William E. Jones, MD

     Everyone (doctors, patients, and insurance company executives alike) takes it as gospel that doctors don't strike.    Period.    We all know that doctors are simply not going to walk out en masse on our patients whom we've sworn an Hippocratic Oath to serve.    Every doctor I know feels deeply committed (morally, ethically, emotionally, and personally) to his/her patients' welfare and would never even consider striking.
     It is our noble commitment to the welfare of our patients that gives third-party payers the leverage they need to continue raping doctors more painfully every year.    The payers know very well that doctors as a group are not going to walk out and abandon our patients; so when doctors come to any bargaining table, they come with no real leverage at all.    If there's no perceived willingness of doctors to strike, then negotiating is going to be ulcerogenic, a waste of time, and... fruitless.
     The Air Line Pilots Association would get exactly nowhere in contract negotiations with American Airlines if they sat down at the bargaining table having pledged in advance that under no circumstances would they go on strike.   Since striking is unthinkable to most doctors, our professional organizations are going to get exactly nowhere trying to "negotiate" our fees with managed care corporations (and Medicare) which have no incentive whatsoever to negotiate with us in good faith.
     I know from past experience that it's a total waste of my time to negotiate (or deal at all) with third-party payers; so I simply refuse to have anything to do with them.    In my opinion, Primary Care doctors who get fed up with low fees have only one workable option; and that is to do what I'm doing, dump all the managed care plans.
     I flat refuse to allow any corporate executive to determine my value to my patients.   On the other hand, I'm perfectly willing to trust my patients themselves to determine my value to them.    If they think the services I provide are worth what I charge them, they'll keep coming back and paying cash (just as they pay cash everywhere else when they've received good service).
     If they're not satisfied with my services, they simply won't come back.
     That seems fair and reasonable to me.

4/4/2002
I just read a bumper advertising a sky-diving company that said,
"FEAR IS TEMPORARY. REGRET LASTS FOREVER.

     That got me to thinking...    Most Primary Care doctors I know are terrified of what might happen if they were to drop their degrading managed care contracts.    Sadly for them, I think their regret is going to grow ever worse (and it's going to last until they finally gut up and bail out of managed care).
     Every day I grow happier that I finally decided last summer to trust in my "parachute" (good reputation and patient loyalty) and take the big leap out of managed care.
     I'm glad to report that the ride so far has been exhilarating; the view to the future is spectacular; and I'd much rather be out here soaring than back clinging desperately to the frame of the airplane door, paralyzed with fear and afraid to jump.

4/9/2002
The Association of American Medical Colleges reports that fewer US medical students are choosing careers in Primary Patient Care:

4/10/2002
     I wonder if patients are as offended as I was at seeing this photo in the newspaper this morning.
     The combination of skyrocketing malpractice insurance rates on top of plunging managed care reimbursements has so beaten down this group of distinguished doctors that they've been reduced to picketing on the El Paso courthouse square to demand fair treatment.   (Good luck, boys.)
     No doubt the sorry plight of these older, well-established, and (formerly) successful doctors is going to be especially depressing to young doctors who are just finishing a gruelling 8 years of training (after college) with high hopes of earning a respectable living with which to pay off their student loans and support their families.
     The really bleak news for young doctors is that it's only going to get WORSE from here on, not better, because their "value" is going to be determined by profit-motivated corporate executives, not by the patients they will actually be serving.
     As for me, my patients will never be seeing their doctor in a newspaper photo like this because I've divorced myself completely from the insurance fray.    I'm perfectly content to allow my patients to determine my value to them.    If they're not satisfied that my services are worth (to them) what I charge, they can always vote with their feet and simply walk on over to some other doctor's office.

4/11/2002
     For the first 20 years of my medical practice, I'd leave the office at the end of every busy day thinking to myself, "Whew, I really worked hard today; but I just love being a doctor; and besides, I'm being paid pretty well for working so hard."
     By last summer, after 10 years of steadily falling income and increasing hassles under managed care, my attitude had deteriorated to, "It's just not worth it to me to have to work such long hours, shoulder so much responsiblity, and put up with all the stress when it's a constant struggle just to collect peanuts from the managed care companies."   The only reasons I didn't retire back then were my love for my work and my love for my patients; but it was clear that something was going to have to change pretty soon; or I'd have no choice but to throw in the towel (as many of my older colleagues had already done).
     I was nervous at first about my decision to drop all the insurance plans, but thankfully the vast majority of my patients seem to like what we do here and have said they intend to stay with me and file their own insurance.
     Looking back, I don't know what I was afraid of.   My one regret is that I didn't wise up, gut up, and simply dump all that infuriating managed care ballast years ago.
     The joy of being a doctor is back, and it feels good!

     I sometimes chuckle to myself at the things patients say.
     One of my lady patients came in today for a physical exam and commented sadly, "Since you're dropping Blue Cross in September, I wanted to come in for one last complete physical exam with you before I have to change doctors."
     I chuckled because by her statement she's acknowledging:

This lady's plan to change doctors didn't hurt my feelings at all, and I didn't try to talk her out of leaving in September. We all need to be free to do what we need to do. Besides, because of our long, positive and warm relationship, I fully expect that she'll be coming back to me within a few months (and gladly paying her own bill) once she samples how little attention she's going to be able to get out there these days for her $10 copay.

