A new future with an old business model.

T hree years ago, after separating from my group practice, I rediscovered an old-fashioned model of practice and found that it is not only desirable but also sustainable in today’s health care environment. Ending my relationships with third-party payers and seeing patients who pay at the time of service has enabled me to decrease my overhead by 90 percent, which is the key to making this type of practice work. I’m earning as much as I did in my previous practice, but I’m working half as many hours. Once my practice matures, I’ll be able to double my previous income. My practice is similar to the practice I joined in 1979 in rural Virginia as a family physician in repayment of a National Health Service Corps obligation. The business model was payment at the time of service, and the practice filed Medicaid claims for indigent patients. The model was simple, market-sensitive, patient-oriented and financially viable. Over the next two decades, I was fortunate to practice family medicine in two different stable multi-physician practices, one rural and one suburban. But insurance coverage, managed care and integrated health care systems added complexity to medical practice. High patient volume and quick service were increasingly necessary to keep the practice afloat. Over time, more resources had to be allocated to service the insurers and fewer resources remained to reward physicians for the clinical care they provided. The joy I felt for my profession began to wane. When I realized I could no longer provide the type of care I wanted – comprehensive, coordinated, continuous care – and still keep the practice financially viable, I took a radical step: I withdrew from participation in every insurance plan, including opting out of Medicare, and developed a business plan that allowed me to focus on my patients’ health care.