Journal04-02.cdr

Robert S. Berry, M.D.
Because of the charitable nature of the clinic, I had considered making it a non-profit to take advantage of tax breaks and to raise The greatest benefit of an insurance-free practice is just money for my own salary. After several discussions with my attorney, I was inclined to decide against it. He pointed out that More than three years ago, I left emergency medicine to start an dealing with a board would probably be about as frustrating as insurance-free practice. I’d studied the feasibility of starting a part- every other bureaucracy I had encountered since my residency. In time clinic primarily for the uninsured.
addition, even though I would be the one building the patient base, Of course, I wouldn’t refuse anyone else willing to Pay At The the board could dismiss me whenever it wished, and the years I Moment Of Service, so I chose the acronym PATMOS as the clinic would have invested might well end in futility and bitterness.
name. By avoiding all contracts with third party payers, I could I reasoned that since the sick and injured we will always have avoid the crushing costs of settling relatively small claims, and with us, it was more prudent in the long run to depend on them for thus provide more affordable primary medical care to all point-of- my income, rather than on fickle donors and ever-changing tax laws. The long-term risks did not appear to be worth the short-term From my experience as an ER physician, I knew the people the financial security a non-profit might offer.
Non-profit status became an academic issue quickly, since my charts classified as “self-pays.” In a small community such as ours, plans to make the clinic full-time were realized sooner than I had I had purchased goods and services from many of them. They were expected. For various reasons, the president of the hospital had my my neighbors, and for the most part they were hardworking trade ER contract terminated abruptly. I no longer had time to start a people and small business owners, too poor for $10 co-pay practice and raise money too. Had I pursued the non-profit option, insurance, and earning too much income to qualify for Medicaid.
the idea of this clinic might still be in committee.
Like John the Apostle banished to Patmos Island, they were I had to make a decision. Either get ER work at another hospital, political exiles within the healthcare system.
or start the clinic full time. I decided on the latter, and the clinic was Most doctors refused to see them. With practices set up for up and running within two weeks of my dismissal.
insurance, the uninsured tend to disrupt patient flow. Many cannot More preparation time might have saved me substantial pay for tests and procedures sometimes needed to exclude expense from misadventures, since I not only had to start a practice potentially litigable misdiagnoses. The uninsured simply take too from scratch and see patients, but I also had to learn on the fly how much time, with too much risk in exchange for uncertain payment.
to run a small business. Yet had I not been kicked out of the nest, the No wonder physicians turn these patients away and refer them clinic might still be a vague longing. Fortunately, I had already to the ER. But as we all know, the ER is not the appropriate place for made a list of all equipment and medicines I was using in the ER.
these patients. Charges are higher, work-ups more extensive, and PATMOS is in a village of 16,000, in a county of 60,000, in a few physicians are willing to see them in follow-up.
state where only 10 percent of the population is without medical Self-pay patients, I learned, are neither destitute nor derelict. I insurance–one of the smallest such percentages in the nation.
felt certain that these farmers, carpenters, plumbers, beauticians, Twenty-five percent have Medicaid. These percentages are housecleaners, and small business owners and their employees would appreciate and value medical care at fair and honest prices.
In addition, there is a government-run clinic in town, two others They didn’t have the time to wait at government clinics, and did not within 15 miles, and a charity clinic in a town 25 miles away. To my like the quality of care they received there. They urged me to start a knowledge, no large company in our community has adopted a practice, and promised that they would come see me if I did.
consumer-driven medical plan, such as a health reimbursement This turned me around. I thought that maybe over time, this account (HRA) or health savings account (HSA), that motivates clinic might replace my income from the ER, and I could then employees to find low-cost medical care. I compete daily against jettison from my medical practice the increasingly wasteful and $10 to $20 co-pays, and regularly have to disabuse patients of the notion that timely, quality medical care costs practically nothing.
