RE: thoughts on specialist ranting

[Guest guest]

Thanks for the perspective, as always. Wish you were in my neighborhood. Hi all,I have read the "specialist ranting" and it strikes me is that the folks on this website are not representative of the average level of quality of primary care available, and the pains that you guys feel might be the result of that. We have often lamented that we wished we were getting referrals from micropractice-style primaries, but we are not. We get many lousy referrals from providers who barely know their patients, and many of the referrals are quite off base. It is silly that your referred physicians decide for themselves whether they will see the patient, but I see why. So many of our referrals have no business in a neurologists office. However, we believe that we are here in the community to serve the primaries (as well as the patients), so if they want a consultation, we do it regardless of how off-base many of them are. We also guarantee same day appts. to primaries if they believe their pt. needs to be seen. (Even though all of the same day "emergencies" that we have stayed late to see were not emergent at all.) The reason these off-base referrals are a problem is that, even though specialists are paid more for that initial visit (not for f/u unless we are formally re-consulted)when you figure the amount of time it takes to do a thorough initial consultation (record gathering, reviewing radiology films and thorough psychosocial hx) and document it in a manner that it is constructive to the primary, we get paid less per unit time than we do for a f/u office visit. The only reason I mention this is that inappropriate referrrals are a money-losing prospect because f/u is not necessary.About not getting notes back-- your specialists can't be billing without proof that they are sending you a note. Requirements for a specialist consultation are that we document the request (and technically differentiate between a one-time consult and an evaluate and tx), write a note, and prove that we sent communication back to the referring physician. Without these, if we get audited by Medicare, you can only bill an office visit, not a consult.) You are also not alone in getting dumped on by specialists-- we also get dumps from other specialists, i.e. my otolaryngologist sent me for an MRI and they told me to make an appointment with you to find out the results. (Never heard of the pt. before.) Kudos to everyone who kicks it right back to the docs attempting to dump. 

[Guest guest]

HAving you and other specialist on t his listserv is sooo

valuable to me, becasue i cannot always know and very often wonder what are

the issues specilaist suffer with

One of my issues has to do with the efficiency of the processes these guys

set up-- if i have to sned for review a possible consult they should

promise to l et me know if they are going to see the patietn or not. and

they do not

or if they sned me a form becasue they need the right data( which duh of

course they do, and i think this is a speciality society issue we should be

expcted to provide this stuff our societies should be fostering that)

i think i can expectthem to see if i have sent them what they need

irrespective of the format

and if they review my request and do not see the patient i have, to on my

dime, do all that work all over agian- so I quickly have nothing more to do

with practices thati ncur this kind of inconvenience to my patients and

workload to me I HAVE endeavored to call a nd talk to offcie mangers

sometimes about why the report went to a place i worked in 2000 for a few

months ,NOT to the address on t he referrral form,but i get the kind of

answers that a re so out of the galax that I am silenced

I guess i should make even more effort and talk to the poor docs How can

they not know what goes on thier offices but it all takes so much time if

there are other choices I just move on to someone else

Thank you so much for your input

I hope yourpractice grows and does well this year Boy do I wish you were

closer

thoughts on " specialist ranting "

Hi all,

I have read the " specialist ranting " and it strikes me is that

the folks on this website are not representative of the average

level of quality of primary care available, and the pains that you

guys feel might be the result of that. We have often lamented that

we wished we were getting referrals from micropractice-style

primaries, but we are not. We get many lousy referrals from

providers who barely know their patients, and many of the referrals

are quite off base.

It is silly that your referred physicians decide for themselves

whether they will see the patient, but I see why. So many of our

referrals have no business in a neurologists office. However, we

believe that we are here in the community to serve the primaries (as

well as the patients), so if they want a consultation, we do it

regardless of how off-base many of them are. We also guarantee same

day appts. to primaries if they believe their pt. needs to be seen.

(Even though all of the same day " emergencies " that we have stayed

late to see were not emergent at all.)

The reason these off-base referrals are a problem is that, even

though specialists are paid more for that initial visit (not for f/u

unless we are formally re-consulted)when you figure the amount of

time it takes to do a thorough initial consultation (record

gathering, reviewing radiology films and thorough psychosocial hx)

and document it in a manner that it is constructive to the primary,

we get paid less per unit time than we do for a f/u office visit.

The only reason I mention this is that inappropriate referrrals are

a money-losing prospect because f/u is not necessary.

About not getting notes back-- your specialists can't be

billing without proof that they are sending you a note.

