L. Gordon Moore, MD: Next on ACO Watch – A Mid-Week Review

On Wednesday, December 15th, at 11AM Pacific, and 2PM Eastern, my special guest commentator is l. Gordon Moore, MD, President of Ideal Medical Practices, former ‘chief evangelist’ of the HelloHealth University, and a participant on Twitter via @lgordonmooremd.

Dr. Moore is a thought leader in ‘exemplary primary care’, and a physician who is actively exploring the value proposition of new media tools, and digital health technologies to enable the more efficient organization of health care services to better meet the needs of consumers, payors and host primary and/or specialty care physicians.

On this third segment of ACO Watch: A Mid-Week Review we’ll explore the role of direct medical practices, aka primary care medical homes, in the unfolding ACO tapestry. While an unconventional dot to connect to a host (or ‘parent’) ACO, or even to extend traditional consideration to serve as a host ACO per se, a suitably configured (but yet to be defined in regulatory language) network of direct medical practices can indeed both qualify for ACO consideration, as well as earn eligibility to be included in emerging state Health Insurance Exchanges (HIE’s) as ‘qualified health plans’ under the Patient Protection and Affordable Care Act (PPACA).

Many believe the core innovation that will determine the granular success or failure of the PPACA to achieve it’s ‘triple aim’ goals as outlined by Don Berwick recently, will be served up via niche and/or so-called ‘marginal players’ in the conversation. The direct medical practice movement (collectively including: retainer or membership based medicine, as well as certain concierge or boutique medical practices) is one of the candidate horses in the race.

To join us live or for an archived replay of the broadcast with Dr. Gordon Moore, click here.

4 Ways to Think About ACO Strategy

Stephen Jenkins, for HealthLeaders Media

We are in the midst of a full-fledged frenzy of activity around accountable care organizations (ACOs). Be wary of a frenzy—these are the times when action becomes separated from thought and we lose track of why we are doing what we are doing. There are good reasons to pursue becoming an ACO, and some bad ones too. Over the past several months I have talked to dozens of organizations to understand the logic behind their strategy—why they want to be an ACO. The following mind-sets capture the four predominant ways that Sg2 sees healthcare organizations thinking about ACO strategy.

Strategic Logic #1: “I don’t understand ACOs, but I don’t want to be late to the party.”Many organizations have not yet wrapped their heads around what it means to be an accountable care organization—either the internal competencies needed to be successful or the external strategic considerations of pursuing this path. But they recognize a rising trend when they see it and are determined not to be left behind, just in case ACOs turn out to be something important. So they join a study collaborative, or engage a consultant to perform an ACO readiness assessment.

There is nothing wrong with this line of thinking, even if there is very little thinking behind it. In fact, the CEOs of these organizations are perhaps more honest than the rest of us in admitting that the strategic logic underpinning their ACO strategy is vague because ACOs are vague. It is a hedge-your-bets approach in the face of great uncertainty. The key caution for this group is:

How much time and money will you invest in an ACO strategy before you are certain about whether it makes sense for your organization? Be decisive about how many dollars and full-time employees you will dedicate, and the time frame for reopening the question about whether continuing that investment makes sense. If, in 6 or 12 months, you cannot articulate a clearer rationale for pursuing an ACO strategy, be ready to pull the plug.

Strategic Logic #2: “I will take advantage of this short-term opportunity to consolidate my position and seize market power.”Policy wonks talk about ACOs as vehicles to drive long-term improvement in clinical quality and cost reduction. But some health care organization CEOs view their ACO strategy through a lens that is much more short-term and slanted toward commercial considerations. These masters of the local market chessboard see ACOs as a way to lock in physician relationships and build their wallet share of health care services in the communities they serve. In this line of thought, ACOs very well may drive broader performance improvement and, if so, terrific! But that would be a happy by-product. The driver of these organizations’ ACO strategies—how leadership convinced their chief financial officers and their boards—is rooted in more prosaic market power considerations. Fair enough.

Read complete story, here.

Is this the model for ‘virtual’ ACOs? Sisters of Charity Health System Creates Safe Haven For Independent Physicians

Sisters of Charity Health System, a faith-based organization, announced today the launch of its subsidiary, Independent Physician Solutions (IPS), to offer Northeast Ohio independent physicians a continuum of services, including revenue cycle management, electronic medical records (EMR), managed care contracting and a suite of a la carte consulting services for practice operations and financial management.

