Dr. John W. Farley

I’ve traveled to London, England to celebrate my daughters 18th Birthday (she is very special; at birth was diagnosed with cerebral palsy).  Not only have I experienced our healthcare system as a physician but also as a parent with a child that requires many unique medical considerations.  We also experience the system of travel and accessibility so my knowledge is expansive in both areas.  I’ll blog a bit about that at another time.  Today I wanted to continue discussing our current system and issues I have personally seen and believe will impact care today.

In my first 2 postings I laid out several of the problems in today’s primary care medical practices.

To sum it up the current fee for service system rewards us for volume. Not quality or patient convenience. Therefore we fill our schedules up daily to generate revenue. This results in shorter visits and difficulty for sick patients to get timely care whom then end up seeking care from much more expensive providers such as urgent care and emergency rooms.

Meanwhile the successful doctor under this model is running himself to death on the proverbial treadmill trying to see all these patients. Many of whom have only minor illnesses.

It’s ironic but my great-grandfather and grandfather practiced under the same model. Change and innovation is clearly needed. 

It is coming, but it is not being physician led, but rather led by entrepreneurs. There are so many well-intentioned laws such as the Stark laws and HIPAA that are innovation killers. They make it hard for docs to develop innovative care models without running afoul of these laws.

So here are some of my ideas on how to build a better primary care delivery model. These ideas are not all my own, but are taken from my years serving in multiple leadership roles, working with insurers, being around great leaders and running my own practice.

First of all we need to kill the idea of the doctor visit. It is currently pretty much the only way we get paid, but it is the root of all evil!

We need to change the model from one of episodic sick care with the occasional physical to a patient management model.

In this model I would get paid a monthly fee by insurance companies to manage my patients 24/7. This fee would be based on patient age, their degree of medical problems(burden of illness) and be adjusted for hitting or missing quality and cost parameters.

I would still be incentivized to work hard as the bigger my panel the more revenue I would generate. How this model is different is that it would be a team based model led by the physician. I would not be filling up my schedule with simple illnesses such as urinary infections, sinus infections etc. These would be managed by my team of nurses and nurse practitioners. I would review their work and be available to consult on complicated cases.

I would spend the majority of my time seeing the sickest patients who need my skill set. They could always get in the same day. This should reduce emergency room visits and hospitalizations.  

Many of the simple illnesses could also be managed over the phone or internet. So called Telemedicine. No need to leave work or get child care. Right now if we treat people over the phone we don’t get paid with a few exceptions. Therefore we plug them into our already crazy day at often inconvenient times for the patient, who then frequently head to the ER or urgent care.

So, all sorts of entrepreneurs are trying new models to satisfy those patients. Telemedicine, retail clinics and direct/conceirge care.

Why aren’t we? Like many great businesses before us we arrogantly think we can survive change. We assume patients will always come sit in our waiting room for 3 hours after waiting 2 weeks for an appointment for an 8 minute visit. If we don’t change our model we will end up like Kodak, Polaroid, Xerox, Sears and newspapers wondering what happened. All these new business models are banking on success because they can count on physician access being inconvenient. That indeed is in many cases their entire business model. As mentioned earlier we are also limited by government regulations that many non physician businesses operating in our table-space do not face.

If we go back to my idea of paying us to manage patients none of these business will be necessary as stand alone entities because patients will always have access to their medical home which is the practice or health system that they have chosen. They will have 24 hour access, care coordination, high quality and cost-effective care. The proverbial right care at the right place at the right price! Wouldn’t you love that as a patient? Care as convenient as shopping online or booking a vacation. Delivered by your trusted physician and his or her team. With not only your health care needs being addressed, but your time being respected.

So I got a little off track. I was going to lay out what my practice has been doing to be transformative working within our current payment model with all of its limitations. Sorry, I get excited thinking about my fantasy model discussed above. More to come next time.

Stay tuned for my next posting from Paris!!