ECMD

Back in the Day

2010-06-29T18:58:00.000-07:00

Remember the good old days? Back when you could see patients, take your time, learn about them and their families, and really understand some of the actual things that affect their health (and not only the measurable metrics of lab values, BMI, and vital signs)?

Remember when you didn't have to decide if a visit was a 99213 or a 99214, and what modifiers to use? And a diagnosis was described using words, not numbers?

Remember when there were paintings on the wall, instead of big signs that say "Copay is expected in advance of your visit" and "Referrals require 72 hours notice. NO EXCEPTIONS."?

Imagine, a life without billing codes, prior authorizations, referral paperwork. Imagine a day where all the patients were entitled to the same treatment, without having to ask permission from a third party. Then add a staff that is dedicated and comes to work expecting nothing in return, (you don't even have to ask them to make decaf, they remember that's what you drink!!). And this staff, they care what happens to the patients. They pay attention to the individual. They do what they can to help them get what they need.

Then, add the fact that the patients have no insurance and very little money. So their visits are free. And the other cool thing about this staff, they work for free.

So there's no money exchanging hands. Just good sound medical advice, lots of patient advocacy, and a whole lot of generosity of time and spirit.

That's VIM, my new job. I'm the brand new medical director of the Volunteers in Medicine Clinic in Cape May Courthouse. It's a volunteer and local donation based clinic for people without insurance who live or work in Cape May County who are unable to afford healthcare. (There's a income limit formula). It started in 2002, open just 2 half days a week, and has grown rapidly to a now 5 day a week clinic for primary care, with dedicated clinic days for eye care, psychiatry, and GI and ortho. VIM has relationships with several other area specialists as well.

I'm still learning about the many ways VIM helps the patients. The staff there works hard to make sure that patients have access to hospital care and services through Charity Care, and they have a computer program to enter every patient's demographics and financial data to apply for Prescription Assistance from the major Pharmaceutical Companies. And what meds are not covered by prescription assistance (or samples), VIM is often able to use their funding to buy patients their meds from the local Acme pharmacy. Can you imagine? Patients getting their meds, without insurance or money? Without begging for authorization, or waiting for approval.

Of course, there are always things that need to improve. Chart flow and communication between the many providers and staff are high on my list. Going between my tiny practice with me and 2 part time non-clinical staff to a practice with providers that may have never met and different volunteer staff on different days of the week presents a whole new set of challenges. It is exciting to me to get to look at all the issues I've looked at for the past 10 years from a completely different perspective. I'm thrilled to be able to challenge myself in this way. And I'm thrilled to be able to explore another system that's outside the "insurance model".

The VIM logo says "Neighbors helping Neighbors". The time I spend at VIM confirms my belief that all people deserve access to quality health care. And that at least in one place in Cape May County, other people believe it too, and are doing something to make a difference.

"Never doubt that a small group of thoughtful, committed citizens can change
the world. Indeed, it is the only thing that ever has." -Margaret Mead

Learning the hard way.

2010-02-15T04:53:00.000-08:00

So right around Labor Day I got pneumonia. Big nasty 'right lower lobe infiltrate with temps of 104, shaking chills, and hypoxia if I walked up the steps' pneumonia. I didn't leave my bed for four days, except to go to the ER and get xrayed. My mom took me. So its clear that I was Really Sick.
Now during this illness, once I was no longer solely focused on breathing, and after i finished all four Twilight books, I had some time to think, about many things related to healthcare, my job, and my life. Examples include the fact that despite a prescription plan, antibiotics are very costly; and the fact that I opted to have some of my testing done at the outpatient lab rather than while I was in the ER, because my insurance covers it at a higher rate if it is done at an outpatient facility, even though it was a participating hospital.
But I learned something more important while I was sick, and much more unexpected. I learned that somehow, in the last 18 months, I have started to develop some balance. Five years ago, when my daughter was born, I was back in the office when she was 5 days old, and I was getting called by the office while I was in labor. When I was sick in September, I was out of the office for an unprecedented 8 consecutive days. Five years ago, it took me about a year to make up financially for my maternity leave. When I came back from being sick in September, I was able to pay my staff paychecks that day and rent when it was due the following week. I didn't pay myself much for that week, but I didn't pay any bills late. I had enough buffer spaces in my schedule to fill in the people that I had to cancel while I was out, and still to work lighter days while I was recovering.
No one died, I don't even think anyone left the practice. And many many of the phone messages I got while I was out of the office were expressions of concerns and well wishes. I even got get well cards from my patients.