4/12/2002
     Here's a little grin for you.
     My plumber has been my patient and friend for many years.   Today he was in the office for an exam and mentioned that he just bought his wife a new $50,000 Lexus SUV.
     That reminds me of the old joke about the doctor who was shocked at how much his plumber charged him for a repair.   He said to the plumber, "My gosh!    I'm a doctor, and I don't make that much an hour."    The plumber calmly replied, "Well, neither did I when I was a doctor."

     One of my older patients faxed me a statement today showing that his health insurance premium is going up from $$676.48 to $781.40 per month!    Holy cow, that's a lot of money!
     My total fee for a complete annual physical exam including all lab work is a flat $325, less than half of this man's health insurance premium for only one month.
     I recommend annual physicals to give us a chance to head off minor problems early, before they become major problems.    If I'm doing a good job of preventive medicine, patient coaching, and education (during the yearly $325 physical), hopefully the patient won't end up spending enough on his health care this entire year to even meet the deductible on his pricey insurance policy; but he's got the comfort of knowing that he's got his insurance "safety net" to fall back on in event of an unforeseen major illness or injury.
     For more information about insurance, you might want to read "What Kind of Insurance Should I Buy?"

4/19/2002
     This week I've attended an interesting 3-day Family Practice Review course.    The program was loaded with useful medical information, but what really left me feeling stunned was an off-hand remark made by one of the speakers, the Emergency Room director at a large regional hospital.
     To establish his rapport with the audience, his opening comment was, "I know that many of you are supplementing your income by moonlighting in an emergency room..."    WHOA!   Moonlighting!    That's absolutely appalling!
     I know that every doctor's income has deteriorated dramatically under managed care; but I had no idea that some Family Doctors in private practice are now doing so poorly that, after having worked long hours in their own offices, they feel a need to moonlight in emergency rooms in order to make ends meet!    Shocking!

A doctor friend who's been in practice in Austin for more than 20 years told me today at the meeting luncheon that he felt forced to open his office for two Saturdays this month, seeing 20 patients each day, because he felt he couldn't have afforded to attend this 3-day meeting at all unless he made up some of the income he was losing by being here instead of in his office (running his conveyor belt at full speed).
Every Family Physician is required to attend at least 50 hours of Continuing Medical Education (CME) courses each year. I think it's very important that we keep up to date with the latest medical developments; so I'm willing to pay the $525 tuition (and give up three full days of gross income from my office) in order to earn the 24 hours of CME from this meeting. However, although CME ends up costing me a lot of money every year, in my 30 years of practice I've never felt that attending medical meetings was going to overstrain my budget to the point that I'd have to put in extra hours on weekends to make up for the lost income.

I think my 50-year-old colleague's plight is just one more indication of how bleak the future is going to be for primary care doctors who remain in bed with the managed care plans. Trying to "make the best" of the managed care debacle by working harder and harder is like trying to bail out the Titanic. No matter how fast we primary care doctors may bail to try to keep our little practices afloat, we're still sinking because the managed care corporations still believe they can drive our fees yet lower... and lower... They will have no incentive whatsoever to arrest their sinking fees until large numbers of doctors begin actually bailing out of their mafia-like "protection" schemes.
Fear is forcing most doctors to cling desparately to the Titanic. My patients and I are rowing away in the lifeboats; so we're not going to be dragged into the suction as this baby goes down.

4/30/2002
     Many primary care doctors these days are considering converting their offices over to Electronic Medical Records (EMR).   The computer salesmen tell doctors that by entering everything into computers (all patient charts, dictation, lab results, correspondence, charges, insurance coding, etc.) and essentially eliminating paper records, they will be able to increase their "patient through-put" (and income) enough to justify spending $30-40,000 for their computer systems.
     The LOGIC of this sales pitch is FUNDAMENTALLY FLAWED because what most doctors say they want is to spend more time with each of the patients they already have, not less time with more patients in order to pay for an expensive computer system.
     In my opinion, no rational businessman (or doctor) should ever spend money adding expensive equipment to his operation unless it meets at least one of the following two criteria, preferably both:

It should improve customer (patient) satisfaction/care.
It should generate enough additional (new) revenue to pay for itself.

     Most commercial EMR systems I've seen do neither.
     The average time most primary (managed care) doctors spend with each patient has already dropped to a mere 5.7 minutes (shocking!); so the last thing these poor, overworked conveyor-belt doctors should be doing is boxing themselves into having to see even more patients per hour in order to pay for an expensive computer system which adds nothing to patient care and whose only reason for existence is to fulfill the vastly increased (and mostly superfluous) documentation requirements of the managed care plans (which pay only chickenfeed anyway).    Think of it this way... if a doctor charges $50 for an office visit, he would have to add at least an extra 600 office visits to his already rushed schedule just to pay for a $30,000 computer system (and that's not even considering the cost of operator salaries, maintenance, and future system upgrades).
     Although my office obviously uses computers to streamline mundane tasks, I think it's clear that most doctors who invest in an EMR system are going to end up working even harder for less money.    Why?    Because with managed care fees continuing to fall, the only way they can generate enough new income to pay for those fancy EMR computers is by seeing ever more patients every day which means even less Face Time with each patient as the doctor is forced to run faster and faster on his conveyor belt to pay for that pricey EMR system.
     At best, instead of "improving collections" from the insurance plans, EMR's are just going to make it possible for an already overworked doctor to see a few more patients in a day by spending less time with each one.
     That's not my idea of "efficiency."   I prefer to spend lots of time with my patients, and I'm comfortable leaving it up to each of them to decide if they value that kind of attention from their doctor highly enough to pay a fair fee for it.