Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Rian is off to do some house calls this morning and I'm not needed in the officeuntil 1pm when we open today so I want to reply from my point of view as office manager/business partner.Here in west Michigan where the economy is fully in the tank and our patientsare losing jobs every day, (another local factory will be closing its doors soon)it is impossible to do a cash practice. This was never a well-to-do little town butit is especially hurting now. In addition to the working or "just had a job but I lostit" poor, a substantial portion of Rian's practice are seniors. As you all know, theirincomes are fixed. Most have 99214 level visits which gives them about a $17responsibility after Medicare. At least half of our seniors do not have anyMedigap/secondary insurance. Factor in that they are trying to get by on social security alone or possibly a tiny nest egg and one can see that adding $10 or $20 fees here and there for paperwork or requiring them to come back in even though they were seen just two weeks ago becomes especially burdensome. We could do it but we would lose a substantial number of them whose old doctor just used to call in a Rx willy nilly. Even though they appreciate Rian's thorough medical care, the ultimate bottom line in these here parts is the cost to the patient and jump ship they would - back to the local multiple doc mill if they sensed that our practice was more costly to them. The idea of thinning our herd of patients byletting go the "somewhat compliant" would be fiscal suicide. (we have dismissed a few very uncompliant patients from our practice) We only average about 35 patients a week so Rian actually doesn't compromise other patient's care due to the more demanding patients. We have plenty of wiggle room in our schedule. It's the hassle factor that gets to him. He's seen a lot of developents that he doesn't care for since he graduated from his residency in 1980 (managed care, prior auths, the endless "advice" from insurance companies regarding patient care, which he views as offensive) but he still enjoys the time with his patients and laughs a lot during the day and rides his Mongoose through our snowy streets to work so keep in mind that reading his emails you can't really get a feel for his demeanor. He's not unhappy, he just needs to rant once in a while.a Mintekoffice managerDowntown Allegan Family PracticeGreat post. Or...we go to some version of a blended capitation and per visit revenue model so that you are compensated for at least some of this non face-to-face work as a certain level of it (more on limits below) is part of great primary care. I'm a broken record on this, but a cash-only retainer/per visit model works. As would a reasonable blended reimbursement model from insurance companies - problem is those don't really exist. What absolutely doesn't work is a fee for service model because it's impossible to completely link allservices provided by primary care docs to a reasonable fee. It works in the OR - it doesn't work in a primary care practice. Now I'm going to put my MBA/business hat on and encourage you to look at every patient from the perspective of whether they are good for your practice. In business-speak, this is the concept that some customers aren't worth having. One angle is whether you make money because they are in the practice. I know this is not the only perspective we ethically should use, but it is one factor. The patient who in effect abuses you by forcing all of this extra work because of their irresponsible behavior is a financial drag on the practice due to all of the uncompensated time. In addition, I believe practices have an obligation to consider how such patient behavior impacts other patients. Are you forced to spend less time with other patients because of this unnecessary run-around? Would you be able to call a diabetic struggling to control their blood sugar if you weren't wasting time playing phone-tag with pharmacies? Are you as happy as you could be professionally if this crap didn't distract you from your mission? Does being less happy in any way affect how much energy you bring to your healing work or for how long you'll practice? If the answer to any of these is yes, you owe it to your other patients and yourself to tell these people they need to change their behavior or get another doctor. Being a martyr for every patient is engrained in us from the first day of medical school - it's an illusion that it is a requirement for being a great doc. In fact, it's an ethical trap as it limits the good work we can do for all patients. My four cents...Chad >> With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > this list-serve needs a grouchy voice, and every once in a while I > feel one of those rising out of my waddle ... Today, a series of 4 or > 5 phone messages culminated in another prescription (for Allegra, no > less) issued to another pharmacy, in a city just across the area-code > border-line from me ... I am lucky to have a cheap long-distance phone > rate, but the time/hassle of making decisions, reviewing charts, and > documenting actions for prescriptions is un-compensated work.> I tell all patients to bring the brown paper bag full of their pill- > bottles to every visit, and scan the labels for the "no more refills > coming" warnings ... Some patients just don't learn, and those are > usually the patients on 8 prescription drugs. We deal with the Lipitor > and the Lisinopril and the Lantus, but they forgot about the Paxil > running-low at home ... that phone call comes back about 3 weeks > later, which is close to the limits of my memory about that last > visit, but then about 6 weeks out comes the phone call about Allegra.