“What is different about IPS is that we are a physician-led organization, which will offer an equity model that physicians can invest in if they so choose and a governance structure that will have more than 50 percent of the board comprised of physicians,” said Orlando L. Alvarez, Jr., IPS CEO and Sisters of Charity Health System senior vice president for physician alignment.

Through a unique market arrangement with GE Healthcare, IPS will offer General Electric’s Centricity® Practice Solution offering as its EMR solution.  The selection of this product included a robust vetting process that involved physicians from across all Sisters of Charity Health System markets as well as a physician advisory committee comprised of independent physicians.

The technology will position independent medical practitioners to demonstrate meaningful use in order to receive federal incentives as well as provide them with efficiencies and other benefits of practicing in an electronic environment. Additionally, IPS will allow independent medical practitioners to maintain their independence while keeping pace with larger, affiliated practices and meeting the new technology requirements mandated under the Affordable Care Act of 2010. IPS will also provide billing and collections services and hopes to organize physicians into an Independent Practice Association (IPA) in order to develop clinical integration strategies and group contract opportunities with health care insurance companies and other payors.

The Sisters of Charity Health System’s investment includes securing a talented management team led by Mark Wiedt, IPS president and chief operating officer. Wiedt most recently served as CEO of the largest independent multi-specialty physician group in Northeast Ohio. With decades of experience in managing physician practices, Wiedt and his team will lead the operations of the physician-focused organization.

The long-term goal of IPS is to position its physicians for the inevitable changes in health care as a result of new reimbursement models and health care reform legislation. With its technology infrastructure, IPS will be able to tackle the challenges of Accountable Care Organizations (ACOs) and other population management models.

In spite of national trends, Northeast Ohio has a large number of independent physicians who have yet to become employed by hospital systems.

“It is really about strategy,” continued Alvarez. “We believe that independent doctors who wish to remain independent need to partner with organizations whose goal is not to control their patient records or gobble them up in an employment model. Our goal is to create a ‘safe haven’ for the independent physician and garner the collaboration of physicians who share our faith-based mission.”

IPS is aggressively recruiting from a pool of more than 4,000 independent physicians in Northeast Ohio to make them aware that they have options that will enable their practices to remain truly independent.

“My partnership with IPS provides my practice the support and expertise I need, without giving up my autonomy,” said Gregory Hall, M.D., internal medicine. “It allows me to continue doing what’s best for my patients without feeling controlled.”

Dr. Hall understands all too well the pressure that independent physicians are feeling to quickly become compliant with the pending health care reform requirements, which often means sacrificing their independence.

“Many of us own practices that are small businesses, and we have been very successful for years in treating our patients and managing our books,” continued Hall. “But with new EMR requirements, some physicians are overwhelmed with the adoption process and feel they have no choice but to completely affiliate with a large health system that can help them with new technology requirements. Now Northeast Ohio physicians have an option that actually encourages their independence.”

“We have a long legacy of collaboration and partnership with our independent physicians,” said Sister Judith Ann Karam, CSA, president and CEO, Sisters of Charity Health System. “We made it part of our faith-based mission to invest in this very important initiative to help ensure the high-quality and efficiency of health care in Northeast Ohio.”

Original source, click here.

Kent Bottles, MD Guest Commentator on 2nd ‘ACO Watch: A Mid-Week Review’

On Tuesday at 10AM Pacific, 1PM Eastern Kent Bottles, MD, (aka @kentbottles on Twitter) noted blogger, health care social media thought leader, lecturer and physician leadership role model and mentor will address ‘physician leadership and the collaboration imperative’.

Clearly as we prepare for the ‘roll out’, ‘ramp up’ or otherwise ‘peppering of the health care landscape’ with Accountable Care Organizations (ACOs), the core driver in any success paradigm given the ‘tripple aim objectives’ of Donald Berwick, MD, the Centers for Medicare and Medicaid Chief, will no doubt be the level and efficacy of physician leadership, and the cultural substrate in which it incubates. This segment will address the role of physician leadership, in a culture collaboration, in what is likely to be at hotbed of ACO development, management and general stewardship.

To listen live, or via archived replay or download, click here.

ACO Comment Deadline Looming | December 3rd, 2010 by 5:30 PM (Eastern?)

Some key questions posed for input also providing context insight into current thinking at CMS relative to ACOs. Here they are direct from the ‘Medicare Program; Request for Information Regarding Accountable Care Organizations and the Medicare Shared Saving Program’ posted in Federal Register /Vol. 75, No. 221 /on Wednesday, November 17, 2010 / Proposed Rules.

