Do You Always Need a Parachute?

Earlier this summer a man jumped out of a plane at 25,000 feet without a parachute and aimed for a net far below.

On purpose.

Why? Well, first he’s a risk taker, daredevil. By aiming for a net far below he wanted to see if he could break the record for the longest free fall without a parachute. Second, and probably more importantly, he had faith in his training and skills.

I feel a little like this right now, though failure for me doesn’t involve certain death. On July 31, after 21 years at an academic institution as an internist and educator I hung my shingle and started my own solo practice, Harper Health Streeterville. Many considered this decision a bit unusual in today’s healthcare marketplace where more often we are seeing consolidation. As I reflect on why I chose to do this, it comes down to five reasons.

1. Mission. A few years back Daniel Pink wrote a book called Drive. In it, he listed the three main motives for people who stay and thrive in their jobs: autonomy, mastery, and purpose. When we’re in control of our jobs and how we do them, we’re more likely to be happy with our work. It also helps if we can continually learn and grow as employees in our skills and responsibilities. Yet most the important reason, in my opinion, is a sense of purpose or mission. Why are we here? Why do we do what we do? Why do we get up every morning to come to work? If we have a good reason for that, getting up and arriving engaged is that much easier.

What I feel is missing in today’s medicine is the clarity of that mission. We should be here in service to the needs of our patients, not insurance companies, pharmaceutical giants, bond holders, or even research or educational interests. When we’re caring for patients it should be all about the patient.

At Harper Health “our passion is to deliver membership-based primary care that is relentlessly focused on you, built on a foundation of trust and supported by the best team and resources available.” This is what we do. The team knows it and the patients know it. Sure there are other priorities. We need to break even so we can pay the bills. We need to document our visits properly and in a timely manner. We need to have an Employee Handbook and adhere to appropriate human resource standards. Yet when we need to do two different actions but only have time for one, which do we choose? We choose the one that best serves our mission, one we all truly believe in.

2. Team: When you’re part of a big healthcare organization, you get dropped into a clinic with its existing staff of coordinators, medical assistants and nurses. It’s an organism with its own dynamic, routines, and hierarchy. Where does the doctor fit? How do we all work together? What happens if one person isn’t pulling his weight? The flip side is also true: how do you reward someone who is going above and beyond? In a large system, it is often very difficult to effect change in the team that supports the care of the patients.

That’s all different now. When I forged out on my own I knew that I was responsible for the staff I put together. I also know that if I have to make a change, I can do it swiftly. This is not to say I didn’t have a great team at my former job, but hiring and firing people at large institutions is always a bear. Critical to our success will be creating a team that has everybody rowing the boat in the same direction.

3. Operations: At one of the clinical sites where I used to work it often got very busy with people checking in and out. The office manager came up with a system to keep track of patients: patients take a numbered ticket. Whenever I saw the sign and ticket dispenser I used to think to myself, “After I make my next appointment can I also get a pound of your finest Swiss cheese, please?”

It was the best system he could come up with and it seemed to work for patients, but I knew that there was a better way. I wanted my patients to feel like the special people they are, not just a number in a long line of patients. Despite my feedback, the system at my former practice remained the same. Founding Harper Health gave me the freedom to create an operational system that best meets the needs of our patients: easy access to care, limited wait times in clinic, simple scheduling of appointments, telehealth visits, and technology tools to help us stay connected to patients and them to us. Sure we didn’t have all the answers when we started, but being independent allowed us to pivot when we felt it was right. No middle managers to get in the way.  

4. Finance: Growing up I as always good at math, but just because you’re good at math doesn’t mean that you can run the finances of a business. What little I do know, though, is that to be successful you need to have a good handle on the money coming in and the money going out. This isn’t so easy in today’s healthcare system: one needs to know payer contracts, copays, coinsurance, deductibles, DRGs, meaningful use, ICD-9, ICD-10, CPT codes, charge master, accounts payable, accounts receivable, current accounts, past due accounts, and on and on. These are just the terms off the top of my head and there are plenty more. How many resources does it take to know and do all of this? A lot! Can we make it simpler for patients? Can we make it simpler for all of us? To make it easier for me and my patients I decided to begin my practice as membership-only and getting out of the insurance game.

I also felt it was time that appropriate value was placed on the care that patients will get from Harper Health physicians and staff. I live in Chicago, so a steak analogy seems appropriate. If you’re the owner of Gibson’s Steak House you know people are going to pay a lot more money for the steak dinner you provide than they will for one at Outback Steak House. And for good reason. (Have you been to Gibson’s? So good.) In today’s healthcare marketplace, though, a steak is a steak is a steak. A visit with an internist at the top of his craft will get paid the same as one who has just finished training.

Yet the best internists are thinkers and problem solvers. They answer questions before they’re asked, avoid needless tests and medications, and reserve specialist referrals to issues that are particularly complex. Harper Health isn’t just about more time and access to your doctor. It’s about top quality care and the operational infrastructure that supports it. There’s value in this, and people are willing to pay for it.

Yes, I am the only physician as we open the practice, but as Harper Health grows the physicians we add will be experienced, respected, and deliver high quality care. Patients will have confidence that any Harper Health physician is one they can trust. Until the healthcare system values these physicians appropriately, there will be doctors like me that search to find a better way to care for patients. Harper Health is one.

5. Success: What does it mean to be successful as a physician? In a big system with varied stakeholders, success means different things to different people. Unfortunately, the patient gets lost in some of these metrics. Being independent allows us to define our own measures of success with the patient at the center. Of course there is security in being employed, and economies-of-scale that come as part of a larger system, yet to me, these benefits don’t outweigh the value of independence from at-times meddlesome input from employers and payers.

I’m a strong believer of the personalization of medicine. By personal I mean care in context – what an individual needs in the context of their life at that moment. This might mean temporarily compromising your focus on diabetes control because the patient just lost a loved one. Is the patient at their HbA1c target? Maybe not according to “quality metrics” dictated by health plans, but they are for right now as the patient and I understand it. Or personalization might mean spending extra time with a patient to counsel them on stress management – is this billable time according to the coders and chart documentation auditors? Probably not, but it should be. Or it may mean seeing just six, eight or ten patients in a day, but delivering high quality, low cost care to them. Am I hitting my “RVU targets?” Maybe not by “the administration’s,” but by my definition, yes.

I know that there’s controversy about how I’ve chosen to create Harper Health. Perhaps I and others wouldn’t feel the need to do this if more patients and doctors demanded appropriate ways to value care from both the patient’s and the physician’s perspective.

Harper Health is in it for the long haul. Wanna come along?