Friends of the Practice
I need to tell you why I have taken my practice and dedicated it to a new model of health care ….. and what it means for you and for your family. This is an unrehearsed statement, unpolished, from me to you. I will do away with tight organization, grammatical rigor, and certainly linearity and parsimony. I hope to tell you what I bring to the office and why I must rededicate myself to your care.
I grew up in the “projects” of New York City in a lower income blue-collar family. A chubby kid with absent athletic ability, diplopia, and some hints of future eccentricity, I was really only good at one thing. I was smart. I could out think, out learn, and out test pretty much anyone around me. While other children were interested in normal kid stuff, I wondered about encyclopedias, religion, global politics, science, and medicine. I dreaded gym class, bowling alleys, and softball. I still get palpitations when I go to my grandkids’ baseball practice.
I adored my grandparents. As a preteen I would compete with my grandfather in mathematical games. I would try to beat him at calculations ….. he with a “slide rule” and me with my head. My grandmothers were generous beyond belief. One of them was dirt poor. She would literally collect rubber bands and tin foil from the streets of New York and fashion them into homemade toys for me. The other grandmother developed Parkinson’s disease after the worldwide Influenza pandemic of 1918. Recognizing my Gd given gifts for intelligence, critical thought, and caring (yes, I am talking about an eight year old) they would say ….. “Mark, become a doctor and find a cure for Grandma”. I watched my grandfather devotedly care for my grandmother through her years of relentless decline to her ultimate demise from advanced Parkinson’s. In my very late teens and early twenties I assisted my own father in caring for my grandfather through his repeated strokes. I learned about the intersection of intellect, discipline, knowledge, and compassion.
At sixteen I entered college with emphasis on physics, mathematics, and biology. As my fellow students did “college” stuff ….. I really had nowhere to go but the library. I was young, socially inept, in hoc up to my eyeballs, and athletically challenged. When they would invite me to go out for a 35 cent slice of pizza and a coke ….. I literally could not afford to. I hid in the “stacks” studying, learning, wondering, analyzing, compiling. I graduated at twenty summa cum laude with multiple degrees. I wanted to be a world famous mathematician but I was not good enough at advanced algebra to meet my own standards for success. Pretty much as a lark, I applied to five medical schools. I was accepted at six! I chose the most difficult, most rigorously scientific, best regarded school ….. Cornell University Medical College. Wow, I studied night and day. The brightest faculty and students anywhere surrounded me. They filled my head with a thirst for knowledge and experience that was insatiable. I learned how to learn. I dedicated myself to a lifetime of exacting self-improvement for the care of patients. I did everything. I was everywhere. From diabetic comas, to gunshot wounds, to every emergency procedure known to man ….. I was a member of the team that could do it all.
With great clarity, I remember so many moments from medical school. I remember the first time I put a white coat on and walked from New York Hospital across the street to Memorial Sloan Kettering. Strangers (New Yorkers nonetheless) made eye contact with me (I had long curly hair and even longer sideburns) and smiled at "the doctor". I remember the first time I walked the hallways of Memorial Sloan Kettering Hospital. I felt I was impersonating a doctor because I could not do the things that “attending doctors” could do. I would work long, long days and nights ….. oftentimes around the clock ….. to acquire knowledge, experience, skill, polish. I became friends and colleagues with the giants of medicine. I took care of people. I loved my patients. I ignored the advice to stay remote …. I took it very, very personally when they suffered. I could “feel” their illnesses. I developed an empathic and intellectual link with patients. Despite this connection, I wore the white coats and the masks of academic discipline. My instincts have very rarely failed me. I won virtually every prize for academic and clinical excellence, leadership, compassion, and honor there was.
When it came time for residency training, I chose Yale. Wow, I loved every second of being at the world’s best Internal Medicine and Dermatology training programs. I hated every second of my internship. My first born was less than one week old when I began my internship. I cried every morning that I left her ….. I left the house at 0600 and knew I would not return home until the next evening at about 1900….. that's thirty seven hours of straight on your feet, intense physical, mental, and emotional work. The hours were brutal (literally 115 hours every week). The working conditions - horrible. The toll on your emotions, on your body, on your friends, on your family absolutely - dreadful.
But the payoff was becoming an elite physician. A healer. I could take care of anyone and any set of conditions with incredible focus, constant attention, star wars science, and transcendent thought. I was part of a team of likeminded individuals ….. the world’s best doctors, nurses, unit staff, transport staff, technicians ….. it was incredible.
My recollection of the training process was as follows. With a solid foundation in science, anatomy, physiology, pharmacology, etc …… the medical student is introduced first to single system disease and then to multiple system disease. Upon moving on to residency training, the intern learns to take care of the most severe illnesses and the most complex presentations. Within one year of residency, you are an experienced resident doctor. In two years you are oftentimes the most senior physician in an entire hospital ….. with responsibility for hundreds of patients and a score of residents, interns, and students. Is it any wonder that, in order to fulfill these roles one needs a strong sense of self worth, an ability to perform under the most adverse conditions, and (yes, the "a" word) an arrogance that permits you to bring your relatively juvenile skills to the most strenuous of life situations. On any given thirteen to thirty seven hour shift you made countless life and death decisions.