> How much free work can a doctor do for a patient, between visits, > before that doctor starts to feel abused and resentful ? ... Any > patient can walk on over to the all-night grocery store and buy a > bottle of Claritin or Zyrtec, without bothering the doctor's office, > but to cash in on his insurance deal, a patient gets the pharmacist to > FAX the first salvo to the doctor's office ... Way too often, this > will lead to a requirement to get "prior authorization" from the > patient's new health insurance company, to prove that the only > antihistamine that will let that patient live in harmony with those 3 > pet cats is the one that takes a prescription ...> I am getting close to the point of declaring that every prescription, > every note for a boss, every handicapper parking form, etc. has to be > composed / filled-out / phoned-in during a face-to-face visit , for > which there will be a charge ...> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Rian is off to do some house calls this morning and I'm not needed in the officeuntil 1pm when we open today so I want to reply from my point of view as office manager/business partner.Here in west Michigan where the economy is fully in the tank and our patientsare losing jobs every day, (another local factory will be closing its doors soon)it is impossible to do a cash practice. This was never a well-to-do little town butit is especially hurting now. In addition to the working or "just had a job but I lostit" poor, a substantial portion of Rian's practice are seniors. As you all know, theirincomes are fixed. Most have 99214 level visits which gives them about a $17responsibility after Medicare. At least half of our seniors do not have anyMedigap/secondary insurance. Factor in that they are trying to get by on social security alone or possibly a tiny nest egg and one can see that adding $10 or $20 fees here and there for paperwork or requiring them to come back in even though they were seen just two weeks ago becomes especially burdensome. We could do it but we would lose a substantial number of them whose old doctor just used to call in a Rx willy nilly. Even though they appreciate Rian's thorough medical care, the ultimate bottom line in these here parts is the cost to the patient and jump ship they would - back to the local multiple doc mill if they sensed that our practice was more costly to them. The idea of thinning our herd of patients byletting go the "somewhat compliant" would be fiscal suicide. (we have dismissed a few very uncompliant patients from our practice) We only average about 35 patients a week so Rian actually doesn't compromise other patient's care due to the more demanding patients. We have plenty of wiggle room in our schedule. It's the hassle factor that gets to him. He's seen a lot of developents that he doesn't care for since he graduated from his residency in 1980 (managed care, prior auths, the endless "advice" from insurance companies regarding patient care, which he views as offensive) but he still enjoys the time with his patients and laughs a lot during the day and rides his Mongoose through our snowy streets to work so keep in mind that reading his emails you can't really get a feel for his demeanor. He's not unhappy, he just needs to rant once in a while.a Mintekoffice managerDowntown Allegan Family PracticeGreat post. Or...we go to some version of a blended capitation and per visit revenue model so that you are compensated for at least some of this non face-to-face work as a certain level of it (more on limits below) is part of great primary care. I'm a broken record on this, but a cash-only retainer/per visit model works. As would a reasonable blended reimbursement model from insurance companies - problem is those don't really exist. What absolutely doesn't work is a fee for service model because it's impossible to completely link allservices provided by primary care docs to a reasonable fee. It works in the OR - it doesn't work in a primary care practice. Now I'm going to put my MBA/business hat on and encourage you to look at every patient from the perspective of whether they are good for your practice. In business-speak, this is the concept that some customers aren't worth having. One angle is whether you make money because they are in the practice. I know this is not the only perspective we ethically should use, but it is one factor. The patient who in effect abuses you by forcing all of this extra work because of their irresponsible behavior is a financial drag on the practice due to all of the uncompensated time. In addition, I believe practices have an obligation to consider how such patient behavior impacts other patients. Are you forced to spend less time with other patients because of this unnecessary run-around? Would you be able to call a diabetic struggling to control their blood sugar if you weren't wasting time playing phone-tag with pharmacies? Are you as happy as you could be professionally if this crap didn't distract you from your mission? Does being less happy in any way affect how much energy you bring to your healing work or for how long you'll practice? If the answer to any of these is yes, you owe it to your other patients and yourself to tell these people they need to change their behavior or get another doctor. Being a martyr for every patient is engrained in us from the first day of medical school - it's an illusion that it is a requirement for being a great doc. In fact, it's an ethical trap as it limits the good work we can do for all patients. My four cents...Chad >> With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > this list-serve needs a grouchy voice, and every once in a while I > feel one of those rising out of my waddle ... Today, a series of 4 or > 5 phone messages culminated in another prescription (for Allegra, no > less) issued to another pharmacy, in a city just across the area-code > border-line from me ... I am lucky to have a cheap long-distance phone > rate, but the time/hassle of making decisions, reviewing charts, and > documenting actions for prescriptions is un-compensated work.