Saturday, December 27, 2008

Many Thanks

I often leap onto my soapbox and forget to mention all the great things about my life and job. I must thank Joel Rose who did the NPR article for Day 2 Day, and did a fantastic job focusing on the positive aspects of my practice. I am so grateful for his spectacular interviewing and editing skills, I can't get over what a great job he did on the article.
And also, thanks to the many people who have sent encouraging replies or emails to the blog or the NPR piece. It always renews my spirit to hear other docs talk about the real priorities in family medicine, and to hear patients that appreciate docs who really do care, and are supportive.
And also thanks to my sister Kath, for sending the letter to npr in the first place.
And of course to Al, because I'd be nowhere without him.
And, I wouldn't want to leave out my friends and family, the support and stress relief are beyond measure.
Happy New Year.

more proof that things really do need to change

It's not that I want people to have to pay. I sometimes feel somewhat hypocritical about charging people a hundred dollars for a doctor visit when in my heart of hearts that healthcare is an unalienable right and should be freely accessible to all. It even looks hypocritical here in print. But here's my argument: it's not just that everyone needs healthcare, its that everyone needs good healthcare. And right now, December 27, 2008, I can't deliver good healthcare for what I would be paid by insurance companies.
And another thing, I think that by continuing to work within a broken system, we are sending a mixed message. Every time I talk to family docs we talk about the unfair payment of insurance companies. Again, I reiterate, we are the ones agreeing to take the crappy pay!!!!! But we are also sending a message to our patients. We want our patients to be educated and empowered and proactive about their health, but then we all to often allow them to think that insurance company rules are more important than our recommendations. Three months ago a woman in her 50s was in my office for a check up, her mammogram was (my favorite) "probably benign" asymmetric density, (irregular lump) recommend 6 month recheck. Knowing her family history, and the fact that she had abnormal mammograms before, I decided that neither she nor I was comfortable with waiting to check out an abnormal, even if it is "probably" benign, so I recommended a breast MRI, something, I realize, that I probably wouldn't have been able to do in a land of "nationalized healthcare". Turns out I can't do it here either. Despite two appeals, it was denied by her insurance. So I explained to her that a lump is a lump, and she should see a surgeon to see if it should be biopsied. The surgeon agreed with me, and ordered an MRI, but never told me the outcome. Three months later she came to my office for "follow up" and I said, "I never heard from the surgeon, what were the results?" and to my shock and dismay she told me the insurance also denied the MRI request from the surgeon so she never followed up (and neither did the surgeon). I told her she must go for mammogram and ultrasound to evaluate for change now. She told me she was afraid the insurance company would deny that, too, since the radiologist recommended 6 month. It got approved, and unfortunately, the irregular lump is now bigger. Lots of things should have been done differently. I don't know how this will turn out, and I pray for a negative biopsy for her.
The fact is, our system was set up to make her feel like the insurance company had the last word, and we have let this happen. And we must stop. I realize that this is not directly related to my practice style, but indirectly it is. Because every day, when my patients make the choice to come "out of network", they are reminding themselves (and me) that good care trumps insurance policy.

