5/17/10:

Today is the last day of my private practice which I started over 5 years ago. I started a private practice because I felt that I couldn’t expect an employer to pay me to spend as much time with patients as I wanted to in order to do the kind of holistic work I wanted to do. That is the nature of much of the health care system today, that a doctor’s time is so expensive that employers don’t want them to spend a lot of time with patients. This is the volume model of health care, in which the doctor sees as large a volume of patients as necessary (productivity measured in terms of “units”). Given that doctors are in short supply in many areas, and definitely psychiatry in central Illinois is under-served, this model is a good way of getting as many patients in to see the doctor as possible. It also maximizes profits for the physician and their employer. The question remains as to whether this is the safest or most effective model of practice.

When I started out in my practice, I took every type of insurance, no matter how low they reimbursement or how difficult the insurance was to deal with. Over a couple of years, I gradually dropped Medicaid, Medicare, and Personal Care insurance plans.

The reason I dropped out of Medicaid was that they wouldn’t accept my electronically generated billing forms. I had to hand write each form that I sent to Medicaid. Also, I had to wait up to 6 months sometimes to get paid, and when I did get paid it was about 1/4th of what other insurance companies paid. This just did not seem like an effective use of my time.

The next insurance plan I dropped out of was Personal Care. This was a private insurance company. When I had worked at a multi-specialty group practice, Christie Clinic, Personal Care was a high percentage of my practice, around 60%. My understanding was that Christie Clinic had created Personal Care HMO, this was then sold to Coventry, and Christie had a capitated relationship with Personal Care as preferred providers. Because of this, this was one of the lower private insurance reimbursers, but not as low as United Healthcare. The main reason I stopped being a provider for Personal Care was how difficult it was to appeal medication decisions and what I felt was an overly restrictive and even discriminative policy in regards to medication. I did not feel that the appeal process allowed for a physician to individualize treatment.

Personal Care also took the creative license to define any extended-release medication as a one pill a day medication. This was a perversion of the scientific language of pharmaceuticals. For instance, to prescribe Effexor XR 225 mg (the FDA allowed maximum for depression), a patient would have to purchase a prescription for #30 of Effexor XR 75 mg and #30 of Effexor XR 150 mg, with two attendant co-payments. If this was prescribed as Effexor XR 75 mg, 3 pills each day, the patient would be charged 3 co-payments for each 30 days or 75 mg capsules, the reasoning being that since it was an XR, once daily medication, that only one pill a day was ever needed and only one pill per day, per co-pay, would be covered. This situation was even worse for someone prescribed 375 mg of Effexor XR (the allowed FDA maximum for severe depression). A patient on this dose would be charged 3 co-payments to get their medication. It would require 2 co-payments for 2 prescriptions of 150 mg capsules and 1 co-pay for 1 prescription of 75 mg capsules. This did not seem fair to my patients and seemed, to me, to discriminate against people with more serious illness.

I filed 7 or 8 complaints with the Illinois Department of Professional Regulation about Personal Care, but the decision was that they were not discriminating, but were simply setting policies as was their right. This, in conjunction with a circular appeal denial policy (we are denying your appeal based on the fact that we do not cover the medication that was initially denied) I felt I was being forced to give care that was less than optimal, more expensive to the client than it needed to be, was disrespectful of physicians’ time, and was not responsive to reasonable requests for individualization of treatment. At that point, I dropped out of Personal Care, as I felt I could not participate in good faith in the system that they had set up.

At this point, in writing this, I am surprised that I automatically started writing about the business side of private practice and I wonder at my self, did I lose touch with the reason I went into private practice, which was not financial, but about providing quality care that was holistic and took into account the whole person? I would say that my commitment to a holistic treatment approach is even greater than ever, but that a lot of my learning in running a private practice was in other dimensions of medicine (taking a holistic look), such as healthcare delivery systems, economic issues in medicine, medical billing, medical ethics, and running a small business. These were not things I set out to learn about, but were necessary components of running any private practice, holistic or not. One thing that I really developed an appreciation for was on how the way a healthcare delivery system is set up greatly affects the kind of care that will be given within any system. I will go into this in more depth at a later point.

In regard to Medicare, I stayed in that system for about 3-4 years of my private practice. One reason that I am probably starting out writing about insurance is that I saw on the news today that Medicare reimbursements to physicians are slated for a 21% cut as of next month. This is one of the reasons that I stopped being a Medicare provider, every year I participated. The other issue is that there was the unfair and discriminatory policy that patients using Medicare for mental health had a 50% co-payment, whereas if they used Medicare for a physical health issue, they only had a 20% co-payment. This created an unfair burden on patients with mental health issues as they had to pay a much larger percentage of co-payment than a person seeing a doctor just as often for a physical diagnosis. This created a great deal of hardship for my patients who needed to see me more than once a month and pay co-payments out of their disability checks.

