patient-centered collaborative care

>

> Then I could say " I've done all I can, and there still exists a gap

> that is unsupportable in my region due to extraordinary:

> malpractice

> cost of living

> reimbursement

> I add my voice to those crying out for health care financing reform to

> free me from having to charge more for certain activities. These

> benefits should be available to all as a right. Until we as a

> country are willing to do this hard work, I'll continue to do the best I

> can. " Gordon

>

> At 08:04 AM 10/13/2006, you wrote:

>

>>So, you are going to be a cash only style of practice (ie, no

>>insurances)? Otherwise, I would think a " registration

fee " would be a

>> violation of your contracts. California sounds like a whole other

>> planet from where I practice in central Ohio because people here would

>> laugh & walk right out the door if I requested a similar

>> " registration fee " here!

>>

>>

>>

>>

[Guest guest]

Tim,

I think you are wrong on your assessment.

I think we are about 6 years or so from reform, and it is important to get in

during the planning stages (now) so our voices are heard later. Why will things

change in the next 5 years? If rates continue to increase like they are,

insurance will be $20,000/family/year which leaves a lot of middle class folks

with no insurance and a lot of businesses laying off

people (a big time economic crisis). Less people with insurance leads to higher

rates for those with and the situation gets worse exponentially. Add to it the question

of what to do with seniors when Medicare goes belly up in 2018, and the

situation is ripe for a revolution. Maybe I’m wrong, but I would bet a

lot of very influential people are looking for any possible solution to the

current problem (it’s just no one has really offered one yet). Enter the IMPs to provide the safety net.

Obviously, seeing the future is not anyone’s

strong point, but I would think whoever runs for president in 2012 had better

have health care as a primary agenda item or he/she will not be elected.

Re:

Microclimates and survivability

A big challenge is getting the general public to understand the

issues...

and these issues are complex.

One question is for society to decide how much a primary care doc should

be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

population salaries????) and for each service we provide. $1500/month of

student loans at the age 40 with daughter to enter college in 4 yrs

changes my needs ... but if I had no kids and no student loans my personal

financial needs would be very different ... but I don't think the general

population really understands that most docs today go into big debt and

don't start really making money until they are 30 yrs old (at least) a

good number of years later than other professionals so the financial

picture is odd.

Another question is that without big, very big, powers-that-be, there

ain't nothing important going to happen. I don't mean to bring up politics

and do not mean to offend, but the current administration uses sound bites

great and has a good portion of the masses supporting their " ideas "

but

the true policies again and again seem to prop up the industries and large

businesses of America. Great case for us would be Medicare Part D and how

the insurance industry and pharmaceutical companies are making a killing

while only a small percentage of the general population save money and

doctors' offices had to do more work without reimbursement... but I

digress...

The point I'm trying to make is that any change needs big-time

government/industry support and right now we are years (decades?) from any

reasonable conditions that will allow that.

Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to simply

love what I do, do it as well as possible, basically stand proud by

Gordon's definition, remain aware of the changing tides and be nimble

enough to do well while serving as a good example for others. And I

appreciate this list because it's helping me be able to do those things.

.... but I too will add my voice to Gordon's statment for reform (even if I

don't think it'll ever happen).

Tim

> One of the shocking discoveries on our network is the degree of

> regional variation.

> It is very evident that some environments are so difficult as to make

> it extremely unlikely that any practice can survive without

> subsidy. We see subsidy from hospitals, from within the practice (e.g.

> " Robin Hood " types or doing a lucrative side business).

> One wonders if there are microclimates where IMPs - in spite of doing

> everything right - would fail to survive due to a combination of

> financial factors.

>

> I suspect that Southern CA is one such place. Cost of living is very

> high and average reimbursement is very low.

> We must explore innovations in financing so that IMPs can survive

> anywhere. While we work on payment reform, some will experiment in their

> own ways.