Solicitation of Comments

As we develop our initial rulemaking for the Shared Savings Program and begin the development of potential models in the CMMI (CMS/Center for Medicare and Medicaid Innovation), we are seeking additional information, particularly from the physician community, on the following questions:

• What policies or standards should we consider adopting to ensure that groups of solo and small practice providers have the opportunity to actively participate in the Medicare Shared Savings Program and the ACO models tested by CMMI?

• Many small practices may have limited access to capital or other resources to fund efforts from which ‘‘shared savings’’ could be generated. What payment models, financingmechanisms or other systems might we consider, either for the Shared Savings Program or as models under CMMI to address this issue? In addition to payment models, what other mechanisms could be created to provideaccess to capital?

• The process of attributing beneficiaries to an ACO is important to ensure that expenditures, as well as any savings achieved by the ACO, are appropriately calculated and that quality performance is accurately measured. Having a seamless attribution process will also help ACOs focus their efforts to deliver better care and promote better health?  Some argue it is necessary to attribute beneficiaries before the start of a performance period, so the ACO can target care coordinationstrategies to those beneficiaries whose cost and quality information will be used to assess the ACO’s performance; others argue the attribution should occur at the end of the performance period to ensure the ACO is held accountable for care provided to beneficiaries who are aligned to it based upon services they receive from the ACO during the performance period. How should we balance these two points of view in developing the patient attribution models for the Medicare Shared Savings Program and ACO models tested by CMMI?

• How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?

• The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

To review the complete request for information or comment online, click here.

Healthcare’s Strategic Mis-adventures: A Trilogy – Act 1 The Hospital Systems

This is a somewhat arbitrary starting point, but given it’s scale, a reasonable place to begin none-the-less; but first a little context.

Luke…there is a disturbance in the force!

In the post ‘HMO Act’ era, circa the Nixon’s administration’s health care cost containment and quality promotion efforts, the antecedents where laid to transform health maintenance organizations (HMOs) from their cultural roots as ‘sleepy’, non-profit, community based entities, into aggressive for profit regional and national players, with a developing thirst to roll-up via acquisition a very fragmented yet profitable ‘cottage’ industry.

As the most promising of private sector disruptor’s and/or transformational agents of the status quo, HMOs with market scale and share clout had the ability to literally penetrate, and fundamentally amend the traditional fee for services payment paradigm upon which the giants of the hospital industry were so dependent. This was a ‘on the come’ threat, though with a 5-7% market share, not yet a real one. However, this early industry movement got the attention of the C-suites of the major for profit as well as their ‘non-profit’ (ahem, I mean tax exempt breatheren) hospital chains.

Given publically traded HMO’s improved  access to capital, and the emerging ‘gravitas’ of Wall Street backed health care ventures, their portrayals of an industry vulnerable to takeover was quite a compelling story, and many were soon to fall in line via ‘me too’ attempts at strategic positioning (this will be a subject of Act 2’s post on The HMO Industry) in the binge of acquisitions that soon followed. Further, with Sanford C. Bernstein’s prediction that non profit hospitals/health systems would not exist by 1990, the for profit hospital management companies became the coveted talk of the town, and were worshiped on Wall Street. As a result, they attracted the best and the brightest from graduate MPH, and MBA programs. Some even offered their own version of internal ‘corporate colleges’.

Shortly thereafter these HMO insights began to register, the PPO movement, an ‘HMO lite’ version that seemed more amenable to mainstream medicine and therefore their aligned hospital operators, was introduced to the national psyche first in California.  The idea of selectively contracting via a ‘preferred panel’ of participating hospitals was more palatable than a more aggressive HMO model, and therefore attracted considerable attention and support from the hospital community.

The major name plates back then included the ‘big three’: Hospital Corporation of America (HCA), National Medical Enterprises (NME) and American Medical International (AMI).

Herein lies the first mis-adventure that kicks off two decades of strategic misfires by the brain trusts of major corporate health care concerns (both for profit and tax exempt).  All correctly saw the threat posed by entities that could minimally redirect admissions, if not more aggressively manage inpatient utilization, compress lengths of stays, and shift care management from inpatient to outpatient alternatives.

