Doctors take big leap, go small

By Marion Davis
Contributing Writer
http://www.pbn.com

In today’s health care environment, spending a full hour to discuss your health with a physician is virtually impossible. And don’t even think that you could call one on a Sunday and have the doctor meet you outside the Little League field, stethoscope in hand, to examine your child.

Yet, that is what it’s like to be a patient at Barrington Family Medicine, opened last January by two doctors and mothers who wanted to practice medicine the old-fashioned way: one-on-one, unrushed, built on real relationships with their patients.

But Doctors Lisa Denny and Andrea Arena are trying a different approach: focus on the bottom line, not the top.

Following a model developed by Dr. L. Gordon Moore, a doctor and health care researcher in Rochester, N.Y., they are building a “micropractice.�

Denny said she and Arena chose this model because “it seemed like nice, old-fashioned medicine,� and it suited their needs as moms.

The typical doctor’s office – even a small one – has several people on staff to answer the phones, schedule appointments, handle paperwork, prepare patients for the doctor, etc. They need salaries and insurance, plus space and equipment to work.

Add rent, utilities, supplies and other expenses, and overhead eats up 60 percent or more of the revenue, which is generated by the roughly $85 per visit that insurers pay. So doctors see more patients, but that requires more staff and more space. And patients spend an hour waiting to be seen, but only 10 minutes with the doctor himself.

Moore had experienced this world himself, working in a hospital-owned group practice where he had to see more than 25 patients per day. But through a project with the Institute for Healthcare Improvement in Cambridge, Mass., he learned about new models for clinical practice built on relationships, improved access to care and technology.

In February 2001, Moore opened a practice that he hoped would embody those ideals – with no staff and only a tiny space to keep costs low. He answered his own phone and did all the grunt work, but allowed patients 30 to 60 minutes per visit, plus 24/7 phone and e-mail access.

To maximize quality and efficiency, Moore used plenty of technology: electronic medical records, scheduling, messaging and billing, plus Web-based tools to track patients’ health, treatment outcomes and satisfaction with the practice.

“By challenging every assumption,� he wrote in a journal in 2002, “I was able to build a Norman Rockwell practice with a 21st-century, information technology backbone, with an investment of just $15,000.�

Moore called his model the “ideal medical practice,� and even as he served his own patients, he began helping other doctors try it. Today, about 680 doctors participate in his Yahoo! group and his Wiki, and about 120 are part of a grant-funded project to test the model nationally.

One of the pioneers is Dr. Lynn Ho’s North Kingstown Family Practice, started in 2004 in an 800-square-foot space and now serving about 750 patients.

Ho went into private practice after working in community health centers – as did, coincidentally, Denny and Arena. And like the Barrington doctors, she has no staff at all except for a biller who works from home for a few hours per week.

Ho took the leap not quite knowing what to expect, she said, and “it took a lot more work than I thought.� It was also a culture shock, grappling for the first time with routine tasks like changing the table paper in the exam room and – this one she hated – collecting copayments. At first she wasn’t efficient enough, either, but over time, she found new tools, such as an online booking system ($14.75 per month) and a Web form for patients to enter their own medical histories ($50 per month), a timesaver that she found also gathers more complete data and helps patients focus on the reasons for their visit.

Today, Ho sees four to 15 patients a day, staying open till 9 p.m. twice a week and offering Saturday hours every other week. She also offers “virtual visits� for $25 each (insurers won’t pay for them). Patients pay online and fill out a Web form, and Ho replies by e-mail; if she decides an office visit is needed, the $25 is applied to the copay. In addition, Ho is on call 24/7.

It’s been four years, and Ho still gets giddy talking about her practice.

“I’m still realizing how great it is,� she said with a laugh. And sure, some colleagues think she’s crazy, but “I don’t blame them, because you can’t understand how great this is until you do it.�

Micropractices are demanding, Ho and Moore acknowledged, but the payoff is huge. Most doctors – especially in primary care – go into medicine to really take care of people and build relationships, and 10-minute encounters don’t allow that. The reason this model has “struck a nerve,� Moore said, is that doctors see it and think, “This is why I got into health care. This is what it was all about.�

Still, neither Ho – who’s become a resource for new micropractices – nor Moore would argue that this model is for everyone. It takes discipline, ingenuity and a willingness to do work that, frankly, some doctors think they are above. And changing an existing practice, Ho said, is really difficult.

Dr. Michael D. Fine, physician operating officer of Hillside Avenue Family and Community Medicine, is a clinical assistant professor of family medicine at Brown University’s Warren Alpert Medical School and a leader in primary care in the state. He’s known Moore for years and sees the appeal of his model, but he also has some concerns about it.

For individual doctors, the lifestyle may be unsustainable over many years, Fine said – being on call all the time, for example – though he acknowledged that working like mad to cover 60- to 70-percent overhead is “unsustainable as well.� Many patients also want to be in and out of the doctor’s office as quickly as possible, Fine noted, and with Medicaid patients, for whom reimbursements are capitated and very low, the model may be unfeasible.

Most important, Fine said, given the shortage of primary care providers, having doctors serve a few hundred patients each, instead of the typical 2,000 to 3,000, would be a real problem. “So the public health effect might be negative,� he said, “though that’s a theoretical concern.�

But both Ho and Moore said if young doctors knew they could practice medicine like this, rather than in the “hamster-wheel� style, they’d be far likelier to opt for primary care, so we’d have a lot more doctors available, and patients would get better care.

At Barrington Family Medicine, Denny and Arena are pleased with the results: They have recruited about 300 patients – they are aiming for about 500 each – and most of them appreciate the extra time and attention. By splitting the work day, the two doctors cover all business hours plus some evenings and are on call 24/7. And they keep up with the work by being disciplined, “doing today’s work today,� as Arena put it.

To further personalize their relationships, they add a photo to each EMR, so when a patient calls, they can see the face right away. But living in town, as they do, they get plenty of personal contact anyway. Arena has gotten paged during her son’s Little League games and given impromptu checkups outside the field; she’s seen patients in shorts and flip-flops.

At first, Arena said, she worried about the dynamics, but now she thinks “it’s kind of cool.�

“That’s the ultimate goal,� she said: “to have the line between work and life blurred.� •
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