>

> I could hold my head up in public if:

> I've done all humanly possible to shave costs to the bone

> I do my share of work for uninsured and Gov't contracts

> I deliver on the principles of patient-centered collaborative care

>

> Then I could say " I've done all I can, and there still exists a gap

> that is unsupportable in my region due to extraordinary:

> malpractice

> cost of living

> reimbursement

> I add my voice to those crying out for health care financing reform to

> free me from having to charge more for certain activities. These

> benefits should be available to all as a right. Until we as a

> country are willing to do this hard work, I'll continue to do the best I

> can. " Gordon

>

> At 08:04 AM 10/13/2006, you wrote:

>

>>So, you are going to be a cash only style of practice (ie, no

>>insurances)? Otherwise, I would think a " registration

fee " would be a

>> violation of your contracts. California sounds like a whole other

>> planet from where I practice in central Ohio because people here would

>> laugh & walk right out the door if I requested a similar

>> " registration fee " here!

>>

>>

>>

>>

[Guest guest]

I agree with . Physicians who do not cut their costs and become

flexible by adopting the long tail tactic, those physicians will be in

trouble. Large groups/hospitals will replace them by NP or suck the

last drop of blood out of them. Smaller groups will be in trouble as

well.

> Tim,

>

> I think you are wrong on your assessment. I think we are about 6 years

> or so from reform, and it is important to get in during the planning

> stages (now) so our voices are heard later. Why will things change in

> the next 5 years? If rates continue to increase like they are,

> insurance will be $20,000/family/year which leaves a lot of middle

> class folks with no insurance and a lot of businesses laying off

> people (a big time economic crisis). Less people with insurance leads

> to higher rates for those with and the situation gets worse

> exponentially. Add to it the question of what to do with seniors when

> Medicare goes belly up in 2018, and the situation is ripe for a

> revolution. Maybe I’m wrong, but I would bet a lot of very influential

> people are looking for any possible solution to the current problem

> (it’s just no one has really offered one yet). Enter the IMPs to

> provide the safety net.

>

> Obviously, seeing the future is not anyone’s strong point, but I would

> think whoever runs for president in 2012 had better have health care

> as a primary agenda item or he/she will not be elected.

>

>

>

>  

>

>  

>

> Re: Microclimates and survivability

>

>  

>

> A big challenge is getting the general public to understand the

> issues...

> and these issues are complex.

>

> One question is for society to decide how much a primary care doc

> should

> be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

> population salaries????) and for each service we provide. $1500/month

> of

> student loans at the age 40 with daughter to enter college in 4 yrs

> changes my needs ... but if I had no kids and no student loans my

> personal

> financial needs would be very different ... but I don't think the

> general

> population really understands that most docs today go into big debt

> and

> don't start really making money until they are 30 yrs old (at least) a

> good number of years later than other professionals so the financial

> picture is odd.

>

> Another question is that without big, very big, powers-that-be, there

> ain't nothing important going to happen. I don't mean to bring up

> politics

> and do not mean to offend, but the current administration uses sound

> bites

> great and has a good portion of the masses supporting their " ideas "

> but

> the true policies again and again seem to prop up the industries and

> large

> businesses of America. Great case for us would be Medicare Part D and

> how

> the insurance industry and pharmaceutical companies are making a

> killing

> while only a small percentage of the general population save money and

> doctors' offices had to do more work without reimbursement... but I

> digress...

>

> The point I'm trying to make is that any change needs big-time

> government/industry support and right now we are years (decades?)

> from any

> reasonable conditions that will allow that.

>

> Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to

> simply

> love what I do, do it as well as possible, basically stand proud by

> Gordon's definition, remain aware of the changing tides and be nimble

> enough to do well while serving as a good example for others. And I

> appreciate this list because it's helping me be able to do those

> things.

>

> ... but I too will add my voice to Gordon's statment for reform (even

> if I

> don't think it'll ever happen).

>

> Tim

>

> > One of the shocking discoveries on our network is the degree of

> > regional variation.

> > It is very evident that some environments are so difficult as to

> make

> > it extremely unlikely that any practice can survive without

> > subsidy. We see subsidy from hospitals, from within the practice

> (e.g.