All also correctly foresaw the ‘upside’ of aligning with, joint venturing, if not owning, the insurance vehicle as a market management tool. Here the path begins to get considerably more opaque and ladened with unfamiliar risk. Hospitals are in the business of providing inpatient and outpatient services, not underwriting, marketing and managing the risk associated with a range of group health or individual insurance products. So, being rather preoccupied by there own successes, i.e., growth in scale and market dominance, in the ‘buy’ vs. ‘make’ equation, they decided to make their own insurance companies, vs. partner with or find some other way to co-venture with a partner who actually knew how to do those things that insurance companies do.

In the frenzy of activity that followed: HCA formed Equicor in association with the Equitable. AMI built AMICARE; and NME launched AVMed, and lest we forget VHA, representing the non profit sector rolled out Partners National Health Plan, with Aetna somewhere in that picture. In all of these cases, though HCA and VHA approached more of a partnership than direct competition with the payors, each hospital corporation basically went head to head with the then indemnity market leaders, and early progenitors of PPOs including Aetna, United Healthcare, Prudential, the Blues, etc.

Instead of collaborating with the payor class, i.e., how can we work better together? What might an aligned interest relationship look like? How can we re-tool to make your/our/our clients lives better did not drive decisions. Instead, mostly arrogance, and market short sightedness drove poor choices as literally all of these entities were discontinued, sold off or merged with other entities as their market objectives were not realized.

Act 2 will feature the ‘HMO bonanza’ which attempted the rather aggressive roll-up of the aforementioned cottage industry – and no better trophy venture can illustrate the house of cards that ultimately had to tumble taking many with them, than Maxicare’s attempt to coral mainstream medicine into the business of HMO’s via independent practice associations (IPA’s) – anybody remember ‘the window project’?

Act 3 will conclude this treatise and focus on the rise and fall of the pyramid scheme also known on Wall Street and in health care management domains as physician practice management companies.

As always, your comments and thoughts are invited.

American College of Physician Executives (ACPE) Hosts Accountable Care Organization Panel in Tuscon with Elliott Fisher

ACPE members met in Tuscon on November 14th – 18th, 2010. Dr. Elliot Fisher, who oversees the Dartmouth-Brookings Pilot (ACO) Project, and who is often credited for ‘coining’ the term ‘Accountable Care Organization’ chairs the panel, featuring:

Mark Werner, MD, CPE, FACPE — Chief Medical Officer of the Carilion Clinic in Roanoke, Virgina, and an ACPE board member.

Palmer Evans, MD, FACOG — Chief Medical Officer of Tucson Medical Center in Tucson, Arizona.

Steven Hester, MD, FAAP — Chief Medical Officer of Norton Healthcare in Louisville, Kentucky.

The panelists addressed the challenges and opportunities experienced setting up ACOs in their respective organizations.

To view the entire session including an informative Q & A, click here.

Hat tip to Mark Browne, MD aka @consultdoc.

J. Peter Rich, McDermott, Will & Emery to Kick Off ‘ACO Watch: A Mid-week Review’

On Tuesday, November 3oth, 2010 at 10:00, Pacific, ACO Watch: A Mid-week Review of the Market will launch with J. Peter Rich as special commentator.

Not a day goes by without some reference to Accountable Care Organizations or ‘ACO’s’ in print or online media whether of the main or ‘lame stream’ variety. Throw in the ‘digital river’, or new age after market whether via Twitter or other digital interactive media including an exploding blogosphere, and the conversations are considerable and will only grow in both volume and intensity.

Since we are time bound, and given the scale of the challenge and level of stakeholder interest, a mid-week review of the market seems a prudent way to track, vet, review and analyze the contenders including key industry issues.

To join us for the inaugural live (or archived replay) broadcast, click here.

Accountable Care Organization Vision: Is it about ‘Principles’ or ‘Principals’?

We’ve witnessed several industry stakeholders step up and issue statements of principles pertinent to the ‘OG & E’ (i.e., the organization, governance & equity) domain for Accountable Care Organizations recently. The American Medical Association (AMA), California Medical Association (CMA), and an alliance of primary care physician organizations, including the American Academy of Pediatrics (AAFP), the America College of Physicians (ACP), and the American Osteopathic Association (AOA) have all chimed in here, here, and here, respectively.

While no doubt central to leading, and navigating the inevitable ‘white water’ of health reform implementation, what is likely to have far greater contribution to a net strategy gain for both patients and sponsoring providers, are the ‘principals’ in that conversation. Many of the leaders in key strategy slots, whether institutional or professional, are ill equipped to sort through the many issues before them; and one more time are groping for ‘check the box’ answers with deliverables’ solutions and implementation timelines. All well intended, but perhaps a case of putting the cart before the horse?

