River City Rheumatology

It has now been over two years since the launch of River City Rheumatology and River City Wellness and Integrated Care!  This has been a remarkable time, and I appreciate all the people who have labored so diligently to make this practice work.  I would also like to thank all the amazingly resilient patients who have entrusted us with their care, and the families and friends who support them.  

I have had a number of thoughts as I’ve reflected over the last two years.

Why I Am So Passionate About Rheumatology

Of course, I am biased, but I think rheumatology is the ultimate specialty in medicine.  This is true for a multitude of reasons, but in part because it is a very challenging, yet rewarding field. It takes a lot of mental energy, a deep knowledge of multiple systems in the human body, as well as a desire to know how these systems can impact each other–all while enabling the development of relationships with people over a lifetime. 

These factors feed a hunger to keep pushing back the boundaries of what can be done to manage and cure auto-immune diseases. I also love how the right diagnosis and  treatment can move a person from being defined and debilitated by a disease, to living a rich and full life again!

Rheumatologists care for some of the most challenging conditions that a person can acquire or develop. These conditions are frequently misdiagnosed, as they often evolve erratically over time and are rarely able to be diagnosed by a simple lab or imaging test.

For these reasons and more, people with inflammatory or autoimmune diseases often have seen multiple specialists, may have been dealing with symptoms for years, and their conditions may persist for a lifetime. Therefore, the evaluation and management of autoimmune diseases takes time and careful consideration of all factors in a patient’s life–a holistic approach.

What is happening to healthcare delivery in our country ?

The time spent on this practice and behind the scenes of a medical business enterprise has solidified my thoughts about what is broken in our current healthcare model, particularly as it pertains to preventive health care and long-term disease management.  

I have now been in the practice of medicine for over 30 years and the disturbing trend toward centralized, system-based and protocolized care continues.  Third-party payors (government or insurance company plans) have been given remarkable power to assign value to medical services. This has led to some forms of medicine being over-valued at the expense of others.

Providers are being forced to see more and more patients in a day, and to shorten their visits to the point where they rarely have the time to address complex or long-term issues. 

Physicians who operate outside of giant medical systems, and who practice medicine at a more deliberate or thoughtful pace with an emphasis on relationships, face diminishing insurance reimbursements.  This is happening as rising business, regulatory, compliance, and staffing costs make tighter operating margins. 

Many physicians get discouraged and end up retiring early or simply shuttering their independent practices.  Over three-fourths of all physicians are now employed by a hospital, health system, or a corporate entity, and obligated to practice medicine on terms defined by their employers!

The current healthcare reimbursement model does not value time, rather, it places a premium on procedures and on numbers of patients seen.  Rheumatology is not suited to either of these metrics! There are relatively few procedures in our field, and our patients often require a good deal of time and contemplation.  Conversely, many medical procedures take little thought and minimal time to perform, and yet are reimbursed at much higher rates than what rheumatologists get for figuring out a diagnosis, planning long term care, and managing complex and unpredictable diseases.

These factors end up discouraging providers from entering the specialty or force many to reduce the time spent in clinic visits–particularly common in large centers or hospital-owned rheumatology clinics.  This in turn has created frustrations for patients who are not feeling heard and too often do not have their concerns fully assessed.  These realities then leave the rheumatologist feeling burned out.  

Why Do These Systemic Issues Hit Rheumatology Providers and Patients So Hard?

In one of the more egregious examples of the current payor system devaluing rheumatology, I recall the letter released announcing the termination of the University of Michigan Health-West Rheumatology Clinic. In that letter, the hospital referred to rheumatology as a “broken” specialty. This is such a misleading statement! The specialty is not “broken”! It has simply been devalued to the point that most trainees do not want to pursue the time and training it takes to master such a complex field with no promise that they will be given the necessary time, space and support to practice it well.  This has created a shortage of practices and providers–even as the number of people needing rheumatology services has risen!

Rheumatology is not broken, it has been defunded, devalued and corrupted by a broken medical model, creating limited access, rushed patient/provider interactions, missed and under-treated conditions and a lack of patient access to compassionate, comprehensive care for their chronic, painful inflammatory diseases. 

As the health care system places a premium on procedures or on volume-based productivity, a practice that is patient centered and provides lifelong holistic care simply cannot meet the productivity goals needed to reach financial sustainability.

What is a “Hybrid Practice”?

The factors described above played a large role in the decision I made to develop a hybrid practice model–  River City Rheumatology (RCR) and its sister practice, River City Wellness and Integrated Care (RCWIC).  RCWIC is a concierge program, while RCR operates closer to a more typical insurance based clinic model. 

