Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care is “insurance free medicine.” The term “insurance free medicine” captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance.

Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like “boutique,” “concierge,” and “cash only” might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. Previously, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies.

With more frequent use of the term “insurance free medicine,” patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

I calculated the other day that I spent about $2000 a year to be set up and able to bill insurance. Further, I spent all that time and money for about 538 patients, or close to one-fourth of my patients per year. Now that Walmart no longer bills many vision plans for me, both numbers will go up, and so will my accounts receivable. In anticipation of this, my fee went up by $5 per patient at the beginning of the year.

I would lower my price if we could all convince the general public that routine medical office visits should be paid out of pocket. Your car insurance doesn’t pay for oil changes.

I protect patients by encrypting my e-mail!

But seriously, sometimes birth dates and stuff are printed on the reports, so if doctors want to use this cool, new thing called “e-mail,” we’ve got to set-up our e-mails to have the capability to send and receive encrypted messages and attachments. What does it look like?
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So your email inbox gets a message that looks like this. You have an e-mail client plugin that you have set up. You input your password, and the message magically translates to:

Dude, isn’t this so cool that not even the government can tell what I’m writing you? Unless…you forward this message to them unencrypted, but I trust you.

You can see this in action on my practice website. To get started and do this you need a few things:

Your practice’s domain name (usually your web host will offer e-mail storage)
or
any e-mail address that you can access via the e-mail client Thunderbird. (ie POP3 or gmail)

Download the following:

• GnuPG- the free, open source engine that runs encryption.
• Thunderbird- a free, open source e-mail client.
• Enigmail- a free plugin for Thunderbird that makes it easy to make your encryption keys, share your public key, store other people’s public keys, and encrypt/decrypt e-mails. You should read the install instructions for Enigmail.

Make sure when you generate your encryption key password that it is extra long and random. You must assume that anyone could capture it and try to brute force it. If it is long and random, it would be nearly impossible to crack. I suggest keeping your random, long password in a password wallet.

Why not do it?

• You are afraid.
• You don’t get paid to e-mail patients.
• Spam? Some people think that if they share their public key on a key server, spammers will harvest their e-mail address. I’ve had mine there for a couple years and that’s not happening…to me.

Barriers to entry:

• It doesn’t do any good for you to have e-mail encryption if the person to whom you want to e-mail the top-secret K-readings doesn’t have e-mail encryption set up. They must have a public key that they share.
• I’ve just presented a free way (unless you have a paid practice URL/webhost) to do this, but it does require some tech savvy to download, install, and implement the tools. This way requires the Thunderbird e-mail client. If you use Outlook or something, there are paid solutions out there.

Why do it?

If every doctor would just get in gear with e-mail encryption keys, we could send patient referrals with high quality color photos and reports instead of low res, black and white faxes (usually with a few vertical black lines on the page). We could send the lab a topography. We could send a patient a report or copy of their Rx. We could talk about the stupid government and how we all secretly agree with Glenn Beck, Rush Limbaugh, and Ann Coulter.

Yup, I’ve said it before and I’ll say it again. Ophthalmic vendors think we optometrists are so stupid. Just because we picked this profession, they think we are prone to making poor financial choices just like some people are accident prone.

Any of you vendors seeking to do insurance billing for me are wasting your time. All I need is my practice management software and Apex EDI. It’s as automated as can be. Most of the vision insurances have their own website for authorization and billing, and then I use Apex EDI for my BlueCross, Medicaid, DMBA, and other miscellaneous insurance companies. (You can do Medicare also, but I am disinclined to participate with them.)

Apex EDI works great. It’s fast and easy. And I don’t need no stinking slick Rick to be some unnecessary middle man. It’s cheap too. I pay 43 cents per claim, less than a postage stamp these days. I also pay the extra $20 a month for the ERAs and Electronic Tools which make my life a lot easier, so it’s worth it.

Call up Apex EDI and tell them I sent you. Use my Champions Code (sales code) to get a better deal: Champ148. I use it in my practice (VisionHealth EyeCare PLLC), and you can use it in yours without the growing cottage cheese industry of Walmart insurance billing middle men.

[Note to Slick Ricks: Any more "comments" made by you to advertise your middle man services will be marked as Spam and deleted. Do us all a favor and go con some other profession.]

Now, I don’t want you to get the wrong idea. I love kids. I have three young ones myself. I don’t even mind if patients bring their kids with them. We do that all the time. I don’t even mind if the kids are somewhat disruptive, like speaking out of turn, constantly asking questions, or even running around. It’s all good.

I was just speculating on what would happen if the kids where heck-bent on destroying stuff or if the parent decided not to manage inappropriate behavior at all and let them run around the office unsupervised. Then I thought it would be funny to put it in a cartoon. So don’t be upset. It’s comedy.

Bye the way, does anyone know the CPT Code for daycare?

I thought it might be nice to share with you all a pattern I’ve noticed about which days are better to work than others, listed best to worst.

