How this primary care doctor found his dream practice [PODCAST]

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“My quality of life is outstanding. I leave work every evening only after every call is answered, fax addressed, a prescription delivered, then retreat to my home a mile away. The proximity makes it easy to see patients after hours, on weekends, and on holidays; I promise to see patients within 24 hours, but I go in less than once a week. Because all patients have my office, cell phone numbers, and business email, patient questions are often answered quickly without a visit.”

John Machata is a family physician.

He shares his story and discusses his KevinMD article, “How this primary care doctor found his dream practice.”

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today on the show, we have John Machata. He’s a family physician, and we’re going to talk about his KevinMD article titled “How this primary care doctor found his dream practice.” John, welcome to the show.

John Machata: Happy to be here, Kevin.

Kevin Pho: So we’re going to get into the article in a little bit. First off, briefly share your story and journey to where you are today.

John Machata: I’m a family doc. I’ve been a family doc for 38 years. I studied at Michigan State, traveled to Boston, where I opened an independent primary care practice, and subsequently moved to Rhode Island, where I served at federally qualified health centers for nearly 15 years. Eleven years ago, I opted to go independent again, and I’ve been a solo, independent micro practice family doc for the past 11 years now. Solo family micro practice: I’m really solo. No nurse, no secretary, no biller. I’m all you’ve got if I’m your doctor.

Kevin Pho: So tell me about your years. You said 30-something years as a primary care doctor, and as you’re aware, fewer medical students are opting for primary care. So before we talk about your micro practice, just tell me about what kept you going in primary care.

John Machata: Well, family practice gives you a wonderful opportunity to really connect with people, and often families, in a really personal way. I know it sounds a little airy-fairy, but I went into medicine because I really did want to help people, and I think I did that. But the rewards I got were that people rewarded me with relationships that gave my life meaning.

Kevin Pho: So you hear about things. Whenever I talk to medical students, beyond a pay disparity between primary care and specialists, and these medical students graduate with hundreds of thousands of dollars in debt, there are a lot of obstacles that prevent that relationship between doctors and patients, whether it’s the electronic medical records, or whether it’s all the regulations and bureaucracy that really obstruct that relationship. So I guess my question is, how can we maintain those relationships that are really at the core of primary care, despite everything that works against that?

John Machata: Well, in fact, and this is without being a sycophant, there’s a wonderful article on KevinMD over the past couple of days, written by a vascular surgeon, if I remember, that reminds us that medicine, or the practice of medicine, has become easy, but health care has become harder. I label it the corporatization of medicine. As you probably know, the administrative role in medicine has grown exponentially over the past four decades, and the result of that is that doctors are required to work harder and harder, spending less and less time with patients and diverting revenue to overhead. The result has been a corporatization, which results in doctors spinning the hamster wheel as fast as they can, but they’re needing to get patients in and out of the office rapidly. That has resulted in a terrible erosion of the therapeutic alliance between doctors and patients.

Kevin Pho: All right, so let’s talk about your unique setup. It’s a micro practice, and you talk more about that in your KevinMD article titled “How this primary care doctor found his dream practice.” Before talking about the practice itself, just give a lead-up, give a summary of the events leading up to the formation of the micro practice.

John Machata: Without being too melodramatic, when I left the federally qualified health centers, and I served at two different health centers, I entered a “premier,” and I say that in quotes, of course, because I’m going to say it sarcastically, family practice in Rhode Island. After really a month, perhaps probably less, I realized that ostensibly the practice was there to serve patients, but in fact it was a mill. I was expected to see patients every 10 minutes, and it was just a horrible experience.

So I contacted my doctor with whom I now share a medical suite. She has a couple of rooms, I have a couple of rooms, and we co-own the condo. When I informed her that I wanted to transition to be her partner, effectively, we share expenses in the condo, she was delighted, because we share call and the like. And of course, being the thoughtful guy that I am, I went to the owners of the practice that I wasn’t happy with, and I said, “You know, it’s really not working out for me. It can’t be that great for you all. I’d like to give a month’s notice so I can transition to this new practice.” They, of course, said, “You’re out of here at the end of the week.” And I said, “Whoa.” Of course, I also said, “We’re not talking anymore. May I have your lawyer’s card?” I then contacted a lawyer and got out of there in a week.

