Leann DiDomenico McAllister

On Tuesday, we announced to our 615 patients, and their parents, that after 11 years we are closing our small pediatric practice in Plymouth, Mass. We explained to families that although we had a number of successful years, our business model is no longer sustainable in the new reality of the local healthcare market.

The reaction from our community has been overwhelmingly positive and sweet. Patients who work in healthcare often greet the news of our closing with, "I can't believe you lasted as long as you did." Quite a few parents have called in tears to express their disappointment in our closing, which gets our staff crying as well.

For us, personally, our emotions are all over the place; sad, guilty, inadequate, angry, acceptance, and hope. We are sad that our dream of a micro-practice in our home state of Massachusetts has ended. We feel guilty that we have let our patients down, and inadequate for not being smart enough to figure out how to be successful where we are.

Although we initially felt anger about closing, our involvement with our state medical society helped us accept our reality.  Specifically, as a member of the Massachusetts Medical Society's Committee on the Sustainably of Private Practice we have seen the system-wide issues facing small practices across the state. We accept that most of the reasons why we are closing are not within our control. And lastly, we are feeling real hope and excitement for the adventure that comes next for us.

Las Vegas is appealing to us for many reasons including competitive physician salaries and a low cost of living. We love to travel, and since Las Vegas is a popular tourist destination, there are frequent, affordable, direct flights nearly everywhere we want to go. And, you bet that it won't be hard to give up New England snowstorms for warm desert air, all the while the closeness of the mountains means that a change in the weather is only a short drive away.

It's the people though, of Las Vegas who we are most looking forward to getting to know. Through family members who already live in Las Vegas, we have come to know Las Vegas beyond the Strip. Las Vegas is a vibrant, diverse city with world-class universities and a thriving local arts and culture scene. It's true that we will shed a few tears as we leave #BostonStrong, but we believe that a happy future awaits us in #VegasStrong.

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Economic opportunity, a busy international airport, and a warm climate are fueling our move from Massachusetts to Sin City, and from owner to employed.

We're Closing Our Practice and Moving On

Our solo pediatric practice, a micro-practice that delivers concierge-level services without membership fees to patients, is dying a certain death. Before we settle on options for what comes next for us, we want to better understand how we got here. How did a once thriving, financially successful and independent practice hit a financial dead end? Thanks to David N. Gans, senior fellow at MGMA Industry Affairs, we're starting to understand the whole, complex picture.

Looking back now, we thought we were so clever! Our start-up business plan from 2006 cited an article from 

Archives of Pediatric and Adolescent Medicine

, which stated that a full-time pediatric practitioner could accommodate an average panel size of 1,546 patients. With that knowledge, we sat down with our pro forma financial statements and, calculating conservatively, figured that a solo pediatrician could limit his panel size to 775 patients, about half of the 1,546, but still earn as much as his peers by cutting overhead costs in half. A physician in a micro-practice has less staff to pay and more time with patients. It was simple and over the years we couldn't figure out why so few physicians were practicing in micro-practices. To us, the experience was idyllic.

In 2006, we saw our first patient. Like any start-up, it took a few years to get going, but by 2009 we had reached our projected financial goals. In 2013 and 2014 we so exceeded our financial expectations, we booked an elaborate vacation through Italy and Greece to celebrate our 15

 wedding anniversary in 2015. This success only increased our hubris.

And then everything changed. Sometime between us booking our anniversary trip in early 2015 and going on that trip later in the same year, the business started to die. In truth, most independent primary-care practices at the time were dying and 

 pointing to the death-grip the insurance oligopoly held on U.S. healthcare.

For the past two years, we told anyone who would listen that our model was failing because our model couldn't accommodate growing patient volumes we believed were common at large practices. You see, for years we'd hear from peers all the time how incredibly busy they are, some claiming to see 35 – 40 patients a day, five to six days a week. These volume claims seemed believable to us. One would have to see that many patients a day to bring in enough revenue to handle the increase in fixed overhead costs.

To confirm our belief, we reached out to the Medical Group Management Association (MGMA) to see what hard data they could share. In truth, we wanted to show the world how dangerously high the volume at large practices had become. MGMA was agreeable, and believing our theory had merit, set to work pulling the data. What the data showed, however, proved us completely wrong.

