To the Editor:

This is in response to the article by Charles M. Kilo, MD, MPH, and Scott Endsley, MD, MSc, “As Good As It Could Get: Remaking the Medical Practice” [May 2000].

In light of the wave of primary care practice failures, “early retirements” and bankruptcies, financial viability needs to be the first priority of medical office practices. Currently, the extinction of the office practice appears to be a de facto part of American health care policy.

Employers and state and federal policymakers continue to focus relentlessly on cutting physician incomes in the name of reducing national health expenditures, and hostile business practices by insurers deny or delay payment for physician services. Meanwhile, federal and state regulations prevent physicians from responding to these business practices. This all runs contrary to the fact that physician professional charges account for less than 12 percent of the national health budget.

In order to survive financially, family physicians need a staffless and paperless office. To ensure ironclad documentation of their coding and to enable legal recourse against delinquent insurers, they'll need an electronic medical record (EMR) that is dovetailed to their claims system and that can provide the increasing number of medical forms required by institutions, schools, claims companies, insurers, pharmacy benefit managers and employers.

Evidence-based practice, patient control of the medical record, unlimited daily access to health services and population management are all very important to the next phase of American health care. Given the current “free market forces” of American health policy, perhaps these service improvements need to be treated as commodities and sold to patients like warranty service packages. It's doubtful many American health care consumers will pay for these services, and physicians with their ailing businesses can ill-afford to support these new expenses.

To the Editor:

I worry about “remaking the medical practice.” For years my group practice has been innovative and has tried to do new and better things for patients. After spending time and money on these projects, I've approached medical insurance companies for reimbursement. Routinely, I am ignored. Third-party payers in my area pay as if the telephone had never been invented; I can't imagine their reaction to the Internet. And Medicare, the mother of all payers, sees nothing of consequence beyond face-to-face time.

I'm all for innovation, and I agree that office practice could be better designed. However, before I follow any prototypes I want to see one that is adequately funded by a payer mix such as mine, not by some grant.

Editor's note:

Financial viability is indeed a key concern for medical practices and an important component of the “idealized design” initiative. By finding ways to be paid for quality, improve their financial management and accounting systems, and drive out waste, the 42 prototype sites are strengthening their finances. Clearly, however, the current financing system frustrates efforts to practice optimally, and nearly everyone agrees that it must be reformed.

FPM will tackle these issues in the coming months, publishing articles that survey promising alternative financing models that are emerging in the industry and that discuss how to get paid for quality in the current system.