[Music]
hi I’m Rob and I’m a recovering doctor
that wasn’t very good let’s try it again
hi I’m Rob and I’m a recovering doctor
much better on September 28 2012 after
18 years in a private primary care
practice I walked out of the door into
the to a new life I stopped being paid
by insurance companies that was five
years four months and six days ago not
that I’m counting it was not easy to
leave we doctors had developed quite a
dependency on insurance money and as is
often the case in dysfunctional
relationships familiar suffering is
often a lot less scary than change even
if that changes for the better but I was
ready to burnout I was unhappy I was
depressed I loved being a doctor and I
feel like I’m gifted at it but I was
ready to quit and unfortunately I am not
alone doctors are reporting burnout and
leaving medicine at increasing and
alarming rates a 2014 study found that
one in four doctors planned on leaving
their practice in the next two years and
just last year 51 percent of physicians
surveyed said that they were feeling
burned out now why is this why would a
doctor who loved medicine and loved his
patients be ready to quit well it’s not
taking care of patients that’s the
problem it’s the system that makes
doctors want to leave it does so in two
ways first it floods us with busy work
taking our eyes off of our patients for
doctors and normal practices much of the
time is spent following insurance
company rules dealing with unruly
computerized medical
kurz and submitting data to the
government and to insurance companies
less than half of the time the doctor
spends is spent with patients and that
is simply not enough before I left I was
going home each day feeling depressed
like I was not able to give good care to
any of my patients
but the bigger reason for doctor’s
dissatisfaction and burnout is the
system itself which has perverse
financial incentives now if you’re a
patient in a normal practice your doctor
is financially rewarded to do the
following to force you to come in for
all care no matter how little the
problem for you to be as sick as
possible because the sicker you are the
more insurance pays to do as many
procedures on you as possible such as
injections or lab tests and finally to
spend as little time with you as
possible
nobody wants this it’s terrible for
patients but it’s also terrible for
doctors I was forced to choose do I do
what’s good for my business or do I do
what’s best for my patients do I
sacrifice money for my children’s
college fund or do a sacrifice time with
the depressed patient or the diabetic
it’s a lousy choice and it’s a choice
that I had to make all day every day so
on September 28th 2012 my sobriety date
I left I looked at a number of options
but my best choice was a practice model
called direct primary care
this model has two central differences
first is that doctors are paid directly
by the patient’s not by insurance
companies and the second is that instead
of paying for office visits the patient
pays a monthly fee generally less than
$100 my patients paid between 35 and 65
dollars depending on their age I believe
that these two changes and how the
doctor is paid are the key to giving
better care cutting cost and radically
improving the experience for both
doctors and patients having patients pay
the doctor directly increases the value
of the care the patient gets the idea of
value is something that’s foreign to
most of the health care system it’s not
normal for somebody to shop around for
the best deals on doctors or lab tests
or colonoscopies but doctors paid by
patient but doctors paid by patients are
motivated to keep things as inexpensive
as possible because people who save
money are more likely to stay the
practice grows if it’s willing to go the
extra mile to save the patient’s money
this isn’t done out of generosity or
self-sacrifice it’s simply good business
and there are lots of ways to save money
such as finding the lowest cost on
medications whether by searching for the
best pharmacy price or as we do by
selling drugs directly out of our
practice at wholesale prices lab costs
can be cut by 80% or more simply by
negotiating prices with the lab
companies and finally there are
significantly less expensive places to
get x-rays MRI scans colonoscopies and
other procedures you just need to know
where to look
patients pain also improves the customer
service now health care is notoriously
bad at customer service but doctors who
are paid by patients are motivated to
give the best experience possible again
because those patients are more likely
to stay directly primary care practices
can improve the patient experience in
many ways like using communication tools
like secure text messaging or video chat
to improve access from outside the
office using online tools to track blood
pressure diabetes and other chronic
problems on a daily basis and by
bringing care to the patient directly by
doing house calls and these this is me
with my very first two patients on the
first day of my practice in their home
now this probably sounds wonderful to
the patients out there which is
everybody but the doctors are probably
getting a little nervous I mean how can
this be done in a way that is still
profitable that’s where the monthly
payment comes in when a doctor is paid
by the month they’re no longer rewarded
for having a full office this means that
doctors don’t need you to be sick all
the time and they don’t have to bring
you in for every little problem
normal doctors lose revenue when they
give care by the phone or via text
message but the monthly fee makes it so
care can be given in whatever way is
