Would A Low Flow - Large Group Hybrid Work?

April 16, 2008

Large medical groups do not seem to be able to offer the same quality

of services that low flow practices deliver. However, large groups are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of 25

could still offer large group services such as group visits, registry

reporting, access to lower priced injectables, maintaining IT, on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but divided into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must have

discussed this idea already.

Lowell

April 16, 2008

Lowell, this is exactly what I expect to see happen over time.

To date the larger organizations interested in our work are having

difficulty adjusting their operational rules to fit the flexibility

required of an IMP. It's just a matter of time until a larger

organization is willing to truly support practice excellence. Then

we'll see how these teamlets/micropractices aggregate.

We see some shades of this aggregation within our community.

Lee and I share space but not staff or patients. We cross cover

when out of town. We share vaccines. It is a very logical

extension to take advantage of shared space for group visit rooms, for

case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not seem

to be able to offer the same quality

of services that low flow practices deliver. However, large groups

are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of

25

could still offer large group services such as group visits,

registry

reporting, access to lower priced injectables, maintaining IT,

on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but

divided into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must

have

discussed this idea already.

Lowell

April 16, 2008

Gordon,

Can you share what operational rules seem to pose the greatest

barriers for these organizations?

Also, what specifically is driving their interest in a hybrid

model?

Thanks.

Lowell Kleinman, MD

5601 Norris Canyon Rd.

Suite 340

San Ramon, CA 94583

www.drkleinman.com

drk@...

From:

[mailto: ] On Behalf Of L. Gordon

Sent: Wednesday, April 16, 2008 9:07 AM

To:

Subject: Re: Would A Low Flow - Large Group

Hybrid Work?

Lowell, this is exactly what I expect to see

happen over time.

To date the larger organizations interested in our work are having difficulty adjusting

their operational rules to fit the flexibility required of an IMP. It's

just a matter of time until a larger organization is willing to truly support

practice excellence. Then we'll see how these teamlets/micropractices

aggregate.

We see some shades of this aggregation within our community. Lee

and I share space but not staff or patients. We cross cover when out of

town. We share vaccines. It is a very logical extension to take

advantage of shared space for group visit rooms, for case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not

seem to be able to offer the same quality

of services that low flow practices deliver. However, large groups are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of 25

could still offer large group services such as group visits, registry

reporting, access to lower priced injectables, maintaining IT, on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but divided

into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must have

discussed this idea already.

Lowell

April 16, 2008

In my local community we are seeing attempts at bringing

together solo and small groups of primary care docs into a larger format. The

predominant driving force is to be able to generate additional revenues by

offering services such as labs, sleep studies, etc. Were these attempts at forming

a group have a mission statement it would be " join together to make more

money " . That's not meant to be critical but I do think it's short-sighted.

Here is the interesting part. The services have relatively low

margins, are expensive to get off of the ground and don't address quality of

care. In other words, they are not tremendously " profitable " for the

docs or the patients. I am starting to think that if the principles of ideal

medical practices are applied to the situation the group would start to see new

services that they could offer that could be more " profitable " for

both patients and docs.

For example, they might discuss using a registry and that

discussion might end with the idea of bringing in patients based on registry

reports or setting up group visits. This would improve care and generate

revenues and is less expensive than setting up a lab.

The point I am trying to make is that the driver for docs

joining together is financial in many cases. Looking at ideal medical practice principles

as the means of generating that revenue is a win win because it includes

quality of care aspects. Ironically, I think some of the ideas of IMP would

create low hanging fruit ideas that could be very profitable in contrast to the

idea of a group purchasing a dexa scanner to make more money.

So, the mission statement might read something like, " Join

together, apply IMP principles, improve care, make more money….go

fishing "

Well, maybe the go fishing is not needed

Lowell Kleinman, MD

5601 Norris Canyon Rd.

Suite 340

San Ramon, CA 94583

www.drkleinman.com

drk@...

From:

[mailto: ] On Behalf Of L. Gordon

Sent: Wednesday, April 16, 2008 9:07 AM

To:

Subject: Re: Would A Low Flow - Large Group

Hybrid Work?

Lowell, this is exactly what I expect to see

happen over time.

To date the larger organizations interested in our work are having difficulty

adjusting their operational rules to fit the flexibility required of an

IMP. It's just a matter of time until a larger organization is willing to

truly support practice excellence. Then we'll see how these

teamlets/micropractices aggregate.

We see some shades of this aggregation within our community. Lee

and I share space but not staff or patients. We cross cover when out of

town. We share vaccines. It is a very logical extension to take

advantage of shared space for group visit rooms, for case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not

seem to be able to offer the same quality

of services that low flow practices deliver. However, large groups are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of 25

could still offer large group services such as group visits, registry

reporting, access to lower priced injectables, maintaining IT, on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but divided

into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must have

discussed this idea already.

