the challenge for young docs is that a lot of them have hundreds of thousands in loans that demand attention immediately and create a fear of taking on more business loans to get started (age 29-32 ish rather than 24 in your case, starting a new family etc), esp in the current medical environment (you might argue that makes it easier to take on the risks, but a lot of people in medicine are fairly risk averse). they don’t know beans about running a practice and still have to learn that and prepare for specialty certification testing simultaneously. imo, that is best learned in someone else’s practice–billing, hr, practice management issues, negotiation with insurance (malpractice at least, possibly health insurances), compliance, reporting, emr, malpractice issues, technology issues, ie phone/voice mail, night services, hospital policies, meeting new docs so you have a network you trust to refer to, personal practice style, possibly clia and osha, etc in the first few years. after you pass those first few years, then you are into middle age and it is too late to take those risks.

being a small business owner, you know billing for 2 mil does not equal receipts of 2 mil. it might be that in a carefully selected population you could bounce out the 15-20% that didn’t pay fairly quickly, but that takes time. people say they are willing until it comes time to write the check. lastly, i think people in medicine have a hard time turning off their altruistic gene and refusing patients they like for economic reasons.

i’m doing okay (not in primary care) but 50% of my patients don’t pay anything. i don’t give them worse treatment, but if i were more financially driven i could make my life a lot easier by not seeing them. unfortunately some of these guys have got used to not paying anything and now expect free health care.
but robyn- i tell you what.

if you can gather 2000 of your friends who are willing to cough up $1000/year, i’m sure my wife (primary care doc) would be happy to move to florida. i would be happy to retire. maybe motivated patients could hire physicians that way. sort of forming your own health care cooperative–i would suggest hiring two part timers to make sure there was vacation coverage and in case someone quit you wouldn’t be left in the cold. if you really had $2mil (gross) to work with, you could definitely find at least 2 and maybe 3 no problemo.

anyways thanks for sharing thoughts from a patient perspective.

How about setting up a concierge practice? No third party payers. I don’t know if 2000 patients is an ok number of patients. It’s been mentioned above so let’s say it is. Charge each patient $1000/year for certain basic services (like an annual comprehensive checkup – a less comprehensive midyear – one or two short little deal emergency visits – like I cut myself and need a tetanus booster). Anyway – you get the drift. And that’s $2 million a year gross. Enough to get a decent office – hire the 2 necessary people (the phone/paperwork person and the PA type person) – and have a nice take-home income.

From my patient’s POV – it has become harder and harder to find a good primary care doc these days – and it will only get harder in the future. And $1000/year is less than most people – affluent or not – spend on cable TV and iPhones. Heck – a cosmetic doc won’t even sneer at you unless you look like at least $3000 walking through the door. Put the $1000 on a credit card monthly – which is $83.34/month. Like a cable bill.

Anyway – as my generation starts to go on Medicare (I’m 62) – it will be harder and harder for us to find good primary care docs (or any primary care docs at all). And unless the economy ruins all of us – I think there are enough of us willing to spend a few dollars to get decent primary care – care where our doctors get paid paid more than the guys who mow our lawns. And we don’t have to wait in crowded waiting rooms with huddled sniffling masses in flu season waiting for our 10 minutes with the doctor.

IOW – it’s back to the old days – like when I was growing up. You saw your family doc – he presented a bill. You paid. Only difference is in a concierge practice – you are basically “on retainer”. Want to know how different things were back then? When I was a kid – I lived in a middle class suburb In New Jersey – and family doctors had their offices in the “basements” of their side-to-side split level homes.

FWIW – I opened my own law office when I was about 24 – and my husband opened his when he was in his early 30′s. He supported me until I got off the ground – and then I returned the favor for him.

Even if my concept falls flat on its face in a particular case – what do you have to lose when you’re relatively young (which is – realistically – the only time you’ll be willing to take a risk like this)?

BTW – my new family doc (have had her for about 3 years since my old family doc retired due to illness) -has said she will “grandfather” in me and my husband (and other existing patients) when we go on Medicare. But she won’t accept any new Medicare patients. And I reckon if the government passes rules that say – if you see one – you have to see them all – she will go to a concierge practice – and I will gladly pay her whatever she charges for her services. Robyn

This is certainly a new way to approach things, but at the same time, it is going back to the basics — when the primary care doctor was the first point of contact in the health care system. Now, the patient has to call, the secretary to make an appt, see the nurse to check in and get their vital signs and chief complaint recorded and by the time the doc comes in, they have to tell their story again for the 2nd or 3rd time.

I am a future family physician and I am keenly interested in how the IMP model will play out along side the PCMH model. PCP as Dr. Everything vs PCP as supervisor to numerous midlevels…

Deferring education and counseling to other providers may have the unintended consequence of adding in obstacles between the doctor and patient forming a strong relationship with each other. Perhaps for some overworked MDs, this is desirable.

The margin behind the medical home should be a blended payment model with 3 components. A risk adjusted per member per month to cover fixed costs, per visit reimbursement to cover variable costs, and a bonus based on objective measures like patient satisfaction, clinical measures, & cost efficiency. It works in Denmark, it will work here as well.