Requirements for a specialist consultation are that we document the

request (and technically differentiate between a one-time consult

and an evaluate and tx), write a note, and prove that we sent

communication back to the referring physician. Without these, if we

get audited by Medicare, you can only bill an office visit, not a

consult.)

You are also not alone in getting dumped on by specialists-- we

also get dumps from other specialists, i.e. my otolaryngologist sent

me for an MRI and they told me to make an appointment with you to

find out the results. (Never heard of the pt. before.) Kudos to

everyone who kicks it right back to the docs attempting to dump.

[Guest guest]

,

I'm wondering if you could give us example of referrals/consults you feel are off base. Just curious (from the other end- primary care)

liz

thoughts on "specialist ranting"

Hi all,I have read the "specialist ranting" and it strikes me is that the folks on this website are not representative of the average level of quality of primary care available, and the pains that you guys feel might be the result of that. We have often lamented that we wished we were getting referrals from micropractice-style primaries, but we are not. We get many lousy referrals from providers who barely know their patients, and many of the referrals are quite off base. It is silly that your referred physicians decide for themselves whether they will see the patient, but I see why. So many of our referrals have no business in a neurologists office. However, we believe that we are here in the community to serve the primaries (as well as the patients), so if they want a consultation, we do it regardless of how off-base many of them are. We also guarantee same day appts. to primaries if they believe their pt. needs to be seen. (Even though all of the same day "emergencies" that we have stayed late to see were not emergent at all.) The reason these off-base referrals are a problem is that, even though specialists are paid more for that initial visit (not for f/u unless we are formally re-consulted)when you figure the amount of time it takes to do a thorough initial consultation (record gathering, reviewing radiology films and thorough psychosocial hx) and document it in a manner that it is constructive to the primary, we get paid less per unit time than we do for a f/u office visit. The only reason I mention this is that inappropriate referrrals are a money-losing prospect because f/u is not necessary.About not getting notes back-- your specialists can't be billing without proof that they are sending you a note. Requirements for a specialist consultation are that we document the request (and technically differentiate between a one-time consult and an evaluate and tx), write a note, and prove that we sent communication back to the referring physician. Without these, if we get audited by Medicare, you can only bill an office visit, not a consult.) You are also not alone in getting dumped on by specialists-- we also get dumps from other specialists, i.e. my otolaryngologist sent me for an MRI and they told me to make an appointment with you to find out the results. (Never heard of the pt. before.) Kudos to everyone who kicks it right back to the docs attempting to dump.

[Guest guest]

I'm going to claim a special understanding of neurologists since I am

married to one. (The same could not be said for me having a special

understanding of women even after 21 years of marriage!)

-- in general, neurologists are cognitive physicians like family

medicine physicians. As such, their pay is nowhere near that of

procedural specialists. Until joining the hospital, my wife's group

was paid no better than family physicians and could not attract

partners because of their poor reimbursement.

--- neurologists do complain about inappropriate referrals. They are

being tactful-what is usually means is that they are getting patients

with no obvious or even close to being obvious neurologic problems.

Basically, (and I have done this myself)-if you have a patient that

has " crazy problems with no explanation " -a neurologists is usually a

good choice to send them to! (And certainly more palatable to the

patient than where they actually need to go which is probably a

psychiatrist or psychologist) What this means for the neurologists is

a comprehensive time consuming, a one-time visit since there is no

neurologic problem.

-- in the " old days " you could call up specialists and run patients by

them. But both family doctors and specialists being so busy, much of

this has gone by the wayside.

[Guest guest]

Lou,

Thanks for some insight. However, these are the patients

we have to deal with too. These are the same patients that we have to do

a comprehensive evaluation and then tell them that their symptoms are not following

any neurological patter or disease. But they are convinced the have MS or

some other horrible neurological disease and will only believe “a

specialist” and often, not even then and will get 2-3 specialist

opinions. Or, headaches like these can’t possibly be migraines, I

must have something else that is being missed, etc.

Neurologists, like family doctors and other primary care doctors

have to filter through a lot of “nuts”, I mean somatoform diseases

and anxiety. But, like family doctors, they could use this time to say “Let’s

talk about stroke prevention” or something else. Being a specialist

means you see a lot of new people and do a lot of one time only

consultations. That goes with the territory. I really don’t

see a way to avoid it.

So neurologists are also victims of the broken system.