convenient since the doctors paid the
same regardless of how the care is given
office visits are fine but I’ve found
that less than a quarter of the patients
coming into my old practice actually
need in an office visit for that care so
indirect primary care if you have a rash
you can just take a picture of it send
it via text message to your doctor and
get it taken care of that way or let’s
say you’re vomiting and have a fever
clearly a virus you’re just staying home
from work but your worker requires a
work excuse well you can send a text
message or call your doctor’s office and
as long as it’s reasonable they can just
give you your work excuse
nobody benefits from pointless office
visits and because most of the care is
done via phone or text message the
office schedule is rarely full I saw
only 15 patients on the busiest day over
the past five years and my normal days
are between eight and ten patients which
is about a third of the volume in my old
practice when doctors first adopt direct
primary care and I did too you have to
resist the urge to freak out when the
office is empty because in truth I’m
paid just as much when the office is
empty as when it’s full the stress level
is so much less and an empty office
benefits the patients as well because
people almost never have to wait to be
seen in the office a two o’clock
appointment can be seen it get this two
o’clock patients can almost always get
same-day appointments to no more waiting
two days or two weeks or two months to
be seen and finally the doctor can spend
much more time with each patient
I give new patients between 30 and 60
minutes of face-to-face time with me and
my routine visits are generally
scheduled for 30 minutes so you see how
the system is better it just makes sense
it’s better for patients but it’s also
much better for the doctors well here
are some real-life examples Joe is a 52
year old who has been my patient for
many years he was at home and he noticed
a lump in his neck and he was worried
about it so he sent me a message I
messaged him back and said come on in
when I examined him I too was worried
about this lump in his neck so I sent
him to a specialist who unfortunately
diagnosed Joe with cancer but we had
caught it early now after he was treated
and in remission he told me that he
would never have come in so soon in my
old office there was way too much hassle
so he would have waited maybe too long
to be seen
Susan is a 48 year old who messaged me
on the weekend saying that she had been
out running and she stepped in a ditch
and hurt her foot she was worried that
it might be broken and wondered if she
needed to go to the emergency room I
said I told her not to bother that she
could just come in on Monday and I’d
check her we ordered an x-ray which only
cost $40 by the way and and it was in
fact fractured but the fracture was in a
place that the orthopedic surgeon would
have just put a boot on it for six weeks
and let it heal so that’s what we did
without the orthopedist sorry
orthopedist now after everything was
said and done I thought about the fact
that she had fractured her foot with
fairly minor trauma especially for a 48
year old who was athletic so I ordered a
bone density test which showed that she
had osteoporosis thinning bones which
we’ve been treating ever since – changes
to central changes in how doctors get
paid and the cost can go down the
quality can go up and the overall care
can be the overall experience can be
much better doctors and patients can be
partners not adversaries and it has
worked I’ve been open for five years I
have over 700 patients I have a small
office staff so my overhead is kept low
I’ve never been happier my nurses have
never been happier and my patients are
delighted with the care that they get
from us and and I feel like I’ve never
given better quality health care to my
patients plus my income is approaching
that which
when I left my old practice and direct
primary care is growing when I started
five years ago there are about a hundred
or so practices in the United States now
there’s nearly a thousand doctors who
make this change are often criticized
for being selfish for doctoring for
wealthy people and that this approach
will be the downfall of American
medicine well obviously I disagree most
of our patients are working-class many
don’t have insurance and a significant
percentage of them are elderly as to the
downfall of American medicine how is
giving better and more cost-effective
care a bad thing the real question is
why don’t more doctors do this and how
can we figure out a way to make this
generalize to the whole system to all
primary care doctors imagine how much
money how much hassle and how many lives
that could save so with all the
depressing news about our system be
encouraged there are new ideas out there
there are ways that we can radically
change our system for the better and
those changes don’t have to come from
politicians or bureaucrats the best
changes come from the people who those
changes affect the most I believe that
people don’t agitate for better health
care because they don’t realize that the
quality of care they’re getting isn’t
all that good and the reason they don’t
realize the quality of their care isn’t
good is because they don’t realize how
good it could be though to the doctors
and medical students out there I say
there is hope you can love medicine
again you can partner with your patients
and you can enjoy them as people if I
did it you can do it and to the rest of
you I ask you to do one thing expect
or from your doctor thank you [Applause]
hi I’m Rob and I’m a recovering doctor