Wednesday, December 10, 2008

Home Improvement

So I've got some angst about the whole Patient Centered Medical Home agenda. The American Academy of Family Physicians explains it thus: "A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system." Key features include: ongoing relationship with a personal physician, comprehensive care, whole person orientation, coordination of care across all elements of the community and healthcare system, quality, safety, evidence based medicine, enhanced access, and physician accountablity. More details on the AAFP website's QandA. I have no problem with these ideals.
This program has support from the AMA as well as the American Academy of Pediatrics and several other groups, with the idea being if we come up with a good system, we can use this as a means to convince Them (the people who pay us) that we deserve to be paid for our work.
These groups, supporting the PCMH, and an organization called TransforMed, have come up with a "strategic transformation process combined with an integrated suite of practice transformation products and services— all derived from our experiences facilitating the NDP and designed to create a framework, a common language and an opportunity for practices to become Patient-Centered Medical Homes". Here is where I start to get a little twitchy. I get it, we have to have a common set of rules and guidelines, we have to be accountable to standards. But I am viscerally opposed to anything that makes our system of payment, reimbursement, and delivery of care ANY MORE COMPLICATED THAN IT ALREADY IS!
Then, people talk about one of the reimbursement improvements would be a set payment per patient. In December 1 AMA news article about the medical home it notes that in a North Carolina program a doctor receives $2.50 per Medicaid enrollee per month to manage their care. That is ludicrous. (Even assuming that medicaid pays per visit as well). Here's the deal, it takes time and resources to provide good medical care. Good systems can help that be more thorough and efficient, but over systemizing it and not giving the support needed to spend the time and resources only makes greater expectations and more frazzled, stressed out, and overburdened docs.
Now, I realize that part of my gut reaction is my inherent resistance to change of any kind, especially right now while my practice is in the midst of this transition. But I really really have a bad feeling about this. We've tried the "doctor manages and coordiates the care for a monthly fee per enrollee", we called it capitation and it was very appealing. But it feels to me like it promotes a system that encourages doctors to have lots of people on their panels and hope that they do not schedule appointments (free money). I sat at a hosptial staff meeting once where a good portion of the time was spent discussing what to do when HMOs remove people from your capitation list and stop paying you the monthly fee for these people, how to compare to prior lists to see who was removed. I asked if they could just check the lists as the patients schedule to see if the patient is on the list, and they explained that the people that were being "removed" were people they had never ever seen or even heard from, they were their assigned group. This is what we waste our time on, and I fear the new and improved system will promote the same attempts to "beat the system" in order to make enough money to stay afloat.
"But," I say to myself, "the new system will have requirements in place to make sure docs have the correct protocols". Well, I respond to myself, there's guidelines now for proper care and lots of docs for lots of reasons don't follow them.
So how to make it more fair then? We could just pay the docs that really and truly do the good job-pay for performance. One more thing to document and list and submit on my list of things to do. And if some docs are willing to upcode, downcode, and double bill now and risk the nightmare of a medicare audit, why wouldn't they be willing to fudge on the P4P submissions too.
Truly, I feel the only way to fix the payment problem is to minimize the red tape and infinite trees of denial and approval rules, and wipe the slate and implement a single payer system. Never will a group of payors (group = N>2) agree to a set of guidelines and payment structure. And the larger the N, the more loopholes they can make to make it confusing to doctor and patient alike.

The other thing that gets me about the Transformation To A Patient Centered Medical Home Model, is that when you transform into something, it implies that you are something different now. Back in med school, I picked Family Med because of the comprehensive, whole patient in the context of family and community approach. That is what I was trained to do. I'm not denying room for "home improvement", there's lots of things I look forward to implementing as advances in medical knowledge and technology explode. But I do not need the headache of managing a team of providers, nurses, social workers, dietitians, and educators in order to be a good Family Doc. I don't feel like I should have to justify myself to anyone except my patients and the medical board. I do not believe that I need to Transform My Practice into a different entity to make my patients feel that my number (or email) is the one they need to call when they have a health problem, issue or question. They will (and do) call me first when they know that I will (and do) give my best effort to provide them the best care.

Thursday, November 20, 2008

Can you blame them??