Being sick is a little scary. Not just the mortal fear of lack of oxygen, but there is a significant dread from loss of business, loss of income, and overwhelming medical expenses. But to come back to work, still recovering, and have a practice that is still viable, and patients that are still loyal, and a schedule that allows for emergency, and a small financial buffer that allows the bills to get paid close to on time, is huge. If I hadn't made the changes in my practice that I made back in October of 2008, I am certain I would have still been in the mill of overbooked and underpaid, scraping by to pay bills late and cramming as many patients as possible into a day.

So, the two most important things that I learned:
1. I can take a day off without losing my livelihood.
2. It really does take four to six weeks to recover from pneumonia.

After about a month, I walked up my steps one day and didn't get short of breath. I felt like I got my life back, and even better than before, because I am now a little wiser. I went back to the gym, and since then have run in two 5k runs. I've taken a short vacation and at least one personal day a month. (not including snow days). I am in the office less than two Saturdays a month. I took a day off to go to New York City with my mom before Christmas. We didn't have to hire anyone to do our leaves this fall. We painted the outside of the house ourselves.
I'd write more, but its a school holiday, so the kids and I are going skating...

Things I love about my Job. Really

2009-07-09T17:07:00.000-07:00

I'm getting tired of hearing myself complain, so I can only imagine what it's like for the rest of the people in my life. Because, when I complain, I am doing it so that I can figure out ways to make a great job even better. But, honestly, truly, I would not trade this job for anything.
So here are some things I love about my job, some are specific to my style and location of practice, some are just wonderful things about Family Medicine.

1. Helping people.
Al once argued (for the sake of debate) that Mother Theresa was the most selfish person in the world, his argument being that it feels so good when you are able to help someone, that all the help she was doing was in order to promote her sense of self worth. It's kind of a silly argument, but it does make a person feel good to get to help others.

2. Learning stuff:
The broad nature of Family Medicine allows me to soak up knowledge from all manner of other docs, today I learned about Alcian blue staining in Barret's esophagus, yesterday about pediatric rhematology and post mycoplasma arthritis. And learning stuff is always fun.

3. My office: I've got new office space since February, and I'm digging it. The walls are "willow tree" green, totally chillin, my office/exam room is nice and big, and comfy. And bill makes coffee quite often, sometimes its too strong to drink, but it always smells great in here. And it's handy to have 2 psychiatrists down the hall, in case i have an urgent psychiatric need, like the need for a very comfy couch.

4. Relationships
I get to meet and share in the lives of so many people every day. And I am blessed with patients who send me photo Christmas cards, share their produce overflow (tomato season is coming soon!!), and invite me to graduations, birthdays, and anniversaries. I care very deeply for my patients, and I am invested in their well being. That's my job. But they don't have to care about me, and they do. That's the bonus.

5. Time: I spend way to much time here, but the fact that I can spend an hour with new patients and complicated patients, and a half hour visit time is standard, is so incredibly relaxing. Gone is the pressure from knowing that if Mr X needs an EKG its going to make me late for the next 6 people. I have the time to do what needs to be done, and it feels good.

6. Staff:
Barbara and Mary, and those who have gone before them, have tolerated my moodiness and crankiness, and still come to work every day and and smile and make the patients feel welcome and cared for. That's so cool.

7. Amazing Charts, and other technological advances: There's lots of cool techno stuff going on these days. Technology is not the answer to our health care woes, but there are some fun things happening. AmazingCharts is a easy to use, friendly, and AFFORDABLE electronic medical record, and I'm excited to be making the transition away from paper. I've resigned myself that it's going to take a Really Long Time, but I'm young. Other cool stuff happening too, I can show people their xrays that they had done in the hospital from my laptop, I can (sometimes) send prescriptions electronically to the pharmacy, I can sign orders for the visiting nurses from my laptop to go to their palmtops that they take to the patients home, and just the other day, a patient texted me a medical question. These are good times to be alive.

Lots of people in the world have to wake up in the morning and go to a job they don't really like. I am not one of those people. All my complaining and pushing for change, its really, really, just so that I can keep doing this job that I love.

