You Define Affordable Care

PCCWinooski, VT

Chip Hart predicts how pediatric care will change and what pediatricians need to do to adapt.

Chip Hart coaches and guides pediatricians as they navigate the changing business world of medicine. He combines more than two decades of experience working with busy pediatric practices all over the country with his passion for real world data and good medicine, to deliver practical observations, pragmatic advice, and proactive strategies.

I met with a client recently to discuss the status of his practice. He’s a rural, solo doc who, after splitting from a larger group, has built a thriving, successful practice. As he told me, he loves working for his patients and he makes an excellent living. He enjoys seeing his “kids” in the grocery store and knows that he’s had a huge impact on some of their lives. He also knows he can pay for college for his own children. He feels blessed.

He then told me how he’d heard from one of his early patients who, he said with admiration, had gone off to med school and become a pediatrician. What advice could he give to this new doctor? Would he recommend returning to their hometown to open up a practice?

“For the first time in my life I was afraid for someone going into pediatrics,” he told me. “Between my state government, the insurance companies, Obamacare, the hospital pushing on me… it’s just a mess. I told him to pick another specialty. I don’t know how he’d ever earn a living. I told him it was a bad idea.

I was aghast. “I thought you just told me you loved your job?”

“I do. I love the kids and families. I just hate all the non-medical intrusion.”

“And I thought you just told me you make good money?”

“I do make good money.” Great money, it turns out. “But I have to work day and night to do it.” He used a different term, but you understand.

I went on. “So, you have a sometimes fantastic and rewarding job caring for children that pays a significant multiple of what any local kid could expect to earn returning to this rural county, and you’re telling him it’s a bad idea? What other career path of such high personal and financial return has less risk? Could farming do the same for him? Or gas station? Or what if he became a teacher? What other career path can you recommend to someone with the ambition to care for people and be his own boss?”

After a minute of contemplation, he turned to me. “You’re right, I hadn’t thought of it that way in a while.”

I was a little fired up. “Earning your medical degree wasn’t a guarantee of anything. Not of career enjoyment, an easy life, or take home pay. There is no education or training that allows you to skip bureaucracy, personal risk, or disappointments. It was just an opportunity to have the world’s best job, with the most control, at a relatively high rate of pay. That’s all it was. An opportunity. And you still have to work hard — harder, perhaps, than anyone else.

”What’s the moral of this story? Have pediatricians undersold their value to everyone, including themselves? In my mind, it’s long past time to start celebrating the hard work and success of every independent pediatrician among us. All the evidence indicates that independent pediatricians, no matter how loosely you define them, provide better care to our children at a lower cost. Does anyone disagree?

“All the evidence indicates that independent pediatricians provide better care to our children at a lower cost.”
That experience isn’t isolated. I recently had the pleasure of addressing the Texas Pediatric Society at their 2013 meeting about the topic of pediatric independence. Texas is the hot spot for some of the more heated hospital/IPA/MSO turf wars in recent memory and pediatricians are feeling the pain. I reviewed the list of perceived threats in our pediatric world and we agreed that most of the noise is being created by the very entities that want you to feel threatened. Who is telling you that you must sell your practice to the hospital or face dire consequences? Why the hospitals, of course. Who is scaring you the most about your limited network and bad contracts? The local megagroup, of course. We talked about the poor treatment many of the doctors had received at the hands of their larger partners. You can read about one doctor, Bryan Sibley, here inside and how he reacted to his hospital employment.

We reviewed the pros and cons of merging with other like-minded pediatric practices. There are many myths about merging, but there’s no question that it can be greatly beneficial for the right practices. I used BCD Health Partners, in NJ, as a prime example of how to merge the right way — with a focus on patient care. Inside, Drs. Krekamey Craig and Jill Stoller talk about how the merger affected their practices.

The discussion rolled to the topic of concierge medicine, which always lights a fire in a group. Texas isn’t as familiar, yet, with some of the hybrid solutions I’ve seen on both coasts, solutions that not only keep a practice viable, but also they improve the quality of care. Dr. Gayle Smith is a prime example.

We concluded our presentation with what has become my mantra for 2013:

If they are bigger, you are faster.
If they are bigger, you are more creative.
If they are bigger, you are more personal.
If they are bigger, you provide better service.
If they are bigger, you don’t have to play by their rules.
If  they are bigger, you make your own rules

I fear when anyone makes absolute predictions about our industry. Anyone who assures you of the future is simply guessing, even I. But I’ll share two predictions here and we can see how I fare in a few years.

First, I predict change. I can guarantee that the overwhelming majority of pediatricians are going to have to do things differently as we all face a national health care challenge. Technology is going to play an important part, for example, as patient access to their own records becomes the norm. Not much of a guarantee, perhaps, but too many of my friends in this business seem unwilling to consider new ways of doing business until, perhaps, it’s too late.

Those practices who embrace change will flourish. Just like in the ’90s, when HMOs threatened us all with scary tactics like capitation. Yet, many of you flourished.

Second, I predict that when pediatricians look back, they’re going to realize we’re at the beginning of a golden era for pediatricians. The federal government has slowly but steadily pushed up reimbursement for primary care work, Medicaid in many states is being paid at Medicare levels, and performance programs like PCMH are improving both care and bottom lines to unprecedented levels. Sure, each of these improvements is imperfect, but can you honestly say things were better 10 years ago? For most of you, the answer is no. You have never had a better time to work with your patients and never have you had a time to generate more revenue.

Now, let’s have your colleagues and peers tell us their stories. And, please, share your story.