"Our data looks at patients encounters, not patients a day or panel size," explained Gans. According to the 

Provider and Compensation Report Glossary of Common Survey Terms

"A documented, face-to-face contact between a patient and a provider who exercises independent judgment in the provision of services to the individual in an ambulatory or hospital setting. If a patient with the same diagnosis sees two different providers on the same day, it is one encounter. If a patient sees two different providers on the same day for two different diagnoses, then it is considered two encounters. Encounters should include only procedures from the evaluation and management chapter (CPT codes 99201-99499) or the medicine chapter (CPT codes 90800-99199) of the Physician's current Procedural Terminology, Fourth Edition., copyrighted by the American Medical Association (AMA)."

This distinction makes the data more accurate, as panel size is not as predictive when outside factors, like an increase in high deductible plans, has an effect on patient demand.

A surprised Gans reported to us that, "Over the past six years, we show a 20 percent 

 in patient encounters. I believe that physicians might feel like they are seeing more patients because quality measures and other administrative tasks have forced them to spend more time thinking about each patient. This added work might give the illusion that they are seeing more patients, but really they are seeing less but spending more time on each patient's paperwork."

This surprising data sparked our curiosity as to how did our number of encounters compare to the national data. In the graphs below, we present both the MGMA data plus our micro-practice data.  We're small and minor things have big impacts on our data, still the overall trend is fascinating. We went from seeing about a third of a typical FTE provider patient encounters down to a half. In other words, the big guys weren't getting busier, we were!

Gans continued, "The increase in quality measures, patient satisfaction scores, and ACOs have done a lot to force providers to slow down and question more the care each patient is receiving. Of course, the cost of that oversite is exactly what is driving small practices like Performance Pediatrics out of business."

The reality of our situation cannot be denied. Perhaps we could start charging a fee for our concierge-level care, but that would mean we only cater to a certain segment of the population. If we want to keep providing care to the whole community, the only option is to become an employed physician.

Predicting the end of our practice is like getting a terminal diagnosis. Knowing it's going to die doesn't make the experience of it any less heartbreaking. What do you think? Why do you think we're failing and what should we do about it?  

Here's why practices like ours can't thrive in this new environment. MGMA has the data to back it up.

Why Our Medical Practice is Dying 

In four short months, we will be switching from the EHR system we've enjoyed since 2006 to a new system now required by our independent physicians' association (IPA). We have mixed feelings about the change. If it was entirely left to us, we wouldn't switch. That said, there are certain potential functions we are looking forward to using. The key here is the word 

. Perhaps it's the cynical times we're living in, but throughout the long process of selecting, preparing and training for the new epic ("epic" the adjective, not the noun, due to liability) system, it has felt like we're being pitched by a stereotypical luxury car dealer from both the technology vendor and our IPA.

To be clear. we are not luddites. When we opened our micro-practice in 2006, it was opened as, and remains to this day, a paperless primary-care office. It's not easy being a paperless office in an industry still in love with paper and with faxing, and refaxing, the same labs or progress notes repeatedly. Over the years we've devised a system where we translate data on paper into structured bits and bytes which our EHR organizes and analyzes. 

Our current system is very functional and reliable. In 2012, we added integrated online bill paying and a secure patient portal. The technology works for us. Most importantly, it's affordable having been designed for primary-care pediatricians (pediatricians always rank last on any published national average doctor salary list). The new system, on the other hand, costs three times as much as our current system monthly. THREE TIMES AS MUCH! To give you an idea as to how we feel about this, let us tell you that we both drive old cars with well over 100,000 miles on them and have no plans to upgrade them anytime soon. In other words, we have no business shopping for technology with new Mercedes-level luxuries. We're used Toyota people.

So, what could the new system possible have that justifies the price tag? In a word: interoperability. Today, we must manually pull and send data to our IPA; data that is necessary to determine if we're coding correctly per IPA rules, getting paid properly by IPA payer contracts, and prove that we are doing everything we're supposed to in order to meet quality measures required by the contracts. Add to this the foolishness that is the Accountable Care Organization (ACO) movement (we believe ACOs are bad economics and have high public-health consequences, but that's another blog for another day), the IPA voted to require all participating physicians to be on one system.