What I learned tonight: Health Insurance Reform Discussion

2009-06-11T18:53:00.000-07:00

So tonight I had the privilege to sit on the panel for an open discussion on healthcare reform sponsored (in a nonpartisan way) by the Cape May County Federation for Democratic Women. Lots of stuff happened, many words bantered. Fun, but really aggravating. I got to speak a lot of my views in a fairly nonthreatening environment, as most of the audience was already in favor of big time health insurance reform, and not many particularly resistant to universal coverage. I also got to sit next to Steve Fenichal, one of the infamous Baucus 13 ,arrested for trying to have doctors represented as equally as insurance companies and pharmaceuticals at the Senate hearing to discuss healthcare reform. He's cool, and knows lots of good supportive facts.
Also got to hear lots of arguments, and also fears from other sides of the battlefield. Lots of people worried about rationing of care, of somehow a rise in cost (how?), somehow trying to come up with common ground that allowed for a competitive market so that people could choose their coverage. It is something to think about, but every time i look at where a competitive market has gotten us, it sucks. if there is a cheap/free plan and an expensive plan, there will never be able to be fair coverage. I was on the fence, but actually the people in favor of the "public/private mix" plan pushed me over the edge (sorry , scrab-bill).

Then, it was all over, I was chatting with the other lovely social reformers there, and, as if i was in a movie, while i was getting a brownie from the refreshments table, appeared my old nemesis, Ann Richardson. And I must take this opportunity to rescind my comment about her being lucky and not having medical problems. And for any other inappropriate remarks I made about her. Her deal was this: if there is socialized medicine, "how will i know that i or my family will be able to continue to get access to the care they get now?" my response was along the lines of "why wouldn't you be able to? I'm not saying you shouldn't, I'm saying that EVERYONE should" . Her fear is that if everyone gets it, she will lose some, or have to wait, or not have choice. And there was no telling her that choice was fundamentally built into the system, that diminishing the waste in the current system will pay for the expense, and that there are even systems in place to help deal with the job losses from the health insurance workers. (which, btw is a pretty lame argument if you ask me, kind of like worrying about if we made cigarettes illegal what would happen to wawa).
And when we went over that ad nauseum, she still came back to being afraid that if everyone had health insurance she might have to give something up.

So what I learned is this: even though I feel I've got nothing to lose, I guess some other people still feel they have something to protect in this system. Misguided, brainwashed, she truly might feel this is the way to protect her family's health. And she is Afraid.

The other thing i learned, which might just save me from going completely insane, is that some conversations aren't worth the time. Everyone wants to win an argument, have the other person finally see the light of day and come to his or her senses. Then everyone wins, right?
But once it reaches "argument" mode, no one is listening, and no one wins. I walked away from Ann furious, that she could be so stubborn and closed minded. But after a brief moment of reflection, I realized that I don't really hate Ann. (i might rescind that if she bashes me in the paper tho, let me know if you see it in the gazette). I do hate the propaganda and fear mongering that she represents to me. She says "how do you know it won't be terrible?" and my answer is "what makes you think it will be?" her fears were answered and addressed in the bill, which she wouldn't answer whether or not she had read it, she said that the single payer plan would make everything worse, but she has NO DATA to back that up. There's horror stories everywhere, but for every "socialized medicine" urban legend I can give you a name of an honest to goodness Canadian that I have met that would gladly go back to Canada to get care. And after that I can give you ten true stories of delay or denial of care by the American system. But people believe the hype. Just like the swine flu and tainted peanut butter. And some people just aren't worth the argument.

But there were lots of people there tonight without an agenda to sell or a gauntlet to throw down, but with honest questions about the difference between single payer and the public/private plan. People who have come out to try to understand the options and make an educated decision. And I almost feel guilty for being so passionate, because I'm sure I might be just as unpleasant to talk to to people who might disagree with me. (maybe). And it's those people that are important. Most people, i think, don't have an agenda, but may be open to hearing arguments on both sides. These people deserve our time and respect.

My favorite moment of the evening was when someone asked what would happen to the thousands of people that would suddenly be jobless if single payer passed and the health insurance companies went away, and someone was saying there would be income protection, and job retraining, etc, and Steve F and I realized at the same time at least they'd have health insurance!

