A medical center is not a hospital
Article written by Thomas F. Lansdale III, M.D. and published in the Cleveland Clinic Journal of Medicine (September, 2008).
You can view the article in its entirety by clicking the following link:
http://www.ccjm.org/content/75/9/618.full
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| It's about time |
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In an ailing profession, a physician finds his own cure.
07/03/07
By Loni Ingraham |
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The prognosis for primary care doctors in this country is not good.
They have found themselves seeing more patients every day and spending less time with each patient because of the insurance-driven reimbursement system, according to Christopher Ewin, president of the nonprofit Society for Innovative Medical Practice Design.
They have found that the cost of getting reimbursement often has exceeded the overhead allocated for it. The endless hours spent on the phone getting authorization and the costs of upgrading and maintaining their billing systems gobble up much of what used to be their profit margin.
Their reimbursement from Medicare has failed to keep pace with inflation. Their payments from Medicaid are frequently below overhead costs.
It is no wonder that, as the American College of Physicians states, insufficient numbers of young physicians are entering careers in primary care just as older physicians are leaving it because they are dissatisfied.
"There are no happy role models," claims Dr. Tom Lansdale of Towson.
Lansdale's answer to the problem was opening a "retainer" practice, which charges patients an out-of-pocket, flat fee annually. He doesn't have to deal with insurance companies any more. He is able to limit his practice to 250 or so patients, and he has the time to give them personalized care.
That's Part I of the story.
But is this just a story about a man finding happiness as a doctor, or is it a cautionary tale? Part II will explore that question in a future issue.
In 2004, when he had been director of the Department of Medicine at Greater Baltimore Medical Center for nearly a decade, he finally listened to Lansdale's Law:
"Never put up with sustained unhappiness," 53-year-old Dr. Tom Lansdale explains.
His work had become increasingly administrative, said Lansdale, a Towson resident who has been practicing and teaching medicine since 1985.
He had spent 13 years to become a doctor, not a businessman: Harvard '76, cum laude; two more years at Harvard to pick up pre-med courses; Case Western Reserve University School of Medicine '82 with honors; then a year of residency at the Hospital of the University of Pennsylvania, before serving on the faculty at Penn and later Harvard and building a general medicine practice in what was then Boston's Brigham and Women's Hospital.
Yet he was bogged down in "bureaucratic lunacy," as he described it.
He was personally supervising the training of interns and residents as the director of the internal medicine residency program, and, at the same time, struggling to keep himself available to the 500 patients he served in the internal medicine practice he maintained at GBMC.
He wanted to focus on the health of the patients, he said, but he was being increasingly pressured to focus on the health of the hospital instead.
After what felt like the 10,000th meeting and the 50th conflict that had to be resolved, he grew weary of the battles, he said. He was working 12-hour days and weekends and didn't have a minute to breathe, much less think. It was affecting his health.
"I knew I couldn't be in the rat race any longer," he said. "I had an 11-year-old daughter, and I wanted to be around to watch her grow up."
Lansdale yearned to return to the practice of medicine full time, to become the family doctor that Norman Rockwell once portrayed on the cover of the Saturday Evening Post.
"In lofty terms," he said, "that doctor was the personal family physician who did his best to protect his patients' health, who played a meaningful role in their lives."
Sad diagnosis
But Lansdale, who had personally supervised the training of more than 200 interns and residents during his years at GBMC, had a seemingly insurmountable problem: the insurance industry.
"I'd rather have my teeth drilled without anesthesia than practice as an internist in the current insurance-based system," he said.
The doctor painted by Rockwell didn't have to deal with the insurance companies and claims processing, he pointed out.
If he was going to go solo, Lansdale needed to find a way to remove decisions about the care of patients from the clutches of the insurance industry and put them back in the hands of the medical profession.
Many doctors may be self-employed, but in one sense they now are working for the insurance companies, which arbitrarily dictate their rates, Lansdale said. As expenses have gone up, reimbursement has gone down, he added.
"Doctors have had to increase their volume of patients just to keep their heads above water," he said.
The result is that internists have to maintain a typical caseload of 1,500 to 2,500 patients, he said, and see 25 to 30 patients a day.
"It doesn't matter how good you are, seeing a patient for 10 to 13 minutes leaves no time for a relationship," he said.
He notes a 1999 study published by the nonprofit National Institute of Medicine, which is a division of the National Academy of Sciences charged with providing national advice on issues relating to biomedical science, medicine and health.
It revealed that at least 44,000 and perhaps as many as 98,000 patients die annually in U.S. hospitals from medical error.
If he opened his own practice, he knew he would be diagnosing and treating diseases. But his real job would be partnering with patients to prevent them from becoming ill, to keep them out of the hospital, he said.
"Yet the current system of reimbursing doctors -- especially internists -- is based on responding to illness, crisis and emergency," he said. "It's not based on maintaining health."
Internists in this system are rewarded for their speed in seeing patients, he added, not their intelligence, experience or ability.
In light of the current situation, medical schools in this country are not generating graduates who are interested in primary care, family practices and pediatrics, he said.
"They have no happy role models."
Prospect of recovery
Lansdale found the answer to his problem after talking to friends who had surmounted it here and out of state.
Each had set up what he calls a "retainer practice," so named because patients pay an annual, flat fee directly to a doctor to retain his services and be on call whenever they need him. Insurance has no role in the out-of-pocket transaction.
Lansdale likens the fee to the retainer some people pay lawyers to be available as they are needed.
The flat fee -- $1,500 in Lansdale's case -- creates a pool of money that allows doctors to limit their patient load -- instead of ever increasing the load to keep up with ever- decreasing insurance reimbursement.
Lansdale's goal is a practice with just 250 patients.
Both the doctor and the patient benefit from a retainer practice because the smaller number of patients allows the doctor to provide personalized care, he said.
