I have felt from the start that this practice model is far better than the one I had in my former life, including: 

  1. Better experience for the doctor
  2. Better experience for the patient
  3. Better care quality
  4. Savings for the patient and for the system. 

The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice.  This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against). 

Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get.  This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model).  I realize that this does not constitute a proof of concept, but it is not without meaning.

Patient 1.  Medicare.  Age: 90+

Pt had a head injury and came to my office wondering if they should go to the ER.  I assessed the mental status did an exam, determining that this was not necessary.  Set up imaging study that day (CT without contrast) which came back negative. 

In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this. 

Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price. 

Savings: Avoided ER with head injury work-up.  Cost: ?  (More than $300 by far).  

Patient 2: Self-Pay (have high-deductible and HSA).  Age 10

Pt fell and injured arm.  Mom sent message to me over weekend wondering about ER visit.  I told them to come in on Monday and I\’d evaluate.  Evaluation was not conclusive, so I sent for x-ray, which showed small fracture.  I suggested ortho, but mother messaged me back saying she talked to a friend who was an ortho and they said to just splint this.  I checked on the recommendation and agreed.  Child was in splinted, had repeat x-ray which was better, and given permission to do sports again.

In my old office, without messaging mom would likely have chosen to go to the ER.  If not, would have seen me and would not have communicated with me about her friend\’s advice (and I wouldn\’t have had time to listen), so cost would have been quite a bit higher.

Cost: 2 x-rays of the forearm – cash price of x-rays $80 each, so total cost of $160

Cost savings: Avoided ER visit and specialist visits. 

Patient 3: Self-Pay.  Age: 40\’s

History of migraines, better with Topamax as a prophylactic drug.  Can\’t take it due to monthly cost.  I found a cheaper cost, but then the price went up dramatically.  Pt came to me saying they had to stop the medication, as it was costing more than $120 per month.  I personally called pharmacy, who said that the cost for them was high, but then noted another local pharmacy had it on their $4 drug list and that they would match anyone\’s price.  I passed this on to the patient. 

In my old office would have required payment for an office visit to talk to me about this, and would not likely have had time to research the cheaper price. 

Cost: $4 per month.  

Cost Savings: $116 per month and significantly improving quality of life. 

Patient 4: Commercial Insurance.  Age: 40\’s

Significant head injury with out loss of consciousness.  Pt had some change in mental status (dazed), some nausea, dizziness.  Came to my office directly.  I evaluated, determined low risk for subdural bleed, more likely concussion injury.  Ordered noncontrasted CT of head and stayed in office for 2 hours before test could be done.  We re-evaluated over time and progressively got better.  CT scan was negative.  I called and did phone follow-up over the next few days and pt recovered completely.

Cost:  CT of head: $300

Savings:  ER visit and workup for head injury with altered mental status.   Cost: ?

Patient 5: Commercial Insurance.  Age 50\’s

Past history of bleed from A-V Malformation in brain.  Pt was out of town and had sudden onset of headache and dizziness, wondered if needed to go to the ER.  Spoke at length, told them to call neurology, but wasn\’t convinced ER was necessary, as symptoms had improved significantly.  Pt never reached neurology, but called me the next day when back in town.  I called neurologist personally and decided ER was not necessary.  Set up noncontrasted CT to see if there was new bleed.  CT negative, and now plan set-up to see specialist per neurology recommendation to have issue addressed in a way it couldn\’t be done with initial bleed >15 years ago.   

Cost:  CT of head: $300

Patient 6: Medicare.  70\’s.

In hospital repeatedly with heart failure prior to coming to my new practice (was patient in old practice).  Husband produced a spreadsheet he made to follow this, which I set-up to be filled out online, having results sent to me on daily basis.  Have since managed this over past 8 months, with patient losing over 30 lbs, coming off of oxygen, and becoming munch more active.  Have had to delicately balance diuretics, blood pressure medications, and kidney function.  Husband hugs me when he comes in office, and son-in-law relates a \”dramatic\” difference in how she is now. 

Cost:  Nothing. 

Savings:  Avoiding likely multiple hospitalizations due to fragile CHF. 


Patient 7:  Medicare.  90\’s.

Well known to me, anxious, calls fairly frequently.  I cared for patient when spouse died a few years back, and pt has voiced a desire to die and be with spouse.  Pt sought me out when I left for new practice.  Recently change home situation.  Called me with chest tightness and shortness of breath.  Caretaker thought this was related to the recent move, but was afraid to not go to ER.  I spoke with patient, explaining that I thought this was probably anxiety, but that even if it wasn\’t, if it was a real heart problem, if she went to the ER they would hook her up to IV\’s, do lots of tests, and maybe even admit to the ICU.  Patient told me, \”oh no, I wouldn\’t want them to do that,\” (which I knew).  I advised them to take a little extra anxiety medication and that I\’d call back the next day.  Fortunately, things had improved and the pain was probably due to anxiety.

