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  • Shenary J. Cotter, MD

Primary Care PTSD

This is a confession. It's not pretty. But it happened and reminded me of my commitment to justice in medicine.


My partner, Althea Tyndall-Smith MD, and I left employed positions as Family Medicine physicians in order to practice medicine in a manner that honored ourselves as physicians, as wives and mothers, and that honored our patients just as much. We stepped off "the treadmill" of frantic running from room to room, documenting enough "bullets" on our EHR notes to make sure and capture all the RVU's ($$$$) our employer would hold us accountable for, and always feeling like we never made anyone happy: not ourselves, not our patients, not our employers.


So, after four months of building Gainesville Direct Primary Care Physicians, LLC, and 17 months of being officially open, we can say, we have succeeded. We have succeeded in building a practice that honors our patients, and ourselves. We are happy. We have meaning. We practice REAL Family Medicine, seeing newborns through elderly, doing procedures, learning new skills, and keeping our promise to ourselves and our patients that we have no profit in what we do other than the once-monthly completely transparent membership fee, that is more affordable than most cell phone bills or nail salon habits.


So then why, last week, did I have a "primary care PTSD moment?"


This has been the busiest time of our practice, yet. Influenza, Strep pharyngitis, Epstein Barr Virus infection, norovirus, and common pharyngeal viruses have made our patients sick....and we've been there for them. Its wonderful. I love having time to see my patients, to thoughtfully consider the cause of the illness, and to have time to explain how they can get better. Not giving antibiotics is not problematic when physicians have time to explain why it won't help, and patients know their doctor will be available just in case things worsen. But then I receive the request from my MA to work in a patient with "ear pain" real quick, just to check. And then comes the next thought, unbidden, and unwelcome, but intrusive and unavoidable. The thought was, "great - that's an easy 99213."


What the heck was that!!!! Where did that come from? For those of you who don't understand billing codes, that is the code for moderately complex visit, that generates something called an RVU. This is a way that employers drive employed physicians to produce money in a practice. Physicians have an "RVU goal." If we don't meet our RVU goal, we get threatened with a demotion, decreased pay, or being fired. So the RVU goal is nothing more than a quota. Its a number of widgets required to be produced. So every time a physician sees a patient - and the patient MUST be SEEN - RVU's are generated. The more a physician does during the visit, the more RVU's are generated. So if a physician circles more things on your patient "encounter form," (that piece of paper you notice being put on a chart when you check in, and that is used to bill you when you leave), the more RVU's are credited to the physician.


Does anyone see a problem with this now? So you have physicians who have an RVU goal at a threat of significant problems or loss if it is not met, but you trust this person to ONLY do what you need, and cost consciously, too. Yeah. There's a problem. There's a conflict of interest here. And no one discusses it.


If you aren't convinced that there's some scheisterism involved in this, consider that there's a very important aspect missing to this encounter form/RVU goal situation: the prices. Next time you visit your "industry health" physician/clinician, ask him or her to show you what is circled on the encounter form (or other form that is used), and tell you the price you will be charged for each thing. There are no prices on the form. There never have been. And while you are at it, ask what his or her RVU goal (widget quota) is in dollar amounts. He or she won't know. Physicians aren't told a money goal. It is hidden from them, and they don't ask. How hard is it to list the price for a 99213 visit next to the code? Or the price for the urine dip? Or the strep swab? Or to know how much money you have to make to keep your job? Why the secrecy?


In our direct primary care practice, we not only can tell you EXACTLY how much each thing we recommend costs, we tell you how much profit margin is built into any of these charges. Its really easy, because its $0. The ONLY thing we charge that is profit is the monthly membership fee. Other charges may be passed on to the member, but never for our care. All of our physician care is included in the affordable membership fee.


So when my MA asks me to work-in a patient, not only now do I have TIME to do it (because I no longer have more than 7 patients scheduled regularly per day), but I don't have to worry about making money off of a patient's illness. I see him or her because I CARE. Dr. Tyndall-Smith and I have a sense of OWNERSHIP over our commitment to our member patients health. We don't see our patients for a profit incentive. We are free to see our patients because we CARE about them. The unbidden thought of the 99213 RVU stands for everything we struggled with in practicing medicine before direct primary care saved our physician hearts. The reason I call it PTSD is because this thought is born of trauma. There is moral injury to physicians working in this type of a system.



When you are ready to abandon a profit-centered fear-based incentive medical system, call us. We are ready to CARE for YOU!


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