Two Rhinelander physicians establish the area's first 'cashed-based micropractice'

Sarah Juon , Editor, NewsoftheNorth.Net

It may seem like a step back in time when you look at the solo practice which Drs. Kim and Brian Erdmann, both internists, have established. There is no question they are bucking a trend of the past few decades in which physicians have abandoned solo practices en masse to join large clinics.

The Erdmanns both have been employed by a large healthcare provider, working for Ministry Medical Group for a number of years in urgent care and internal medicine. But they decided to try another approach.

“We respect what the large medical facilities offer,� says Brian. “For us, however, it’s a desire to have a more personal relationship with our patients and a better quality of life for ourselves.�

In December 2007, the Erdmanns established Priority Medical Partners (PMP). They rent space at 140 S. Brown Street in Rhinelander, in a building owned by Randall Natrop, a dentist. And the space they rent is very small: one room, in fact.

Their setup is reminiscent of the days when you went to an office in a business district and saw your family physician, someone who wasn’t checking his watch every two minutes to make sure you didn’t stay too long.

The difference, is, the husband-and-wife team have no receptionist, no nurse, no IT person and no lab tech on site. It’s just the two doctors, and they time-share: Kim has three-fourths of the office hours; Brian provides the remaining quarter.

Cash-based micropractice medicine

The Erdmanns are not, however, harking back to a simpler, nostalgic era. They are very modern in their approach and are, in fact, an example of an emerging trend across the nation, called the cash-based micropractice medicine.

Brian explains: “PMP operates with one physician at any time, without any staff, using high technology for efficiency and quality service. We don’t contract with insurance companies. For patients with insurance, we provide a form and code and then we ask that they file the claim themselves. By working with minimal overhead, we’re able to provide cost-savings of up to 50 percent to patients who pay at the end of the visit.�

A typical 15-minute first visit at PMP is $56.28, Brian notes, and routine visits often are much lower. Compare this to an average of around $90 per visit at larger facilities in the area.

The Erdmanns’ micropractice model appeals to those with no insurance or with high-deductible insurance. According to recent studies, as many as 50 million Americans are without any kind of insurance, and many more are insured only at the catastrophic level, with deductibles anywhere from $5,000 to $10,000. Many of the Erdmanns’ patients fall into these two categories.

But they also appeal to patients who may have adequate insurance but appreciate having a doctor spend more time with them, in a more direct, personal relationship. Often, the Erdmanns say, these people say it is worth paying out-of-network costs.

“We’re seeing more people who are intimidated by the impersonal approach of standard healthcare delivery, who feel nobody’s going to be there for them, and who let that feeling affect how they care for themselves,� Kim says. “The majority of patients want to go into a doctor’s office and know the doctor is listening to them and understanding what they’re saying.�

A key to providing high-quality care at a lower cost, Brian says, is the Electronic Medical Record, a web-based, HIPPA-compliant medical program that enables Kim and Brian to pull up a patient’s medical record from anywhere in the world and fax it to a specialist or provide it to in-hospital doctors.

“When we’re on vacation, we are connected to our patients and to the Electronic Medical Record by cell phone and computer,� Brian says. “We can import outside documents and schedule appointments. The patient can even create his own personal iHealthRecord at our interactive website, allowing us to remote-access it. We’re close to a paperless practice.�

One drawback to their cash-based micropractice, Kim says, is that they don’t handle Medicare insurance. “We would have to sign a contract with the government to handle Medicare,� she says, “and that brings in all the regulations and red tape, and the risk of doing it wrong, for which the penalties are very high.�

“We say no to Medicare insurance, yes to Medicare patients,� Brian clarifies. “We treat Medicare patients, but any services performed within our office can’t be submitted as claims. We can refer services we don’t do—like a mammogram or pap test—to a Medicare facility and those services will be covered.

“But even paying out of pocket for what we do here—a glucose or blood test, for instance—may end up being less expensive for the patient anyway,” he adds. “We joke around about this, but seriously, if you have to see us four times a year for $56 per visit, adding up to $224 a year, it’s still pretty economical. To put it in perspective, how much is a year’s worth of fish fry dinners?â€?

