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Nate Kaufman
This is Nate Kaufman with the Healthcare Bridge. This podcast is based on a very unscripted but brutally honest perspective from insiders of the healthcare industry, and today I am lucky enough to get Dr. Harry Albers to be our guest. Dr. Albers is a preeminent internal medicine physician in San Diego, and he is my doctor. [Laughter] So, what we’re going to... (Dr. Albers: Enough said!] enough said, exactly. Harry, why don’t we start with your origin story? People talk about primary care and that’s the answer, and all that. You are a primary care doctor. Tell us about how all this got going.
Dr. Harry Albers
First of all, I’m honored to be here, Nate. Thanks for asking me. I’m not quite as honored as I was when you named your puppy after me, but close. [Laughter] I’m a pseudo San Diego native. I went to San Diego State undergrad and UCSD medical school residency, chief residency. Finishing up my chief resident year at UCSD, I pondered specializing in pulmonology, critical care, and I had reached a point where I wanted to take care of patients. I said I can’t be in training any longer, I’ve got to get out there and start doing something productive. Ended up on junior faculty at UCSD for a couple years before moving over to Scripps Clinic almost 30 years ago, and was at Scripps until three years ago when I made a jump to private practice. But the theme throughout, the thread throughout, is how I know I made the right decision—primary care is the most rewarding career I could have had.
Nate Kaufman
So, let’s talk about that for a second. Research has come out recently about primary care physicians, and a lot of them are burning out and leaving practice. The other thing I notice, as a business guy, is it’s a high overhead business with low reimbursement. It’s very difficult to be sustainable. Any thoughts on why people are burning out or how to make it a more sustainable practice?
Dr. Harry Albers
I definitely have a couple thoughts. One is, I won’t say an existential issue, but the nature of primary care is you’re not getting instant gratification, so it takes a unique personality to do primary care. You’re not fixing a broken bone and sending the patient on their way, you’re not putting a stent in that artery and sending them on their way—you’re managing chronic disease. So it really takes a unique personality to start with, in terms of knowing that you’re not going to have those big wins. You’re going to have great relationships with the people you’re responsible for, but that wears on people, I think, over time, dealing with chronic disease. I don’t know that that is something we can remedy, that’s the person themselves, I think. My observation is the advent of EMR (Electronic Medical Record) has exponentially worsened more than the burnout in primary care, and it’s so physician-centric. A PCP’s happy place is one on one in the room with the person they’re taking care of. But outside of that happy place, there’s so much added on in terms of documenting the visit, ordering medications, ordering tests, fighting with insurance companies for studies that get denied, and that’s all essentially—I think of it as—uncompensated work. We’re doing it off the clock and I think that’s where the enthusiastic young physician hits a wall five or ten years out.
Nate Kaufman
I guess now, I think it’s something like 70% of primary care doctors are employed by health systems as I said, because Medicare’s conversion factor is so poor. And you have a high Medicare population and your overhead is high, it’s hard to be financially sustainable in independent practice. When you go into these health systems, they put you on the RVU (Relative Value Unit) treadmill. What’s that like?
Dr. Harry Albers
Well, I’m speaking from distant memory, because thank goodness I haven’t had to deal with that for a long time, but I do know, and many of my colleagues do, and the other Dr. Albers sleeps under the same roof as I have, she’s been doing it for 30 years, so it’s rough. It’s a system set up... especially for primary care, since primary care doesn’t get to do much high RVU work—we don’t do many procedures —how do you increase your compensation? You increase it by volume, you increase it by seeing more visits which diminishes the relationship with the people you’re taking care of. It diminishes your confidence. Now I’m getting personal; for me it diminished my confidence in what I was doing in the care I was providing, because I felt like I was going home at the end of a day, not having had time to pee, never mind think about problems that I’m talking through with people. So it’s rough. You have to make a decision whether you want to churn and burn and increase your compensation versus having relationships.
Nate Kaufman
And if you have your relationships, your compensation goes down.
Dr. Harry Albers
Exactly, your compensation goes down, maybe your workload decreases a little in terms of the charts you’re doing at night, but yeah, you have to strike that balance or you are burned out.
Nate Kaufman
I mean, it seems to have taken it from a profession to an employment. Like you’re just working for the man type of thing, and so that makes it difficult. You worked at Scripps and when you were there, I know some doctors were capitated. Did you ever get involved in those value-based programs?
Dr. Harry Albers
Yeah, definitely. I was always of the mindset that relationships were what drove me, that was the only reason I continued to do what I’ve done for 30 years, so I didn’t pay that much attention to numbers. But I do think to your point, Nate, about how you approach an RVU-based system. My observation is a lot of the younger doctors that are coming out have a different mentality about this. The comment you just made, I think there’s a lot more of prioritizing quality of life over compensation—I want this to be a job. Not that they don’t care about the people they’re taking care of, but they want it to be a job where they don’t have to take it home every day.