Again, I am surprised that in sitting down to write about my practice, I ended up first writing a critique of health care delivery systems. I am reminded of Foucault’s statement that the first responsibility of a doctor is a war against bad government (paraphrase from The Birth of the Clinic). I suppose that inherent in my desire to create a practice in which I could spend time with clients for medication management, psychotherapy, and healing, I was implicitly critiquing the health care delivery systems in which I had previously worked (academic, VA, multi-specialty group practice, community mental health).

What hits me at this time is the relationship between the structure of a health care delivery system model and the impact on what kind of care is possible within that model. In the volume model, a biological role for the psychiatrist is favored, because it does not require in-depth human understanding (which requires time), it only requires the ability to “read” and “interpret” symptoms that a human being exhibits and reports. (No wonder I am reminded of Foucault).

This awareness of the structure of health care delivery system models and the kind of care that is possible within those structures is very salient to me at this time with my impending move to Auckland, New Zealand, to work as a psychiatrist in a public health setting. I know that I will most likely not be able to provide direct psychotherapy or healing sessions with clients in this system, but I am curious to see what other kinds of care might be possible in a model in a socialized health care system. I really do believe that the “best practice” is also the most cost-effective model in the long run. Part of the crisis in American health care is that “best practice” is seen only in terms of short-term responses to medication and surgery rather than in the long-term happiness of human beings who are encouraged to reach their full potential. I am interested to see what might be possible in a socialized health care system regarding fully human medical care.

What are some of the core tenants of the private practice model that I have developed over the years? This is a good question and I imagine that these may shift somewhat over time. I would say that the basis of health is found in the full expression of each person’s humanity, or in other words, their Self. A short-hand breakdown of what this means is that optimal health would be found in a balance of physical, emotional, mental, heart, self-expression, intuition, and spirit, in each individual. Illness should be addressed in regard to these dimensions of human being.

This kind of work requires the input of time, willingness to listen, and patience on the part of the physician. On the part of the client, it requires engagement, responsibility, and honesty. The partnership between physician and client should include mutual respect of each other’s humanity (physical, emotional, mental, compassion, self-expression, intuition, and spirit).

I do feel that I was able to create a health care delivery system model in which I could strive to reach this ideal of human interaction in the service of health.

What are some of the shortcomings of my practice that I created? I would say that the first one that comes to me is around the issue of time. The more time I spent with clients, the less time I had for other things. An obvious statement, but one that created an ongoing dilemma that I tried to address in a number of ways. I am reminded of something from M. Scott Peck’s book, The Road Less Travelled, in which he complains to a supervisor that he is spending more time with his patients and all the other psychiatric residents are getting out of work earlier each night. His supervisor simply, says, “Yes, you do have a problem,” but just gives the dilemma back to Peck to solve for himself. This is the obvious problem of spending more time with clients is that there is less time for other things.

In the beginning stages of my practice, it was very important to me to learn how everything worked, even if I grumbled and groaned about insurance, billing, scheduling, and various administrative issues (I always loved having to go to the office supply store and would always make sure I had lots of different pens to write with, a geeky pleasure, but you have to find small pleasures where ever you can). At a certain point in my practice, these administrative issues were no longer supportive of my learning, but became things that I was constantly trying to fit in somehow into my worklife. I purposely write this as worklife, because this is what I really wanted in my life. I wanted work that was an expression and extension of my life. I successfully created this and then sometimes despaired that my work was always a part of my life! Another example of be careful what you wish for because you just might get it.

Time has been a central issue in my work. I started a private practice in order to spend more time with clients and this was also my biggest complaint throughout my practice that it was difficult to balance quality time with clients and having enough time left to in my life to attend to my own human needs. Some of this, I am sure, has to do with my own neuroses and personality quirks, that I often don’t feel that I am doing enough or working hard enough, but some of it is inherent in the health care delivery system model that I created.

I hired a part-time office assistant in the summer of 2009. The biggest help from this was that I could delegate certain things, like calling clients to move around appointments so that I could clear space in my schedule for other interesting or supportive things that came up, such as scheduling a massage, going to a talk, meeting a friend for lunch. Oftentimes, I would skip something I wanted to attend rather than face calling a number of clients to try to re-arrange my scheduled because I was already so red-lined for time. Time and space, these are two universal realities and dilemmas.

I realized that I really needed someone full-time as an assistant, but I realized even with the part-time assistant that I wasn’t really able to see any more clients, but “just” to have a better quality of life. This meant that the cost of the extra office and payroll came out of my current income. I was willing to take some cut in pay for better quality of life, but I felt that I didn’t want to take as big a cut as a full-time assistant would require.

I realized that one way to proceed with this was to partner with other health care providers who had a similar, holistic, philosophy. I looked into partnering with a nurse practitioner, but that didn’t work out. I did look into the possibility of starting a holistic health care center. I examined possibilities of creating a non-profit, but that seemed like it would be complicated if I wanted to work in the non-profit and also retain control over the direction it took. I feel like I was just really starting to look into these issues over the past year or so. I didn’t really come to a sustainable long-term solution in regard to the time issue, although with the decision to move to New Zealand, this no longer was a pressing concern as I shifted my time and energy to closing my practice.

This will continue to be a work in progress of re-evaluating my private practice and figuring out what I have learned from it.

Dave