Field Trip to DC

2009-04-17T12:08:00.000-07:00

So we decided to have a family (family of origin as well as husb and kids) vaca to DC for mom's birthday. (She's 29, if anyone asks). We're staying with my brother Mike, and when we arrived last evening there was a small gathering of his friends. I really enjoy meeting people, seeing old faces too, and learning about what they do. And of course, leaping loudly onto my soapbox to anyone who will listen.
Since this is DC, the job options are slightly more varied than they are in Cape May County, and one of the people I met was a "Healthcare Policy Analyst". At the current phase in my life, that was about as exciting to me as it would be to meet the drummer for Van Halen or a pro baseball player. I'm embarrassed to say that I monopolized her attention for at least an hour after the other guests had left! But what a great conversation!
Here's what I learned: The Agency for Healthcare Research and Quality has a program called CAHPS: consumer assesment of healthcare providers and systems. https://www.cahps.ahrq.gov/default.asp
This group has developed patient surveys for hospitals that have been used for years in order for hospitals to get full medicare payment.
This group has also developed surveys for patients about the healthcare experience in outpatient primary and specialist settings. They are freely available, but I'd never heard of them.

There are people in this group who fear the development of the PCMH model as is stands. This particular individual who would prefer to remain anonymous (as if anyone reads this) could even remember about the time when we all embraced capitation and it didn't work out. She worried about the huge push for technology as the savior of healthcare, and realized that just having a computer and emr didn't make someone a better doctor. This sounds familiar.

So here is someone in Washington, who knows and advises people who make what amount to life changing decisions for me and my patients. (She gave me the example of Medicare D, she communicated with Senator Kennedy about the fact that it was and remains a Really Bad Idea.)

So here I've got this great opportunity, and I'm sure I looked like a total spaz! She is involved in the development of surveys for patients to evaluate healthcare quality, and hasn't heard of howsyourhealth. Correction, hadn't heard of it. I am a little lost on how to follow up on the conversation. I am again overwhelmed with information. I wonder how in this world of information overload, do people who share the same views combine their data and resources to influence policymakers. Or do we need to? Maybe it will all filter up. (Like salmon getting past the status quo of profit driven healthcare policy). And I wish I knew more about the system and how it works.

But mostly I'm just excited every time I meet someone that welcomes system-wide healthcare change.

The More Things Change

2009-03-09T02:48:00.000-07:00

So I recently read the novel "Middlemarch" by George Eliot. (actually I listened to it, a free recording from librivox.org which is a fantastic resource for audiobooks that are in the public domain). Among many other things, there was a doctor in Middlemarch, Tertius Lydgate, that came into town with lots of new ideas about how things should be done. He felt that if doctors directly dispensed medications and charged for them, they had a conflict of interest and would, perhaps, overtreat. He volunteered in the a new "fever" hospital, designed in case the cholera spread to middlemarch. He spent time knowing his patients, analysing thier conditions, and recommending approprate pharmaceutical and non pharmaceutical interventions. Some patients liked him, some didn't. Sometimes they got better, sometimes they didn't. But one thing was universally true. The stodgy old doctors in town hated Lydgate.
*small spoiler* In the end, Lydgates wife couldn't handle his dedication to his profession, he couldn't make enough money to pay his debts, he left town and went to the city, and he died young. His spoiled brat of a wife went on to marry a rich "more traditional" old doctor.

I guess I was fairly taken by the fact that even in 1870 the economics and politics of medicine were deeply enmeshed with the "medical" part of medicine. (and of course, there was no health insurance or government funding then, the hospital for the poor was financed by rich benifactors). The citizens of Middlemarch (perhaps spurred on by the old doctors) after seeing the financial and political trouble Lydgate had, began to question his medical judgement.

So I ponder the current climate. I wonder if I should make less waves. (This is purely hypothetical, because making waves is so a part of my nature that I doubt I could stop if I tried.)
I read the descriptions of the old docs in Middlemarch and had no choice but to envision the graying, balding, slightly overweight men I see at hospital and board meetings. (If you're someone I go to meetings with and reading this, I likely don't mean you). I feel as though I jump up and down and wave my arms and scream "THERE HAS TO BE ANOTHER WAY! LOOK!! TRY SOMETHING DIFFERENT!!!" (although I don't think I actually do jump up, I'm pretty sure I raise my voice.) And they look at me and shake their heads and mutter "poor misguided Tac. She had so much promise." If they see me at all. How long before they run me out of town, and I die young, penniless, and unloved.