Nate Kaufman
So like, if I went to visit you, and my lifestyle... let’s assume at the time wasn’t very good—I was smoking too much and I was pre-diabetic. By the way, I guess everybody’s pre-cancerous and pre-diabetic, from what I understand. But say I was pre-diabetic and you needed to really work with me to stop eating those Cheetos and drink all of that nasty sugar beverage stuff. How many RVUs do you get for something like that?
Dr. Harry Albers
Oh, shoot, I don’t have a number. I mean, it’s not much, right? Which is why the motivation is for PCPs to just refer everything out. You send them to the nutritionist or the endocrinologist, because no, you’re not compensated for it, for that time.
Nate Kaufman
So then you went from being a—let’s call it rank and file internal medicine physician to forming the private internal medicine group within Scripps Clinic. Can you tell us about that?
Dr. Harry Albers
Sure. I had been with the clinic for 11 years and, actually, I didn’t pioneer the concierge group, I was one of the early members. But the motivation with Scripps creating this little concierge division—which they actually modeled after the Virginia Mason concierge group, which was modeled interestingly after MD2, which started in Seattle—my motivation was what I said, I couldn’t do the 25-30 visits a day. I think now that I wouldn’t have been doing that anyway even if I was doing general internal medicine. So it’s gotten a bit more humane. But I couldn’t do it anymore and feel like I was really taking care of the people that I’m responsible for. So it was a make or break—my first make or break moment—and I knew that with decreasing my patient panel from 2800 people to about 300 patients I was going to be able to enjoy those relationships again and feel like I wasn’t just pushing care onto all the specialists. I was actually within my the limits of my ego, I was able to really practice medicine again.
Nate Kaufman
If every doctor did that—let’s make believe, okay—we already have a 29,000 shortage of primary care physicians, and if physicians basically limited their practice—either through direct primary care or through concierge or some other method—that shortage would increase, wouldn’t it? I guess from one perspective it’s a great solution for you and a great solution for me, but not necessarily a great solution for society, would you say?
Dr. Harry Albers
Absolutely. My perfect medical world would be that all patients get to have, within their means, some level of concierge care. That you have some way in—in terms of access, in terms of somebody who’s looking out for you, somebody’s your advocate. But absolutely, I mean, it’s not sustainable for caring for the population.
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Nate Kaufman
Any thoughts from your perspective? I mean, you’re not necessarily in my position of having to be a strategist, but how do we care for the rest of the people out there?
Dr. Harry Albers
I think probably my most obvious response today is we need to train more physicians in general. Medical schools need to train more physicians. We need to encourage people to go into medicine, that you’re not going to be turned away at every medical school you apply to. I think within medical schools we need to encourage more PCPs to be produced, whether that’s through government subsidy to get people to commit to being primary care providers, or whether it’s through some kind of a mandatory payback, like military people do. Then I also think significant thought needs to be put into cross-training people who are interested in going into primary care, to give us more ability to do things like procedures, for example, where it’s going to benefit our patients, it’s going to benefit us at our bottom line—our paycheck—it is going to benefit the access issues with specialists. I mean, too many PCPs just really don’t do anything procedurally.
Nate Kaufman
You mentioned specialists, and in order to have a successful primary care RVU-based practice today, you need to be a traffic cop—if a patient’s going to require a procedure or take a lot of time and so on, then you would refer them to specialists. Specialists are in short supply and in exceptionally high demand. Over your 30 years are you finding that it’s harder and harder to get a new patient in to see a specialist?
Dr. Harry Albers
Without a doubt. Not to be cynical, but obviously surgeries and high RVU interventions are what a lot of that community is interested in and where their focus is. So PCPs are left with essentially everything else. I mean, that’s where my thinking about cross-training is. It would be gratifying for the PCP to be able to do more for their patient rather than just being a traffic cop.
Nate Kaufman
I’m having a personal experience right now—I have a couple. Let’s say I’m in a little bit of pain and I go to you and we’ve tried to work through it, but probably it’s time to see a specialist and you refer me. One of the things I rely on you for is the fact that there are better specialists and less better specialists. Healthcare is not a commodity, and you want to go to the better specialists and the better hospitals. When you refer me to one of these places, I immediately get a call and they say you’ve gotten a referral from Dr. Albers, how does your July or August look?
Dr. Harry Albers
Unfortunately, I think that one of the ways I’ve evolved over the years is, in many instances, relying more on personal outreach and relationships, and it really takes that now. Unfortunately, most PCPs don’t have the time to do that for the people they’re taking care of. But the personal outreach to specialists you trust, either a text or an email, makes a big difference. And then using specialists in the community too, I think there’s value in establishing good relationships with people in the community who are more interested in getting people into their practices.