"Retainer" is the politically correct term, he explained, but the terms "concierge," or "boutique" are often used to describe such practices.
In any case, the doctors he talked to who had made the change were helpful in making the decision, he said, "primarily because they were so happy."
'Doctor Craine'
Lansdale opened his practice in November 2005 in Suite 500 in the GBMC Physicians Pavilion North building on the Sheppard Pratt campus.
He likes to say that's when he went to work for "Dr. Craine."
Susanna Craine is the office manager he hired. She is his sole employee.
A decade older than he is, Craine has virtually no medical experience. But she has two master's degrees and was assistant vice president of community relations and spokeswoman for Towson University for eight years.
Lansdale wasn't willing to share the days he spent in his office with just anybody. He was looking for "a warm, intelligent person to share the workday with," and if the core of a retainer practice is personal service, he needed an individual who would make patients feel very special.
To find the right person, he engaged in a process that he likens to speed dating. Colleagues or friends would recommend someone -- a niece, a former employee, an acquaintance -- and he would take her to lunch and "know within five minutes it wasn't going to work," he said.
He contacted Craine by e-mail after a friend recommended her. They found common ground immediately, after she told him that she too had sung with the Handel Choir -- he once had considered a career as an opera singer.
"Susanna is perfect," he said with a big grin. "She uses big words all the time."
Worth the cost?
After Lansdale sent out letters to his patients at GBMC announcing the opening of his retainer practice and giving them six months notice, about a fifth of his former 500 patients signed up.
Hunt Valley resident Edith Maynard said she willingly paid the fee "because he is such an excellent physician and a marvelous human being.
"In the final analysis, when you think about all the money you spend on medical care, it doesn't cost you that much because you don't have to pay for other things."
"I wanted to be able to go to someone who is sincerely invested in my health," said Dean Krapf, a co-owner of the Lluminaire hair salon on Allegheny Avenue. "He is old-style, bedside manner combined with new technology."
Retired surgeon Bill Ryan, who with his wife, Lynne, became a patient of Lansdale's new practice in December of 2005, said he was initially against joining the new practice "but the questions in my mind were immediately dispelled when we met with him and saw the time he took."
But Timonium resident Mimi Williams was among those who chose not to join Lansdale's new practice.
She and her husband have the utmost affection and respect for Dr. Lansdale in every way, she said, "but we are senior citizens, and it was not feasible for us to go in that direction because he doesn't accept Medicare or private insurance" for the retainer fee.
A retainer practice doesn't appeal to all patients, Lansdale said, "even to those with means beyond imagination.
"I didn't get a single letter or call, but I think people still labor under the false assumption that health care should be free. The idea of paying extra for what I believe is extra service doesn't appeal to all people."
The annual pool the $1,500 creates -- $375,000 -- may seem like a lot of money.
But there are huge costs to setting up and maintaining any practice -- expensive equipment, salaries, furnishings, various types of insurance, dues for professional organizations and, in Lansdale's case, a lease in a high-end location.
His wife, Jennifer, an Emmy Award-winning set designer, saved him some money by designing his office herself. He thinks it's terrific.
His $1,500 retainer fee seems to be the going rate in this part of the country, he said. "It allows me to have an income similar to internists in their prime who handle a high volume of patients."
Lansdale didn't want to reveal what he expects to earn once his practice is in full swing, but "I will make far less money in this practice than I did as a physician executive at GBMC," he said.
He has a thrifty streak anyway, he said. "That's from a blue-collar background; we grew up very aware of the Depression. We never threw out food in the refrigerator even when it was moldy."
He believes in dressing the part as a doctor, he said, "but I've been a thrift shop hound all my life -- I hate buying retail."
Forget the Mercedes Benz. Lansdale drives a 1995 Honda Accord with 130,000 miles on it -- that he bought used -- and he's wearing shoes on their fourth reincarnation.
What does $1,500 buy?
In Lansdale's case, the fee covers unlimited visits with him at no further charge.
However, his patients still need medical insurance to cover the cost of tests, hospitalization and treatment by other doctors. "We all need insurance," he said.
He issues patients a bill each time he meets with them, but the bill is always marked "paid in full." Patients can submit the bill to their insurance companies if they wish.
The $1,500 is a latte a day, he said. "Some people spend more than that on their hair."
In exchange, Lansdale makes himself available to his patients 24 hours a day, seven days a week, and through e-mail and by phone.
He allocates no less than 90 minutes for initial visits and annual examinations and no less than 30 minutes for return visits.
He needs time to coach patients, to help them understand their medical problems and work toward wellness, he said. "I view teaching as my fundamental role."
He not only visits patients when they are hospitalized and oversees their treatments, he visits them in their homes.
He has been known to bring soup with him -- soup he makes himself.
He likes making soup. After his wife and daughter have gone to bed, he is happy prowling cookbooks.
"There is no end to the kind of ways you can make soup," he said. "It's a nice, creative, nourishing thing to do. My patients don't seem to mind the fruits of my labor."
He finds his patients have been "intellectually very interesting," he said. They run the gamut from schoolteachers, college students, nurses and a retired farmer to a journal editor, a carpenter, a hairdresser, CEOs, judges, lawyers and doctors.
"They are people who have joined the practice because they value their health more than other people value their health," he said.
The medical profession will be facing new challenges as the 76 million baby boomers age and life expectancy increases, he said.
Lansdale predicts more and more primary care doctors will resort to retainer practices as insurance companies continue to drop compensation and costs rise.
"I think I'm ahead of the curve," he said.
Lansdale is now three-quarters of the way toward enrolling 250 patients. He is healthier than he has been in 10 years, he said.
He whistles on his way to work.
He doesn't consider it work anymore.
Tom Lansdale is a happy man.
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