Happily, the woman with whom I share the office condo is one of the sweetest, brightest doctors you’ll ever meet, and she made a one-week transition possible. I literally didn’t have any furniture. I’m not putting in a plug for Jeff Bezos, but thank heaven for Amazon. I was working during the day and staying up till midnight every night putting together furniture delivered by Amazon, buying a computer, buying a scanner, buying everything I needed to set up my practice. And a week later, indeed, I saw my first patients.

Kevin Pho: So contrast your day in the micro practice with the previous job you had in the previous practice.

John Machata: As I stated, we had 20 minutes for a new patient and 10 minutes for a routine visit. In my practice, I allot 55 minutes for a new visit or an annual check-in and 25 minutes for a routine visit. I also buffer every appointment, so after every appointment, there’s five minutes during which time I can address faxes, answer phone calls, and call pharmacies to address prescriptions. Bottom line is, 99 percent of the time, I have plenty of time to address my patients’ needs, be cordial, and set up a follow-up if appropriate. In sum, I’m not time-pressured, patients don’t feel time-pressured, and I’m able to do my work without feeling like I’m a hamster on a hamster wheel.

Kevin Pho: Now tell me about the business structure of this practice. Like, how do you get paid?

John Machata: It’s a fee-for-service practice. Because I was at a federally qualified health center, many of my patients followed me. Of course, you can’t solicit patients, but they found out where I was and followed me. And I say this proudly: I still serve, almost 25 percent of my patients are Medicaid patients, which is to say reimbursement is a lot less. I’m proud I serve people who aren’t particularly well off financially, as well as people who can afford commercial insurance. So it’s a fee-for-service model. I am insurance-dependent, and while I like to think I offer concierge care, there is no fee associated with seeing me.

It’s worth saying that I’m extraordinarily well compensated, because, as I said, I’m a micro practice. I do not have to pay a nurse and a nurse’s benefits. I do not have to pay a secretary and a secretary’s benefits. I estimate that alone, I save $150,000 a year. To translate that, from my gross income, I don’t have to subtract $150,000 before I get paid. The result is, while my gross income is very similar to other family doctors in Rhode Island, my net ends up being more.

Now, I’m not going to lie to you, Kevin, and of course, beware of anybody who says, “I’m not going to lie to you,” because it suggests they’ve been lying to you up until that point. But I spend an hour remoting into my office computer every day to make sure all of my patients’ needs are met. Now, I only book 35 hours a week, but in reality, I’m working closer to 45 or 50 hours a week. So I probably work more than the average doc who clocks in, puts in their 40 hours, and forgets about it. I do not have that option, because I am on call 24/7, 365.

Kevin Pho: Tell me how much of your time is spent on nonclinical tasks, like billing and fixing computer problems and installing programs. What percentage of time is dealt with on stuff like that?

John Machata: Happily, technical issues are infrequent. From every technical perspective, my applications and software are quite stable, so that’s very infrequent, far less than an hour a week. I would say an hour or two a month, perhaps. But I do spend a substantial amount of time reconciling claims every week. My best guesstimate is about five hours a week reconciling claims.

And then, of course, you mentioned it, there is the annoyance of such things as NCQA, where I have to be certified as a patient, what is it, PCMH, a patient home. But I don’t spend a lot of time on that annually, because I have a service. It’s called PRIME Registry, which data-mines my chart. This is sponsored by the American Academy of Family Medicine. It’s a wonderful service, so all of the HEDIS values that I might need to satisfy an insurer or Medicare are data-mined, and I have very easy access, and the cost of the service is very low. So while that used to be a real burden, now that I have PRIME Registry, it is not a great handicap.

Kevin Pho: Now, we have a lot of primary care physicians who listen to the show, and the concept of a micro practice may appeal to them. What kind of physicians would be suited to a practice like that?