Nate Kaufman
Let’s talk about MD2. You were with Scripps and you were a concierge physician there, and then I got a letter saying you were moving to MD2, and that was kind of interesting. What is MD2 and why did you do this?
Dr. Harry Albers
Thanks for asking. As I said, 11 years in, I decided I had hit a wall and needed to do something different to reestablish my love for patient care, and then another 14 years after that, I was at the second breaking point in my life, where I decided I was either not doing this anymore—even though I love it—or I needed to give myself a chance to really practice pure medicine—practice medicine in the ideal where you just do that, you just have your happy place with the people you’re taking care of, and you don’t have to deal with the overhead, the HR, the back office, etc. etc. etc. And that’s what MD2 is. The backstory is Howard Marin, an internist in Seattle, opened the first MD2 office in 1996. He was a team doc for the Seattle Supersonics NBA team before they moved to Oklahoma City, and he wanted to create a practice where he got to provide this the same high touch care for his cohort of patients as he was doing for these young athletes who couldn’t care less. And 30 years later, MD2 is almost 40 offices around the country. Every office is just two physicians—two PCPs—and 100 families total, 50 families per MD. So it ends up being 200-210 patients total that myself and my partner, Ramona Master, are taking care of, compared to the 350-400 I had with the concierge group at Scripps, compared to the 2500-3000 or more that a general internist has. So MD2 squared really is the top of the pyramid, in my opinion, in the concierge world.
Nate Kaufman
Some of the things that I’ve noticed in the practice... I have to pay a monthly membership—I’ve never seen a bill. You don’t participate in Medicare, and I just go in, ring the doorbell, there’s no waiting room. It’s an awful nice place to get your care.
Dr. Harry Albers
Thanks for saying that. I think it’s, again, relationships. It just lets the relationship between us thrive and lets the relationship with my partner thrive, and then there are these relationships with the other MD2 docs around the country. It’s an incredible group of physicians. I never would have thought the collegiality, for me, would improve by moving out of the large multi-specialty group. Now, I’m honored that I’m still affiliated with the Scripps Medical Group, and I have all my great specialists. The relationships, even there, have only gotten better. It really is a unique situation where you have 24/7 access in any way, shape, or form to the person you’re trusting with your health, but we also have this national reach when, unfortunately, we have to make diagnoses that we don’t want to make.
Nate Kaufman
Again, I like that primary internal medicine, I mean, I think we need to move more towards that kind of model, at least as a patient. I know that most people that have traditional RVU-based doctors, when they get sick, they can’t see their doctor and they’re told go to urgent care or you get to see a PA or a nurse practitioner—nothing against them. I guess that’s one of the questions I have; have you ever thought about a model, not necessarily MD2, where you can actually train a nurse practitioner to be your partner and expand your practice, so that maybe gets away from this RVU treadmill type of model?
Dr. Harry Albers
I think that is something that would really work for a lot of PCPs and a lot of patients. As I would envision it, it would be a larger practice, because with MD2 there’s no need for that. We are available and have no interest in growing the number of people we take care of. But absolutely, for example, for these concierge light practices—which can be anywhere from 300-500 to even a thousand patients that a physician is responsible for, depending on what the membership fee may be annually—I think that would [work]. APCs (Advanced Practice Clinicians) whether they be nurse practitioners or physician assistants, again, if you find the right one, they can be amazing.
Nate Kaufman
Yeah, I guess that’s probably true. So let’s talk about some advice. Let’s start with with our producer’s son, who is coming out of residency next year. He’s going to be a full-blown primary care doctor. What would be your advice to him and other established doctors that are teetering on burnout or trying to figure out what to do? What thoughts do you have there?
Dr. Harry Albers
Well, I think for the young physicians right out of training, it’s setting realistic expectations for that mythical work-life balance. It’s really, from the get go, from day one, sitting down and trying to decide what is going to make me happy in not only five years, but 15, 20, 30 years, and that includes do you have some background in business. Would you be someone who could have a private practice, or do you need to be an employee of a hospital, as we talked about earlier. But I think with the young physicians that’s already at the front of their thinking. For the physicians who are later on in their career, how do they sustain—I think it’s diversifying, it’s not getting stuck in a rut. Most primary care physicians have a bit of OCD, which is why we are doing charts for three hours at the end of our day. When you’ve already had a busy day, you don’t want to leave any stone unturned, so it’s easy to get into doing the same thing every day rut, and then you just lose interest, you’re just going through the motions. So I think it’s trying to diversify yourself within the profession and cross-train, as I was saying earlier, learn to do new things, learn to offer new things to the people you’re taking care of. Don’t let your ego get the best of you, but continue to try to improve the product you’re offering to the people you take care of.