Cost:  Nothing. 

Savings:  At least the cost of an ER visit and possibly a full admission for something the patient absolutely didn\’t want done. 


These are just some of the cases recently that have come up.  I think it explains how having a doctor available to help deal with crises or decisions for care will help patient make better decisions and save money. 

So, to the insurance companies (including CMS) I say: You are Welcome. 


7 thoughts on “Evidence”

  1. I continue to follow your new practice model with great interest. A couple of things came up for me with this post.

    Patient 3 – In your old practice was there (or could there have been) a nurse to call the pharmacy? I’m not clear if it was you or the pharmacy who brought up the other pharmacy’s $4 list and this pharmacy’s price-matching policy (but well done!), but I do wonder if that is the best use of your time. I suppose this is also a question about what the goals are in this case. To help the patient get the medicine, off course, but is relationship building with them also part of it?

    Patient 6 – I recall that having this sort of on-line interface between you and the patient was one of the things you discussed early on. How is that working out? What kind of patients or conditions are you finding most responsive to it?

    Your personal relationship with your patients continues to impress me. Telephone, emails/texts, relaxed visits. That in and of itself is almost certainly a factor that promotes wellness, but I’ll be hanged if I can figure out how to measure it.

    Thank you so very much for these "bulletins from the front" – and continued good luck!

  2. The idea of spending time with a person to figure out the pharmacy is this: it is in mine and this patient’s best interest for them to be on the medication, and it is in my best business interest to give my patients value. Saving them money in whatever way I can will keep them paying their monthly payment. The idea is to, as a person told me long ago as the key to marketing, "raise the cost of leaving."

    I have some online interface, but am a bit frustrated at the disconnectedness of everything when it comes to communication tools. The best communication leads to the best care, and the best communication happens with the best information. Somehow I want to have a communication tool embedded with the patient record on both sides of the communication interchange: within a patient record that they have access to and within my record system (which is just a different view of the same information).

  3. I really, really, really wish I lived near your practice. I was just dropped by a doctor because I had not been in for two years. I guess I wasn’t a profitable patient. I was told I must come in for physical at least once a year in order to be a patient, something about it being too much trouble to maintain records unless I come in regularly. I have Medicare plus a Plan F supplemental so I am well-insured. So far, I’m gratefully healthy, but now I must search for another doctor who will accept me as a patient, or go to an immediate care facility which will cost Medicare and my insurance company a whole lot more than if I had a regular doctor. What a crazy system we have, designed only to support illness. I wish you the best possible success and I hope more doctors follow your example. (Also wish you had the resources to develop the perfect EMR software so that you could make a ton of money with it while also making it easier for other docs to transition!)

  4. Dr. Rob, question about the $300 cost for CT. How does a patient negotiate that rate with the imaging center or hospital? Are you saying that if I offer cash, I can get a rate this good? Or are you doing CT scans at your office? I know you aren’t running what you would call a "concierge" practice (and I agree), but the closest equivalent we have in my neck of the woods to what you are doing are concierge practices. I would benefit from this type of practice because, even though my wallet would be much, much lighter, I need the increased time those doctors can allocate to me. I have a serious and rare chronic illness and have no choice but to find doctors who are willing to spend a little extra time with me to manage my condition. But I fear the costs of imaging and other pricey testing, because a lot of these practices don’t do those in-house. Can you speak a bit on this point? Thank you.

  5. There’s a local independent imaging center which offers a cash price for the tests. It’s not as good as I could probably negotiate if the patient paid me and I paid the center, but I am not ready to start doing that quite yet (which is how I do labs as cheaply as I do). If there were other DPC docs in town I’d probably just go in with them and get our own x-ray facility to offer care at cost.

    I can’t say how concierge practices would do it, as they often are still looking to skim some profit off of their ancillary services. For me it’s all about offering a value people can’t put down once they experience it. There are a few other DPC docs doing this kind of thing, but it’s not the mainstream yet, that I know of.

  6. Amen, Karen. I like that "ton of money" part (probably because it’s just a guilty fantasy).

  7. Thanks for the explanation. The concierge practices here that I have spoken to just write the order for the CT scan, and you go and get it on your own. They have never mentioned having negotiated rates for their patients at any imaging centers. So I think unless there is a center like the one you are referring your patients to that offers a steep discounted price for cash payments, the concierge patient is going to have to pay a ton for the scan (unless they have good insurance that will pick up the tab).

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