> I tell all patients to bring the brown paper bag full of their pill- > bottles to every visit, and scan the labels for the "no more refills > coming" warnings ... Some patients just don't learn, and those are > usually the patients on 8 prescription drugs. We deal with the Lipitor > and the Lisinopril and the Lantus, but they forgot about the Paxil > running-low at home ... that phone call comes back about 3 weeks > later, which is close to the limits of my memory about that last > visit, but then about 6 weeks out comes the phone call about Allegra.> How much free work can a doctor do for a patient, between visits, > before that doctor starts to feel abused and resentful ? ... Any > patient can walk on over to the all-night grocery store and buy a > bottle of Claritin or Zyrtec, without bothering the doctor's office, > but to cash in on his insurance deal, a patient gets the pharmacist to > FAX the first salvo to the doctor's office ... Way too often, this > will lead to a requirement to get "prior authorization" from the > patient's new health insurance company, to prove that the only > antihistamine that will let that patient live in harmony with those 3 > pet cats is the one that takes a prescription ...> I am getting close to the point of declaring that every prescription, > every note for a boss, every handicapper parking form, etc. has to be > composed / filled-out / phoned-in during a face-to-face visit , for > which there will be a charge ...> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Rian is off to do some house calls this morning and I'm not needed in the officeuntil 1pm when we open today so I want to reply from my point of view as office manager/business partner.Here in west Michigan where the economy is fully in the tank and our patientsare losing jobs every day, (another local factory will be closing its doors soon)it is impossible to do a cash practice. This was never a well-to-do little town butit is especially hurting now. In addition to the working or "just had a job but I lostit" poor, a substantial portion of Rian's practice are seniors. As you all know, theirincomes are fixed. Most have 99214 level visits which gives them about a $17responsibility after Medicare. At least half of our seniors do not have anyMedigap/secondary insurance. Factor in that they are trying to get by on social security alone or possibly a tiny nest egg and one can see that adding $10 or $20 fees here and there for paperwork or requiring them to come back in even though they were seen just two weeks ago becomes especially burdensome. We could do it but we would lose a substantial number of them whose old doctor just used to call in a Rx willy nilly. Even though they appreciate Rian's thorough medical care, the ultimate bottom line in these here parts is the cost to the patient and jump ship they would - back to the local multiple doc mill if they sensed that our practice was more costly to them. The idea of thinning our herd of patients byletting go the "somewhat compliant" would be fiscal suicide. (we have dismissed a few very uncompliant patients from our practice) We only average about 35 patients a week so Rian actually doesn't compromise other patient's care due to the more demanding patients. We have plenty of wiggle room in our schedule. It's the hassle factor that gets to him. He's seen a lot of developents that he doesn't care for since he graduated from his residency in 1980 (managed care, prior auths, the endless "advice" from insurance companies regarding patient care, which he views as offensive) but he still enjoys the time with his patients and laughs a lot during the day and rides his Mongoose through our snowy streets to work so keep in mind that reading his emails you can't really get a feel for his demeanor. He's not unhappy, he just needs to rant once in a while.a Mintekoffice managerDowntown Allegan Family PracticeGreat post. Or...we go to some version of a blended capitation and per visit revenue model so that you are compensated for at least some of this non face-to-face work as a certain level of it (more on limits below) is part of great primary care. I'm a broken record on this, but a cash-only retainer/per visit model works. As would a reasonable blended reimbursement model from insurance companies - problem is those don't really exist. What absolutely doesn't work is a fee for service model because it's impossible to completely link allservices provided by primary care docs to a reasonable fee. It works in the OR - it doesn't work in a primary care practice. Now I'm going to put my MBA/business hat on and encourage you to look at every patient from the perspective of whether they are good for your practice. In business-speak, this is the concept that some customers aren't worth having. One angle is whether you make money because they are in the practice. I know this is not the only perspective we ethically should use, but it is one factor. The patient who in effect abuses you by forcing all of this extra work because of their irresponsible behavior is a financial drag on the practice due to all of the uncompensated time. In addition, I believe practices have an obligation to consider how such patient behavior impacts other patients. Are you forced to spend less time with other patients because of this unnecessary run-around? Would you be able to call a diabetic struggling to control their blood sugar if you weren't wasting time playing phone-tag with pharmacies? Are you as happy as you could be professionally if this crap didn't distract you from your mission? Does being less happy in any way affect how much energy you bring to your healing work or for how long you'll practice? If the answer to any of these is yes, you owe it to your other patients and yourself to tell these people they need to change their behavior or get another doctor. Being a martyr for every patient is engrained in us from the first day of medical school - it's an illusion that it is a requirement for being a great doc. In fact, it's an ethical trap as it limits the good work we can do for all patients. My four cents...Chad >> With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > this list-serve needs a grouchy voice, and every once in a while I > feel one of those rising out of my waddle ... Today, a series of 4 or > 5 phone messages culminated in another prescription (for Allegra, no > less) issued to another pharmacy, in a city just across the area-code > border-line from me ... I am lucky to have a cheap long-distance phone > rate, but the time/hassle of making decisions, reviewing charts, and > documenting actions for prescriptions is un-compensated work.