On Tuesday, CNN headlined an article "Half of primary-care doctors surveyed would leave medicine" (if they felt they had an alternative. ) And we learned a few weeks ago (in many major papers) that only 3% of medical school grads are going into primary care. Now, using logic, primary care should be pretty important. Not everyone needs a surgeon, or a neurologist, or an ob-gyn, but anyone with a body that might someday get sick, should have a primary care doctor. So if everyone needs a primary care doc, but 97% of med school graduates are going into other fields, and half the primary docs out there want to leave, what the heck good is it going to do to give everyone health insurance?!?!?
So before we go around mandating or dishing out health insurance to everyone, lets step back a sec.
Here are the cover articles from my (snail) mail on Monday morning:
American Medical News: "Medicare rated as poor performer during debut of pay-for-reporting"
Physician Practice Journal: "Finding lost treasure: Search for billing and coding gold"
Journal of Family Medicine: "10 Billing and Coding Tips"
I could easily spend 90 % of my "medical reading" time on figuring out how to get paid. There's got to be better stuff for me to learn. Why would people want to go into this job?? It has gotten much worse in the past 4 years, I think. (or i've just become more aware, but judging by the amount of articles about payment, I think the situation is crumbling)
When looking at the changes in the healthcare plan, we must ABSOLUTELY NOT lose sight of the fact that if we do not simplify this process it will not work. (Two ideas that are interesting right now are Sen Baucus' proposal, which highlights improvement in primary care with modifications of the current system, and the US National Health Insurance Act which supports a Single Payer system.)
I am all about the "new model of Family Medicine" the Patient Centered Medical Home. In essence it means that patients, who want to stay healthy or who are sick, have a Family Doc to call their own, that they can go to for advice, treatment, and coordination of care. Nothing new about it if you ask me. The "new model" calls for better payment though, which would be nice. But I cannot imagine how the laundry list of things to be paid for could make billing easier. So they came up with the idea of paying Family Docs based on the number of patients they care for, if they keep up a basic practice requirement. BEEN THERE, DONE THAT!!! We've spent 20 years proving that capitation doesn't work out for the docs.
I'm loving the fact that I could ignore the "how to get paid" articles. In the many articles I've read about "cash only" or "no insurance practices", none have ever indicated that they were a bad idea or didn't work. I am infinitley less stressed in the last 48 days. I feel for the first time in years that I have job security. I don't think that a cash only practice is the final answer, but until we get a system that works, maybe the "no-insurance" docs will be the ones to survive.

Tuesday, November 11, 2008


It has been an interesting mix of people that have decided to "stick with me" through this practice change. Some, despite having money to go on several cruises a year, have opted to save their money and transfer. (Which is fine). Others, with seemingly very little money, come in and pay, and often with a bit of pride about it. Many will come into the exam room and try to pay me directly (rather than the receptionist), and others will say to their spouse as they walk down the hall, "don't forget, we have to pay the lady". But they don't seem begrudging, or annoyed, I get a sense of pride from them, that they have opted to spend their limited resources on something important. It is as though, I feel sometimes, I am backed by a small, ragged, and sometimes sick little army in this battle against a failing healthcare system. And they are rallying. Its cool.
In the past week since the election, I can feel the energy and hope. Cape May County is strongly republican, and there are still some difficulties understanding that skin color is not relevant to leadership ability. But people will whisper to me behind their hand that they are secretly glad that Obama was elected, and that he will be a great president. (One person told me they even voted for him!) It is this optimism, I think, that at least this week, keeps me, and my small army going. Once more unto the breach!