My longest shift was sixty two hours straight in the blizzard of '77. I was one of very few doctors in the hospital and it was either I took care of scores of critically ill patients or they died. No one died on my watch. Indeed, everyone was extremely well taken care of.
With further study, the resident becomes a chief resident and experiences the application of all of his training, experience, G-d given abilities, and human dedication to solve the riddles of human afflictions. It is a feeling of power and ability that, if not for the continual exhaustion and short shrifting of one's outside life, would be positively intoxicating.
I was given the great privilege of doing everything in my power to heal people. There were no limits on the resources at my disposal. There was no limit to how far I would push my body and my mind in the service of others. No one, not the hospital administrator, nor the insurance company would or could interfere with my best judgment and my recommendations. This is not to imply that I was unsupervised.
Tested senior physicians, peers, wise nurses, and a host of other colleagues were quite aware of which of us was deserving of the trust and which not so much.
I can honestly say this was the golden age of medicine. Wonderful, integrated teams of professionals cared for families. It was truly patient centered, respectful, responsive, multidimensional treatment. We formed a strong bond with our patients and their families ….and they were grateful. I loved being an Internist. I showed great promise.
And then I met dermatologists. They were the smartest, most intellectually gifted, the most humorous, the happiest, the most clinically adept people I had ever known. The dermatology residency was the most coveted position in residency training. I changed track from Internal Medicine to Dermatology….. but not until after completing three rigorous years of training in Internal Medicine and ultimately becoming a board certified Internist. I worked three long years with my fellow residents in Internal Medicine in order to be fair to them (had I left prematurely, they would have had to “take up the slack”) and to broaden my experience. And then I started all over again. Most medical doctors had under two hours of formal training in Dermatology over the course of their entire seven years of medical training. I was back in medical kindergarten except this time, the giants in the field were even larger. I chose the absolute best Dermatology residency program in the world …… Yale!
The Dermatology residency was magical. Although a profound neophyte, I found I had an ability to “read the skin” that very few others in the world had. I was mentored by the best of the best. One world famous doctor scientist after another became my friends. I wanted to be like them. They saw great promise in me. I felt I could be a great Dermatologist if I brought my Internal Medicine work ethic to my Dermatology skills. I was close to standing shoulder to shoulder with the best in the field. I honed my observational skills, my critical thinking, and my technical surgical abilities to a very sharp edge. After another three years of training (three years for Medicine, three years for Dermatology), I looked for somewhere to be of greatest use ….. in teaching, in practice, in research, in raising a new family.
Enough of my story for now. I must get down to work and attend to my practice. I promise to continue each week to address the why, how, when, and what FOTP (Friends of the Practice) means to you . What I can tell you is that for many of you FOTP will be less expensive. For each of you, this will mean great care unfettered by your insurance company, your ACO, your PBM, your ABC …. I will bring the full resources of my experience and of this office to you. You will be better for being a friend of the practice. More to come…………..
It has been a bit since I began this blog. I want this entry to convey to you the sum of my professional life thus far. I want it to inspire you to be a friend of the practice.
I was in the elevator at Yale New Haven Hospital going up to the fifth floor in order to participate in Grand Rounds. "Grand Rounds" was an exercise in excoriation where one resident stood before the grand assemblage of the most knowledgeable, clear thinking, and respected doctors in the world ….. and presented a description of a patient, the differential diagnosis, the most likely diagnosis, the proper work up of the patient, and the likely treatment and outcome. At any rate, on the ride up in the elevator, a resident one-year senior to me urged me to aim for a career in research and teaching. I decided then that I would be a physician, a scientist, and an educator!
Having only one board certification under my belt (Internal Medicine) I was the junior of our residency group ….the other two had advanced certifications in Internal Medicine and Rheumatology; and in Pediatrics, Endocrinology, and Genetics. All told we possessed SIX board certifications before we even started our Dermatology residency! We were undoubtedly the most self confident, mature, iconoclastic, skilled, fresh three-some that Yale Dermatology had ever encountered. That was a heady time in my life. There was no competition among us …. only camaraderie, hard work, and relentless dedication to molding ourselves into compassionate ivy league trained physicians. We accomplished amazing things for our patients, for our students, and for our institution and specialty. There was a saying that went around Yale at the time among the medical residents. It went, if the intern can’t figure it out, ask the Medicine Resident, if the Medicine Resident can't figure it out, ask the Medicine Chief Resident, then the Medicine Attending …. and if no one can figure it out, ask the Dermatology Resident! We were at the vanguard of Dermatology practice, research, and education. Each of us became Chief Residents in Dermatology at Yale. Wow!!