> I tell all patients to bring the brown paper bag full of their pill- > bottles to every visit, and scan the labels for the "no more refills > coming" warnings ... Some patients just don't learn, and those are > usually the patients on 8 prescription drugs. We deal with the Lipitor > and the Lisinopril and the Lantus, but they forgot about the Paxil > running-low at home ... that phone call comes back about 3 weeks > later, which is close to the limits of my memory about that last > visit, but then about 6 weeks out comes the phone call about Allegra.> How much free work can a doctor do for a patient, between visits, > before that doctor starts to feel abused and resentful ? ... Any > patient can walk on over to the all-night grocery store and buy a > bottle of Claritin or Zyrtec, without bothering the doctor's office, > but to cash in on his insurance deal, a patient gets the pharmacist to > FAX the first salvo to the doctor's office ... Way too often, this > will lead to a requirement to get "prior authorization" from the > patient's new health insurance company, to prove that the only > antihistamine that will let that patient live in harmony with those 3 > pet cats is the one that takes a prescription ...> I am getting close to the point of declaring that every prescription, > every note for a boss, every handicapper parking form, etc. has to be > composed / filled-out / phoned-in during a face-to-face visit , for > which there will be a charge ...> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Lou, As usual, I agree with you completely. Re: drawing the line I prefer to think of you as the listserv lobster rather than crab. (And then the lyrics to " rock lobster " go through my head- " everyone had matching towels " ) I've really been enjoying this conversation and I especially like Chad's posting-I think the idea of a concierge practice can certainly be expanded beyond the meaning that we consistently give till it. My take on all of this- Encounter based care is coming to an end one way or another. Good riddance. The current economic crisis will force things to happen-either family medicine will go down the tubes or it will be seen as the best way to add value to the system. Just as democracy is the best system that we have, family medicine is also the best medical system that we have in spite of its many flaws. We definitely will provide the best value if we are allowed to do so. We just need to get reimbursed for the value that we provide. (And I believe-encounter based care won't do it-we need to get paid for value not paid by the hour and not paid by à la carte methods) I have been lucky enough to work part time for the past few years but I would be glad to start working full time as soon as the system changes. The ICD and CPT systems were the worst inventions ever produced for medicine. Even the problem oriented medical record should be scrapped and change to something that better fits what we do and the more sophisticated tools that we have. Just my four cents (I assume that is two cents with inflation. > > > With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > > this list-serve needs a grouchy voice, and every once in a while I > > feel one of those rising out of my waddle ... Today, a series of 4 or > > 5 phone messages culminated in another prescription (for Allegra, no > > less) issued to another pharmacy, in a city just across the area- code > > border-line from me ... I am lucky to have a cheap long-distance phone > > rate, but the time/hassle of making decisions, reviewing charts, and > > documenting actions for prescriptions is un-compensated work. > > I tell all patients to bring the brown paper bag full of their pill- > > bottles to every visit, and scan the labels for the " no more refills > > coming " warnings ... Some patients just don't learn, and those are > > usually the patients on 8 prescription drugs. We deal with the Lipitor > > and the Lisinopril and the Lantus, but they forgot about the Paxil > > running-low at home ... that phone call comes back about 3 weeks > > later, which is close to the limits of my memory about that last > > visit, but then about 6 weeks out comes the phone call about Allegra. > > How much free work can a doctor do for a patient, between visits, > > before that doctor starts to feel abused and resentful ? ... Any > > patient can walk on over to the all-night grocery store and buy a > > bottle of Claritin or Zyrtec, without bothering the doctor's office, > > but to cash in on his insurance deal, a patient gets the pharmacist to > > FAX the first salvo to the doctor's office ... Way too often, this > > will lead to a requirement to get " prior authorization " from the > > patient's new health insurance company, to prove that the only > > antihistamine that will let that patient live in harmony with those 3 > > pet cats is the one that takes a prescription ... > > I am getting close to the point of declaring that every prescription, > > every note for a boss, every handicapper parking form, etc. has to be > > composed / filled-out / phoned-in during a face-to-face visit , for > > which there will be a charge ... > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
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