As we are going through this transition, the words of AMA CEO Dr. James Madera keep running through our heads. Last summer Dr. Madera 

 that digital health products are modern-day snake oil. EHR interoperability sounds good in theory, and we want to believe coordinated care will magically lower the cost of healthcare, but the empirical evidence just isn't there. It doesn't really matter how well coordinated our care is, it does nothing to lower the cost of EpiPens. More importantly, we don't believe it does anything to impact our most vulnerable patients who are disadvantaged by their socioeconomic status, as demonstrated in 

ground-breaking article on infant mortality

We did consider leaving the IPA, but we know of no better option to both stay in our home-state of Massachusetts and remain somewhat, sort of independent. And so, we're switching EHR systems from the known and affordable to the unknown and salary-reducing expensive. You better believe we'll keep you all posted on how it goes!

To fall in line with its IPA, this practice is reluctantly switching its EHR system. Here's why they aren't happy about it. 

Switching EHRs is a Headache for this Practice 

Historically, pediatricians have had little risk of being named in a malpractice case. Parents tend to like their kids' pediatrician and a doctor's likeability plays a big role in whether a patient sues. When pediatricians are sued, it's mostly for failure to diagnose and for honest, unavoidable professional errors. We've always told ourselves that if we followed common-sense policies and kept clear and complete documentation, we should be able to avoid the nightmare of a malpractice suit.

A recent encounter with a university-bound patient, however, got us worried. After losing a lawsuit in 2008, the National Collegiate Athletic Association (NCAA) set rules requiring sickle cell trait screening for student athletes, even though medical societies, including the American Society of Hematology (ASH) 

.  In fact, ASH considers sickle cell trait screening 

 medical policy since ASH recommends that 

 athletes receive the same training and preventative care regardless of their sickle cell status. The lawsuit was frivolous.

The NCAA case, and others like it, have led to the sharp increase in form and "doctor note" requests to practices throughout the US. The work for our office and for the families in tracking down a college-bound athlete's newborn screen, when the sickle cell testing was performed, is a total waste of time. These requests are a time-consuming nuisance, and given the fact that the NCAA lost that unfounded suit, we wonder if our signing forms and notes is opening us up to frivolous suits as well.

For example, last month we were asked to ensure in a note to a daycare center that a patient was "not contagious." Occasionally we can do this, say for a rash that is obviously a contact dermatitis, but often we simply cannot make a "not contagious" guarantee. A rash that may be viral or a child with a cold who is contagious might be contagious, on and off, all winter and most of the spring. This is not a reason to keep a child out of daycare. We are stuck between a rock and a hard place since daycare centers can keep parents from work and earning a living. If we don't write the note, the parent can't return to work. But if we write it, and another child happens to catch a similar virus to the one we diagnosed, are we opening ourselves up to a lawsuit? 

Waste-of-time, uncompensated requests from a school, coach, camp, or daycare moves risk, both real and imagined, onto a doctor. We often reply to requests with a simple, "No, thank you." And when our polite refusals are ignored, we write angry articles and send a copy of the text instead of the "note" to the requesting institution.

We link the increase in note requests to helicopter parents. In recent years, there has been a noted increase in research and press coverage, both in the U.S. as well as in the UK, confirming the negative impact of risk-adverse parenting. 

 the negative effect of  of helicopter parents as children transition to adulthood. It turns out that treating our children as fragile, helpless beings turns them into fragile, helpless adults.

, we've taken steps to reduce school note writing by setting 

 most requests. We've also had success in reaching out directly to local school nurses and superintendents to learn more about their needs and concerns, which has helped all parties involved. And yet, like a bad game of whack-a-mole, the harder we work to keep the requests at bay, the more requests, varied and creative, stream in.