> > " Robin Hood " types or doing a lucrative side business).

> > One wonders if there are microclimates where IMPs - in spite of

> doing

> > everything right - would fail to survive due to a combination of

> > financial factors.

> >

> > I suspect that Southern CA is one such place. Cost of living is very

> > high and average reimbursement is very low.

> > We must explore innovations in financing so that IMPs can survive

> > anywhere. While we work on payment reform, some will experiment in

> their

> > own ways.

> >

> > I could hold my head up in public if:

> > I've done all humanly possible to shave costs to the bone

> > I do my share of work for uninsured and Gov't contracts

> > I deliver on the principles of patient-centered collaborative care

> >

> > Then I could say " I've done all I can, and there still exists a gap

> > that is unsupportable in my region due to extraordinary:

> > malpractice

> > cost of living

> > reimbursement

> > I add my voice to those crying out for health care financing reform

> to

> > free me from having to charge more for certain activities. These

> > benefits should be available to all as a right. Until we as a

> > country are willing to do this hard work, I'll continue to do the

> best I

> > can. " Gordon

> >

> > At 08:04 AM 10/13/2006, you wrote:

> >

> >>So, you are going to be a cash only style of practice (ie, no

> >>insurances)? Otherwise, I would think a " registration fee " would be

> a

> >> violation of your contracts. California sounds like a whole other

> >> planet from where I practice in central Ohio because people here

> would

> >> laugh & walk right out the door if I requested a similar

> >> " registration fee " here!

> >>

> >>

> >>

> >>

>

>

>

[Guest guest]

Sometimes, I like being wrong!

.... I hope you are right and that what we are all doing in our IMP's can

be helpful to the situation in both the short term and long term.

Tim

> Tim,

> I think you are wrong on your assessment. I think we are about 6 years

> or so from reform, and it is important to get in during the planning

> stages (now) so our voices are heard later. Why will things change in

> the next 5 years? If rates continue to increase like they are, insurance

> will be $20,000/family/year which leaves a lot of middle class folks

> with no insurance and a lot of businesses laying off people (a big time

> economic crisis). Less people with insurance leads to higher rates for

> those with and the situation gets worse exponentially. Add to it the

> question of what to do with seniors when Medicare goes belly up in 2018,

> and the situation is ripe for a revolution. Maybe I'm wrong, but I would

> bet a lot of very influential people are looking for any possible

> solution to the current problem (it's just no one has really offered one

> yet). Enter the IMPs to provide the safety net.

> Obviously, seeing the future is not anyone's strong point, but I would

> think whoever runs for president in 2012 had better have health care as

> a primary agenda item or he/she will not be elected.

>

>

>

> Re: Microclimates and survivability

>

> A big challenge is getting the general public to understand the

> issues...

> and these issues are complex.

>

> One question is for society to decide how much a primary care doc should

> be paid both for annual salary (top 1%, top 5%, top 10%, lower %ile of

> population salaries????) and for each service we provide. $1500/month of

> student loans at the age 40 with daughter to enter college in 4 yrs

> changes my needs ... but if I had no kids and no student loans my

> personal

> financial needs would be very different ... but I don't think the

> general

> population really understands that most docs today go into big debt and

> don't start really making money until they are 30 yrs old (at least) a

> good number of years later than other professionals so the financial

> picture is odd.

>

> Another question is that without big, very big, powers-that-be, there

> ain't nothing important going to happen. I don't mean to bring up

> politics

> and do not mean to offend, but the current administration uses sound

> bites

> great and has a good portion of the masses supporting their " ideas " but

> the true policies again and again seem to prop up the industries and

> large

> businesses of America. Great case for us would be Medicare Part D and

> how

> the insurance industry and pharmaceutical companies are making a killing

> while only a small percentage of the general population save money and

> doctors' offices had to do more work without reimbursement... but I

> digress...

>

> The point I'm trying to make is that any change needs big-time

> government/industry support and right now we are years (decades?) from

> any

> reasonable conditions that will allow that.

