Irene Kazmers, MD, discusses the heavy administrative burden placed on all practicing physicians in the last decade and why she chose to begin concierge, or membership medicine, a practice model that has "proven to be a tremendous fit for my career at this point in time and made it possible for me to continue as a practicing rheumatologist."
For the past 4 decades, I have enjoyed working as a clinical rheumatologist in the most fascinating subspecialty in all of medicine. My jobs through the years have spanned university faculty and private practice employment models, and as a solo private practitioner for the past decade.
However, over the last few years, it has become more challenging than ever to thrive as a “cognitive specialty” clinician and small business owner, due to ever-increasing electronic health record (EHR) documentation plus burgeoning prior authorization and Step Therapy demands, which exact inordinate staff effort and time. For rheumatologists in particular, the administrative work needed to ensure that our patients receive indicated but extremely expensive specialty medications has become voluminous. Combined with declining reimbursements for services, it is difficult to cover overhead and maintain a workable income margin, despite the inevitable ramp up in patient visits as an attempt to compensate.
Recently, I reached the point of seeing up to 17-20 patients a day who had chronic, and in many cases, complex rheumatology conditions with pertinent comorbidities. Finishing all visit notes in real time became unrealistic, leaving me with dozens of notes to complete by end of week, and I routinely needed to spend long nights and most of the weekend working on these as well as other office-related paperwork and returning patient phone calls. My “bag” of patient visit paperwork, filled to capacity nightly, became a tangible symbol of the heavy administrative burden placed on all practicing physicians in the last decade.
Telemedicine visits necessitated by the COVID-19 pandemic further eroded reimbursements. At the start of the pandemic lockdown in March 2020, the maximum reimbursement provided by Medicare for a telemedicine audio visit (without use of a face-to-face video platform) was $16, regardless of whether the visit lasted 10 minutes or an hour. Relatively few of my mostly elderly patients in our rural area had ready access to Zoom or similar platforms and many were not comfortable dealing with video technology in general. Although reimbursement for audio visits was eventually adjusted, this was a stark reminder of how unrealistic and inadequate the reimbursement system can be for the practicing physician.
Despite surging demand for rheumatology specialty care, sustaining my private rheumatology practice was becoming too challenging. I had arrived at the point where the need to close my practice was a looming and ever-present specter. Thankfully, I chose to look into the option of concierge, or membership medicine, a practice model that has proven to be a tremendous fit for my career at this point in time and made it possible for me to continue as a practicing rheumatologist.
Working with Specialdocs Consultants, a company long recognized for advising and supporting physicians to successfully transition to a concierge medicine model, enabled me to do more than simply keep the doors open at Northern Michigan Rheumatology. It has restored my practice, rejuvenated my staff and allowed me to care for patients exceptionally well in a time of great change and opportunity for rheumatology. I now see a smaller and much more manageable number of patients per day, allowing ample time for visit note documentation and calls to patients and consultants. I am able to see patients promptly, with longer visits as needed in this time-intensive field. Patients may call, text or email me directly and we are able to add them to our schedule quickly, if needed.
As a rheumatologist, it is often necessary to order specialty medications, many of which cost $6,000/month or more and require considerable paperwork and coordination between physician and staff, patient, insurer, manufacturer and/or foundations to seek cost coverage. Prior authorizations for needed medications may be denied, necessitating one or more appeals for coverage. Insurance company Step Therapy protocols add additional time and effort as the company may decline to cover the specific medication carefully chosen for the patient by the physician unless 1 or more other medications of the insurance company’s choosing are tried first. Many medications used in rheumatology care also require frequent and regular lab monitoring due to potential toxicities, generating large volumes of lab reports received by our office daily to review and handle. Notably, the time and effort spent by my staff and me on these functions remain uncompensated in the traditional practice model. In the concierge practice there is more time available for these tasks and membership fees help to support the work involved.
Integrative medicine modalities, including mind-body techniques such as breathing meditation, mindfulness, certified massage therapy, movement therapy, dietary approaches, and nutraceutical supplements can be extremely helpful therapeutically in many cases, typically in combination with pharmaceutical and other conventional treatments. I now have more time to explain and apply such modalities to patients when indicated. It is so gratifying to use these means to help patients regain function and return to activities previously given up as too painful and difficult, such as playing the organ at church services, strumming the guitar, knitting, or tending a garden.
My office is still very busy, but in a much more satisfying way. Patients are being seen more promptly and responded to quickly with improved channels of communication. I am able to address their rheumatology concerns thoroughly and keep up with visit documentation and paperwork without devoting many nights and weekends. With stable revenues based on membership rather than sole reliance on third party payer reimbursements, the viability of Northern Michigan Rheumatology has thankfully been restored.
For me, the most important change has been the incredible lifting of work pressure, resulting in a much better quality of life. From the first night of transitioning to the concierge medicine model, I was able to sleep well, knowing my patients were being better served, my staff was happier, and that I could continue to practice as a rheumatologist within the changing and challenging landscape of medicine today.
Kazmers, MD, owns Northern Michigan Rheumatology,a concierge rheumatology practice in Petoskey, Michigan.