I really think that Chef Ramsey relishes in confrontations. He thrives on the adrenalin of screaming so close to someone that you, and they, can taste each other’s spit. I, on the other hand, hate confrontations . . . yet, it is part of doing business. I loose sleep over it, even when I know that I’m 100% right. Yesterday was a tough day, mostly from a physical standpoint. I’ve had a really bad summer cold and sore throat. It was my day to bike to work (I try to every other day). I got up in the damp, cool . . . 47 degrees . . . fog and bike the 8 hilly miles to work. I think from the sore throat and cough keeping me up most the night then the long bike ride I developed, ironically, one of my rare bad migraines. But I had a full patient schedule to work through despite the headache. It was actually funny that, while it is a habit of mine to keep the lights off in the office for my patients, that one patient said, “Oh you can turn the lights on, I’m having a good day.” I stood up and turned the lights on . . . only to realize that I was the one who couldn’t stand them. But that’s not my point. While things are going relativity well with the practice, I am still embarked onto two major battles. Actually one of the wars is over, but the mop up fighting still needed to be done. The first, and still engaged, battle is with Group Health HMO. They are refusing to do business with me because now I own the practice while previously, they represented my largest patient share. In our correspondence yesterday, I raised the bar by hinting towards a possible law suit by me. You can read more about it here . But that could get really messy, prolonged and emotionally draining and I know from experience. There is a fine balance between holding a business associate’s feet to the fire, but not over-reacting in hostility, thus poisoning the relationship. The mopping up had to do with my malpractice insurer, Physician’s Insurance. I won’t repeat all the gory details, but I had asked them back in November 2010 if they would insure a practice owned by a PA. “No problem” was their confident reply. I had approached them first because they were my previous insurer and continuing with them would have solved the problem of tail . . . or nose coverage. Then I started the very, very frustrating process with them. They said it would take 4 weeks to get my declaration of insurance (which I needed badly so I could start credentialing with health insurance companies and get the doors open). However, that friendly process turned into a very ugly three month saga. We ran into “snag” after “snag,” all of them related to problems with me, a PA, owning the practice. I had to jump through all kinds of ridiculous hoops. It seemed that the only thing left was waterboarding me. I did eventually go with them, because I was so deeply invested in the process. However, I didn’t like the policy, which they eventually wrote for me. In summary, because I am a PA, I am invisible to them. The policy was actually written for the SP, even though he sees patients 2-3 times a month. The last straw came when they required me to have an alternate supervising physician. I asked my old SP if he would do it and he agreed to. But then he said he needed to run it by his malpractice carrier, which of course was also Physicians Insurance. His intention was to find out if acting as my alternate SP would affect his rates. Then, Physicians Insurance told him–yes the same Physicians Insurance which required me to have an alternate SP–that it would be illegal to be a SP for a PA which does not work in your office. That has never been the law for a PA-C in the state of Washington. So, of course, he backed out. I decided then that I was done with Physicians Insurance at that point. I actually think they are a very company . . . for physicians. But PAs are nonpersons to them. So I found a much better company, Medical Protective. They dealt with me as a practice owner without any questions. They wrote a policy that covered not just the MD, but myself (as equal provider-partner) and my company. The most important practical difference is that Medical Protective deals directly with me. Physicians Insurance treated me, like I said, I was invisible. All their mailings went to my SP, who didn’t give a rat’s ass about the insurance. I’m the one who chose them. I personally paid all the bills, yet every single mailing only went to my SP. Seriously, I did not exist in their eyes. So what do you think would happen if I, or my SP was sued? I decided to drop them back in late April after they destroyed the chance for me to get an alternate SP. Now, I will have the close my doors for 4 weeks a year (when my SP is out of the country) and loose 40K a year in response. I knew the day of reckoning was coming, where I had to tell Physicians Insurance I was dropping them. I debated whether I would leave in silence or go out with a bang. For better or worse, I decided to go out with a bang. I wrote them a long letter with me protesting, in not-so-gracious tones, of how they treated me as a PA. I told them I thought they were professional bigots. Did I really say that? Well, my letter set off a firestorm. I’ve had several heated e-mail exchanges and phone conversations with executives with their company over the last two days . . . yet another reason I haven’t slept well. I feel really bad about it but I don’t feel wrong about it. They are officially fired and I hope that this is over. However, the one executive told me that I would be hearing from their boss. It would be one thing if they were apologetic, but their attitude is trying to convince me that they are very PA friendly. It is like an exclusive men’s club in the 1950s tell women, “We are very pro woman. We even have one dress as a bunny selling cigarettes to our distinguished gentlemen.” But after such a hard day, it did end glorious. I had finally slayed my migraine with two Maxalts, 2 double espressos, a 20 oz Mountain Dew and two aspirin. My wife met me after work and we literally walked out of the door of my building, crossed the parking lot, and boarded an authentically reproduced 18th century tall sailing ship . . . the Hawaiian Chieftain (pictured here). We spent the next four hours sailing across Puget Sound in a strong breeze. The ship had a crew of about 15 twenty-somethings, dressing and living in period clothing and style. They climbed the 80 foot mast like monkeys, shouting strange orders back in forth in a well-orchestrated aerial ballet like a rustic Cirque du Soleil. As they say, “Red skies at morn, sailors take warn . . . red skies at night . . . sailors’ delight.” The day had started with me seeing red, but also ended in a delightful red sunset.