Then I realize that I am none of those things. I am slowly chipping away at my debt. I have good community support, and home support like none could expect. And, alas, I am no longer young. So maybe we have learned something in 139 years. Or maybe things will always be in a constant state of change...

Moving Day is a very Dangerous Day

2009-02-10T19:33:00.001-08:00

Ok, nothing quite like moving to make you realize how much stuff you have that you really, really don't need. Unfortunately, the stuff you really do need is mixed all in with it, so you can't just dump it all. But it's been an exciting few weeks despite it all.

Packing: I had these great plans of taking the opportunity to go through all my file cabinets and folders and get rid of the outdated guidelines, and organize the useful ones into something in some sort of order, downsize, computerize, and declutter. You can go ahead and stick that one on the list right after "find cure to common cold" and "world peace". I did manage to thin out the patient chart room down from 5 cabinets to 3, and put an additional 40 boxes into my storage (attic), adding to the over 30 that were already there. Someday I'm going to have to deal with all of these, but not right now. (and we are painstakingly starting to scan the charts of transferring patients, so storage of them will be on disc, not in actual space, eventually).
I also took 380 pounds of paper to the Giant Shredding Truck. Mostly old billing paperwork that I realized it wasn't worth saving when I admitted to myself that even if I needed the EOB from my 3rd patient on June 7 2004, I wasn't going to be able to find it in the boxes. It was great to be rid of all that stuff, but shredding really gives me anxiety.
By last saturday afternoon, my packing/storage plans became more of a "sweep the entire contents of your desk into a large box and deal with it later" . That large box is now under my desk, to be rummaged through when I need something. Not exactly as I had planned, but it works.
Choosing: I was fortunate to be able to make some minor changes in the new place, including having a hole cut in the wall between the receptionist office and the waiting room, and a sink into the exam room, and paint. I was also fortunate enough to have an absolutely fantastic contractor do this work for me. Most of the choices were easy, (went to home depot, picked out the least expensive reasonable looking sink and cabinet, etc), but choosing paint was hard. I'm not the most visually perceptive person, but I've made some unusual paint choices in my life, and since I look at the office walls all day every day, I wanted to to be right. Most paint stores will sell you small "sample" jars of paint (the local one by me they are $5) to test on the wall. If I can give one bit of advice GET THE SAMPLES. Even if you need to try 10 different ones, it is worth $50 not to screw up the paint color. I picked out the one I liked, it was a sortof greenish aqua, but the lighting in the room made it look like baby blue. I would have been so annoyed with my little baby boy nursery walls all day. I ended up picking one that on the little square looked way too dark, but on the walls looks peaceful and calm and deep.
Moving: There is always, always, more than you think. Saturday morning I went to the office to make sure all of Fridays "real work" medical patient stuff, was done (friday ended up being a super busy day after a really slow week). Then came the joy of moving all that stuff that was so caringly packed (10% of the contents of the office) and the stuff that was haphazardly thrown into boxes (the other 90%). It turns out that most of what doctors do is not actually hands on medical care, we actually fabricate paper. It comes out of our machines in every shape and size and fills boxes and files and drawers and covers every flat surface until none remains. (Mind you, not much of it is the small green kind that you can exchange for goods). It is really scary.
The wonderful contractor I mentioned also was saintly enough to offer us his truck and trailer, and he and his wife spent the day with us saturday. I think I would still be sitting in the back of my old office looking around wondering how to move everything if not for them. We were able to get chart file shelves onto the truck with the charts still on them, alas, we could not get them through the new foyer without tiliting them onto their sides, so thus had to remove the charts while they were in the foyer. That was a bit of a drag, but aside from little stuff like that, it was super smooth. By saturday night, the old place was empty, and the new one overflowed.
Unpacking:
I went from four small rooms to two large rooms, deciding to minimize on unneeded space and duplication of stuff and work, so I have a room that is my office and exam room, and it's great. It has all my exam stuff (table, ekg, supplies), but also my desk, computer, bookshelf, phone etc. I really really like having a centralized work area. But unpacking my crammed office, and my cluttered exam room into a useable space was not exactly easy. Ditto for the front staff area-chart room, reception desk, copy area, and storage are all in one now. I think it would have been easy to start a new practice with this very efficient layout, but cramming my old style into this new one is going to take some work. I just keep on saying to myself "I don't need more space, I need less stuff."
The first week:
I've moved about one mile from my previous place, into an office building owned by two psychiatrists. It's been years since I've shared office space with other doctors, one forgets that not everyone does things the same way. They haven't thrown me out yet, so I think it's going to be ok tho. There's still a few kinks to work out (thermostat, door locks, and psychiatrists with overly sensitive noses who smell curry when it's not really there and try to blame you for making a smelly lunch). But all in all, I am so very glad to be in my new place. The new exam room/office is comfortable and roomy (if not yet perfectly organized and arranged). I can have 3 extra chairs now for patients and family, and there is plenty of breathing space. And breathing is good, right?

