Robert S. Berry, M.D.
Because of the charitable nature of the clinic, I had considered
making it a non-profit to take advantage of tax breaks and to raise
The greatest benefit of an insurance-free practice is just
money for my own salary. After several discussions with my
attorney, I was inclined to decide against it. He pointed out that
More than three years ago, I left emergency medicine to start an
dealing with a board would probably be about as frustrating as
insurance-free practice. I’d studied the feasibility of starting a part-
every other bureaucracy I had encountered since my residency. In
time clinic primarily for the uninsured.
addition, even though I would be the one building the patient base,
Of course, I wouldn’t refuse anyone else willing to Pay At The
the board could dismiss me whenever it wished, and the years I
Moment Of Service, so I chose the acronym PATMOS as the clinic
would have invested might well end in futility and bitterness.
name. By avoiding all contracts with third party payers, I could
I reasoned that since the sick and injured we will always have
avoid the crushing costs of settling relatively small claims, and
with us, it was more prudent in the long run to depend on them for
thus provide more affordable primary medical care to all point-of-
my income, rather than on fickle donors and ever-changing tax
laws. The long-term risks did not appear to be worth the short-term
From my experience as an ER physician, I knew the people the
financial security a non-profit might offer.
Non-profit status became an academic issue quickly, since my
charts classified as “self-pays.” In a small community such as ours,
plans to make the clinic full-time were realized sooner than I had
I had purchased goods and services from many of them. They were
expected. For various reasons, the president of the hospital had my
my neighbors, and for the most part they were hardworking trade
ER contract terminated abruptly. I no longer had time to start a
people and small business owners, too poor for $10 co-pay
practice and raise money too. Had I pursued the non-profit option,
insurance, and earning too much income to qualify for Medicaid.
the idea of this clinic might still be in committee.
Like John the Apostle banished to Patmos Island, they were
I had to make a decision. Either get ER work at another hospital,
political exiles within the healthcare system.
or start the clinic full time. I decided on the latter, and the clinic was
Most doctors refused to see them. With practices set up for
up and running within two weeks of my dismissal.
insurance, the uninsured tend to disrupt patient flow. Many cannot
More preparation time might have saved me substantial
pay for tests and procedures sometimes needed to exclude
expense from misadventures, since I not only had to start a practice
potentially litigable misdiagnoses. The uninsured simply take too
from scratch and see patients, but I also had to learn on the fly how
much time, with too much risk in exchange for uncertain payment.
to run a small business. Yet had I not been kicked out of the nest, the
No wonder physicians turn these patients away and refer them
clinic might still be a vague longing. Fortunately, I had already
to the ER. But as we all know, the ER is not the appropriate place for
made a list of all equipment and medicines I was using in the ER.
these patients. Charges are higher, work-ups more extensive, and
PATMOS is in a village of 16,000, in a county of 60,000, in a
few physicians are willing to see them in follow-up.
state where only 10 percent of the population is without medical
Self-pay patients, I learned, are neither destitute nor derelict. I
insurance–one of the smallest such percentages in the nation.
felt certain that these farmers, carpenters, plumbers, beauticians,
Twenty-five percent have Medicaid. These percentages are
housecleaners, and small business owners and their employees
would appreciate and value medical care at fair and honest prices.
In addition, there is a government-run clinic in town, two others
They didn’t have the time to wait at government clinics, and did not
within 15 miles, and a charity clinic in a town 25 miles away. To my
like the quality of care they received there. They urged me to start a
knowledge, no large company in our community has adopted a
practice, and promised that they would come see me if I did.