Balancing work with life

Both Kim and Brian admit that going out on their own was a big step, a move neither took lightly. “Doctors tend to make less in a micropractice,� Brian says, “but it’s a trade-off. All the paperwork associated with insurance contracts and with billing takes away from the satisfaction of caring for patients. Yes, you earn less, and yes, you have to perform all the jobs yourself, but you are your own boss. If you want to spend a half-hour with a patient, you can.�

Kim and Brian, both state-licensed physicians, have the requisite credentials (not to mention the requisite medical school loans they are still paying off). Brian, 38, received his medical degree from the University of Wisconsin, specializing in urgent care. Kim, 39, likewise received her MD from UW, in internal medicine.

Kim is the primary physician at PMP, with Brian filling in around her hours. When he’s not at PMP, he works as the medical director for the Mole Lake Reservation and does urgent care at Aspirus in Wausau.

Being their own bosses clearly means a lot to both Kim and Brian, primarily for family reasons. They have two sons, Calin, 12, and Evan, 10, and enjoy the idea of being available to watch their soccer games and have evening meals with them, and “helping to mold and shape them into good adults,� as Brian puts it.

“If we’re able to have balanced, healthy lives,� Kim says, “we feel that makes us better doctors for our patients.�

The downside to a solo practice is being on-call 24 hours/seven days a week for patients. “We have regular office hours,� Kim says, “but when we leave the office, we’re always available by phone. Our patients respect us for this, and we find they don’t abuse it. They don’t treat us as an information hotline, as I’ve seen happen elsewhere.�

“We do a thorough visit and explain everything to the patient,� Brian adds, “so the calls we get usually are emergency, and those we want because we need to know what’s happened for continuity of care.

“Ours is an outpatient clinic,” he continues, “but if a patient is hospitalized, we work closely with their in-hospital physicians. We have an arrangement with Howard Young, Marshfield Clinic and Aspirus for anyone who needs to be hospitalized.â€?

Providing continuity of healthcare

The Erdmanns say they have worked hard to establish good relationships with local clinics, labs and specialty doctors for referrals. “It’s very important to us to work in harmony with the local medical community,� says Brian. “We don’t feel in competition with any of the local providers. We feel we are offering an alternative service to a group of people who are not being adequately served by today’s healthcare system of delivery.�

PMP patients come for treatment of chronic conditions such as diabetes and hypertension, and diseases of the heart, kidney, thyroid and lung, and gastrointestinal disorders and muscle and joint disorders.

PMP also sees patients for acute conditions such as coughs, colds, flu, sore throats, muscle strains and sprains headaches, insomnia, bronchitis, sinusitis and urinary tract infection. The physicians do minor procedures of the skin and also labs and diagnostics—such as digital ECG, lung function testing, finger stick protime/INR, urine pregnancy, urine dipstick, blood pulse oxygen testing, rapid strep testing and stool testing for blood.

“One of my greatest satisfactions,� says Kim, “has been treating diabetics who weren’t taking care of themselves because of the high cost of office visits. With us, they’re willing to come in and get their check three or four times a year, paying $30 to $50 a visit, and that’s more affordable. So I see people coming in who are taking better care of themselves, and that has been very rewarding for me.�

Kim says she hopes area medical providers will adapt what is called the “hospitalist� system of healthcare delivery. “A hospitalist is a specialist working with inpatient care—just as we are specialists working in outpatient care. A hospitalist system, I feel, is the icing on the cake. It’s a way to give patients optimal care, while allowing doctors to have the quality of life they need to do a very good job for their patients.

“It’s very hard to be two places at once,� she continues, “to be a good outpatient physician and a good inpatient physician, and have a balanced life besides. The hospitalist system gives everyone a better chance to have a balanced life.�

The insurance conundrum

Micropractice has been described as an old-fashioned medical practice with modern-day convenience—where a patient can get a same-day appointment, just like in olden times, yet that same same patient can go online and update his medical records.

The cash-based component is a response to all the time-sucking paperwork associated with filing insurance claims. Put these two models together and you have a new hybrid for delivering healthcare.

Will the cash-based micropractice model succeed? The Erdmanns can’t say yes definitively. “We’re taking a risk,â€? Kim says, “because of long-standing habits, it’s hard to retrain people away from the idea that their healthcare is somehow ‘free.’

“If a person has insurance,” she says, “they don’t pay attention to the cost—they don’t see it coming out of their paycheck. But anyone who has had to go out and shop for their own coverage knows how expensive it is. Full coverage can be as much as $12,000 to $15,000 a year.

“As a society,� she adds, “we need to become better consumers of our healthcare. It should be more like the kind of attention we pay when we go shopping for a new car. We need to do our research, be efficient with our visits and insist on quality care.�
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