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Urologist who opted out: No regrets after 5 years

Apr 1, 2006
By: Urology Times

News ArticleTraverse City, MI�Oct. 1, 2006, marks the fifth anniversary of the date on which Michael Harris, MD, opted out of Medicaid and Medicare and rid himself of all commercial insurers. He put his urology practice on a strict cash-for-services basis in 2001 and he has not looked back.

"This is how you practice medicine," Dr. Harris told Urology Times in a recent interview. "All the bureaucracy that is inflicted on a typical medical practice today contributes absolutely nothing to the care of the patient. All it does is hamper performance."

Dr. HarrisOn his web site, Dr. Harris informs other physicians who may be considering opting out that "the bank deposit on Tuesday evening is the money collected for urologic services rendered in Tuesday's clinic. Friday's deposit includes payment for services rendered in the Friday clinic and the next Monday's elective surgery schedule.

"Accounts receivables are almost nonexistent," said Dr. Harris, whose practice has been what he calls "pure cash and carry" for 4-� years.

Dr. Harris anticipates the arrival of Oct. 1, 2007.

That is the date on the affidavit. You have to opt out every 2 years; otherwise, you are automatically back in. One doctor I know compares it to a time-limited divorce," he explained with a chuckle.

October 2006 marks another milestone. By this date, Dr. Harris will exceed the 5-year statute of limitations created by the 140-year-old False Claims Act of 1865, which was updated in 1986 to increase penalties. This act allows government auditors to review charts.

"I will be beyond their reach," he said.

Four years ago, Dr. Harris was interviewed by Urology Times when he had been out from under insurance plans for only 1 year. We contacted him again recently to see how much his life and career have changed in the interim.

The changes he noted were those that affect most practices: Business goes up; it goes down.

He estimates that about two-thirds of his patients were Medicare recipients when he decided to become a non-participating provider at the close of 2000. Ten months later, in October, he opted out of the program altogether. Federal law allows practitioners to withdraw participation from Medicare annually on Dec. 31. Opting out can be done quarterly.

Repercussions of independence

When Dr. Harris opted out, he lost about half of his clinical volume overnight. He has been steadily rebuilding his patient base, but estimates his clinic is 20% under capacity. This is not altogether bad news, he claims. The reduced workload allows him to spend more time examining patients and educating them about their disease and therapeutic options.

As might be expected, Dr. Harris' income plummeted, but so, too, did his overhead. When he was accepting government and private health care insurance payments, he says overhead consumed 45% of his revenues. By opting out, Dr. Harris estimates that overhead dropped by about 75%.

He currently has two office employees: a receptionist who works Tuesday through Friday and a nurse who works 4 days per week, with Wednesdays off. He does little advertising. Sometimes he places a small, informative medical article in the local Sunday paper when business seems slow. The majority of his practice is dedicated to prostate cancer.

"Most of my patients come to me [after] having heard of me from someone else," Dr. Harris said. "Someone gets diagnosed with prostate cancer. They start talking to their buddies, and, somehow, they end up at my web site where they can see my prostatectomy outcomes."

Practice parameters

Dr. Harris serves a specific segment of the region's patient population.

"Most of my patients undergo radical nerve-sparing perineal prostatectomy. This is kind of a niche. There are only a handful of us in the world who still take this approach seriously. This creates incredible opportunities for me," he explained.

His outcomes rival those of any other approach and can be viewed on the web site of his practice, Northern Institute of Urology, PC. Dr. Harris has built a database of more than 700 patients and has published studies of the procedure in peer-reviewed journals.

He keeps the costs of his services competitive, although he is not competing so much with other physicians in his region as he is with insurance organizations and their reimbursement rates.

When Urology Times first spoke with Dr. Harris 4 years ago, his charges for three common CPT codes were $57 for code 99213, $132 for code 99203, and $137 for code 99243. He has since raised these charges to $65, $140, and $150, respectively.

"These charges increased to stay reasonably adequate for the respective services, given that I only see two patients per hour and remain at or below what the local insurance companies pay their contracted physicians," he said.

Other charges he noted were $1,200 for extracorporeal shockwave lithotripsy, $624 for prostate ultrasound and biopsy, $1,500 for TURP, and $2,800 for radical perineal prostatectomy.

A quiet movement

Dr. Harris is one of two urologists who are members of the 63-year-old American Association of Physicians and Surgeons (AAPS), a 4,000-member organization based in Tucson, AZ. (The other urologist, a practitioner in Houston, declined Urology Times' request to be interviewed for this article.) The AAPS strongly advocates opting out and establishing independent practices. Membership fluctuates, but appears to be growing.

"It [membership] has doubled twice since 1988, but it was, at one point, quite a lot larger than it is now," said Jane M. Orient, MD, a Tucson internist who is executive director of the organization. "Doctors seem to have given up the fight when Medicare passed."

Membership in AAPS is diverse.

"We have more members in surgical specialties and subspecialties than in internal medicine. We also have a lot of psychiatrists, a lot of dermatologists, and a lot of surgeons," Dr. Orient told Urology Times.

When asked what the most common question asked by doctors is when they first contact AAPS, Dr. Orient laughed.

"They want to know how the hell are we different from the AMA because they are pretty upset with the AMA," she replied. "It often seems to be working at cross purposes to the interests of private physicians."

Dr. Orient said AAPS provides its members with a newsletter, periodic political action alerts, a quarterly peer-reviewed journal, advice, instructions on opting out, and limited legal consultation.

"It [legal service] is not so much for malpractice as it is for issues of health law," she explained. "I think we are the only physician organization that does much to help individuals who are having difficulty with abusive Medicare audits and abusive prosecutions. Often, we just answer questions as to how to deal with threats from insurance companies and Medicare."

The organization has a distinct political bent, as is evident from the wealth of literature posted on its web site.

Properly labeling the group's political leanings is not easy.

"Some say conservative. Some people call us Libertarian," Dr. Orient said. "There is a certain tension between the two. Some people call us classic liberals."