Journal of American Physicians and Surgeons
Summer 2004
Given a market so stacked against us, how have we been able to The financial realities, the lack of a compatible partner willing survive these last three years? The answer of course, as any other to opt out of Medicare, and the need to reconstruct the books to successful small business will tell you, is by providing value and provide accurate records for the Internal Revenue Service forced I realized quickly that I had to let my core clientele–the Today I have one full-time employee and one part-time, about uninsured and people with high deductibles–know about the cost 1.3 full-time equivalents. The clinic is open 35 hours a week, 29 breaks of a clinic not taking insurance. Although it ran counter to hours walk-in and six hours of scheduled appointments. We have my own feelings of professionalism, I broke with nearly 5,000 patient charts with, at last count, about 51 percent convention–though within the bylaws of the Tennessee Medical uninsured, 38 percent commercially insured, 8 percent Medicaid Board–and made my fees public in newspaper ads and flyers. Visits for poison ivy and sports physicals cost $25; for sore throats, One physician who contemplated quitting medicine was quoted coughs, and sinus infections, $35; and for simple cuts, $95. I in a story in Time magazine last summer, “The Doctor Is Out,” as thought this represented timely, high-quality medical care from the saying, “Our income is completely controlled by the government, type of physician who seems rare today–one who actually enjoys but we have no control on our expenses.” In contrast, I rely on practicing medicine. And we gladly take MasterCard! appreciative neighbors for my income, and by avoiding third-party payment contracts I have a handle on costs.
We have worked out discounts with various other facilities in My overhead is about one-third that of the typical family the area so that a CBC and lipid panel cost the patient $20; a practice and requires about three employees fewer. In absolute complete chemistry and TSH are $25; a chest X-ray with an dollar terms, the savings produced by our clinic over other clinics interpretation is $70; and an MRI with an interpretation is about that offer similar services–but accept insurance–is about $200,000 $500. Costs to the patient here are about 60 percent of those at other per year, more than 40 percent of the typical family physician’s physicians’ offices, 40 percent of the local urgent care, and 10 to 20 My break-even volume is about 1.2 patients per hour. My Not wishing to turn Medicare beneficiaries away from my average volume over the last six months has been about three clinic if they wished to pay me at the time of service, I was forced to patients per hour, which makes my net income before taxes a little opt out of Medicare, effectively preventing me from working in any less than what I was making at the local ER. At four patients per ER to supplement my income, the logical consequence of an hour, I would be earning about 50 percent more than I did at the ER.
As I said, the greatest benefit of an insurance-free practice is the The biggest mistake I made was starting out with grander freedom: I have freedom to take care of patients in the way I would visions than this town was ready to support. I employed an ER nurse want to be taken care of, rather than the way an insurance and paramedics, providing a mini-ER for the uninsured. Once I bureaucrat wants me to. Freedom to refuse care to the disruptive even helped resolve a case of mild diabetic ketoacidosis (the and unappreciative. Freedom from increasingly wasteful, bicarbonate level was 17) in a 12-year-old, using intravenous fluids capricious, and dehumanizing bureaucracies. Freedom from and an insulin drip over eight hours. His mother recoiled at the betraying the confidence of my patients from unannounced audits thought of taking him to one of the local ERs.
of my charts by insurance companies. Freedom from arbitrary I took care of some serious infections with several days of documentation requirements. Freedom to set my own schedule and intravenous antibiotics, leaving a heparin lock in patients and bringing them back repeatedly. On occasion I cooled off an episode I’m now free to reconnect with the pure, spiritual purpose for of unstable angina with a nitroglycerin drip, intravenous beta- which I entered medicine: to see to the medical care of people who blockers, and Lovenox, and had the patients admitted directly to the in turn value and appreciate my knowledge and skills.
coronary care unit at a tertiary care hospital equipped with a cardiac I have made many mistakes. I have few regrets. I have learned catheterization laboratory 25 miles away, bypassing its ER and the that it is easier to change the course of a moving wheel than to move a stationary one, and I am convinced that if I’m not making at least There were many such professionally satisfying cases when the some mistakes, I’m probably not making progress either.
practice operated as an “EmergiClinic.” However, this also forced me to hire expensive staff and made me rely on an office manager Robert S. Berry, M.D., is board certified in internal medicine and
emergency medicine. Address: PATMOS EmergiClinic, Greeneville, TN
who, although having every appearance of sharing the clinic’s 37745. E-mail: [email protected].
vision, was embezzling practically from day one! Journal of American Physicians and Surgeons
Summer 2004

Source: http://www.multi-cast.tv/voiceofdoctors/pdf/Freedom_RBerry.pdf