Risk-adverse daycare centers, in addition to having appropriate policies for written orders for prescription and nonprescription medications, also require a physician note for ordinary everyday items including sunscreen, bug spray, and even physician permission to give non-water or non-dairy beverages. When we encounter these ridiculous requests, we question the judgement of the adults who set these draconian policies in the first place. As parents, we wouldn't want these fearful adults to provide care to our child.

A new trend we're seeing at our area's schools is a refusal to accept the words "spine normal" on our standard school form as confirmation that a scoliosis screening was performed. Schools are forcing children to undergo an in-school scoliosis screen, even though one has already been performed in our office. It's important to note that school screening for scoliosis has long been of 

 anyway, and the U.S. Preventive Services Task Force recently updated its recommendation 

Daycare centers, school administrators, and leading public-health groups owe it to our children to set reasonable rules for and, more importantly, 

 requirements for physician notes and forms. Most importantly, our state and national legislators must pass laws to protect institutions who educate and care for children to shield them from litigious parents who mistakenly think they should shelter their strong, confident children.

(Editor's Note: The U.S. Preventive Services Task Force reached out to say it has previously issued an "

," concluding that the current evidence is

insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in children and adolescents ages 10 to 18 years. Essentially, this means that the Task Force can not recommend for or against screening - there simply is not enough evidence to come to a conclusion either way.)

There is a precedent happening in pediatrics as helicopter parents and overbearing daycare centers have created a sharp increase in "doctor's notes."

Stop Signing Doctor's Notes to Avoid Being Sued

Last month I said goodbye to a great-aunt who scared me as much as I knew she loved me. In her youth, Aunt Chickie was a badass bookie who would have washed my mouth out with soap if she heard me call her a badass. I remember when "The Sopranos" first aired on HBO and the shock in the media over the "bad language" and constant use of the "f-word" in the show. I didn't get what people were surprised about – that language was a normal Sunday afternoon with my Italian relatives.

I often credit my self-confidence and assertiveness to my Italian female elders who taught me to value myself enough to overcome any trepidation or fear of confrontation that I might feel. That said, I am aware that I can get loud, even shrill, when backed in a corner. And nothing gets my blood pressure higher than when payers and patients dare to delay payment or question the value of services delivered by my husband, the solo pediatrician I collect for.

There is a great line in the film "As Good as It Gets" when Cuba Gooding Jr.'s character gets aggressive with Jack Nicholson and then regrets it blurting out, "I hate doing this! I'm an art dealer." That's exactly how I feel when I hang up the phone with certain patients and insurance representatives (I'm looking at you Aetna). I'm a medical administrator, not a strongman, but sometimes I feel like if I don't lay down the law, I'm never going to get paid.

I am aware that adding to my current stress is the liberal guilt I feel as I watch working and middle-class patients struggle to meet high deductibles. When we first opened our practice nearly 11 years ago, the state of Massachusetts had a generous Medicaid program. Back then I was confident that if a family wasn't paying, and if they didn't qualify for Medicaid, they were cheap, not poor. Today I'm not so sure, as even in liberal Massachusetts qualifying for and staying on Medicaid is much harder. Not only that, but like many of our fellow practices, we've had to cut back on the number of Medicaid patients we can see due to extreme reimbursement cuts.

, which we strictly adhere to, states that patients pay all bills in full and on time or they are dismissed from the practice. Primary-care is a marathon, not a sprint, and we are fortunate to work in a community where the patients outnumber the providers. But, even though I can afford to banish non-payers, it still weighs heavy on me.

At the end of the day, I must collect every penny owed to our practice in order to remain a viable business. One of my favorite episodes of "Friends" is when Phoebe and Monica cater a funeral and the widow turns on the waterworks every time Monica tries to collect on the bill. Pheobe lectures Monica stating, "Look, I've had a lot of jobs, okay, and there are some people who just always try to get out of paying. It's either, you know, 'That massage wasn’t long enough,' or, 'I don't recognize any of those songs,' or, you know, 'These sombreros aren't big enough. Bad little white girl!'"

Pediatricians need to be paid and I'm not going to apologize for earning a living.

How are your payer relations and patient collections? Are you a pushover or, worse, an aggressive bully? How do you deal with the stress of collecting from patients? 

