Guest Column: Bruce Milliman, ND, on ND Incomes, Care Models and an Invite to Play Stump the Chump
Written by John Weeks
Guest Column: Bruce Milliman, ND, on ND Incomes, Care Models and an Invitation to Play "Stump the Chump"
Summary: The son of the founder of employee benefits consultant and actuarial firm Milliman and Robertson (now Milliman, Inc.), Bruce Milliman, ND, has broad experience informing this commentary for the Integrator regarding naturopathic physician incomes. He's an advisor to the AMA's CPT coding committee, helped found what may be the nation's largest integrated primary care practice and talked a Blue Shield plan into allowing their members to choose naturopathic physicians as their primary care providers ...
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Most people in the healthcare industry will know the name "Milliman" as part of Milliman & Robertson a well-known, international actuarial and employee benefits consulting firm. Those who are involved with the AMA's CPTcoding committee will also know the name Milliman as that of Bruce Milliman, ND, the token naturopathic physician who advises that influential committee. Turns out the latter, a microbiologist before entering John Bastyr College of Naturopathic Medicine with its first entering class in 1978, is the son of the founder of the former. Some genetic material appears to have passed between generations.
Bruce Milliman, ND -yes, from that Milliman
Milliman is known by many in the naturopathic medical profession as an esteemed clinical mentor, and as a national leader on insurance issues. Clinicians in Washington State will know him as an important source of their paychecks: He's the fellow who talked Regence Blue Shield into allowing their members to choose naturopathic physicians as primary care providers back in 1995. To the broader integrative medicine community, Milliman may be known through features in numerous publications as the partner, with Fernando Vega, MD, in developing Seattle Healing Arts (SHA). SHA is perhaps the nation's largest, primary care-focused integrative medicine operation.
Milliman last appeared in the Integratoras a naturopathic physician interviewed as part of a forum on the role of 3rd party payment in shaping his profession. Here Milliman follows the Integrator report on an income survey by the Association of Accredited Naturopathic Medical Colleges, and two subsequent articles of responses accessible hereand here. Nice to have him back. I added the bold and the subheads.
"I am overcoming my resistance to
joining the conversation, not because I don't agree with its importance, but
that doing so fuels my inner tendency to procrastinate from dealing with what
is already on my plate... All right, all right, so...
On Natural Pharmacy Income
"I believe some
assumptions may be being made that have not been subjected to primary source
verification. For example, are products usually sold by our
colleagues for twice their purchase price? (Personally,
I follow the advice of Alan Gaby (MD) and use a lesser mark-up, and have a
ceiling price, beyond which a flat 'pharmacy handling charge' is added
on. (I believe that part of our service responsibility is to make our
care affordable, not only to have a profit center, separate from patient care.)
On Hours and Days in a Typical Practice Per Week
"Is it true that no naturopathic
physicians see patients, 40 hours per week? (I know I don't. I
do 30 hours of patient contact, some weeks more, some less) but, I have always
told students and new grads that the best way to build a practice is to 'be there or be square.' In other words, show up and stay
there, treat patients for free or at low cost, but at first, see as many people as you can for
as many hours as you can, regardless of their ability to pay. In our
practice (61 practitioners, 17 on our floor, mostly primary care MD or ND),
most doctors come early and stay late. The average workday for
seasoned practitioners at Seattle Healing Arts is 10 or more hours, (and yes, I
would say we are having fun!)...only 6-8 of those hours are patient contact
hours.
"I am always disturbed by denigrating
feelings expressed regarding third party payment, not because they (the
feelings) aren't warranted, but because they are rarely accompanied by a stated
awareness of the importance of making services, naturopathic or otherwise,
available to those who cannot afford to both pay
for health insurance and pay for our great medicine.
On this note, I also agree that ours is not a field wisely entered into by
those whose 'prime driver' is financial gain; in fact, to students, I
liken entering our field to entering the clergy, that is, it should
be a 'calling' that one can't
not respond to, and a service that is part of one's path.
