Essay Preview: Micropractice
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Patients at his “micropractice” can call or email to get appointments the same day. Visits last 30 minutes. Dr. [Gordon Moore] can be reached day or night on his cellphone. To refill a prescription, he walks “zero feet,” he says, and taps a few keys on his laptop. “I was able to build a Norman Rockwell practice with a 21st-century information-technology backbone,” he says.
The doctors compensation plan changed from a guaranteed salary to a share of the practices revenue, making it less secure. “It seems that all of the conversations in our office were about money,” Dr. Moore later wrote in a medical magazine, Family Practice Management. “A good doctor, it seemed, was one with high visit volume.”
Once or twice a year, Dr. Moore asks his patients to complete a free Web survey called “Hows Your Health.” Developed by John Wasson of Dartmouth Medical School, the 10-minute survey is a series of carefully formulated multiple-choice questions about the patients symptoms, medications, diet, past tests, emotional issues and habits, such as smoking and drinking. The survey evaluates the answers and converts them into a one-page snapshot of the patients health. It also suggests links to relevant health Web sites, and can tell the patient how to track blood pressure, cholesterol or weight.
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ROCHESTER, N.Y. — After eight years as a staff doctor at a hospital-owned medical practice, Gordon Moore began to really dislike his job.
To increase revenue, the hospital pressured him to see more than 30 patients a day, usually for 15 minutes each. Many patients couldnt get appointments for weeks. Dr. Moore determined it took 19 separate actions and 253 feet of corridor-walking to order a prescription refill. He says he was so rushed he often failed to provide the best medical care, and once mistakenly prescribed a blood-pressure drug for a toddler.
So in early 2001, Dr. Moore took a risky step. He borrowed about $15,000 to start a solo medical practice in a tiny space with no nurse, receptionist or waiting room. He bought computer software to help him track patients appointments, illnesses and medications, and to process insurance claims.
Patients at his “micropractice” can call or email to get appointments the same day. Visits last 30 minutes. Dr. Moore can be reached day or night on his cellphone. To refill a prescription, he walks “zero feet,” he says, and taps a few keys on his laptop. “I was able to build a Norman Rockwell practice with a 21st-century information-technology backbone,” he says.
Dr. Moore belongs to a small but growing number of physicians converting to high-tech, low-overhead practices to try to preserve a disappearing style of care often provided by lone family doctors. They are working to counter a sustained decline in primary-care medicine, long the mainstay of the U.S. health system.
Primary-care doctors — family physicians, general practitioners, pediatricians and obstetricians — address patients health comprehensively and usually over a long period of time, aiming to catch problems early on. Their numbers have dropped by half in the past decade, according to a series of surveys by the American Academy of Family Physicians.
A series of surveys of several thousand doctors by the Center for Studying Health System Change, a nonpartisan Washington, D.C., group, found that primary-care physicians made about $121,000 in 2003, about a third less than most specialists, and were losing ground. Their inflation-adjusted average income dropped by 10% in the previous eight years, the survey found, while specialists income was stable. Today, only about a third of doctors in the U.S. are primary-care physicians, compared with roughly half in most other industrialized countries. Studies have shown that primary care tackles many medical problems early on, before they turn into difficult and expensive-to-treat conditions. That partly explains why other countries spend far less per patient, often getting similar health results.
Some physicians and institutions are trying to harness technology to make family practices more manageable and profitable for doctors. In April, the American Academy of Family Physicians attracted 300 applicants when it offered to put 20 primary-care physicians in a pilot project to help better manage patients and their ills. In Washington state, a dozen family-health practices have linked up on a private high-speed network. They all use electronic records, give same-day appointments, and offer patients email consultations for a $7 monthly fee.
In a blog called Solo Practitioner, Vincent Pedre exhorts fellow micropractice owners to “automate, automate, automate! That is the name of the game. Make everything automatic, including billing.”
Going solo isnt always an easy sell. Some doctors arent keen to give up the financial security of belonging to a larger, salaried practice. Many arent tech-savvy or good at organizing things for themselves. Most who take the plunge initially find it hard to sign up patients, and many make less money than they did before.
Gary Seto, author of the blog SoloDoc, quit his job at Kaiser Permanente three years ago and started a one-man practice in South Pasadena, Calif. After losing money for two years, he scaled back to part-time and only makes a fraction of what he used to. In a recent blog, he writes, “Thats the tradeoff. But its much more enjoyable to me and my patients.”
Dr. Moore, 46 years old, says he has persuaded about 60 physicians to officially adopt his model. He doesnt charge doctors to use his idea, but a year ago he received a two-year, $850,000 grant from the Physicians Foundation for Health System Excellence in Boston to promote the approach. A local business group in St. Louis has been pushing his model to doctors there. As his evangelizing takes up more time, he has cut his own practice down to part-time.
Dr. Moore never intended to go solo. In the early 1990s, he started at a physicians group practice owned by Highland Hospital in Rochester. Two years later, he says, the hospital asked the doctors to increase revenue by scheduling 32 patients a day, up from an already high 28.
“We were given monthly sheets showing how much money we were losing individually and collectively,” recalls Dr. Moore, noting that other hospitals adopt similar measures. “It felt extremely uncomfortable.”