consumer-driven medical plan, such as a health reimbursement
This turned me around. I thought that maybe over time, this
account (HRA) or health savings account (HSA), that motivates
clinic might replace my income from the ER, and I could then
employees to find low-cost medical care. I compete daily against
jettison from my medical practice the increasingly wasteful and
$10 to $20 co-pays, and regularly have to disabuse patients of the
notion that timely, quality medical care costs practically nothing. Journal of American Physicians and Surgeons Summer 2004
Given a market so stacked against us, how have we been able to
The financial realities, the lack of a compatible partner willing
survive these last three years? The answer of course, as any other
to opt out of Medicare, and the need to reconstruct the books to
successful small business will tell you, is by providing value and
provide accurate records for the Internal Revenue Service forced
I realized quickly that I had to let my core clientele–the
Today I have one full-time employee and one part-time, about
uninsured and people with high deductibles–know about the cost
1.3 full-time equivalents. The clinic is open 35 hours a week, 29
breaks of a clinic not taking insurance. Although it ran counter to
hours walk-in and six hours of scheduled appointments. We have
my own feelings of professionalism, I broke with
nearly 5,000 patient charts with, at last count, about 51 percent
convention–though within the bylaws of the Tennessee Medical
uninsured, 38 percent commercially insured, 8 percent Medicaid
Board–and made my fees public in newspaper ads and flyers. Visits
for poison ivy and sports physicals cost $25; for sore throats,
One physician who contemplated quitting medicine was quoted
coughs, and sinus infections, $35; and for simple cuts, $95. I
in a story in Time magazine last summer, “The Doctor Is Out,” as
thought this represented timely, high-quality medical care from the
saying, “Our income is completely controlled by the government,
type of physician who seems rare today–one who actually enjoys
but we have no control on our expenses.” In contrast, I rely on
practicing medicine. And we gladly take MasterCard!
appreciative neighbors for my income, and by avoiding third-party
payment contracts I have a handle on costs.
We have worked out discounts with various other facilities in
My overhead is about one-third that of the typical family
the area so that a CBC and lipid panel cost the patient $20; a
practice and requires about three employees fewer. In absolute
complete chemistry and TSH are $25; a chest X-ray with an
dollar terms, the savings produced by our clinic over other clinics
interpretation is $70; and an MRI with an interpretation is about
that offer similar services–but accept insurance–is about $200,000
$500. Costs to the patient here are about 60 percent of those at other
per year, more than 40 percent of the typical family physician’s
physicians’ offices, 40 percent of the local urgent care, and 10 to 20
My break-even volume is about 1.2 patients per hour. My
Not wishing to turn Medicare beneficiaries away from my
average volume over the last six months has been about three
clinic if they wished to pay me at the time of service, I was forced to
patients per hour, which makes my net income before taxes a little
opt out of Medicare, effectively preventing me from working in any
less than what I was making at the local ER. At four patients per
ER to supplement my income, the logical consequence of an
hour, I would be earning about 50 percent more than I did at the ER.
As I said, the greatest benefit of an insurance-free practice is the
The biggest mistake I made was starting out with grander
freedom: I have freedom to take care of patients in the way I would
visions than this town was ready to support. I employed an ER nurse
want to be taken care of, rather than the way an insurance
and paramedics, providing a mini-ER for the uninsured. Once I
bureaucrat wants me to. Freedom to refuse care to the disruptive
even helped resolve a case of mild diabetic ketoacidosis (the
and unappreciative. Freedom from increasingly wasteful,
bicarbonate level was 17) in a 12-year-old, using intravenous fluids
capricious, and dehumanizing bureaucracies. Freedom from
and an insulin drip over eight hours. His mother recoiled at the
betraying the confidence of my patients from unannounced audits
thought of taking him to one of the local ERs.
of my charts by insurance companies. Freedom from arbitrary
I took care of some serious infections with several days of
documentation requirements. Freedom to set my own schedule and
intravenous antibiotics, leaving a heparin lock in patients and
bringing them back repeatedly. On occasion I cooled off an episode
I’m now free to reconnect with the pure, spiritual purpose for
of unstable angina with a nitroglycerin drip, intravenous beta-
which I entered medicine: to see to the medical care of people who
blockers, and Lovenox, and had the patients admitted directly to the
in turn value and appreciate my knowledge and skills.
coronary care unit at a tertiary care hospital equipped with a cardiac
I have made many mistakes. I have few regrets. I have learned
catheterization laboratory 25 miles away, bypassing its ER and the
that it is easier to change the course of a moving wheel than to move
a stationary one, and I am convinced that if I’m not making at least
There were many such professionally satisfying cases when the
some mistakes, I’m probably not making progress either.
practice operated as an “EmergiClinic.” However, this also forced
me to hire expensive staff and made me rely on an office manager
Robert S. Berry, M.D., is board certified in internal medicine and emergency medicine. Address: PATMOS EmergiClinic, Greeneville, TN
who, although having every appearance of sharing the clinic’s
37745. E-mail: email@example.com.
vision, was embezzling practically from day one!
Journal of American Physicians and Surgeons Summer 2004
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