>

> Sorry, but yeah, I'm pessimistic in this case. And I'm hoping to simply

> love what I do, do it as well as possible, basically stand proud by

> Gordon's definition, remain aware of the changing tides and be nimble

> enough to do well while serving as a good example for others. And I

> appreciate this list because it's helping me be able to do those things.

>

> ... but I too will add my voice to Gordon's statment for reform (even if

> I

> don't think it'll ever happen).

>

> Tim

>

>> One of the shocking discoveries on our network is the degree of

>> regional variation.

>> It is very evident that some environments are so difficult as to make

>> it extremely unlikely that any practice can survive without

>> subsidy. We see subsidy from hospitals, from within the practice (e.g.

>> " Robin Hood " types or doing a lucrative side business).

>> One wonders if there are microclimates where IMPs - in spite of doing

>> everything right - would fail to survive due to a combination of

>> financial factors.

>>

>> I suspect that Southern CA is one such place. Cost of living is very

>> high and average reimbursement is very low.

>> We must explore innovations in financing so that IMPs can survive

>> anywhere. While we work on payment reform, some will experiment in

> their

>> own ways.

>>

>> I could hold my head up in public if:

>> I've done all humanly possible to shave costs to the bone

>> I do my share of work for uninsured and Gov't contracts

>> I deliver on the principles of patient-centered collaborative care

>>

>> Then I could say " I've done all I can, and there still exists a gap

>> that is unsupportable in my region due to extraordinary:

>> malpractice

>> cost of living

>> reimbursement

>> I add my voice to those crying out for health care financing reform to

>> free me from having to charge more for certain activities. These

>> benefits should be available to all as a right. Until we as a

>> country are willing to do this hard work, I'll continue to do the best

> I

>> can. " Gordon

>>

>> At 08:04 AM 10/13/2006, you wrote:

>>

>>>So, you are going to be a cash only style of practice (ie, no

>>>insurances)? Otherwise, I would think a " registration fee " would be a

>>> violation of your contracts. California sounds like a whole other

>>> planet from where I practice in central Ohio because people here

> would

>>> laugh & walk right out the door if I requested a similar

>>> " registration fee " here!

>>>

>>>

>>>

>>>

>

[Guest guest]

Wow, Annie, you have had A LOT of

turnover.  I know you work hard for your patients, and it seems that many of

them don’t appreciate it at all.  I would agree with you that it is

usually the middle aged, healthy individuals who move on and are not interested

in a medical home.  Since I opened 3 ¼ years ago, I have had 842 charts, but

112 of them are for people that are not allowed into the practice or return to

the practice (drug seekers, people not willing to work with me, personality

conflicts, etc).  I limit my practice to 400 people, part time doctor, part

time mommy.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

From: [mailto: ] On Behalf Of Annie Skaggs

Sent: Saturday, October 14, 2006

7:13 AM

To:

Subject: RE:

Microclimates and survivability

I have been up for 4 ¼ years now and last night again checked a

count of active charts. (I inactivate the chart anytime a patient dies, moves away, transfers records to another office, or

fails to come in for 2 years and doesn’t respond to two mailed reminders)

The number was 819. It has stayed between 810 and 825 for a year now,

even though I have been accepting new patients (got three just yesterday, total

of 6 this week). Needless to say, they leave about as fast as they come

in. Since I started, I have registered over 9000 patients, but over 8000

of them are inactive now.

I have really tried to make sure they are not leaving due to

dissatisfaction, and mostly I don’t think they are. Most that leave

because of insurance changes go out of their way to say they wish they could

stay. Some leave because they get tired of me insisting on good care

(harping on smoking or weight, demanding that they get mammograms or blood

tests…)The few that leave in a huff are usually the ones I am glad to see

go.