Nate Kaufman
That’s the individual primary care doctors. Now, here’s the data. The data shows that if physicians work in a physician-owned practice, 54% of them are satisfied—that’s about the best you’re going to get—but if they work in a hospital practice, only 19% of them are satisfied. You have experienced all this stuff. What advice do you have for health systems or—excuse the expression: Optum—or others on how can you make their work life better without going bankrupt? Because, as we know, a lot of primary care practices were bought by CVS and Walgreens and others, and that was a disaster. How do you employ primary care physicians and make them feel like owners, and not just simply piece workers?
Dr. Harry Albers
In some respects the Kaiser model has it right, where you have a financial incentive to be a shareholder. I also think—and I hope I’m not delusional—that artificial intelligence is going to make a difference for PCPs. In short order, I think in just the next few years, if insurance companies are using AI to deny requests for MRIs and CTs then we’re already using AI to do our documentation. I foresee that taking over a lot of the billing responsibility, a lot of the requests for studies, prior authorizations, prescriptions, etc. I think that’s coming, whether we want it or not, and it will make PCPs’ lives better. But from the large multi-specialty or hospital perspective, I think it’s a respect issue. I really think, without sounding too ominous, a lot of primary care providers feel that they’re not respected. Specialists are respected, PCPs are not. I don’t know how you remedy that, Nate.
Nate Kaufman
Well, I think communication is pretty important in that whole process. Let’s just talk one final point because you have to go see patients. [Laughter] All of you, I can tell, and if that was me, I’d be saying, why didn’t Harry answer? But the question I have is, you’ve been a primary care doctor for 30 some odd years, you were the primary care doctor for the San Diego Padres, you’ve seen tons of patients, you do science experiments on people like me and all that stuff, what advice do you have for patients?
Dr. Harry Albers
I think the best advice I can give is, if you have the means, there’s value in some level of concierge practice, even if it’s only a few hundred dollars a year. If that’s within your means, as I say, the two big issues I think are access and advocacy, and anything you can do to get on your PCPs radar in that way, it makes a difference, I think. Beyond that you want to ask the right questions when you’re looking for a PCP. You want to know, are you available to me? When you’re not in the office, how is my health managed? If something comes up, do you have a partner who covers you, or is it going to be one of 30 physicians who don’t know me from Adam? Can I reach you or your partner after hours? How do you take care of me when I’m out of town? I mean, these are these are questions that people don’t think to ask. And lastly, what’s your relationship with the specialists that you work with? Can I trust that you’re going to advocate for me there as well?
Nate Kaufman
But some people say that the answer is, well, primary care, I mean, the answer is, we’ve got to make people healthier, so primary care physicians. We have a sick care system, not a healthcare system—which, by the way, thank you for having a sick care system. At age 72 I don’t need a well-care system right now, necessarily, or a healthcare system. How do we put this burden on the primary care physicians or health systems... like we’re supposed to change people’s lifestyles, especially when we don’t get paid for it?
Dr. Harry Albers
Yeah, you’re so right. I mean, it’s a matter of there’s only so many hours in the day, and for primary care providers, its chronic disease management. You’re putting out fires. You don’t have the time to really spend on preventative medicine, on proactive care, on educating the people you’re taking care of to how best to optimize where they’re going to be in 30, 35, 40 years. More than anything that’s the piece that needs to be fixed, is the allocation of time that PCPs are currently burdened with.
Nate Kaufman
Yeah, and we’ll just end with this point, which is—I hear this all the time—that these primary care doctors that have a regular practice, they say, oh, I provide my patients with concierge service, and if they pay me a little bit more, they’ll get more access, or something like that. My experience is this is something like you’re either pregnant or you’re not, right? You’re either a concierge practice or you are not. I mean, that’s how I view it.
Dr. Harry Albers
Totally agree. I don’t like the “hybrid” model, I mean, you’re either available and responsible and engaged with people, succeeding with their health, or you’re trying your best in a system that’s not conducive to doing what you really would like to do.
Nate Kaufman
Well, as a patient who started with RVUs, went to primary care within a system, and now have MD2, I’m pretty satisfied with where I ended up. I think that if people haven’t ever experienced or learned about MD2 they probably should take a look at it as an option. It’s been a great option for us, and I appreciate all you’ve done. As Harry mentioned, we honored Harry by naming our Italian greyhound after him.
Dr. Harry Albers
And that’s what’s really important when you visit, is getting updates on Harry.
Nate Kaufman
Exactly, that’s the most.. and oh, by the way, I have this pain. [Laughter] Anyhow, this is Nate Kaufman with the Healthcare Bridge, thanking Dr. Harry Albers for giving us his time. It’s been a great talk, thanks a lot, Harry.
Dr. Harry Albers
Thanks, Nate.
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