Is "the hipster doctor" primary care's future?
Following up on Andrea's post yesterday about the number of un/underinsured people in the US, the web (or some corner of it) has been buzzing lately about Jay Parkinson. He's an MD who's set up a house call practice in Brooklyn aimed at uninsured younger adults. (He specifically mentions that he doesn't have interest in treating older people with chronic diseases.) The practice works on a retainer model: patients pay $500 a year, for which they get two in person visits (at home, work or wherever) and unlimited "e-visits." Parkinson also says he he will help patients find additional care (MRIs, prescription meds, etc.) for the lowest prices.
Parkinson's practice has been met by skepticism, both snarky and serious. Said the president of the American Academy of Family Physicians* to the NY Post about Parkinson, "I would be wary of anything diagnosed solely over the Internet ... video and e-mail should be a tool, not a primary driver." And at the Wall Street Journal's Health Blog, which has an interview with Parkinson, one commenter said, "A niche play. A cherrypicker too. Runny noses and lots of email chat about vitamins. Wake up with an acute abdomen and he'll pass you to someone willing to get his or her hands dirty." Parkinson responds to these criticisms in the comment thread and it's worth a read.
Maybe the most interesting part of Parkinson's plan is his pledge to help patients become better consumers of health care. Consumer directed medicine has been getting a lot of attention lately as a means of lowering costs. But people who need medical care aren't exactly in the best state of mind to go shopping around for the best quality and price. Parkinson promises to help people navigate that market. He's even looking to become an insurance agent so he can help patients find the best health plan if they decide that's what they need.
(via)
-Greg Dahlmann
photo: JayParkinsonMD.com
*corrected 2007-9-28 to include full name of the AAFP
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Good for Dr. Parkinson and his patients. What's wrong with niches?
I can't tell you how many times patients have said that they were too sick to come in - and they probably were. Home visits make sense, it's just that they are expensive, with time out of the office that could be used seeing other patients. I used to joke about my rule for home visits: bedridden and your kids are in their 70's. And there was one woman who could barely get around that I just couldn't abandon.
Most of what "general practitioners" Pediatricians, and Family Practitioners do with patients is very low-tech. As with Dr. Parkinson's practice, there's a lot of interpretation and guidance, with referral when necessary. (FP's are trained to set those broken bones and many do. I refer to orthopods, because they do so much more and will catch the unusual sign or symptom I might miss.)
Seriously, I couldn't do the e-medicine, because I'm a big believer in face to face. But, he's a doctor, with time in a Pediatrics residency and preventive medicine. The retail clinics are staffed with nurse practitioners who say they can do 80% of what docs can do. But it's that 20% - what you don't know you don't know - that can cause the problems.
By the way, it's the American Academy of *Family* Physicians. (Dr. Parkinson's not an FP) We're the first ones to require continuing education and recertification with boards every 7 years. Just re-upped for the 2nd time - 3rd set of boards.
- by Beverly Nuckols on Sep 28, 2007 at 9:17 AM | link
Beverly: I'm curious about the scaling and financial feasibility of this kind of practice. In the interview with the WSJ, Parkinson mentioned that he'd like to cap his practice at about 1000 patients. If each patient uses both of their home visits each year, that's about 8 patient visits a day, which seems possible when you can hop the subway to your next appointment. Of course, that doesn't include any of the e-visits. That might make for some long days (nothing new for a primary care doc, of course).
If Parkinson can sign up 1000 patients on retainer, that's $500k a year in gross revenue. That may seem like a lot, but I wonder how that kind of revenue stacks up against other small single-physician practices.
And thanks for catching the name mistake. The "Family" just got lost in the shuffle.
- by Greg on Sep 28, 2007 at 10:00 AM | link
IMHO $500 for two visits and some advice sounds a little dubious in terms of value for money--especially if it provides the illusions of substituting for health insureance in a meaningful way. My first question is just how much this doctors advice is truly worth.
- by emily on Sep 28, 2007 at 12:29 PM | link
Emily...I think the $500 is quite a good value for what they get. Two home visits -- other docs in NYC charge $700 a visit. I do this as a means of lowering overhead to keep costs down. Like Greg mentioned, it's a densely populated area that I can whip around in no time on a scooter or via subway. By no means am I giving any illusions that this replaces insurance. As a matter of fact, during the first visit, I have an algorithm I use to tell them their insurance options and whether or not they qualify for some sort of low cost plan. If you read my website, you'll understand just how valuable my advice is, especially when considering the price lists I've amassed. Read my blog to see examples of my advice.
- by Jay Parkinson on Sep 29, 2007 at 12:58 AM | link
15 years ago, we could keep our overhead to 40% or less. I believe that the best anyone hopes for these days is 55% or more. It's estimated that we need 1 1/2 employees for billing alone. Dr. Parkinson's overhead would be a (very good) phone, malpractice, licensing, supplies and probably some billing expense. Very little for office supplies, no rent, no nurses or billing staff, no insurance or taxes on the latter. He could afford taxis instead of subway tokens.
Emily, the doc could save thousands in one ER visit alone. Add in employer's insurance or a Major Medical policy, and the coverage gap wouldn't be so much.
- by Beverly Nuckols on Sep 29, 2007 at 1:51 AM | link
I guess having grown up in a country with socialised medicine and avoided seeing a doctor at all in 5 years in the US, I have no idea of the economics of paying for it myself beyond taking out work-place sponsored insurance. The complexities of the issue rather encourage me to keep it that way. It does seem to me that the greatest saving can be made by centralising provision and mandating minimum coverage including home visits for the non-ambulatory.
- by emily on Oct 1, 2007 at 9:38 AM | link
I just checked the figures for New Zealand where the government spends 10 billion on health care, about $200 per person per year. And that is NZ dollars which are theoretically worth rather less. Some people still feel the need for extra coverage but it does mean you can get a major operation over there for less than the cost of one house call on this plan.
- by emily on Oct 1, 2007 at 4:19 PM | link