Confidence and ADD have served me well in my career and in your service. I am eccentric, socially challenged, blunt, and …. unbelievably well trained, knowledgeable, confident, and dedicated to you. I am quite certain that I can diagnose things that few others can. I possess an intuition …. probably based on very subtle clues from you …. that I trust implicitly. I can literally “feel” illness. I have a discipline about physical examination, morphology, analysis, integration that has been drummed into me by the best of the best of the best. I believe that the difference between a good doctor and a great doctor is …. your health. I am continually tweaking my skill set. My diagnoses are crisp, my surgeries elegant, and my cosmetic procedures spot on. My confidence has been formed over four decades of dedication to my specialty and to you. I strive to be a “complete physician”. I pride myself on others calling me the “doctor’s doctor”. I am proud of my membership in the American College of Physicians. I am proud to be a Dermatologist and Dermatologic Surgeon.
Several years ago a young student at a nearby university visited me. He had a "mole" taken off from his skin by his local medical doctor. He said the doctor felt it was "nothing" and "to save money for his insurance company" he proceeded to "toss the specimen into the medical waste garbage". He had no idea what the “mole” was and certainly no idea whether his surgery was adequate. He was the “gatekeeper” for the insurance company. This ill advised shortcut to save money for his medical care would prove tragic.
Our new patient was nineteen, handsome …. with an equally young and handsome girlfriend at his side. I examined him quite thoroughly and found a large lymph node in his armpit .... precisely where a "mole" would have traveled had it been, in fact, a melanoma. I feared the worst. I "hung crepe"…. explaining that this might be a metastasis.
Back in the 1990’s there were virtually no effective therapies for this stage of melanoma. Back then pretty much the only hope for improved survival was early recognition and prompt surgical therapy. The doctor had provided neither option. The doctor had bent to the will of the insurer. The patient was unaware that this was derelict medical care. He did not recall being given a choice in the handling of the specimen. How could such a simple act of throwing a bit of skin in the medical waste container rather than in the pathology bottle affect anyone? And yet, it was impossible to go back in time and provide the right care. The patient would suffer.
When the pathology report returned it read metastatic malignant melanoma. I called the young man up and asked him to bring his parents to my office. We sat, the man, his girlfriend, his parents …. as I delivered the facts as clearly, honestly, humanely as I could. I gave them both reality and hope. I felt myself drawn into the horrible terror along with them. I wanted to be alone, apart, removed from the rawness of his disease. I wanted to protect my own emotional self. Instead, I provided strong, kind advice and kept myself always available to them. They put their faith in me and in the team of experts that I assembled….the best doctors I could find in the region and around the nation. With great speed we did everything humanly possible for this young man, his girlfriend, and his family. For a very short while, he was a happy college student in Rochester.
A few months later he returned for his regular check up. Although he hadn’t noticed them, he was riddled with BB sized tumors all over his body. I had trouble hiding my horror. I took a biopsy through the skin, and there it was … a sickening blue black metastatic nodule. This was the pigment that would sign his death warrant.
A month or so later I was attending our annual convention in Washington DC. I felt a terrible cold realization come over me. I knew this young man was dead. I was so, so sad. I called my office ….. they asked how the family had called me so quickly since they just got off the phone with them. The family had just called to say their son had passed.
And now, in so many ways, I find myself lacking the robes, the power, the influence of a Physician. I have become a health care “provider” ….. a “performer” ….. and, worst of all, “leakage!” Somehow, over three decades, there has been a transfer of influence from the patient and the doctor to the insurance company, the political system, the affordable care organizations, the pharmacy benefits managers …… my role, and the role of every single other physician in this region, has changed. The physicians providing your care are no longer able to be the powerful advocates for your care. We are discouraged from reaching far and wide to assemble the finest colleagues for you. Instead we are bound by hospital affiliations, ACO's, insurance companies, etc.. Physicians providing care less frequently influence, much less decide, sound medical policies that hospitals, insurance companies, and politicians consider. We click on our computers, follow the rules, do our best within the system. The system is not your friend. The system worships control, big data, uniformity, mediocrity, sweeping rules and regulations. Where no good data exists, the system must act … and often without logic. Dreadful things happen when the doctor, the patient, and the family lose their voices. Allow me to tell some more stories that frustrate me, anger me, and break my heart. They explain why Friends of the Practice has come into existence.
Two children were referred by their pediatrician to see me for their atypical moles. Their pediatrician and their parents entrusted me with their care. They called me Dr. Grandpa! At each visit I asked to see their mother and their father because atypical moles are familial…. and they carry the very real risk of malignant melanoma. Each year, mom would tell me that although she and her husband felt a visit was needed, although her doctor felt it was recommended, the HMO would not "allow" a referral for preventive dermatologic care until she could present a lesion worthy of a referral. One day, years later ….. she presented to the office; her hairdresser had found a bloody, non healing spot on her scalp. I was so relieved to finally see her in the office. Even before I examined her I realized she had a huge mass on the left side of her neck. A rock hard lymph node. So large, in fact, that she had trouble turning her head fully to the left.