Unfortunately, since the success of the big ‘risk push-back’ in the 1990s, i.e., hospital systems, medical practice management companies and captive or independent MSOs (i.e., utility type management companies) all returning to their ‘core businesses’, there is precious little institutional memory, insight or competence in these circles at the moment.

Lets not forget to mine the ‘wisdom of the elders’ forged in the 1980’s though mid 1990’s run up to adopt the prior iteration of Berwick’s ‘triple aim holy grail’. In this blog, we will start recounting some of the more strategic mis-adventures associated with rather large, and smart, entities virtually all of them counseled by many of the same usual suspects (or there derivatives) still in that conversation today, and positioning themselves as ‘strategy experts’.

More will be revealed….

Vertically integrated delivery system can be a boon or bust depending on the principles driving the process

L. Gordon Moore, MD

With permission from the author I post below a long anecdote about a high functioning solo primary care practice looking to link up with a local group.  This is supposed to be the way to a future state in which primary care practices operate as the front lines of vertically integrated Accountable Care Organizations.

The notion makes some sense on paper but the real world is a bit messy.  I post this example as a caution that even good intentions can go awry and leave both sides feeling burned.

We are in the midst of another wave of mergers and consolidations on the delivery side of health care.  With thought and care this can be done well.  Let the principles of high performing health systems guide this work. High performing health systems stand on a foundation of effective primary care.  Doing this well means working with the front lines, not just swallowing up practices with boiler-plate contracts and top-down management.

High performing primary care and vertical organizations are not mutually exclusive, but we need to consider the effect of organizational policy has on the ability of a practice to deliver on the promise of effective primary care.

This email is long and I know that some of you will yell “WHAT WERE YOU THINKING?!?!”  Please refrain from that, as we’ve already kicked ourselves in the head over and over about this.  If you don’t want to read it, I won’t be offended if you hit your “delete” button.

Background:  We were sharing our space & staff with another MD up until July, 2009.  At that point in time, we compensated for the lost overhead from the gentleman who does research in our office by charging him rent (previously we took only a % of what he earned, now we are supposed to be paid rent + a %).  Things were going OK, but Rob’s practice was not as busy as our current spending habits dictate, so he started working for a company called X which does concurrent chart review for hospitals to determine inpatient vs. outpatient status, mainly for Medicare patients.  He started there in February this year, and while it is a lucrative job, it is not personally fulfilling in the same manner that a clinical practice is.  Rob shared with our former practice management advisor about this position, in case the PMA knew of any other physicians who were looking to add income after hours.  The PMA shared with us that he was now working for a large hospital organization, and that they were looking to expand into our area.  Thus begins the saga….

Rob started talking to the Medical Group in April or May.  They were definitely interested in folding our practice into their group.  It required multiple interviews with multiple physicians, and at the outset, we thought this would be good.  The group would provide a stable income for the next couple of years, would promote the practice (thus increasing patients to the level needed to make the sort of income that they were offering while not being on a hamster wheel), and would give Rob what he thought he wanted back – a collegial group of physicians with which to practice, a say in how the office would be run, while at the same time allowing him some time “off” (not being on call while on vacation).  The group’s non-profit Foundation would provide everything that the practice needed – paying all of the bills, including rent, an EMR system, payroll, etc.  And the group’s Research Division would contract with the research guy in our office so that research could continue.  Talks with the Medical Group went well in May and the first part of June and then stalled out when the president of the group went away for a month.  At the end of July, agreements were made and a formal employment contract was sent to us the week before we left on vacation in August.  Mid-August, we came back from vacation and Steve signed the employment contract.  Things started to progress.

The next step involved the purchase of our assets by the Foundation.  Within 2 weeks of signing the employment contract, an appraiser was sent to our office.  We were told it would be about 2-3 weeks and then we would get the purchase offer for our assets.  3 weeks went by, and we then started calling on a weekly basis to inquire about the appraisal.  Foundation’s Legal department would NOT release the appraisal to us.  They were working on the purchase agreement.