An administrative director reflects on the many emotions of collecting money from payers and patients in today's healthcare climate.

Collecting from Payers and Patients Is Draining

The minimum penalty for violating HIPAA is $50,000 and up to one year in jail. And just like my annual mandatory HIPAA training does, let me repeat that: 

The minimum penalty for violating HIPAA is $50,000 and up to one year in jail.

This fact was running through my mind last month when my receptionist informed me that transferred medical records that we had mail 

 USPS certified mail to another physician's office never reached their intended address. But, I argued, I have a signed, certified mail return card. My receptionist nodded and quietly said, "The other doctor's office has never heard of the man who signed the certified mail card." Panic set in.  

Thinking back now, I tell myself that my panic was silly. But was it? What if the patient's parents were going through a nasty divorce and a HIPAA complaint to one parent's choice of pediatrician's office was just the fodder the other parent needed to inflict legal pain? After a decade in practice, I'm convinced that my practice's biggest legal and financial threat isn't profit-seeking insurance companies and their meaningless quality metrics or poorly-funded Medicaid primary-care programs, the biggest threat is, in fact, the hell that is two adults who use their children and our office to settle their marital arguments.

We sent the records, per the parent's written consent, to another HIPAA covered-entity, a physician's office no less. We took on the extra burden and cost of sending said records, as we always do, 

 certified mail return receipt. We've mailed records certified for more than 10 years not just because of my fear of HIPAA, but because of my distrust of other physicians' office staff. There is nothing like the feeling of 

 when another office calls to say they never received the records we mailed, and I can gleefully tell them exactly who in their office signed for them.

It took half a day, but eventually, with the help with my receptionists and nurse, we tracked down the post office that handled the mail piece and even spoke with the mail carrier who made the error. She couldn't have been nicer or more apologetic. The mail carrier tracked down the records, delivered them to the correct address, and the receiving doctor's office confirmed they hadn't been opened. In addition, we did the right thing by both recording the incident in our HIPAA log and informing the patient. I enjoyed a very dry martini that night.

Every week it seems I am being asked to make calculated risks in releasing medical records. There are the parents who call and claim their child is going to be kicked out of daycare, which means the parent will lose their job, if our office doesn't get vaccine records over to the daycare that very hour. There are the domestic abuse victims on phoneline 1 who request that we not let their abusive ex know when their mutual child's next appointment is while the lawyer of the other parent is on phoneline 2 tersely explaining that his client has a right to know the date of the child's next appointment. And don't even get me started on parents in a panic because little Johnny is going to lose a perfect attendance award unless we write a compelling note excusing his two weeks off from school.

Clouding my judgement as I act on all these little, mostly low-risk, and yet not HIPAA-compliant requests to share or withhold medical records, are media stories. Anti-HIPAA arguments are made clear when tragedies like the attack on the Pulse nightclub in Orlando happen. Nurses and administrators, wanting to do the right thing, fail to release comforting information to friends and family in a timely manner. Equally persuasive are stories like that of Henrietta Lacks and her decedents whose privacy and consent rights were trampled on by doctors who sought both cures and profits.  I have no doubt the HBO movie about Ms. Lacks and the famous HeLa cells premiering on April 22 will make a solid, if not complex, pro-HIPAA argument.

HIPAA law is, I think, like a lot of laws: complicated and contradictory. In my own work experience, I can spend the morning lecturing a medical records person at a hospital about why he doesn't need written consent to release records to us, the patient's primary-care practice, and then hear myself explain to a parent that very afternoon that I can't give the step-parent, who is by all evidence is a primary parent in the child's life, a copy of the vaccine record for fear of his ex-wife's legal vengeance.

The legal, ethical and financial risk of releasing or withholding medical records is a tremendous burden for any professional working in healthcare today. For now, I will continue to take my annual training seriously, pay the cost to mail medical records certified return receipt, and pray I never have make the compassionate choice to violate HIPAA in the wake of a tragedy.

What do you think? Do you always follow the exact letter of the law or do you sometimes fudge when you release or withhold protected health information?

A practice is discovering that the universal truth around HIPAA compliance is there is no universal truth. Every scenario is different. 