2008 so far (January to April I worked Mon 10-7, Wed 10-7, Friday 10-7, and Saturday 9-5, and May to present I worked 5 days a week, Tues 9-6, Wed 10-7, Thursday 10-7, Friday 9-5, Sat 9-3):

1. Tuesday
2. Wednesday
3. Saturday
4. Monday
5. Friday
6. Thursday

2007 from April to December I worked four days a week (Monday 10-7, Wednesday 10-7, Friday 10-7, and Saturday 9-5):

1. Wednesday
2. Monday
3. Friday
4. Saturday

In 2007 Mon, Fri, and Saturday were almost identicle in revenue earnings, but Wednesday gross averaged $98 more than the other days. In 2008 so far Tuesday and Wednesday (TuW) are close and so are Saturday and Monday (SaM). TuW gross averages $71 more than SaM, and SaM averages $79 more than Thursday.

In 2007 my private practice appointment book would fill up fast on Tuesdays and not so much on Thursdays. At the Wal-Mart, they told me I’d missed quite a few walk-in opportunities on Tuesdays, but not many on Thursdays.

Anyway, my take home message is this:

• I advise O.D.s looking for fill-in work to stay away from Thursdays and Fridays and try to get in on the action for Tuesday and Wednesday. (Conversely, if you are an optometrist looking to hire fill-in work, then switch what I just said.)
• If you need to take a random day off, Thursday or Friday is a safe bet

Your mileage may vary. For instance, from what I’ve heard, everywhere else in my district (Salt Lake to Ogden area) is gangbusters on Saturdays. I think that in my Northern Utah town the people like to go play on Saturdays and not worry about having to spend time at the doctor’s office. We notice that Saturdays are better in the winter than the summer because our area has lots of good hiking, boating, and other summer fun activities nearby.

Can the doctor physically be at two places at once or work eight days a week? No, so he hires someone. Let’s call the multi-contract owner Dr. Fingers and the two doctors who work for the contract owner we’ll call Drs. Desperate and Disgruntled. Wal-Mart needs three locations filled: Bountiful, Ghetto, and Rough Diamond.

So let’s say Dr. Fingers works Bountiful and hires Dr. Desperate at the Ghetto location and Dr. Disgruntled at Rough Diamond. The contract is similar to “I’ll pay you 70% of your gross receipts.” Dr. Desperate says fine because she just needs a job and doesn’t care about a long term commitment because she’s willing to relocate in a moments notice. Dr. Disgruntled is in a bind because he really wants to live in the city of Rough Diamond forever, but he doesn’t want to pay Dr. Fingers 30% of his gross receipts, especially when he finds out that Dr. Fingers is only paying Wal-Mart 10% or if the contract is some ridiculously low flat fee not even based on receipts.

So what happens? Usually Dr. Disgruntled will leave and try to find his next best ideal location. Dr. Fingers will probably have to funnel in and out doctors every couple years. The vision centers stagnate and never grow because the doctors who work there have no vested interest in growing the practice since they know they won’t be there long term since Dr. Fingers takes so much of their money.

I believe that it is a mistake for Wal-Mart to give any doctor a contract for more than one location just so he can suck cash from other doctors for no reason other than, “Hey, I own the contract.”

Now, I can see how some of you might say, “But what if you had a multi-doctor parnership share multiple locations equitably?” Well, you’d still have the problem of the last location not growing because the doctors rotate every day, and then which of the doctor partners would volunteer to work at the last location on its poor performing days?

It’s better for the vision centers, the doctors, and even the community to have each doctor own the contract for the vision center that they work in.

“But what about vacation days?” you say. Well, wouldn’t it be cool if each area could have it own full time fill-in person? Maybe the fill in person could always keep 100% of his receipts and not have to pay rent to subsidize the days when there isn’t an opportunity to work? I don’t know, I’m just thinking out loud here. Or you can probably find a private practice doctor who needs supplemental income to work for you.

“But our store needs someone, and we can’t find anyone, so thank Heaven for Dr. Fingers,” you say. Well, that’s a short term solution that defeats you in the long run. None of your sub-contracted doctors would be motivated to grow the practice (an thus increase vision center sales) like a contracted doctor would. This scenario will just stagnate you at mediocrity. If you must hire Doctor Fingers, I think the terms should explicitly say that Wal-Mart has the option to not renew Dr. Fingers contract at the satellite location if they can find a permanent doctor when the contract expires in three years. I don’t care if Dr. Fingers is taking a “risk.” He has three years to recoup his “risk.” Take it or leave it, Fingers.

But let me restate. Multi-location contracts for a lone doctor who invariably gets greedy and pockets cash for not doing any work: BAD. Allowing a doctor to own the contract where he actually works in order to change it from slow to crazy-busy: GOOD.

Now he is transitioning into kind of a franchise system.

When we think of traveling outside the office, its usually just to do screenings at the old folks home, but I’m not talking about that. What if the industry made available light, portable and cost-effective exam equipment in a nice kit? What if you kept your Wal-Mart job 4 days a week but provide home eyecare one day a week? Would you want to provide home eyecare full-time?

I’m just thinking out loud here. Does anyone think there is a way optometrists can deliver home eyecare? If we can, should we?

**Update: I saw in Review of Optometry’s edition of Women in Optometry June 2008, that Dr. Tamara Hill-Bennett, O.D. makes house calls 80% of her practice. Since I couldn’t find a link to the article, here is a copy (PDF, 490 KB).