When I examined her I found abundant evidence for the dysplastic nevus syndrome (familial atypical mole syndrome) with its attendant risk of melanoma. But for the intransigence of her insurance company she would have followed my advice. But for the false advertising and pervasive influence of the insurance company, I absolutely feel she would have been saved. She could afford the visit fee, but believed strongly in the concepts of her HMO. The HMO philosophy was based on several false assumptions. They had nothing to do with health maintenance. Their marketing campaigns were false. Their gatekeepers received no special training or certification to handle conditions that they previously declined to manage. Predictably, rather than maintaining the woman's health, it was willingly, repeatedly, and belligerently preventing her health care needs from being properly addressed. A complete dermatologic evaluation performed when I first met this family might have saved the mother from what was to come. I absolutely believe that given the chance, I would have saved her life.
Checking her scalp, here was a huge, advanced melanoma eating away through her skin. It had already widely metastasized. I knew this in an instant, in a glance borne of decades of experience. I knew this because the insurance company finally issued a “referral” – but tragically late. The young mother and business executive lost weight. She developed metastatic tumors. We did everything we could for her. She died. Her family was filled with sorrow. I was shaken. For many, many days and nights I struggled with my anger and my frustration at the lack of an opportunity for preventive care which could have saved this woman's life. The reason for my failure was not a lack of education, resources, or treatments. This woman died because she trusted her insurer and could not get a referral. I said to myself that I did everything I could. The family said they had lost a wonderful wife and mother. The insurance company said “no referral.” Did they hold any liability? No.
I doubled up on examining the rest of the family. I assured them this would not happen to them as long as I continued to see them (not entirely true, but essential to mitigate their nightmares and their fear). I promised them there was nothing they could get that I could not cure (almost true). I was always available to them, always counseling them, always confident in their care. I made certain that they and we did everything we could to minimize their very real risk of melanoma. We have been successful.
A few years after the young mother's death, her daughter told me she loves to run as fast as she can. It was one of the first times I had seen her light hearted and free of sadness. I asked her why she loves to run as fast as she can. She said "because when I run fast I don't think of mommy". Sometimes I believe I run this fast for the same reason.
Despite my many attempts to hold the insurance companies accountable for their actions there was nothing to be done. Despite my efforts to wrest control back from the bureaucracy, I was impotent. The situation is far worse now. The system is not working for you. The diversion of resources away from your care has passed a critical point. The health care system itself dangles on life support.
The concept of an HMO was ill reputed prior to 1973. Before the government embraced the HMO, it outlawed it …. as a clear danger to patients’ well being. The HMO was a negative reimbursement kickback scheme …the less care delivered, the greater the profits for these “non profits” …. you know, the ones with naming rights and promotions all over town. At first, the HMO struggled to survive …. on newly minted resident manpower and with the backing of the giant insurers. They concocted the five dollar copay, referrals, prior authorizations, tiered prescription coverage, step therapy, mandatory waits for mri’s and ct scans. They "branded" themselves, bought naming rights, signs, advertisements, and doctors. More insidiously, they virtually eliminated working physicians from input into policies that directly affect your care. They have buried physicians under a deluge of “requirements”, rules, “steps”, and "thou shalt nots" …that distract the doctor, reduce the range of care the doctor can bring to your family, and lead to physician burnout.
What I personally seek in my doctor is a healthy physician …. a complete physician, an elite physician …. one who has the determination, the independence, the defiance, the resources, the emotional energy, the freedom to take the very best care of me.
I am preparing the final portion of this blog. I will answer your questions as clearly as I can. I will give you both an explanation of my vision for this practice, the enormous value to you and your family, as well as a bit of a rant about the frustration I feel as a physician in the current health care system.
I envision a welcoming office, a respectful and open doctor visit, and results. To the extent humanly possible, I will tolerate no outside interference. I am re-dedicating my career to you and to your family. In my office, we will not worship mediocrity, uniformity, or nonsense repetition of insurance company mandates. I am so pleased to have the opportunity to greatly improve your care.
What is Friends of the Practice?
Friends of the Practice is the name I use to describe a self pay model of health care.
It is about a valuable improvement in your care.
It safeguards direct access to quality medical care for you and for your family.
It eliminates the insurance companies, the politicians, and the medical practice consultants from our examination room.
It enables meaningful interaction with your doctor and the development of personalized, thoughtful, broadly based treatment plans that work for you. It sidelines many of the outside influences that worship mediocrity and control.
It is a logical evolution in my medical career and in the development of this office. It is about you and me. It is about my staff. It is about the people in the examination room.
It is about what is missing from the American Health Care System.
It is not a political statement, it does not address the huge issues facing the American Health Care System.
It is a bold and risky venture on my part and on the part of our entire staff. We do it because you deserve uncompromised access to our judgment, experience, and services.
I am not in any way altering your insurance coverage. If you have decent insurance, including out of network coverage, you may wish to submit the statement from this office to your insurance company. We will give you all the information the insurer should need.
If you have an HSA or FSA you may be able to submit the bill to your insurance plan.
For our "bread and butter" services, we are going to a one price, no surprises, fixed fee. One number, one price. That's it. That's the entire routine pricing schedule. On January 1, 2017 the fee will be $200.