Lowell

April 16, 2008

The interest stems from the rather universal recognition that the current

approach to health care delivery falls far short of all meaningful goals

(outcomes, experience of care, per capita costs).

The interest is further enhanced by the recognition that multiple

attempts and initiatives aimed at improvement are abject failures or

result in cost shifting or other unacceptable trade-offs.

Some are then interested in transformative approaches and IMPs are a

stand-out in this category because we're not just speculating about the

future of health care or the medical home, we're living it and have

data.

The operational rules needed to support the work are relatively simple at

the conceptual level:

Superb and unfettered access to the provider 24/7/365

No wasted time in the office

Superb continuity

Patient-centered collaborative care (includes reminder systems, outreach

function & all the Care Model components of planned care)

Coordination of care

Example of rules around the access part:

Direct phone line to the care team.

Some of the organizations have invested heavily in call centers, phone

systems with voice attendants/decision trees, and appointment rules

driven by 'triage.' They've not been willing or able to cut through

all this red tape and just give the patients a direct line to their

provider and team. Of course I make that transition sound simple

and it is not. Superb access is sustainable only when the panel

size is matched to the capacity of the team. After hours calls are

not burdensome when the office turn-around for calls and messages is

counted in minutes and not hours or days. These are transformative

changes. IMPs accomplish this with ease because that's the way the

office was set up from the start.

Gordon

At 12:12 PM 4/16/2008, you wrote:

Gordon,

Can you share what operational rules seem to pose the greatest barriers

for these organizations?

Also, what specifically is driving their interest in a hybrid

model?

Thanks.

Lowell Kleinman, MD

5601 Norris Canyon Rd.

Suite 340

San Ramon, CA 94583

www.drkleinman.com

drk@...

From:

[

mailto: ] On Behalf Of L.

Gordon

Sent: Wednesday, April 16, 2008 9:07 AM

To:

Subject: Re: Would A Low Flow - Large Group

Hybrid Work?

Lowell, this is exactly what I expect to see happen over time.

To date the larger organizations interested in our work are having

difficulty adjusting their operational rules to fit the flexibility

required of an IMP. It's just a matter of time until a larger

organization is willing to truly support practice excellence. Then

we'll see how these teamlets/micropractices aggregate.

We see some shades of this aggregation within our community.

Lee and I share space but not staff or patients. We cross cover

when out of town. We share vaccines. It is a very logical

extension to take advantage of shared space for group visit rooms, for

case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not seem to be able to offer the same

quality

of services that low flow practices deliver. However, large groups

are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25

docs

might be divided up into 5 low flow practices. The larger group of

25

could still offer large group services such as group visits,

registry

reporting, access to lower priced injectables, maintaining IT,

on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but

divided into

low flow sub-groups? Is there any literature on this

approach?

As I write this it occurs to me that the folks on this site must

have

discussed this idea already.

Lowell

April 16, 2008

Lowell,

To tag on. You make the assumption that only large groups can offer the things

you listed. I am solo/solo and have IT, x-ray (not ct or mri), patient

registries, could do group visits, and i belong to an IPA that has the best

rates in Colorado (164% of Medicare, or 80% of charges depending on contracts.)

I am not a fan of the % of medicare contracts, but works for now. My daugher is

joining me in practice, and I certain we can maintain the lowest overhead model,

not sure that a 5 person group can, but let me know if it works.

________________________________

From: on behalf of L. Gordon

Sent: Wed 4/16/2008 10:06 AM

To:

Subject: Re: Would A Low Flow - Large Group Hybrid Work?

Lowell, this is exactly what I expect to see happen over time.

To date the larger organizations interested in our work are having difficulty

adjusting their operational rules to fit the flexibility required of an IMP.

It's just a matter of time until a larger organization is willing to truly

support practice excellence. Then we'll see how these teamlets/micropractices

aggregate.

We see some shades of this aggregation within our community. Lee and I

share space but not staff or patients. We cross cover when out of town. We

share vaccines. It is a very logical extension to take advantage of shared

space for group visit rooms, for case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not seem to be able to offer the same quality

of services that low flow practices deliver. However, large groups are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of 25

could still offer large group services such as group visits, registry

reporting, access to lower priced injectables, maintaining IT, on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but divided into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must have

discussed this idea already.

Lowell

April 16, 2008

For sure we solo docs can offer these services. However, setting up and

managing these services takes time away from patient care and creates a lot

of background " noise " .

Hiring extra personnel to accomplish the services is problematic but perhaps

being part of a larger entity that offers these services might work well.

Case in point is the IPA you are in which I see as tantamount to being in a

very large group of sorts. Theoretically your IPA could produce a registry

reports for you, call and schedule the patients, and offer them access to

group vists while you maintain your low flow status.