that wasn’t very good let’s try it again
hi I’m Rob and I’m a recovering doctor
much better on September 28 2012 after
18 years in a private primary care
practice I walked out of the door into
the to a new life I stopped being paid
by insurance companies that was five
years four months and six days ago not
that I’m counting it was not easy to
leave we doctors had developed quite a
dependency on insurance money and as is
often the case in dysfunctional
relationships familiar suffering is
often a lot less scary than change even
if that changes for the better but I was
ready to burnout I was unhappy I was
depressed I loved being a doctor and I
feel like I’m gifted at it but I was
ready to quit and unfortunately I am not
alone doctors are reporting burnout and
leaving medicine at increasing and
alarming rates a 2014 study found that
one in four doctors planned on leaving
their practice in the next two years and
just last year 51 percent of physicians
surveyed said that they were feeling
burned out now why is this why would a
doctor who loved medicine and loved his
patients be ready to quit well it’s not
taking care of patients that’s the
problem it’s the system that makes
doctors want to leave it does so in two
ways first it floods us with busy work
taking our eyes off of our patients for
doctors and normal practices much of the
time is spent following insurance
company rules dealing with unruly
computerized medical
kurz and submitting data to the
government and to insurance companies
less than half of the time the doctor
spends is spent with patients and that
is simply not enough before I left I was
going home each day feeling depressed
like I was not able to give good care to
any of my patients
but the bigger reason for doctor’s
dissatisfaction and burnout is the
system itself which has perverse
financial incentives now if you’re a
patient in a normal practice your doctor
is financially rewarded to do the
following to force you to come in for
all care no matter how little the
problem for you to be as sick as
possible because the sicker you are the
more insurance pays to do as many
procedures on you as possible such as
injections or lab tests and finally to
spend as little time with you as
possible
nobody wants this it’s terrible for
patients but it’s also terrible for
doctors I was forced to choose do I do
what’s good for my business or do I do
what’s best for my patients do I
sacrifice money for my children’s
college fund or do a sacrifice time with
the depressed patient or the diabetic
it’s a lousy choice and it’s a choice
that I had to make all day every day so
on September 28th 2012 my sobriety date
I left I looked at a number of options
but my best choice was a practice model
called direct primary care
this model has two central differences
first is that doctors are paid directly
by the patient’s not by insurance
companies and the second is that instead
of paying for office visits the patient
pays a monthly fee generally less than
$100 my patients paid between 35 and 65
dollars depending on their age I believe
that these two changes and how the
doctor is paid are the key to giving
better care cutting cost and radically
improving the experience for both
doctors and patients having patients pay
the doctor directly increases the value
of the care the patient gets the idea of
value is something that’s foreign to
most of the health care system it’s not
normal for somebody to shop around for
the best deals on doctors or lab tests
or colonoscopies but doctors paid by
patient but doctors paid by patients are
motivated to keep things as inexpensive
as possible because people who save
money are more likely to stay the
practice grows if it’s willing to go the
extra mile to save the patient’s money
this isn’t done out of generosity or
self-sacrifice it’s simply good business
and there are lots of ways to save money
such as finding the lowest cost on
medications whether by searching for the
best pharmacy price or as we do by
selling drugs directly out of our
practice at wholesale prices lab costs
can be cut by 80% or more simply by
negotiating prices with the lab
companies and finally there are
significantly less expensive places to
get x-rays MRI scans colonoscopies and
other procedures you just need to know
where to look
patients pain also improves the customer
service now health care is notoriously
bad at customer service but doctors who
are paid by patients are motivated to
give the best experience possible again
because those patients are more likely
to stay directly primary care practices
can improve the patient experience in
many ways like using communication tools
like secure text messaging or video chat
to improve access from outside the
office using online tools to track blood
pressure diabetes and other chronic
problems on a daily basis and by
bringing care to the patient directly by
doing house calls and these this is me
with my very first two patients on the
first day of my practice in their home
now this probably sounds wonderful to
the patients out there which is
everybody but the doctors are probably
getting a little nervous I mean how can
this be done in a way that is still
profitable that’s where the monthly
payment comes in when a doctor is paid
by the month they’re no longer rewarded
for having a full office this means that
doctors don’t need you to be sick all
the time and they don’t have to bring
you in for every little problem
normal doctors lose revenue when they
give care by the phone or via text
message but the monthly fee makes it so
care can be given in whatever way is
convenient since the doctors paid the