Maybe they can join in with our laments and outcries for reimbursement reform.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

PS: Men, they just don’t get us. ;-^)

From:

[mailto: ] On Behalf Of l_spikol

Sent: Wednesday, January 02, 2008 4:21 PM

To:

Subject: Re: thoughts on " specialist

ranting "

I'm going to claim a special understanding of

neurologists since I am

married to one. (The same could not be said for me having a special

understanding of women even after 21 years of marriage!)

-- in general, neurologists are cognitive physicians like family

medicine physicians. As such, their pay is nowhere near that of

procedural specialists. Until joining the hospital, my wife's group

was paid no better than family physicians and could not attract

partners because of their poor reimbursement.

--- neurologists do complain about inappropriate referrals. They are

being tactful-what is usually means is that they are getting patients

with no obvious or even close to being obvious neurologic problems.

Basically, (and I have done this myself)-if you have a patient that

has " crazy problems with no explanation " -a neurologists is usually a

good choice to send them to! (And certainly more palatable to the

patient than where they actually need to go which is probably a

psychiatrist or psychologist) What this means for the neurologists is

a comprehensive time consuming, a one-time visit since there is no

neurologic problem.

-- in the " old days " you could call up specialists and run patients

by

them. But both family doctors and specialists being so busy, much of

this has gone by the wayside.

[Guest guest]

Hi Lou,

I certainly understand what you are saying, and what

neurologists and other specialists say about “inappropriate referrals”

But (there’s always a “but”, isn’t

there?)… this year I have been covering for my hospitalist some, and have

been consulted for “medical management” on ortho patients, admitted

by the orthopedic docs for elective or emergent knee or hip replacements,

lumbar lami, or sometimes fracture repair or infected joints/prostheses..

sometimes there really are multiple medical issues (CHF, DM, depression…etc),

but sometimes “medical management” adds up to not much more than

continuing the “home meds”. At first I felt really uncomfortable

with these….after all, even an orthopedist can write “lisinopril

10mg po daily, hold for SBP<110”. (OK, I do a little more than that,

like make sure the foley gets pulled, and transfuse them if need be)

Anyway, I was uncomfortable providing “inappropriate” care, until I

realized that I get paid to do the consult, whether it is really “necessary”

or not. So I quit fussing about it.

I observe that around here, the willingness of docs to see my “inappropriate”

referrals seems to be directly correlated to the number of practitioners of the

given specialty there are. Rheumatologists and ID guys are in short

supply, and they have all the “appropriate” business they can

handle. They require that I send records and an “application”

and they let me know IF they are willing to see my patient. On the other

hand, we have a cardiologist on every corner, and they will see ANYONE, for

pretty much ANYTHING…. And we have quite a few neurologists: I note

that they can take my inappropriate, there’s-nothing-wrong-with-her-that-a-good-swift-kick-won’t-cure

people and manage to turn the workup into 4 to 6 visits over about a month,

then 3 to 4 times per year follow up for whatever it is that you treat with their

favorite Lyrica, Cymbalta, Mirapex and Klonapin cocktail…

Oops, my cynicism got out again already….another New Year’s

Resolution, down the tubes!

Please don’t think I mean to say that neurologists (or

anybody else) are not good docs, or ethical professionals. They just have

to function in the same insane milieu that is dragging us into the quicksand…

Annie

From:

[mailto: ] On Behalf Of l_spikol

Sent: Wednesday, January 02, 2008 4:21 PM

To:

Subject: Re: thoughts on " specialist

ranting "

I'm going to claim a special understanding of

neurologists since I am

married to one. (The same could not be said for me having a special

understanding of women even after 21 years of marriage!)

-- in general, neurologists are cognitive physicians like family

medicine physicians. As such, their pay is nowhere near that of

procedural specialists. Until joining the hospital, my wife's group

was paid no better than family physicians and could not attract

partners because of their poor reimbursement.

--- neurologists do complain about inappropriate referrals. They are

being tactful-what is usually means is that they are getting patients

with no obvious or even close to being obvious neurologic problems.

Basically, (and I have done this myself)-if you have a patient that

has " crazy problems with no explanation " -a neurologists is usually a

good choice to send them to! (And certainly more palatable to the

patient than where they actually need to go which is probably a

psychiatrist or psychologist) What this means for the neurologists is

a comprehensive time consuming, a one-time visit since there is no

neurologic problem.

-- in the " old days " you could call up specialists and run patients

by

them. But both family doctors and specialists being so busy, much of

this has gone by the wayside.