One thing I am beginning to believe is that for many, if not most,

of generally healthy young to middle age people, a “medical home”

is just not something they value. They purchase medical care the same way

they purchase groceries: whatever is cheapest and easiest. My feelings

might be hurt by them choosing the urgent care place by their house, but they

don’t think anything of it, and they don’t even think I

notice… Now my 70-90 year old folks, and

younger ones with serious health problems….THEY want a medical

home. Makes it hard to consider opting out of Medicare, when I consider

that those are the patients with whom I really do have an ongoing relationship

that matters….

Food for thought,

Annie

[Guest guest]

Wow, Annie, you have had A LOT of

turnover.  I know you work hard for your patients, and it seems that many of

them don’t appreciate it at all.  I would agree with you that it is

usually the middle aged, healthy individuals who move on and are not interested

in a medical home.  Since I opened 3 ¼ years ago, I have had 842 charts, but

112 of them are for people that are not allowed into the practice or return to

the practice (drug seekers, people not willing to work with me, personality

conflicts, etc).  I limit my practice to 400 people, part time doctor, part

time mommy.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

From: [mailto: ] On Behalf Of Annie Skaggs

Sent: Saturday, October 14, 2006

7:13 AM

To:

Subject: RE:

Microclimates and survivability

I have been up for 4 ¼ years now and last night again checked a

count of active charts. (I inactivate the chart anytime a patient dies, moves away, transfers records to another office, or

fails to come in for 2 years and doesn’t respond to two mailed reminders)

The number was 819. It has stayed between 810 and 825 for a year now,

even though I have been accepting new patients (got three just yesterday, total

of 6 this week). Needless to say, they leave about as fast as they come

in. Since I started, I have registered over 9000 patients, but over 8000

of them are inactive now.

I have really tried to make sure they are not leaving due to

dissatisfaction, and mostly I don’t think they are. Most that leave

because of insurance changes go out of their way to say they wish they could

stay. Some leave because they get tired of me insisting on good care

(harping on smoking or weight, demanding that they get mammograms or blood

tests…)The few that leave in a huff are usually the ones I am glad to see

go.

One thing I am beginning to believe is that for many, if not most,

of generally healthy young to middle age people, a “medical home”

is just not something they value. They purchase medical care the same way

they purchase groceries: whatever is cheapest and easiest. My feelings

might be hurt by them choosing the urgent care place by their house, but they

don’t think anything of it, and they don’t even think I

notice… Now my 70-90 year old folks, and

younger ones with serious health problems….THEY want a medical

home. Makes it hard to consider opting out of Medicare, when I consider

that those are the patients with whom I really do have an ongoing relationship

that matters….

Food for thought,

Annie

[Guest guest]

Hi everyone,

I have an update on my practice in the Albany, NY area. Started in

June at 9hr/week, and now 4 days a week since July 10th. Got to my

400th patient mark yesterday (after eliminating the inactivated

ones). Seeing about 6-7 patients a day (if it was a 5 day week).

About 35-40% are my patients from my previous practice. Averaging

about 2 new patients a day, and 1-2 transfers from the old place.

This includes 40 new patients at 2 assisted living home where I go

to see patients once a week.

My father (office manager) insisted I advertise heavily, and I

reluctantly agreed, and it seems to have paid off. The most

expensive advertising was in the beginning--direct mail cards in the

local area, and then the 2 week run in the largest local newspaper--

this was the only way I could let my old patients know where I was.

The relatively cheaper weekly inserts in the Local free " advertiser "

is getting me 40% of ongoing new patients and rest are by word of

mouth. In my case, advertising has been very expensive, but helped

me build a patient panel quickly, so in the long run will boost my

bottomline.

My billing person recommended conducting flu-clinics in the

community--these we'll start this week. We'll see how it works. Have

stated some Prolotherapy, and expect that to build up gradually. In

the meantime, have been moonlighting for a hospitalist group which

helps pay the bills. Will soon be picking up 50 nursing home

patients. In the first year there will be no such thing as quality

of life! After that I will drop the other gigs.

The patients love the extended visits, and most of those who switch

to me say they want a doctor who listens and cares.

Thanks to each and every one of you in this group. Couldn't have

done it without all your ideas.

--Padma