Whenever I tell someone I started a new primary care practice, the first question is essentially, "Why would anyone do that?" It's understandable...these days there are fewer and fewer private practices, and doctors are increasingly working for large health systems. Starting even before medical school, the general advice given to aspiring doctors boils down to: "You don't know how to do the business side of medicine" or "It's too complicated" or "Malpractice insurance is too expensive" or "the hospitals have teams of people that take care of the administrative side so you don't have to." And I, always eager to follow the rules and be a good student, followed this advice and worked for two different health systems in two different states after graduating from residency. Ultimately what I experienced forced me to decide that there HAD to be a better way.
There were certainly a lot of reasons NOT to start Emerald Direct Primary Care. Most obvious being the timing: who starts a new business in the middle of a global pandemic? I had a reliable paycheck working for the hospital, guaranteed vacation time, and lots of staff members. I had partners who would take call for me when I was out of the office. I had two small children - one of whom was starting kindergarten virtually, and what the school year would look like was very unclear. I still had medical school loans to repay. And while direct primary care is growing throughout the country, there were no other practices using this model in Cleveland. Finally, my early advisors weren't wrong: I had no business experience whatsoever.
Clearly, if things were going along swimmingly working for the hospital, there would be no reason to go out on my own. But after a few years of being frustrated by the healthcare system and finding no option to solve the problem from within a hospital, I had two options: A) suck it up and try to do my job as best I could under the circumstances, or B) create my own circumstances that would allow me to practice excellent medicine. I chose option B.
I'm not actually here to bash hospital systems or blame them for all the problems of medicine - it's much more complicated than that. Here's part of the problem:
There's a lot to unpack here but I'll give you the abridged version. Insurance companies prefer to keep money than spend it on the health of their patients, so they make it very difficult for doctors and hospitals to get paid (via prior authorizations, denied payments, requesting massive chart reviews, etc.) At the same time, laws and regulations are enacted to try to make sure doctors are giving quality care, and they require healthcare providers to submit proof of their quality stats (these don't actually help patients live longer or be healthier, but they look good on paper.) As a result, hospitals hire more administrators to manage the burden created by insurance companies and regulations, and produce all this data so they can make money. These hospital administrators then start micromanaging how doctors care for their patients to further increase their revenue: starting with which patients can be scheduled and when, how many patients should be seen per day, and how long doctors can spend with each patient. As an example, I was forced to see complicated patients I had never met after they were discharged from the hospital...in 20 minutes.
The clear losers in this [depressing] tale are the doctors and the patients. Patients are faced with so many barriers it's no wonder people would prefer to google their symptoms than try to get professional advice. If they do try to go to the doctor they wait... on hold, then weeks or months for an appointment, then finally in the lobby. I think most people generally like their doctors, but they don't get to spend enough time with them to have all their concerns addressed. They feel rushed, and as a result, important things are missed. Mistakes are made, a result of seeing too many patients and doing too many things at once. How many times have you gone home after a doctor's appointment and remembered something you forgot to ask the doctor, but knew there was no way you were going to be able to talk with him or her in a timely fashion? I'm experienced in navigating the healthcare system, and this still remains a challenge for me. Then there's the difficulty of getting in with your own doctor...adding new doctors or NPs or PAs into the mix that don't know you and your health history. There are miscommunications and plenty of confusion. Another huge issue is finances...insurance premiums are insanely expensive, and hospitals have a habit of charging for every little thing to ensure they make money. I was at one of my jobs for a year before I learned my patients were being charged a facility fee at every visit! (A facility fee is meant for emergency rooms and hospitals, but it has been stretched on technicalities to apply to outpatient centers as well.) It took me even longer to learn that my patients were being charged for every routine questionnaire they completed. The end result is patients avoiding the doctor at all costs, and I can hardly blame them.
At the same time, doctors are feeling frustrated and burned out. We all want to give the best care possible to our patients; we want to explain everything fully and address every concern. We definitely don't want to make mistakes. When we can't do that because of all the pressures mentioned above, doctors tend to respond in multiple ways (I've seen each of these responses in some form in every colleague I have worked with). We get down, withdraw, get angry, take it out on other people, drink too much, quit medicine, or retire early. (I won't depress you with the statistics on physician suicide.)
My personal response, which my husband can attest to, is internally raging at the injustices of the healthcare system. There were times I suffered from depression in medical school and burn out in residency. Since becoming an attending and no longer working 80-100 hour weeks, my mental state is much better. But that internal rage of seeing my patients suffer needlessly or feeling I wasn't meeting my patient's needs never went away. One day in my last job, I was finally pushed into action. It started when I saw one of my patients in the office after she had been discharged from the hospital for pyelonephritis and sepsis (infection in the kidney and bloodstream). I advised her she looked to be on the right track toward healing, but to call me if she developed any concerning symptoms. The next week, I happened to be glancing ahead at my schedule for the next month, and I saw that same patient's name, next to the complaint, 'back pain.' I saw the appointment had been made two days prior. I immediately had a nurse call her and ask her to come in right away - that I would stay late to see her. A quick exam and urine test in the office revealed that her pyelonephritis had returned, and I had to send her directly to the hospital for admission. In the end, she healed well...but it scared me that this patient could have died because of the barriers to get in to see her own doctor. She later told me she waited on hold for 45 minutes, and then was told I couldn't see her until 4 weeks later. This was far from the truth - I had plenty of openings that were being filled up or reserved for new patients. After this incident, I went to my leadership and told them I needed to stop taking new patients if I couldn't adequately care for those already under my care. I was told that was not an option.
That day, I went for a walk at lunch. It suddenly occurred to me that I didn't have to take rage walks at lunch for the rest of my life. I knew I could do it better, and it was a like a lightbulb had gone off. From that moment on, I never looked back! A few months and a lot of work later, I opened Emerald Direct Primary Care.
Now, there are no rage walks. Or rage, period. I have never been happier professionally. These days, I spend as much time with my patients as they need, whether it's for a sick visit, a physical, or a follow up appointment to address a laundry list of problems. I know if my patients need help, they will reach out to me, and I know that because I'll be the one answering their phone call, text message, or email when they do. The business part actually isn't as scary as it always seemed - I am really enjoying learning so much! (What can I say, I'm a nerd at heart.) I'm also happy to be adding more and more uninsured patients to my practice; now I can provide affordable care in a way that I was told was impossible. I'm very proud to be a part of the direct primary care movement, joining other doctors who are taking control of their futures and standing up for their patients.
If you or someone you know needs a great, reliable primary care doctor (who is presumably as happy as I am), check out the link below to see a map of all the direct primary care practices in the U.S. It's a rapidly growing movement because doctors and patients love it!
If you're in the Cleveland area, feel free to reach out to me directly at dr_moini@emeralddpc.com.