Wednesday, October 29, 2008

The Guilt Factor

I think I've touched on this before, about feeling bad when people have to leave here, but the guilt issue is really the worst part of this whole setup.
Most people, even if they have to change doctors ("have to" vs choose to is a different topic), are not bitter or angry, and send their verbal support and words of encouragement. There's a source of guilt right there, these people aren't mad or bad, and I'm "driving them away". Then, there are the angry ones, I am ok with them leaving, because I don't really like to deal with angry people anyway. But there are others who might as well have taken lessons from my Mom about how to make me feel guilty. One lady couldn't even call me herself, her daughter called to cancel her appointment because the patient had been in the hospital twice "because of all the stress I had caused her." Her appointment was scheduled before the Medicare end date, but she could not even bear to come in and see me. As unrealistic as that is, and as much as logically I want to say "if you're that upset about it, find a hundred dollars or fill out the financial hardship form!!", I know this lady, she matters to me, and while I think she needs to reevaluate her coping skills, I truly do not want to cause stress in her life. Part of my job is to help people through stresses, not to cause them (real or imagined). I have also heard from several people variations on "how can you do this to me?" and "I thought we were friends". And really, I do have a connection with these people. I don't just look at them as "customers" or "clients".
Then, there are the ones who stay. I know that it is hard for some of them to come up with $100, or the discounted fee schedule if they qualify. And it is near impossible for me to charge people the $175 for "extended" visit. That's a lot of money. And I just keep telling myself that the plumber, the electrician, the mechanic, the vet, the lawyer all charge high fees, and many of them do not have student loans the size of a small mortgage. But I still feel bad.
Then of course there's all the other things in this job I can feel bad about, making people wait (not usually too long), addressing lifestyle issues like weight and smoking without offending people, my own human error and (hopefully rare) mistakes, and delivering bad news. I'm mostly used to that stuff though, and that's part of why they pay me the big bucks...

Thursday, October 16, 2008

What to charge?

Ever notice when you go to the doctor or a hospital, the bills seem outrageously high? That's why all doctors are rich, right? But then did you look at the EOB (or explanation of benefits)? They are very tough to read, and even when you do realize what the different columns are, it seems there a magic 8 ball somewhere determining percents, amounts, and denial codes.
So here's a brief overview. When a doctor contracts with an insurance company or agrees to a medicare contract, they agree to accept "fair and reasonable payment" for services rendered. In many cases, the standard contract does not list what that will be, the insurance company changes the reimbursement rates based, somewhat, on the current "market value". Except that they can really just pay whatever they decide is fair and reasonable. Often this is a percentage (usu from 70-150% ) of the medicare allowable amount. (not usually 150.)
So medicare decides what is "fair" to pay for an appendectomy, a pap test, a chest xray, a basic office visit, open heart surgery, etc. These all have codes, and a medicare committee determines the value of each code. (this committee, by the way, is made up of 17 surgeons and 9 non-surgeons, that's fair, right? not.)
So I could charge $10,000 for a 99213, (a standard office visit), but it doesn't matter because I am only going to get whatever medicare says is "fair and reasonable". (Unless you are one of the uninsured, in which case you're just paying the full amount, whatever it is.) But, medicare and the insurance companies won't pay you extra, so if I only charge $50 for a 99213, even if they "allow" $77 I will only get the $50. So I should really make sure I charge high for every visit to make sure I get the maximum amount back. But if you are in the category of "cash patient", that higher charge makes a big difference. It makes it tough to evaluate what people charge, because in this industry, very few people expect their charge amounts to have any relationship to their amount received.
But I think it makes us look bad to charge more than our service is really worth, just to make sure we get paid the bare minimum. Someone told me they had surgery for a knee replacement. The total bill was $50,000. The final amount paid out was $12,000. How does one financially analyse what was "lost" or not in this transaction. What was the surgery really worth?
So when revamping my business model to exclude the Magic 8 Ball Effect, it is really hard for me to figure out what to charge. I tried to factor in my expenses (ouch this year), my debt from school and the practice, how many patients I hope to see a day, how many patients I am able to see a day, what people might be able to afford, and what other docs get paid. I decided on $100 a visit, unless the visit is over 40 minutes, and shots would be based on market price (like when you order lobster at a fancy restaurant). Is $100 enough? If I can see about 50 people a week it will be fine. Is it too much? I almost hope it is, so that I will be able to lower my rates and make care more accessible to more patients.
I wonder how much the perception of the healthcare crisis would change if doctors really charged what they needed or deserved. I personally have a hard time being sympathetic for someone who is charging $50,000 for a surgery, even if I know they are only getting $12,000. How can people understand what is really going on with their healthcare dollar, if the numbers are so abstract? How can doctors really know what their write offs are if their charges are not really what they need to be? This is a fairly easy step that doctors could take to demystifying health care finances.