Meanwhile, the Foundation computer and phone people started hounding us.  Multiple visits to our office were made so that they could look at where they would need to install “their” equipment.  There was to be a computer in every single exam room.  “What a waste!” I thought…..Rob currently uses a tablet and carries it from room to room and it works great.  They also wanted to put phones in every exam room…..ditto the wastefulness.  Our office is so small that one simple yell for help will bring the staff running from the farthest corner.  The phone lady was like a Border Collie; she really “needed” to have AT&T come out and do work in our suite.  We kept telling her that until we had a signed Purchase Agreement, that was not going to happen.  The other thing that was supposed to be happening during this time was the Foundation was to hire our LVN.  Even after coming and talking to her personally, no one bothered to mention to us OR HER that she was supposed to apply for her job online through their website.  It was only after we pushed and told the President of the Medical Group that it was unacceptable for her to start working for an employer without knowing what her salary and benefits were going to be that they even bothered to tell us that she would need to apply online “for any job – just tell us which one.”  She complied, did the online application and had many phone calls with confused HR people wanting to know why an LVN would be applying for an MA position.  Our first clue that the left hand of this organization does not know what the right hand is doing…

Move forward to the last week in October.  Three days before the end of the month, with Rob supposed to be starting to work for the medical group on Nov. 1, we finally get the purchase agreement.  Not only is the amount bottom-dollar for the Fair Market Value of our assets, but in it they state that he cannot continue to work for X.  We told them that this is a deal-breaker.  Back in August when we signed the Employment Contract, we specifically asked if his work at X would be a conflict.  We have IN WRITING that it would not.  (They made a HUGE assumption that it was an Independent Contractor type of employment and not and Employment Agreement when they answered that question.  That has now come back to bite them because it wasn’t until October that they even bothered to ask for a copy of his employment.)  Foundation’s Legal department is stating that anything that uses his medical license is a conflict of interest and all income must flow through them and be passed on to Rob.  We knew that X wouldn’t do an independent contractor agreement because we asked about that in January upon the advice of our CPA.  But their Legal Beagles wanted to try anyways.  So the start date was pushed back to Dec 1.

On 10/29, AT&T called to state that they were on their way out to do work in the suite.  I said NO WAY.  I had a password protection put on our account because the Border Collie was ordering things to our account without telling us and without authorization.  (She was told – in no uncertain terms –  that there was to be NO WORK done in our suite until we had a signed Purchase Agreement.  And I have Building Management on my side for this one.)

We gave them until Nov. 5 to work something out with X.  Nothing was worked out.  On Nov. 8, Rob send a “Dear John” email to the Medical Group and told them that he appreciated all of their hard work, but without him being able to continue his work at X, we could not progress with the deal.  Never mind the fact that a deal had not been worked out with our research guy and our LVN still did not have an offer of employment.  That got the Medical Group freaked out.  They called and asked Rob if he would consider an “administrative” position with the medical group to offset the income that we currently get from X.  He said yes.  They told him by the middle of this week that they would have something.  He told them that they had until yesterday to come up with an agreement for research and a written employment offer for our LVN.

Needless to say, no administrative position has been offered.  No offer of employment for our LVN.  No contract for research.  No Deal.  Rob called the Medical Group yesterday, said “Enough is enough, thank you for the offer.”  Oh, and I forgot to mention that meanwhile, we have learned that their EMR is 1990’s technology (way behind our current EMR system, which just got certified this week for Meaningful Use), that many physicians are unhappy with the Foundation due to the top-heavy management and inability to get things done (like repair holes in walls and fix non-working computers), and we have decided that it’s just not going to be a good fit for an entrepreneurial physician to work in this monster of a system.

The past 6 months have been an exercise in patience, but have also been a learning experience for us.  Although large organizations may be the only way to make it work going forward with Healthcare Reform in areas such as ours, we are going to make sure that we participate in an organization that is not top-heavy and where the physicians have a say in the running of the business.

What will we do now?  The future is uncertain.  We’re not sure that we can sustain a practice and live in the area that we do.  Our house payment alone is 65% of our income because we moved here right before the market peaked and then tanked.  We don’t really want to move – our kids are doing really well in top-rated schools.  They have lots of friends (which is hard for our son to do).  We love our community. We like our house (even if it is overpriced).  My mom lives close by.  We are looking at sharing our office space again with another provider.  Rob will continue with X and research, and we will try to get creative about marketing our practice. Our story will continue, but without a top-heavy, unorganized group.  We are looking at migrating our EMR system to an ASP, Rob is drooling over the fact that he might be able to use an iPad, we don’t relish him continuing to work 20+ hours per week plus holidays for X, but we see it as temporary, although it is a long-term “temporary.”

Lesson learned:  Solo is the best option for us at this time. Just say NO to the big groups when they come knocking on your door.  And really do your research if you think you want to not be solo any more.

Happy Saturday and thanks for listening to me vent!