John Machata: Such a doctor would need to be resilient, because problems do arise. There was a time when my electronic health record was unstable, and there’s nothing quite like your health record going down and resorting to paper to require that you be resilient. You need to be really independent. And honestly, I think the person who would be attracted to my practice is somebody who has probably been in what I call the corporate medical rat race for a few years and loves practicing medicine but is disgusted by the bean counters and the administrative oversight, because I don’t have to deal with any of that. I’m my own boss, 100 percent, and it’s wonderful.

Kevin Pho: Now, you did mention that you were on call 24/7, 365 days a week. So what happens with things like vacations and whatnot?

John Machata: As I alluded to earlier, I’m blessed with a wonderful colleague, who in fact is going on vacation next week. I will be attending to her patients while she’s away, and when I go on vacation, she attends to my patients. The bottom line is that with the advent of telemedicine, and COVID obviously gave us this gift, telemedicine has enabled me to deal with more than 95 percent of my patient problems remotely. When I am on vacation, and I was on vacation not too long ago, I had no need for my coverage physician. I did speak with patients every day I was away. It wasn’t a 100 percent vacation like you might get if you were a corporate doctor, but the patients’ needs were met, because I knew the patients, and I was able to attend to their problems without any great difficulty.

Kevin Pho: We’re talking to John Machata. He’s a family physician, and we’re talking about his KevinMD article titled “How this primary care doctor found his dream practice.” So, John, for those other physicians who may be interested in a micro practice like yours, and they’re in that corporate rat race, as you so put it, what are some of the next steps that they can do?

John Machata: If I were to rephrase the article, it is: Do you want to practice in a wonderful setting with a wonderful colleague? It is my goal to gift my practice to a physician, to take over the 700 patients that I am now serving, because in my area, there is a relative shortage of primary care doctors, and certainly family doctors, and I’m trying to avoid the trauma of them having to look for a new doctor. I’m hoping to find a doctor who is amenable to my style of practice. One can’t ask that one be identical in their practice style; everyone has their own practice style. But that is my goal: to find a doctor who lives not too far away from me, who would like to literally sit in the chair and look at the computer screen that I’m looking at every day and use the computer database. So they get 700 patients gifted to them, so their first visit is the easiest visit you ever saw. That’s my goal: to attract one doctor who will sit in my chair.

Kevin Pho: So short of taking over your practice, what resources can you recommend if someone wanted to start a micro practice of their own?

John Machata: There are a ton of resources, and one thing I would recommend is to literally get in touch with me. Although I’m a busy doc, I would love to serve as a mentor to somebody looking to explore this route, and I say that with all sincerity, because I believe this preserves an option for patients who do not want to be served by what I call corporate medical doctors.

Beyond that, you need to set up the various software applications to enable you to be independent, and happily, they are out there. My EHR is inexpensive. I remote into my computer for free. I have a clearinghouse that is very inexpensive. But essentially, it’s having the apps that enable you to be independent. For example, I have a scheduler. I don’t need a secretary because literally all I have is a voice answering machine, and I attend to all my calls before the day ends. That’s my secretary for calls. And if patients want to make an appointment, they simply go on my website, they hit the scheduler, and they make an appointment, which helps to explain why you don’t need a secretary. I don’t need a nurse, because I have time to do vital signs. I have time to take a medical history. I’m not dependent on a nurse to preload a medical history.

But the actual mechanics, I should write another article for you, Kevin, outlining what you need to do to set up a micro practice, because I think this short interview setup that we’re doing today doesn’t lend itself to running through them. There are probably 12 to 15 critical apps that you need to have in order to set it up, all of which are free or nearly free. But I’m going to write that article. So there’s a commitment: That’s my next KevinMD article.

Kevin Pho: I’ll be looking forward to it. And my final question: Your take-home messages to the KevinMD audience?

John Machata: You don’t have to be a corporate master. You can be your own master. As I like to say, my boss is an expletive, but I never disagree with him. You can be your own boss. It’s the best decision I’ve ever made, except marrying my wife.

Kevin Pho: John, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

John Machata: My pleasure, Kevin. Thank you.

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