We are doing away with "a la carte" pricing for office visits. We are replacing them with "enhanced" office visits. Included in this single price will be a reasonable number and intensity of services. A comprehensive dermatologic examination including epiluminescent microscopy, in office laboratory services, and the harvesting of specimens for outside laboratories is included. The taking of biopsies is included; no need to return on another day and pay another co-pay. Treatment of pre-cancers is included without restrictions on the number of pre-cancers that I can treat at your visit. Everything that I can reasonably do for you, I will do for you.
Whatever is on your wish list, let's talk about it. Removal of minor benign lesions, use of peels, spot laser therapies are all available to you. Guided by fairness, I will include these procedures in your one price visit. I want to improve the value of the services we provide to you. I am successful when I improve your health, when I can bring our global expertise to you and to your family, when you are amazed at what a great office this is. I envision the combination of medical dermatology, surgical dermatology, and cosmetic dermatology to enhance your health wellness ….. and with the one fee pricing, I am putting my money where my ideas are.
This is not a step towards retirement. I would like to continue in my life's work. We shall see in time whether our new plan is sustainable, and what the rest of the health care landscape looks like.
We hope you come to your visits with an open and fair mind …… and a list of what you would like to accomplish in skin health over the next several years. This will not only save you time and money, it will revolutionize how we interact as patient and physician.
We will post online and in the office the fees for larger procedures … such as full surgeries, peels, laser therapies, vein therapies, fillers, neurotoxins, etc.. We hope you take advantage of these services. Our procedure fees will be all inclusive for related services provided in this office. There will be one payment rather than three co-pays, three coinsurances, and three deductibles. We are eliminating the bloated and hideously inefficient interactions with insurers, aco's, pbm's, etc…… you will be pleasantly surprised at how cost effective our services will be.
We hope to post fees for shorter visits, group visits, or any other arrangements to make Friends of the Practice more viable and more valuable for you and your family. Please give us ideas …. it’s ok to think outside the box.
We are tremendously excited about the inherent benefit to you and your family.
We are grateful to the hundreds of patients who have expressed their profound support for Friends of the Practice and are already imagining ways to enhance their health with our expanded services.
For many patients …. because so many additional services are included in the price of an office visit, doing more for yourself is essentially free!
Why Friends of the Practice?
Every single day, every single decision made by every single doctor in this country is influenced by power brokers …… insurance companies, hospital systems, government, big pharma, etc.. Despite their best efforts and in part because of their crushing workloads, physicians have failed to maintain a powerful voice supporting your right to great health care. Consider this: your doctor is not allowed to accept a free pen from a drug rep for fear that it will unduly influence his behavior. Meanwhile, the power brokers, the “big boys” are allowed to employ your doctor, set fees for your doctor, pay your doctor when and what they want, restrict your doctor, monitor your doctor, have access to all of your private records, punish your doctor ….and it is all done with layers of secrecy so that you don't know what you don't get.
Things in health care are getting worse. Insurers are more powerful than ever. They hire legions of consultants whose job it is to withhold services from you…but they keep it quiet. Just this week, a giant insurer ordered doctors across the nation to submit laboratories and pathology specimens to laboratories of the insurer's choice…and many, in my opinion, are under-qualified. I won't do it. Who reads, or misreads, your biopsy can influence whether you live or die. At Friends of the Practice, I will stand up for you.
Hospital systems are more powerful. They buy up virtually every primary adult care practice in sight, urgent care centers, and specialist offices as well. With their ever-present logos, they are concentrating on "branding" so that you will go to their doctors, their labs, their hospitals, their everything. They call independent physicans "leakage". Consolidation of health care systems creates huge monopolies that may increase the cost of care and may reduce the quality. They certainly restrict choice and competition.
Big Pharma's price increases are unconscionable. For many patients, I find myself unable to find any affordable treatments. Tetracycline should not cost $900. Biologics, critically important in the treatment of Crohn's disease, rheumatoid arthritis, psoriasis, etc., should not cost over $40,000 per year. In life threatening situations, epinephrine rescue injections should not cost $600. Who can afford these prices? The claim of the pharmaceutical companies that your insurance will cover most of the cost is specious: we all pay for the rate hikes in insurance to cover these increased drug costs and we all pay higher co-payments. Why there is no patient outrage is beyond me.
If you believe your health care has not been influenced by these changes, I respectfully disagree. The American health care system is broken. Many times a day and every single day I see well meaning doctors (with whom I communicate) aligning their practices with the “new” health care mandates. Ours is a bloated, unaffordable, and unproductive system. It leads to burnout for physicians and danger for patients. Despite the hideous record of “health care reform” since 1973, we continue down a path to micromanaged mediocrity. I will not expose you to care that I know is wrong. I have seen too many tragic outcomes. I will not be silent in the face of unreason. Have you explored with your doctor the powerful forces at work in American health care? Truly, how your health care is insured, managed, and micromanaged is ultimately more important to your well being than whether you receive a sustained release pill or an extended release pill! When almost every doctor you see is unhappy with the current system, dismayed by the lack of affordable drugs, angry over even the concept of prior authorizations …shouldn't you be listening? When your doctor is working harder, typing more and spending less quality time with you, don’t you see it? When there is acceleration in the rate of experienced doctors becoming disenfranchised and quitting health care, when most primary care practices are closed to new patients, when does this become a call to action? The emperor has no clothes. At substantial personal risk, I am realigning my practice for you….and for me. To repeat my opening comments: I envision a welcoming office, a respectful and open doctor visit, and results. To the extent humanly possible, I will tolerate no outside interference. I am re-dedicating my career to you and to your family. In my office, we will not worship mediocrity, uniformity, or nonsense repetition of insurance company mandates. I am so pleased to have the opportunity to partner with you.