Change is good.

2009-01-21T17:02:00.000-08:00

So I'm sure blogs all over the great wide world are talking about Obama and his great speech and how the world is changing right now, so why should I be any different?
Let me start by saying I am so so so so so so very glad to see Barack Obama as president. I just feel like his attitude aligns with mine on so many economic and foreign policies, and he's got great plans and he's not afraid to point out things that screwed us up. He's going to to a lot of good, I think. Except, of course, for healthcare.
He said two things in his (beautiful) inaugaral speech that touched on The Healthcare Issue, and I'm not going back to look at the exact quote or I'll never get anything done so I'll paraphrase. He said we will use technology to improve healthcare delivery. I got the impression, probably from other talk I've heard about budget allotment and planning, that he means that by pushing for an Electronic Medical Record (EMR) we will be able to give more organized, coordinated care. Sounds great, but the reality is computers can't make medical decisions. Computers, as we all know, are good when used correctly, and can make life much more complicated if not. I know too many doctors that have saved lots of time with thier EMRs (I hope) that now are incapable of writing a coherent note or summary of care. They click the template for the visit, add in if indicated, and off it goes to the pcp with an electronic signature, and I get a letter that makes no sense at all. (e.g. the "routine post op check, wound healing nicely, pt recovering well and can resume her normal activites", by the time i got the letter a week later, the patient was dead, I called the surgeon to ask why he thought she took such a sudden decline, he said that she was in fact very ill at her routine post op check, and not even walking without assistance, he was not at all surprised at her death, but her wound had healed well so he sent the standard note). So my point is, getting an EMR might help make good doctors more efficient (maybe), but they can also make bad doctors faster at being bad.
The next point of concern I had with President Obamba (which still sounds beatiful to say) is when discussing things that will change for the better, he said "we will lower healthcare costs". I wish people would stop saying we need to do that. It's not the care costs that need to be cut, it's the adminitration cost. (Ok, some care costs too). I feel somewhat threatened when people say that healthcare is too expensive. Health Insurance is too expensive, and some parts of health care costs are expensive, but it is unfair to lump them. I fear that "lowering healthcare costs" means lowering reimbursement for docs, and tradtitionally, the primaries lose out first. We need to reduce the administrative costs of healthcare, the wasted time spent on useless hassles, the unnecessary paperwork and multiple faxes and phone calls. We need to reduce healthcare waste by having a strong primary care system so studies and procedures and meds aren't duplicated. We need to reign in pharmaceutical costs somehow. And at some point we need to buy in to the fact that we as physicians have a moral, ethical, and economic responsibility to not administer care that we know is futile. Then, if we haven't saved any money, we can talk again.

Small scale change is good too. I'm getting ready to move into a different office, about a mile from my current one. I usually hate the stress of moving, but right now its not so bad. I like the opportunity to clean out the cobwebs, and get rid of the excess. (which is why there are 16 boxes of charts in my bedroom and hallway right now). I like chosing paint colors and deciding where furniture will go. Its just fun to step out of the grind, look at processes, and how they can be better. I might not feel this good about it in two weeks, when its time to be done and i'm not even packed, but right now, it's all ok.

Many Thanks

2008-12-27T15:01:00.000-08:00

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

2008-12-27T14:38:00.001-08:00

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.

Home Improvement

2008-12-10T20:19:00.001-08:00

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.

Can you blame them??

2008-11-20T06:56:00.000-08:00

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.

Empowerment

2008-11-11T07:19:00.000-08:00

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!

The Guilt Factor

2008-10-29T10:21:00.000-07:00

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...

What to charge?

2008-10-16T09:45:00.000-07:00

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.

so that's what my kids look like!

2008-10-08T10:12:00.001-07:00

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.

government cheese

2008-09-30T16:33:00.000-07:00

"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.

"are you crazy?"

2008-09-25T19:01:00.000-07:00

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