Determined Doc Retrofits Family Medicine
COLORADO SPRINGS, Colo. -- On a windy hill facing the Rocky Mountains, less than 10 minutes from the U.S. Air Force Academy, Mark Tomasulo, DO, stands on a mound of red dirt surrounded by steel beams and exposed electrical wiring.
Over the din of construction, the 43-year old urgent care physician describes his vision for American healthcare.
"I've already made my fortune," Tomasulo, who drives a Mercedes M-Class SUV, tells MedPage Today. "Now, I'm going to do what I went into medicine initially to do: to be a doctor, to provide care the way I want to provide care, and not have to answer to a third party on why I'm doing what I'm doing."
When the dust settles, the clinic, PeakMed, will house two conversation-oriented consultation rooms fitted with large, landscape-framing windows, and an in-house lab and pharmacy stocked with wholesale prescriptions.
"The point for me is to save you as much money as I possibly can. And provide a service to you that makes you want to come see me," he says.
Tomasulo is gearing up to treat patients in this all-in-one direct pay clinic of his own design, devoid of all third-party oversight. That also means he won't even bill insurance companies or Medicare.
With no family practice client base to bring with him, the success of Tomasulo's clinic -- which will require a few hundred families to sign up -- is far from assured.
"There are a lot of little bumps in the road that I see," Matt Dallmann, President of Creative Practice Solutions, a practice management group in New York City, told MedPage Today. "If you're going to pitch this to a community, they're going to want it to be easy."
Early Career
Tomasulo wasn't an obvious pick for a career in medicine. He nearly flunked out of high school with a 1.125 GPA. But after yet another round of summer classes, he earned his diploma, and followed his father's footsteps into the Navy.
In the service, Tomasulo developed a knack for fixing airplanes and a taste for riding bulls.
"We didn't have safety gear when I rode bulls; we didn't do helmets; we didn't do the vests, and all that stuff," Tomasulo says. And after enough injuries, he didn't do lifting heavy objects either. "I couldn't work anymore, my back was pretty messed up," he says.
Results from a workers' comp aptitude test led his case officer to steer Tomasulo away from higher education. "Well, you're really not all that smart, and I think a trade school would be much better for you," Tomasulo recounts the case officer's 'guidance.'
But Tomasulo would not be dissuaded. He took advantage of his GI Bill, moved back into his childhood home in Fort Lauderdale, Fla., and aggressively pursued an education at a community college.
"I realized that I loved school and I was really good at it, which was baffling to me because I hated school with a passion when I was younger," Tomasulo says.
After finishing his Associates degree, Tomasulo took a partial scholarship and attended Nova Southeastern University. At this small, intimate, nearby program he buckled down even harder to earn near perfect grades.
In light of his 3.95 GPA, it made no sense when Tomasulo tanked the MCAT. But after an evaluation revealed a reading comprehension disorder, Tomasulo finally understood his earlier struggles in academia. "It was a real breakthrough point," he says.
So, loyal to Nova for shepherding him through his undergrad, properly diagnosing his reading disorder, and helping him achieve his goal of passing the MCAT, Tomasulo took a big risk -- he applied only to Nova's medical school.
His gamble worked. Tomasulo graduated with his DO in 2004.
Return to Service
After finishing his residency in family practice, Tomasulo traded his medical school debt for an Army scholarship, which landed him in flight surgeon school.
In 2007, as chief flight surgeon for The Big Red One, based in Fort Riley, Kansas, Tomasulo deployed to Iraq for 15 months.
"It was a very traumatic time in my life. It's war," Tomasulo says before a long pause.
"That's the way it is. It's one of those things you hope no one ever has to go through. But if they do, you hope that you're the right person when stuff does happen, and that you can help them," Tomasulo says.
Post-deployment, Tomasulo was reassigned to Fort Carson, an Army base roughly 15 miles outside of Colorado Springs. There, as Chief of Aviation Medicine, Tomasulo also worked in family medicine at the Evans Army Community Hospital.
"All of his patients always loved him," says Joshua Will, DO, a family physician at Martin Army Community Hospital in Fort Benning, Ga., who went through residency with Tomasulo.
"He was an exceptionally hard worker and he always had your back," Will told MedPage Today.
Tomasulo's patients and colleagues may have been very happy, but he wasn't.
"I hated family practice, because of the way it was being done," Tomasulo said. "So I left family practice and went into emergency medicine."
Tomasulo wasn't really happy practicing urgent care medicine either, but at least he could earn a good living. "The money is twice what you make in family practice," he says.
But Tomasulo always held onto the dream of practicing family medicine -- just on his own terms.
PeakMed
With plans to open PeakMed on Aug. 1, 2014, Tomasulo has already hired a medical assistant and a family nurse practitioner. He is still seeking one other physician.
Tomasulo is enthusiastic about his EMR system, Atlas MD, which he will use to crunch health data and synch fit-bit information from his patients to track, store, and integrate with his records.
Monthly subscription fees for patients will range from $25 per month for children up to 18 to $85 for adults 65 and older. Subscriptions will include unlimited office visits, 24-hour physician access, and nearly at-cost prescriptions and onsite lab work.
Tomasulo says he intends to encourage all of his patients to maintain a catastrophic policy for hospital coverage. "Our goal is to provide primary care, not all-encompassing care. It's imperative that someone has insurance. You would never want to go without insurance," he says.
Colorado Springs is 26% nonwhite, has a 9.5% unemployment rate, and 10.4% of families live below the federal poverty line, so the additional costs and hassles won't be right for everyone in the community.
For a typical family of four, then, a subscription would cost $168 per month, or $2,016 per year.
Randy Bauman, President of Delta Health Care, a practice management consulting firm out of Franklin, Tenn., is the kind of person who fits Tomasulo's patient profile.
Bauman has health insurance, but not everyone takes it. He recounted a recent trip to an urgent care clinic where they wouldn't take his BCBS plan. Bauman told MedPage Today he had to pay $279 for an appointment with a PA for an acute sinus infection. That amount would cover almost 4 months for Bauman at PeakMed.
In Colorado Springs, 32.9% of households have an annual income of $75,000 or more. If these folks are frustrated with access to care, PeakMed might be the right fit for them.
According to Dallmann, the success of the clinic will come down to how many people Tomasulo can get in the door who are willing to pay for the subscription; as well as carry a catastrophic plan, and any additional costs associated with seeing a specialist, and having to see another healthcare professional for vaccinations.
"If there are a lot of extra road bumps like that [additional costs and outside care], I don't know how easy it would be to get people on board," Dallmann said.
And, if they fall and break a bone, they're going to have to go and see a specialist, which will require insurance, Dallmann said.
"Insurance ... Is Your Problem"
With direct pay, there won't be any third-party oversight: no insurance, no reimbursements, no billing, no coding, no collections, no government regulation, and no ICD-10 updates.
"Insurance, in my opinion, is your problem. It's not my problem," Tomasulo said. "Unfortunately physicians live in a fee-for-service world right now. And the only way physicians get paid is by insurance companies."
Tomasulo sees insurance as the greatest expense in healthcare. "When you cut the administrative process out of medicine, it's incredible how cheap healthcare is," he said.
"The point of me going into this practice model is because as a physician, I feel like it's our obligation to control our profession. I went in to family practice for a very specific reason when I was younger -- to be a small-town provider, to have that relationship with the patient that is truly connected, intimate," he said.
At PeakMed, finished floors will soon cover the loose dirt; painted walls will soon cover the naked beams. And this doctor will find out whether or not he can build an American primary care clinic from the ground up -- and finally enjoy practicing medicine.