Difficult and important questions:
Well, patients ask me …. exactly what haven’t you done for me that you would otherwise have done? I think you're a fabulous doctor and I always feel well cared for. I like my insurance, they cover everything. I get the best referrals, the best medicines, and they pay for it all. I already pay for insurance, why should I pay you as well? If my insurance were to withhold care from me, I would know it and together with my doctor, I would change it.
If you are basically healthy, you may not have experienced the frustrations of being denied adequate evaluation, testing, surgeries and medications to treat your illness. But some of you may have known a friend or family member who was denied the chest X-ray, the CT scan, the biopsy, the appropriate surgery by an insurance company that has never examined you and will bear no responsibility for your failure to heal. Intuitively, you know that the insurance companies are unqualified to be guardians of your health.
Please allow me to demonstrate:
Have you ever seen the policy manuals your insurance companies use to deny you care? Try to check one out. You will be astonished.
You may see a "best practices" guideline. It is certainly a "tidy flow chart". I see a 38 year old engineer with agonizing back pain who can't afford to take six weeks off from work, from family, from hobby, from life …… without further customization of her treatment plan. I see in the above tidy flow chart the powers of greed, control, micromanagement, and secrecy perverting your medical appointment. I see scores of highly paid practice management consultants restricting your care. I see legions of insurance clerks sitting at monitors denying your doctors' repeated appeals for your care…..treatments that are required to alleviate your suffering and to make you well.
You never get to see the tidy flow chart. You assume, and the insurance clerk insinuates, the doctor must be in charge ….. if his recommendation is denied, it must be because he and his office are failing to make a strong enough case for the recommendation. You assume the insurance company certainly doesn’t have the power to deny a doctor’s request for treatment….or do they? You need to understand there is NOTHING the doctor can do to make the tidy flow chart go away. The system is stacked against you. The clerk is unfazed. The practice management consultant earns a bonus. The patient …. is lost in the system.
So the answer to “what haven’t you done for me that you would otherwise have done?” is complicated. Since 1973 the “big boys” have been working to alter the practice of medicine in the USA. In my opinion, it has been a dangerous, destructive, colossal failure. There are not many physicians practicing today with the freedom, imagination, focus they were trained for and possessed in 1972. The verdict is in, managed care is a failure. Call it evidence based medicine, accountable care, the medical home, patient centered care, electronic medical records, pharmacy benefits managers, variation detection and marginalization …. whatever slick marketing term is in vogue …. it is more expensive, less personal, less focused than before. You deserve better.
On January 1 2017 I will no longer be subject to these abstract algorithms of care. I will neither bow to the wisdom of the practice management consultant nor to the insurance company clerk. Based on my life experience, my professional education, and the wise counsel of colleagues and of my Specialty, I will do what's best for you. Period.
Did you ever wonder why that prescription medication is not allowed? Why you have to use a series of the wrong medications before you can use the right one?
Back in the early eighties ….. just after the dawn of the HMO, a very nice, smart, hardworking man signed up for one of the leading insurance plans in this region. The insurance company was methodically and covertly influencing his doctors, limiting their choices, reducing their autonomy, and punishing them if they put the patients' needs above the insurance company's mandates. The patient was wholly unaware that a monumental transfer of influence was occurring…from the examination room to the boardroom. A financial empire was rising. It was all kept very quiet.
This hard working man developed a skin rash. It spread. The rash ulcerated. Finally, he was referred to "a dermatologist". I diagnosed the condition and treated it properly. His skin cleared rapidly. I knew to check his mouth ….because the rash often involved the mouth and could lead to aggressive mouth cancer. I prescribed the right medication for him, but the insurance company declined coverage for this man's medication. I protested. Their response was stony. I protested. Over and over I protested. They wanted the scientific literature, I sent it. They wanted photos, I sent them. They wanted me to write a letter to their medical director, I wrote it. I spent hours working on this man's behalf. There was simply nothing any physician could do to force the insurer to cover the man's medication.
I suppose the man reasoned that it was just a skin and mouth rash. How much could a rash hurt him? Although he understood the rash could cause aggressive oral cancer, he figured the insurance company knew best. The insurance company would never do anything to hurt him. The insurance company would surely listen to the arguments made by a board certified, fully licensed physician. And so, he did not fill the prescription. He lost interest in his rash. No longer an active patient here, the man went about his life.