When done well, as (Christy Lee Engel, ND, LAc) implies, 'enoughness' happens. On the Gender in ND Practice
"Regarding the gender divide, 'many
are called, but few are chosen' comes to mind. While I am well aware that
there are substantially more women currently enrolled in medical
(including naturopathic) education, what are the facts regarding 'who's still
standing' (5 years out, 10 years or 25 years...)? I don't know, I
haven't seen the data. On Time Spent with Patients
"Regarding 'time', I haven't met a
doctor in general practice who doesn't agonize about this issue. In our
(Seattle Healing Arts) practice, the average time allotted, across
all physician-level providers (MD/ND), for a return visit is 30 minutes
(range 20-40); and for the intake of a new patient, it is 60 minutes
(only acupuncture schedules 10 or 20 minute visits, which, as they say about
the fish in mountain stream: 'they're little, but there are lot's of
'em'). Wellness exams and annual exams are universally 40
minutes. My experience with coding would suggest that this 'practice
model' is adequately reimbursable by following a few simple guidelines in care
and documentation. An Invitation to Play Stump the Chump
"I believe that the balance
between professionalism, efficiency and easy patient rapport ripens with
age...perhaps this is why our work is called 'practice', even to the present
day. A visit, the majority of which was devoted to counseling, is
reimbursable at the highest level, according to CPT, if it is documented
in the patient's medical record. (On this last point, I refer skeptics to
page 8, paragraph 3 of CPT, 2007). I know, in fact, of very few things
that naturopathic physicians do, that are not codeable (go on, take me up on
the challenge, and let's play 'stump the chump'). The problem, also shared
with our MD counterparts, is that the reimbursement is often not adequate
(witness CMS fee schedules).
"Probably the best solution in the
current economic environment is to have a mix of demographics in our
practices, where the legislative underpinning exists (that would be for
'health insurance') to provide patient access to naturopathic services and
care. Meanwhile, the politicos in our ranks will continue to try to
change the system...and I mean, really change
the system.
"All the best!"
Bruce Milliman, ND
Seattle, Washington
Comment: A little anecdote on myself and Milliman. Back in October of 1996, before Oxford Health Plans started its revolutionary "alternative medicine" benefit (their PR people said to use "alternative") and in the first year of Washington State's "every category of provider" law, I was given a chance to co-chair one of the first integrating CAM into ... conferences in Washington, DC. Milliman was a speaker.
Washington, DC was then about a zillion miles from any naturopathic medical school and exponentially further from the concept of a legitimate, licensed naturopathic physician. I was overcome, as planner of the event and moderator, by an internal, controlling Mrs. Dalloway self. I wanted the party to go well and didn't want to rock things too much. The whole integration conversation was new enough. Did it, particularly on the East coast, really have the stomach to swallow the idea of a primary care naturopathic physician. What??
I grabbed Milliman, as he strode to the podium, and asked him to censor himself. Stay away from that primary care business. He didn't. He likes to remind me of this act, typically when we're somewhat inebriated, and when I, too, am likely to be as busy reminding other friends and colleagues of things they would rather forget.
My bad, as my 11 year old daughter has taught me to say. Milliman's work pushing that theme, and success in convincing Regence to treat the NDs as such, has created the single most interesting body of under-analyzed data in the country. We have 10 years of a significant population treated by a set of whole person-oriented, integrative (NDs in Washington have some conventional pharmacy rights) primary health care practitioners.
What a gold mine, should we ever have the sense to invest more deeply in understanding it. To date, William Lafferty, MD, has shown, via an NIH NCCAM grant, that there is limited financial risk from offering NDs and other complementary healthcare services. We should be looking more deeply - thoroughly mining this site and compare costs, and populations, with the outcomes in the typical primary care practice. Are there savings from this version of integrative primary care? If so, from what?
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for inclusion in a future Your Comments article.