same regardless of how the care is given
office visits are fine but I’ve found
that less than a quarter of the patients
coming into my old practice actually
need in an office visit for that care so
indirect primary care if you have a rash
you can just take a picture of it send
it via text message to your doctor and
get it taken care of that way or let’s
say you’re vomiting and have a fever
clearly a virus you’re just staying home
from work but your worker requires a
work excuse well you can send a text
message or call your doctor’s office and
as long as it’s reasonable they can just
give you your work excuse
nobody benefits from pointless office
visits and because most of the care is
done via phone or text message the
office schedule is rarely full I saw
only 15 patients on the busiest day over
the past five years and my normal days
are between eight and ten patients which
is about a third of the volume in my old
practice when doctors first adopt direct
primary care and I did too you have to
resist the urge to freak out when the
office is empty because in truth I’m
paid just as much when the office is
empty as when it’s full the stress level
is so much less and an empty office
benefits the patients as well because
people almost never have to wait to be
seen in the office a two o’clock
appointment can be seen it get this two
o’clock patients can almost always get
same-day appointments to no more waiting
two days or two weeks or two months to
be seen and finally the doctor can spend
much more time with each patient
I give new patients between 30 and 60
minutes of face-to-face time with me and
my routine visits are generally
scheduled for 30 minutes so you see how
the system is better it just makes sense
it’s better for patients but it’s also
much better for the doctors well here
are some real-life examples Joe is a 52
year old who has been my patient for
many years he was at home and he noticed
a lump in his neck and he was worried
about it so he sent me a message I
messaged him back and said come on in
when I examined him I too was worried
about this lump in his neck so I sent
him to a specialist who unfortunately
diagnosed Joe with cancer but we had
caught it early now after he was treated
and in remission he told me that he
would never have come in so soon in my
old office there was way too much hassle
so he would have waited maybe too long
to be seen
Susan is a 48 year old who messaged me
on the weekend saying that she had been
out running and she stepped in a ditch
and hurt her foot she was worried that
it might be broken and wondered if she
needed to go to the emergency room I
said I told her not to bother that she
could just come in on Monday and I’d
check her we ordered an x-ray which only
cost $40 by the way and and it was in
fact fractured but the fracture was in a
place that the orthopedic surgeon would
have just put a boot on it for six weeks
and let it heal so that’s what we did
without the orthopedist sorry
orthopedist now after everything was
said and done I thought about the fact
that she had fractured her foot with
fairly minor trauma especially for a 48
year old who was athletic so I ordered a
bone density test which showed that she
had osteoporosis thinning bones which
we’ve been treating ever since – changes
to central changes in how doctors get
paid and the cost can go down the
quality can go up and the overall care
can be the overall experience can be
much better doctors and patients can be
partners not adversaries and it has
worked I’ve been open for five years I
have over 700 patients I have a small
office staff so my overhead is kept low
I’ve never been happier my nurses have
never been happier and my patients are
delighted with the care that they get
from us and and I feel like I’ve never
given better quality health care to my
patients plus my income is approaching
that which
when I left my old practice and direct
primary care is growing when I started
five years ago there are about a hundred
or so practices in the United States now
there’s nearly a thousand doctors who
make this change are often criticized
for being selfish for doctoring for
wealthy people and that this approach
will be the downfall of American
medicine well obviously I disagree most
of our patients are working-class many
don’t have insurance and a significant
percentage of them are elderly as to the
downfall of American medicine how is
giving better and more cost-effective
care a bad thing the real question is
why don’t more doctors do this and how
can we figure out a way to make this
generalize to the whole system to all
primary care doctors imagine how much
money how much hassle and how many lives
that could save so with all the
depressing news about our system be
encouraged there are new ideas out there
there are ways that we can radically
change our system for the better and
those changes don’t have to come from
politicians or bureaucrats the best
changes come from the people who those
changes affect the most I believe that
people don’t agitate for better health
care because they don’t realize that the
quality of care they’re getting isn’t
all that good and the reason they don’t
realize the quality of their care isn’t
good is because they don’t realize how
good it could be though to the doctors
and medical students out there I say
there is hope you can love medicine
again you can partner with your patients
and you can enjoy them as people if I
did it you can do it and to the rest of
you I ask you to do one thing expect
or from your doctor thank you [Applause]
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