Unbeknownst to the man, he had been wrong about the insurance company. They most assuredly did have the power to ignore the expert physician. They most certainly did forcefully, repeatedly, and tragically deny coverage for the properly prescribed medication. They did unleash a ticking time bomb, the responsibility for whose detonation they would later wash their hands of.
Decades later the man returned to see me. He remembered that his doctor, not his insurance company, had cared for him so well in the past. He was glad to see me. He complained of a year or so of mouth sores. He said they were canker sores, but deep inside dreaded that they were more. I knew they were more. He had progressed, untreated, to the dreaded aggressive mouth cancer. It was painful, frightening, multifocal, and recurrent. Over the past several months this man has lost a good part of his face to surgery. His life has been altered beyond recognition. The clerk that denied the medication has been promoted. The tidy flow charts are more detailed and restrictive. The doctor is disillusioned, his staff is fed up. They have given up trying to fight the giant insurance companies, the accountable care organizations, the politicians. It sickened me to see this happening then. But things are even worse now.
Why can't you have an MRI until after you suffer for six weeks with intractable back pain? Why can't you have more than seven precancers treated at a visit? Why do you have to have a "howdy" visit before your full physical? Why you are referred within an ACO ("affordable care organization") when there are world famous doctors in other systems right here in our very own community?
With respect to "never receiving a bill from your doctor", here's how it works …. the insurers, together with the other big players, decide on what they will offer the doctor for a particular service. They list the rules, the exclusions, the "not allowed's". They present the fee schedule to the doctor ….take it or leave it. The doctor then performs the service, the electronic medical record spits out a multipage documentation note, it is electronically submitted to the insurer …..and the insurer pays only a fraction of the amount they said the service was worth. What? Is this fair?
Have you ever wondered why the doctor's charges are not fully paid? Are you wondering why the doctor doesn't simply bill you for the "fair, negotiated fee"? The insurance company prohibits the doctor from doing so. You are left imagining the scores of luxury cars in the doctors' garages, thinking how great your insurance is, how wonderfully the system works. In fact, the insurer is controlling and limiting your care, shortchanging your doctor, and influencing your doctor towards providing only the services that the big boys dictate. All the while, you are left in the dark.
So, in response to the questions: I like my insurance, they cover everything. I get the best referrals, the best medicines, and they pay for it all. The answer is you may not get the best referrals, medicines, and care. You get what they allow. As far as them paying for it all …. in fact they control what they pay and they forbid the doctor from “balance billing” you. And how do you find out about this giant, repressive machine …. you don't. Sometimes, you get what you pay for.
I had a friend who taught me how to fish for bass on Conesus Lake. I had met his wife at the lake a few times and was very impressed with her "Southern charm". After a year or so of deepening friendship, the "fish master" asked me if I would mind seeing his wife for her year of belly pain. I thought, “not my field,” but he had been so kind to me I felt it appropriate to go out of my way for him. (Lest you think I was practicing beyond my training, I am a Yale trained, ABIM certified Internist). His wife was in agony. She had been in agony for sixteen months. Being incredibly polite and patient, she had dutifully seen her doctor several times and accepted her role in the following events. Her doctor ordered the proper referrals and tests. Her insurance company rejected coverage for the proper referrals and tests. And so, the referrals and tests were never done. The patient felt the need to protest the insurance company's actions, but was too "proper" to do so. She had paid her premiums. She had followed the rules. She trusted the insurer and their glitzy advertising messages. It did not even occur to her to pay a doctor for some expert advice and actual treatment.
And so, I examined the fish master’s wife. Based on my history and physical examination as well as my "intuition", my presumptive diagnosis was cancer …. and an advanced one at that. I told her to take a hundred forty dollars, march down the hall to the Gastroenterologist's office, and I would have her seen right then. Within one day we had the awful diagnosis of advanced, metastatic pancreatic cancer. Caught sixteen months earlier she had a chance to live. Because she was in a “captive” insurance plan, an insurance plan that repeatedly overrode her doctor's advice, she was dealt a death sentence. It cost one hundred forty dollars to make a diagnosis. Sometimes you have to pay to get what you need. She died a horrible death. I felt angry, so angry, helpless, and alone.
Everyone had followed the rules …. except me. I stepped outside the insurance company's rules and regulations. In this case, as in so many others, the woman was consciously unaware that the insurance company was undermining her care. I was the only one who stood up and said “this is wrong, get yourself evaluated and treated…. and do it outside of the insurance company’s influence”. I was subject to reprimand. Everyone else had followed the “best practices algorithms” made by the practice management consultants and articulated by the clerk with the tidy flow charts on their computer screens. I helped the fish master's wife, but it was too late. It is not too late for you. I will no longer be influenced by the perverse; we are going Friends of the Practice for your benefit. I am still friends with the "fish master". He still mourns the death of the love his life.
Dr Goldgeier, I don’t believe my insurance doesn’t guarantee me the best care. I would know if it didn’t. And if it didn't, I could just pay for it, couldn't I?
There was a tiny restaurant in a small town south of Rochester. I loved their pasta putanesca. Their chef-owner would prepare it for me and for any other patron at the restaurant. It was a menu item. More olives, no problem. No anchovies, no problem. It was delicious!!
