August 19, 2004

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Dr. Doug Wimer's medical bag, packed and ready for housecalls.
Photo by Bob Doran.

by HANK SIMS

LOOKING BACK OVER THE FIRST FEW YEARS OF HIS MEDICAL practice one morning last week, a personal saying -- one that he had obviously said to himself many times, in the old days -- sprang to Dr. Doug Wimer's lips.

"Doctors are the lowest form of existence," he said. He partly recanted the comment the next day -- Humboldt County has an excellent, dedicated medical community, he said -- but the old feeling of being constantly rushed, of having to run the gauntlet daily, had obviously returned to him, if just for a moment.

At 35, Wimer retains in his manner much of the small-town Idaho kid he once was -- he's talkative and plain-spoken, but hesitant to speak with a reporter about his work for fear that it would smack of self-promotion. Local television viewers know him as "Dr. Doug," the affable young physician who answers medical questions on KIEM-TV's 5 p.m. broadcasts every Monday.

While most people know that doctors work long hours, probably few think of them as people who are hurting financially. But Wimer said that over the last few years, physicians have suffered from many of the same pressures that other local businesses have faced -- the rising cost of Workers' Compensation Insurance, the higher cost of rent and utilities -- plus special business problems peculiar to the industry.

"At the same time things were going up, the reimbursement [from insurance companies and Medicare] for doing them was going down," he said last week. "The way we compensated for that was seeing more patients. Instead of seeing them in 15 minutes, we'll see them in 10. We'll see them in five. It was just a mill. You were plowing your way through it.

"It wasn't satisfying to try to see someone in three to four minutes -- or five, or 10 minutes -- and get out of the room even though they weren't done asking questions. It just wasn't satisfying to do that, and I wasn't making any money, anyway."

Wimer isn't alone. The Massachusetts Medical Society conducts an annual survey called the Physician Practice Environment Index, which in the words of the society is intended to track "selected factors that shape the overall environment in which physicians provide patient care." Last year the index dropped to its lowest point since 1992, when the society started keeping score. In the last eight years, the index has dropped over 20 percent. The main factors driving the fall are the same ones that Wimer lists when he speaks of his frustrations with his old practice -- the explosion of paperwork required by Medicare and insurance companies, smaller payments for services and the rising cost of malpractice insurance and other essentials.

By the time he made a decision to break with the system, Wimer had 2,700 patients on his books -- right in the range that most doctors need to have to keep their practice afloat in an age where prices are set by insurers and, in the case of Medicare, the federal government. More than anything -- more than the fact that he wasn't doing as well financially as he had hoped, or that he was working long hours -- it was the sheer impossibility of taking care of 2,700 people that caused his own, personal job satisfaction index to plummet.

"There were times when I would wake up at night and say, `What ever happened to Joe?'" Wimer recalls. "'He had those pains and he said he was going to try this, and I never heard back from him.'"

He began to have what he calls the "How do I get out of medicine?" dream -- a not uncommon one among physicians, he said. "I was dissatisfied with it enough that I knew I couldn't keep going to work every Monday morning. I didn't want to do it any more."

But before he quit his practice, or became so burned out that it stopped meaning anything to him, he took the plunge and reformed his business in such a way that he would never have to take orders from the money people again.

BACK TO BASICS

In May, Wimer became the first local doctor to adopt a "retainer-based" business model, an option that is appealing to more and more primary care physicians each year. The economics of the model are simple: Patients pay Wimer $1,000 each year (people under 40 pay $500). In return, they receive unlimited medical attention -- appointments at short notice, questions answered by e-mail, 24-hour phone consultations and house calls. Blood tests and EKGs are free. Wimer will cap his patient load at 350 -- and after three months, he said he's already halfway there.

With his cash flow coming in directly from his patients, Wimer doesn't spend any of his time dealing with the copious amounts of insurance and Medicare paperwork that other doctors must. He has been able to reduce his staff from about five support workers -- some of whom he shared with a colleague -- to just one, a receptionist. Patients may still try to bill their insurance on their own for visits to Wimer's office. Though he doesn't make any promises about whether insurers will pay, his office reports that a few people have been able to get companies to reimburse them at their standard rates for general practitioner visits.

"It's so much more rewarding," Wimer said. "The feedback I get from patients is positive. I don't worry as much anymore about stuff slipping through the cracks. I know that I have the time to follow each problem until its resolution, and I also know that when I put a chart back on the rack I'm going to be looking at it again in a few months. I called two people up yesterday and said, `Hey, you never did stop back by for that urine test.'"

Though there are no definitive numbers, retainer-based practices -- often called "boutique" or "concierge" services, terms Wimer deplores -- seem to have exploded over the past 10 years. A professional organization, the American Society of Concierge Physicians, was recently formed to be the public face of the new industry. Magazines and journals that cover the medical field are increasingly following the phenomenon, and doctors fill online bulletin boards with wistful dreams about taking the plunge.

"OK, anyone out there besides me have dreams of telling insurers to take their contracts and their quality control/utilization management/nurse case reviewers and shove them?" one frustrated physician asked the users of docsboard.com earlier this month.

The modern history of retainer-based practices goes back to 1996, when two Seattle-based physicians formed a practice they called MD2, offering a limited clientele many of the services that Wimer offers today. Many new firms -- ranging from single-doctor practices to large, coast-to-coast conglomerates -- have since built on the model, some of them offering luxury amenities like personal bathrobes, according to online newsletter bankrate.com.

