Val Jones Q&A on Fee-for-Service Medicine

Val Jones, MD, founder and creator of the blog Better Health (http://getbetterhealth.com), and physician with DocTalker Family Medicine, a pay-as-you-go, time-based practice, discusses what it’s like to be a physician in an unconventional practice. Jones, like many physicians at DocTalker, was a patient before asking to come aboard as a member.

Tell me a little about yourself and DocTalker Family Medicine.

I am trained in physical medicine rehabilitation—the primary care physicians for the disabled. DocTalker Family Medicine includes four practitioners: me, Dr. Alan Dappen, a family physician; Dr. Steve Simmons, an internist; and Valerie Tinley, a family nurse practitioner.

DocTalker Family Medicine has actually been around for seven years. It was founded by Dappen as a sort of a response to the ever-increasing clinical treadmill that makes medicine not fun for practitioners, especially in primary care in which you ned 4.5 support staff per physician just to manage the coding and billing; and that creates a lot of overhead and a lot of time spent on paperwork or paying other people to do paperwork just to get reimbursed.

Alan was just exhausted and frustrated and said, “I just want to go back to the way things used to be, directly having a relationship with the patients, not having to worry about having all these people in between us, and I’m going to take the plunge, not accept insurance anymore, create a model that’s affordable and fair, and price it so that anyone can afford me. And if they pay me directly, I don’t have to worry about the coding and billing stuff, and then I can pass on the savings to them.” He created a pay-as-you-go, time-based billing model, which is unlike anything else out there because most of the folks who decided not to take insurance have what we call a concierge model where there’s a membership fee or a monthly fee; we work more the way an attorney would, getting paid for our time. We bill in 5-minute increments, and the average person in our practice only ends up paying about $300 a year on their primary care. It’s great for us, because we don’t have anyone coming between us and the patient; we do what’s right for them at their convenience, it’s fun, we can spend as much time as we need to with each patient, and we don’t have all the stress of having 4.5 people per doctor to pay salaries. We pick up our own phones; people call the practice, and they hear “hello, it’s Dr. Val?” At first, people are like “Uh, I’m supposed to speak to the receptionist.” And I answer, “Well no, you’re not. Let’s take care of this now,” and they say “oh, you mean I don’t have to wait three months for a meeting with you.” And I say, “No, basically I can take care of your problem right now. What’s going on?”

You mentioned the 5-minute increments? What kinds of fees are involved?

It’s $25 every 5 minutes, so an hour-long house call would cost $300, but if you need a prescription refill, maybe that’s five minutes. Actually, prescription refills are $20, and we’ll do up to five in a batch.

How many patients do you, as well as your practice, serve?

The practice has about 3,500 patients, and the four of us take care of those people depending on the day and who needs help. We cover phones, and someone is always available 24/7. It’s like taking shifts, but our patients can ask for us independently. They understand that sometimes we may not be available and that one of the others will take care of things and let the other one know how they’re doing.

How long have you been at DocTalker Family Medicine?

New York

When I moved to DC from , a friend of mine recommended Alan as a family physician to me. After 2 years of being his patient, I said, “you know, I think your model is the best I’ve ever seen, and it’s so great and convenient. Can I join your practice?” And he said, “Well, sure.” And new staff all were patients first. I’ve been a partner here since the summer of 2009.

In a December 12, 2009 blog post at Better Health, (“Why Concierge Medicine is not the Solution to Primary Care Woes”), you wrote that the “concierge model doesn’t accomplish what we need in health reform.” Why doesn’t it?

First, you have to ask what you mean by concierge medicine, because there are different ways to do it, but what I mean by it is the general practice of charging a membership fee of some sort and reducing the number of patients that you carry in response to that. Does concierge medicine work? Sure. Would I love to only have 400 people in my practice and make a million dollars a year? Yeah, that works great for the doctor, doesn’t it? And, I guess it works pretty well for those 400 rich people who now have guaranteed access, but my point about how I didn’t think it was a great model was just that we’re in a primary care crisis right now, and we don’t have enough physicians and nurses to cover the need of Americans; when you take out more primary care physicians and nurses with the concierge model, you end up increasing the problem—there’s no incentive for these people to see more and more patients. I think our model is better because we’re incentivized to see more patients, because we get paid for our time.

Is concierge medicine a viable option for medical practices?

It’s viable, and people are starting to do it, but when you drop insurance, and if you stop taking Medicare, you can’t take them again for two years. And if you accept Medicare, the fees have to be the same for all the patients. That’s why the treadmill thing happens.

In order to be less risky, you can understand that for people who want to go to a concierge model, the easiest way to do it is to say “alright, I’ve got 8,000 patients in my practice, I’m going to concierge and I’ll just tell those 8,000 people if any of them want to come with me, they’re going to have to pay out of pocket at an X-number of $1000 a year.” Maybe 1 in 10 will do it, but if you get 400 people to do that, and they’re each paying an x number of $1000, you’ve got a million dollars cash right there. That’s why, when people do leave the insurance world, they tend to go with the high membership fee concierge model, and I can sort of understand why that would happen, but ultimately the more people that do that, the worse it is for primary care access.

You also predicted that your “practice model will eventually overtake the concierge approach?” Do you still believe it will?

Massachusetts

It really depends on what’s going to happen politically. I can imagine a future in which if enough doctors go to the concierge model that the government will say it’s illegal to practice medicine without accepting Medicare; and if they make that rule, which is sort of happening in , I believe that if that sweeps the country that what we’re doing now is not going to be legal. So, it’s possible that won’t work out and there are a lot of unknowns. However, people are very price conscious. With the economy being the way it is, there isn’t a lot of high demand or comfort level with people paying high membership fees for anything. If your option is to join a concierge practice and pay x number of $1000 a year upfront to have access to these doctors, or a pay-as-you-go time-based billing plan with doctor Val and doctor Alan, what would you choose?

Our goal is really to enjoy a great quality of life, to feel like we are making a difference for our patients, that we’re not stressed out with mountains of paper work that’s suffocating us, and that we can be free to do what’s right for the patient on their terms. If that’s what doctors are looking for, then our model works great.