My desire in this design is threefold:

• To adhere to the principles outlined above and remain committed to the highest quality holistic care in the management of chronic inflammatory disease.
• To expand or maintain access to the widest number of people possible, including those in traditionally underserved communities.
• To still be able to survive as a private practice in this fraught healthcare system! 

In order to accomplish these goals, a certain percentage of my appointments have been allocated to River City Rheumatology (insurance based) practice, while the remaining percentage are reserved for the River City Wellness and Integrated Care concierge members.

The patients seen in River City Rheumatology will continue to be seen by either their physician or by one of our highly trained advanced practice practitioners (Nurse Practitioner and Physician Assistants) at each appointment.  Our APPs facilitate what our patients are used to receiving here since we opened:  high quality, thorough visits conducted at regularly scheduled intervals.

River City Wellness and Integrated Care is an annual membership concierge program that is independent of the RCR program, but enables access to RCR Rheumatology services such as routine appointments, injections, and infusions.  Membership in the program secures patients immediate access to their physician, as well as on-demand, same day or same week appointments, and urgent visits virtually or in person as needed. RCWIC members also have one-to-one call access after business hours, extra time during regular appointments intended to explore the integration of holistic aspects of wellness (including diet, sleep, exercise, and stress management) and enhanced coordination of care with other providers.

This program is suited well to people who prefer to see ONLY a physician for their visits, for those with highly complex or long-standing auto-immune issues, athletes with complex interactions of factors placing them at risk for aggravation or injury, and people whose schedules require a higher degree of scheduling flexibility–and finally to those who believe in and wish to support the vision of medical excellence we are trying to build.

River City Wellness and Integrated Care is a key part of my vision for the future of medicine, and particularly rheumatology.  Its success is vital to support and facilitate our goals of providing comprehensive health and wellness for patients for many years.  The ultimate goal for the hybrid program is to create a space where we can demonstrate our core commitment to providing exceptional, accessible care for all our patients, while staying viable as a private practice.

Why I Remain Committed to Practicing Independently

Over my career, I have worked in nearly every type of health system imaginable including large tertiary university hospitals, community hospitals, academic centers, private practice, free clinics, and in missionary medicine overseas.  In all these settings my goal has been to remain faithful to basic principles. The Hippocratic Oath calls on physicians to “first do no harm”. This means that a good doctor will make decisions and recommendations in a way to ensure the lowest likelihood of hurting someone. This takes technical and scientific expertise but also requires attention to detail and avoiding judgments based on assumptions. These occurrences are far too common in today’s productivity-based model, or when a clinician is tied to protocols that are often driven by insurance guidelines rather than by clinical judgement.  

Secondly, I try to follow the “Golden Rule”, which is to do to others as you would want them to do to you. In other words, I am committed to treating my patients the way I would want to be treated.   

Since the current payment models (or valuation) for providing care make this type of practice difficult, if not impossible, modification to practice design was necessary. The hybrid RCR practice and Integrated Care concierge program were developed to be able to accept and participate with insurances and see the broadest demographic of people, while also recognizing the need for enhanced valuation to support the practice’s independence.

In thinking outside the traditional payor box, I remain steadfast in my commitment to patient-centered care and to making sure that ALL people are given a fair hearing, compassionate interactions, and adequate time.  The longer I am in medicine the more convinced I am that these elements are essential to being a good clinician, and it is particularly true for those patients dealing with the mental, physical, financial and familial impacts of having chronic, lifelong conditions.    

What EVERY Patient Can Expect  

Our entire team is mission focused and shares the common vision—which is to provide high quality, compassionate, patient-centered care to every single person who comes through our doors.  Our infusion therapy is on-site for the convenience of our patients who need it, and we continue to develop a network of trusted ancillary medical service providers.  One day I plan to add more of those providers on site as well, including physical therapists, exercise training, counseling services, nutrition therapy, and collaboration with hormone assessments and replacement for those who would benefit from them.  

There is an unmet need for patient-centered, comprehensive care for autoimmune and inflammatory disease management. Ultimately, my vision extends well beyond this clinic. I hope that by partnering together we can prove this model of care to be successful. I truly believe that management of chronic illness doesn’t demand a high volume, productivity-based approach, but can be comprehensive, integrated, and truly holistic.  It is my hope that we can replicate our model and that we will eventually see more availability for patients in need of this type of care.

I look forward to working with you and I appreciate your encouragement and support. As always, I covet your prayers and am open to discussing philanthropic opportunities that may also exist for those who share in and wish to expand this vision. 

Feel free to reach out if you have any questions or concerns and we will do our best to respond in a timely manner.