Wednesday, October 8, 2008

so that's what my kids look like!

In the past week, I've put my kids to bed every night (that didn't mean they went to sleep though), made lunches the night before they were needed, known where the shoes were most of the time, and thourougly decluttered my kitchen. I still have not been home for dinner much, but I see progress. I've also played scrabble and watched a movie with my husband, and taken the guest dog for a walk. And gone to the gym twice.
It's not that things have changed so much here at the office, but I feel like the burden has been lifted, that I will someday get through the charting backlog, and that I can go back to worrying about people first and money later. I still get panicky when 2 or 3 people cancel in a day, but so far, when that happens, the spots have filled back up.
There is another strange phenomenon too, yesterday I received 2 gifts from patients that are transferring. It seems funny to me that people who are changing doctors would be sending a thank you gift to the current doctor, but not staying. I understand that a little angel statue is a much more affordable token of appreciation than $100 a visit, but if my care is worthy of a hallmark card or even better, gourmet German chocolate, wouldn't it be worth it to get fewer manicures and get the top notch medical care.
Then, when I say that, I feel like I'm being snobby, and I don't want to be. I know that there are many Family Docs out there that are doing a wonderful job, but I know too many that seem like they are pressured to to more and more in less and less time. Every patient satisfaction survey I've looked at notes that amount of time is one of the biggest complaints.
So that's where we are a week into this adventure. So far so good.

Tuesday, September 30, 2008

government cheese

"Why should I pay you for a visit, when I can go to the doctor up the road with my medicare and get the visit for free?" asked the cute little lady whom I've grown to love despite her arguments and noncompliance. I asked her if she remembered government cheese. I tried to tell her that she's welcome to go to the doc up the road, and might very well do fine there, and I in fact like the doc up the road. But if she's looking for something else in healthcare, something different in her visits, she could pay to come here. Maybe, with healthcare, we are getting to a point where the government subsidized plan isn't the best one for everyone (I said carefully without trying to offend those still participating the government program). So I tried to parallel government healthcare with government cheese.
Turns out she loved "ronnie's cheese" as she called it, gave me a good recipe for veggies with melted government cheese, and wished me luck. I'll miss her, truly, but maybe she'll be back...
or maybe she'll make the best of the change.
Today is my last day as a medicare participating provider, and boy am I glad september is over. I'm still bogged down in charts to copy, issues to follow up on, and getting Connor to do his work, but I feel, at least, like I can move forward.

Thursday, September 25, 2008

"are you crazy?"

So I've been thinking about trying to capture all my thoughts and ideas about what's going on with the practice, how it effects (affects?) my life and the life of those around me, thoughts on medical economics and "healthcare", maybe if it all makes sense I can avoid reliving some of the mistakes I've made in the past, and repeat some of the more positive stuff. I also want to track my hours worked, patients seen, and overall satisfaction, to see if all this effort is worthwhile. So this is the start.
Here's the baseline: graduated residency 2000 West Jersey Family Practice Resiency (Virtua), joined a group in Cape May County, decided I wasn't a team player, so bought out the "satellite" office down here in Cape May Courthouse. Was going along fine until I realized that I needed to be spending a bit more time with my patients in order to make sure I was doing a thourough job, so I spaced out my schedule to allow it. Then I realized that I didn't really get paid enough per visit to see less patients so in 05 I started dropping insurance plans, and up till now have been down to 3 plans, medicare, and 2 others. Starting october 1, I will be "opting-out" of medicare, and the other two plans will terminate in early november. I'll be all cash. People keep saying "are you crazy?" It is a little scary, and very hard to hear people say "I just cant afford to pay you" (and lots of other stuff). But scarier to think about how much I work for so little money.
So now it's 10:09 pm, I've got about 40 more minutes of paperwork, in addition to trying to process the charts of people who are transferring.

Future topics may include: what to charge, patient reactions, reactions of other docs, scanning charts, my dream practice