"You don't charge enough."

I've heard this from a lot of folks. I've heard it from my accountant (of course), other doctors, consultants, and even some of my patients.  I've had some patients who are especially complex offer to pay me more because of the difficulty of their care.  I think they feel guilty and worry I'm upset that they are being "too demanding" for what they are paying.  I don't ever take extra money.

When I recently told an elderly patient's family that I was willing to do house calls if/when the woman needed it, their question was: "how much extra does it cost?"  No extra charge, actually.  They were delighted at how "old fashioned" I am.  Yep, Dr. Smartphone is certainly old fashioned.

Doesn't this seem like a stupid move for a guy who did a major life change while three kids were college age, who spent most of his retirement money after he turned 50, who has lived the past few years doing a balancing act with both work and home bank accounts?  Shouldn't I charge more?  Shouldn't I try to get more money now so I can sustain the business better?

I don't think so.

I recently had a conversation with a friend who has a practice that is very similar to mine.  He complained to me about how "high maintenance" his under-30 patient population is to him.  I was surprised, as this same population in my practice is nowhere near the label of "high maintenance."  After further investigation, the big difference between our practices (besides location) is that I charge only $30 per month for folks under 30, while he charges $50.  Then everything made sense.

I initially came upon the $30 price when I considered the young families I had taken care of in the past, and the likelihood they would tolerate a price of $50 per month.  It seemed to me that people would be much more willing to pay a dollar a day for access to my care than they would a higher price.  Since my model of practice (a monthly fee without copay or other profitable procedures/products) benefits most from people paying for my service without heavy use of those services, this seemed to be prudent.  It seems that I was right about this, when comparing experiences with my colleague.  People are much less likely to pay $50 per month (or more) unless they have significant need, so a higher price essentially selects for more complex and/or demanding patients.  

This is why I can reasonably handle 640 patients today with only two nurses (one of whom is away on vacation).  Yes, I don't get as much money as I would for 640 patients at a higher monthly rate, but I wonder if I could actually handle that number of patients with only two nurses if I selected out for more demanding patients with that higher rate.    I doubt it.  The longer I consider this, the more I'm convinced of its truth, and the less I am inclined to raise my rates (much to the chagrin of my accountant).

But this doesn't just apply to my practice model; it applies to all of healthcare.  I have family members who don't get routine care for their blood pressure or undergo routine screening tests because of the cost (and yes, they do have insurance).  I've had many patients who wait until the value-proposition becomes overwhelming to seek care.  Treat blood pressure?  Not worth it.  Treat congestive heart failure? I guess I can fork out the money.  This is not out of stupidity or carelessness, necessarily, but instead it is an ignorance of the potential long-term harm of seemingly small, treatable problems. 

So what's the point of all this? Am I suggesting we make primary care really cheap for everyone? Maybe.  But the bigger points are that the economics of healthcare is not always straightforward, and that our emphasis on paying more for high acuity, high complexity patients yields exactly what we are paying for.  Somehow we need to find a way to lower the barrier for people to seek care when it has the biggest economic benefit: early.  On the other side, we need to somehow reward providers for engaging patients in early intervention and disease prevention.  Finally this all needs to be done without penalizing or discouraging the care of complex problems or diseases.

Like I said, it's hard economics.  But I've been able to show it is possible in my growing sample.  There is still a lot of work to be done, as I try to grow the practice into something that is a viable alternative to our fee-for-service (using the word "service" lightly) payment model.  None of this is easy, but at least I (and other docs doing what I do) are trying to show there are viable alternatives.

Many folks initially told me this practice model couldn't work.  Many said that I would cater to the rich, excluding the poor.  Many said I'd avoid complex patients or time-consuming diseases.  Many say my prices are too low.  Yet here I stand, 3 years sober from taking insurance, with a growing practice filled with people from a wide variety of economic backgrounds, with a good mix of healthy and sick, and with an ever improving personal economic future.  I actually put some money back into my retirement accounts recently.

There.  At least that gives something for my accountant to be happy about.

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