Times got tough in small town America and so, after an intermediate move to a larger town, the owner was bought out by a larger entity. This larger entity was in the entertainment business, but was neither chef nor small business. They told the chef what to cook and in what style. They branded and they advertised. They provided a really nice kitchen and a computerized order entry system. They had a professional bookkeeper, they employed and kept track of the staff, they ordered new menus, tables and chairs, lighting. No longer a “hole in the wall”, the new restaurant “felt” like a chain. Nevertheless, whenever I could, I would call the chef and ask for the pasta putanesca. It was great ….not the same, but still tasty.
To my knowledge I was the only patron to eat the pasta putanesca. It was no longer on the menu; it was not allowed by the new management. The other diners did not know that they did not get the chef’s masterpiece specialty. Why would anyone bring up something that wasn’t available? They were seated on time in a lovely, well-lit restaurant with a shiny new menu. The bar was spanking new, the servers all young and handsome, the décor was bland but acceptable. The “books” were kept to the penny. The branding was bringing in lots of new diners. The chef was “the same”. Since nothing had changed, and since surely the chef must be in charge of his own cooking, they could presume they were getting the best and most authentic food garnished with the chef’s personal attention. Or could they?
Shortly thereafter the chef gave up. His heart was not in serving chain restaurant style food. The stifling attention to mediocrity, record keeping, penny pinching was too much for him. He opened a restaurant in the South. A few months after he left I called the restaurant to order the pasta putanesca. They had never heard of it. No one knew how to cook it.
Of course you don’t know what your insurance doesn't allow. They may never tell you what was taken off the menu. Sometimes you only get what you pay for. Sometimes, the choices are no longer available to you!
I already pay for insurance, why should I pay you as well?
Because I know how to get you better. I know how to keep you well. I will listen to your needs and address them. Because I will not follow the “tidy flow charts”. Because I am sick of seeing people suffer needlessly. Because I don’t want to see patients needlessly die. Because your health insurance is not really insurance …. it is managed care. Because now you get only what the insurance company and the “big boys” will allow.
Because, in good faith, I will no longer be a mouthpiece for the system …… what one of our leading physicians has called "the medical industrial complex". The level of care that I will be providing to you is vastly beyond what they would allow you to have.
Because I have lost faith in the current system and its future direction. It is a failure. Has “managed care” brought down your premiums? Improved your health? Contributed to the ability of your doctor to care for you? My answer is "No". Right here in Rochester it has led to hundred ten dollar co-pays, coinsurance (I am still not certain what this is …. it seems to be a second co-pay), fourteen thousand dollar deductibles .. no wait! twenty thousand dollar deductibles, thousand dollar medicines, and million dollar insurance company salaries with twenty million dollar retirement buy-outs for insurance executives.
Because I believe in our office and my patients. You and your family need us, trust us, like us. So many of you have told us this is the best office and I am the best doctor they have.
Because I love Dermatology. I love my patients and my staff. I have strived mightily for them. Because I see a terrible void in the fabric of health care and despite decades of effort, I have been unable to work within the system to mend it. Because things are getting worse for you and for us, rather than better. Because you deserve better. Because when your health and the health of your family is at stake, I believe you are better off with me directing your care than your insurer. Don’t you?
Fee schedules for cosmetic services and larger procedures to follow in late September.
Here is what our patients saying about Friends of the Practice:
That sounds fair
I applaud you
You've saved my life, I'll never leave you
I understand completely
It's my life
I can’t think of any way the insurance company actually improves my health care - it’s between me and my doctor
I'm staying with you
You've helped me and my family so much
Who needs the cheap insurance anyway?
I have a high deductible, this will actually be cheaper.
This is how it was when health care was better
Buyer and doctor together, I like it
My friend was almost in tears when she read the letter. I'm so happy this will work for all of us.
I pay more than that now
It's worth it to me for the convenience
I trust you ….. do what's best for me.
I wouldn't go anywhere else.
You’ve been talking about this for a long time. I was expecting this and I welcome your principled stand.
You’ve taken great care of me these years.
Every visit here has been great.
You are so sweet and kind ….. woops, they were referring to Karen!
I wouldn't change a thing about how you take care of me. I get great care and entertainment as well
I leave here happy and smiling. I wouldn't go anywhere else.
I have a high deductible, they don't pay anything anyway.
I respect your abilities totally.
I have an FSA that will cover these visits.
I always want to have free thinking, dedicated professionals around me.
I absolutely applaud your professionalism.
You stand up for me and I will stick with you.
No doubt, you are my favorite doctor.
I'll have to figure something out with you.
I can't leave you, you're one of my favorites
You always take such good care of me.
Wow that's worth it. I'm in.
It's a great deal.
- You can do all of that for me …… great!!
As of March 28, 2016, a new NYS law will take effect for prescriptions written and filled in New York State.
We will NO LONGER be allowed to call in OR fax ANY prescriptions into your pharmacies.
New prescriptions and refills MUST BE transmitted electronically. You must tell us the name and location of your primary pharmacy.
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