But the retainer model isn't all that new or innovative. Dr. Richard Ricklefs [photo at left] , the pioneering Hoopa physician, originally charged his patients $25 per year -- about $150 today, after being adjusted for inflation -- for his services when he opened his practice in the early 1950s (see "Medicine Man," North Coast Journal, April 1996).

"That's what I started out with about 50 years ago," Ricklefs said last week when told about Wimer's practice. "It gives you an opportunity to treat them properly without them having to worry about paying for another visit."

Ricklefs, who is now retired, added that he was happy that he wasn't starting out in these times, when the bureaucracy associated with the industry has such a powerful hold on how a physician spends his time with patients.

"The economics of medicine I wouldn't like it all, the way it is now," he said. "I don't think I'd want to do go into medicine now, though I'd probably find some way to get around it."

STANDING ALONE

"I would describe the medical community as being clinically depressed," Dr. Alan Glaseroff [photo at right] said last week in his office Humboldt-Del Norte Independent Practice Association.

As president of the association, Glaseroff pays particular attention to the problems local physicians face in their attempt to serve the public. He agrees with much of Wimer's diagnosis of the business climate physicians must work under now, and sympathizes with the temptation to chuck it all away in favor of a practice supported directly by its clients.

"I understand why he did it," he said. "I think he's a good doc, and his motivation is to provide better care and have a reasonable life. Those are good things."

But Glaseroff had two main concerns. First, he felt badly for Wimer's former patients who could not afford to follow him into his new practice and had to find a new doctor. Just as importantly, though, by withdrawing from the mainstream Wimer had lost the incentive to fight to reform it.

"We're right on the edge of exciting times, I think," Glaseroff said.

Thanks to pressure from patients and businesses, which in the current system are charged with providing health care coverage to their workers, there is strong movement to reform the way in which health care is practiced, Glaseroff said. He envisions a system in which insurers pay for preventative care, for patient education and e-mail consultations -- all things that could reduce the number of patients a doctor must see any given day.

For Glaseroff, the best cure for the "clinical depression" besetting doctors is to lead efforts for system reform -- and in doing so, remember what attracted them to medicine In the first place. Like Wimer, he believes in a return to the ideals that they both had in medical school. But Glaseroff said that true reform in how care is delivered must extend a doctor's reach, not limit it. He said that he knows many doctors who still love practicing medicine because they find ways to extend their work to ever-greater numbers of people.

"What I find is that the more involved people are in quality improvement efforts, in community-wide efforts and things like that, the more they enjoy their lives, even with all the stuff they have to put up with," Glaseroff said. "The further you are away from the mission of health care -- those are the depressed people. The people who are involved in the things that go beyond themselves and their office are happier and more excited. Doug's model is a model that sort of isolates him. It doesn't make him part of a bigger effort."

350 OR NONE

One recent morning, Patricia Petersen of Eureka [photo at left] came in to get some blood tests. Like Wimer himself, Petersen has type I diabetes -- a chronic illness that requires frequent medical check-ups. (Wimer said that his practice attracts a good number of diabetics, as patients appreciate the fact that he has first-hand experience with the condition.)

As she requires closer and more constant medical attention than most, Wimer's retainer practice is more cost-effective for her than it would be for many other people. But that's not the reason she chooses his practice, she explains.

"I've been a patient of Dr. Wimer's for maybe four years -- myself, my husband and my 94-year-old dad," she said. "He's a wonderful doctor. He just takes time to explain everything. He draws illustrations and tells us more than our non-medical brains are probably able to absorb. I never felt, even with the patient load he had, that you didn't get the quality care you were seeking."

Still, Petersen acknowledged that with his new billing practices, not everyone could afford to have a doctor as careful and meticulous as Wimer. Her own father, she said, was one of the hundreds who had to seek a new doctor when he went to the retainer model. And Petersen, like most of Wimer's patients, continued to keep up to date on her insurance payments; the biggest medical bills come after a patient has to see a specialist, or go to the hospital, and Wimer's $1,000 per year certainly doesn't cover that.

Wimer isn't insensitive to the plight of those who can't afford his services, but he believes he made the right choice. "It came down to -- either I'd see 350 patients or I'd see none," he said. If he had simply given up the business, if his "How do I get out of medicine" dream had come true and he found work with the Juvenile Diabetes Research Foundation, that would be 350 more patients dumped on Humboldt County's already overtaxed network of primary care doctors.

The great fear, Wimer said, is that the retainer model will be so tempting that large numbers of doctors will abandon the insurance/Medicare system to go it alone. If any significant percentage of Humboldt County's approximately 100 family doctors were to go to a retainer-based practice, it wouldn't take long for the remaining doctors to become overloaded with patients who can't afford the retainer. Wimer doesn't see it happening.

"Probably the biggest fear that people have is that this is going to create an exodus of providers from the current system," he said. "Being on call 24/7 is definitely not for everybody."

Wimer is still working out the kinks. One of these days, he's going to have to figure out a way to get someone to cover for him, in case he has a family emergency or he ever wants to take his wife and kids on a vacation. Getting a partner or swapping down times with another retainer-based doc would be one solution, if another local doctor wants to adopt the retainer model. Or he could get a doc-for-hire to cover his practice, but they do charge about $1,000 per day.

Despite his new practice's shortcomings, though, Wimer isn't looking back. He's unearthed the doctor's bag that his old family physician, the one who treated his diabetes when he was a kid, gave to him when he graduated from medical school. When he first got the present, Wimer thought his old doctor had lost touch with how medicine operated these days. It turns out he was ahead of his time.

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