I think the background noise is very costly. It's what exhausts the docs (at

least it does in my case) and staf plus it significantly contributes to

overhead. Yet the patients benefit from these services.

I want to have a low flow practice that delivers high quality care ala IMP

principles and offers lots of beneficial services without the noise.

Lowell

Lowell Kleinman, MD

5601 Norris Canyon Rd.

Suite 340

San Ramon, CA 94583

www.drkleinman.com

drk@...

Re: Would A Low Flow - Large Group Hybrid

Work?

Lowell, this is exactly what I expect to see happen over time.

To date the larger organizations interested in our work are having

difficulty adjusting their operational rules to fit the flexibility required

of an IMP. It's just a matter of time until a larger organization is

willing to truly support practice excellence. Then we'll see how these

teamlets/micropractices aggregate.

We see some shades of this aggregation within our community. Lee and

I share space but not staff or patients. We cross cover when out of town.

We share vaccines. It is a very logical extension to take advantage of

shared space for group visit rooms, for case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not seem to be able to offer the same

quality

of services that low flow practices deliver. However, large groups

are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of

25

could still offer large group services such as group visits,

registry

reporting, access to lower priced injectables, maintaining IT,

on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but divided

into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must

have

discussed this idea already.

Lowell

April 16, 2008

I admit that I am different, the " noise " does not bother me, since it often

brings me closer to the patients. The IPA could not do any of these things,

since they only contract, have no data about my practice, actual billing data or

quality data. Also they are in Vail, a long way off.

I hope you can accomplish this in today's reimbursement climate. I think teams

are good overall, I am not sure they all need to be in the same building. My

town is only about 500 people, the entire county 1500 sq miles only has 12,000.

Many team members are unavailable.

________________________________

From: on behalf of Lowell Kleinman, MD

Sent: Wed 4/16/2008 1:54 PM

To:

Subject: RE: Would A Low Flow - Large Group Hybrid Work?

For sure we solo docs can offer these services. However, setting up and

managing these services takes time away from patient care and creates a lot

of background " noise " .

Hiring extra personnel to accomplish the services is problematic but perhaps

being part of a larger entity that offers these services might work well.

Case in point is the IPA you are in which I see as tantamount to being in a

very large group of sorts. Theoretically your IPA could produce a registry

reports for you, call and schedule the patients, and offer them access to

group vists while you maintain your low flow status.

I think the background noise is very costly. It's what exhausts the docs (at

least it does in my case) and staf plus it significantly contributes to

overhead. Yet the patients benefit from these services.

I want to have a low flow practice that delivers high quality care ala IMP

principles and offers lots of beneficial services without the noise.

Lowell

Lowell Kleinman, MD

5601 Norris Canyon Rd.

Suite 340

San Ramon, CA 94583

www.drkleinman.com

drk@... <mailto:drk%40drkleinman.com>

Re: Would A Low Flow - Large Group Hybrid

Work?

Lowell, this is exactly what I expect to see happen over time.

To date the larger organizations interested in our work are having

difficulty adjusting their operational rules to fit the flexibility required

of an IMP. It's just a matter of time until a larger organization is

willing to truly support practice excellence. Then we'll see how these

teamlets/micropractices aggregate.

We see some shades of this aggregation within our community. Lee and

I share space but not staff or patients. We cross cover when out of town.

We share vaccines. It is a very logical extension to take advantage of

shared space for group visit rooms, for case management, supplies.

Gordon

At 11:22 AM 4/16/2008, you wrote:

Large medical groups do not seem to be able to offer the same

quality

of services that low flow practices deliver. However, large groups

are

a reality and they do offer some advantages for patients and docs.

Perhaps a hybrid model might work. For example, a group of 25 docs

might be divided up into 5 low flow practices. The larger group of

25

could still offer large group services such as group visits,

registry

reporting, access to lower priced injectables, maintaining IT,

on-site

lab services, x-ray, better contract rates, etc.

Is anyone aware of medical practices that are " large " but divided

into

low flow sub-groups? Is there any literature on this approach?

As I write this it occurs to me that the folks on this site must

have

discussed this idea already.

Lowell

April 17, 2008

Hi Lowell,

The group you’re referring to, Steve

& I jokingly call “the confab.” We agree, it seems that

the mission statement (if there actually was one) is exactly what you

state. Steve & I haven’t heard anything come out of the confab

that we would go along with so far. If we could come up with a good

business plan to present to this group of doctors, I think we could join forces

and help reduce overhead, improve patient care, and have more family time as

well for a lot of the doctors in this valley. We won’t be going

fishing, but we will go climb a mountain!

Pratt

Office Manager

Oak Tree Internal Medicine P.C.

From: [mailto: ] On Behalf Of Lowell Kleinman, MD