PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Annals of Internal Medicinehas a nice study on the ability of ”structural capabilities” to improve  primary care.  Let me translate: structures are systems implemented in a practice, such as EMRs, paper based reminders, on site language interpreters etc.  They are mechanisms a practice puts in place to improve quality and efficiency of care.

So what works?

An EMR is helpful to bring up scores on some HEDIS measures such as: screening for breast cancer, colorectal cancer, and chlamydia, and diabetic eye care and nephropathy monitoring.  Even at that, it only improved scores if it was a “frequently used multifunction” EMR–meaning that xray reports, labs, med lists, problem lists and specialist notes were ALL on the EMR.  If the EMR was underutilized, or not as functional, it would generate lower HEDIS scores.  So, if your practice is getting an EMR, better make sure you get a highly functional one and actually use it!

Systems to remind patients to obtain necessary screening  improved HEDIS scores, but paper notes to physicians were not helpful.  (Now why is that?  The authors speculate that is may represent practices that have barriers to optimal care.)  Having an interpreter on sight wasn’t particularly helpful either, nor was a multilingual practitioner.

Having frequent (at least quarterly) meetings where quality of care was discussed led to higher HEDIS scores as well.

So simple steps to improve quality of care at your practice:

1. If you are getting an EMR, get a highly functional one that includes multiple functions such as labs, x-rays, medication lists, notes etc, and use it.  Best if subspecialists use it as well.  (Don’t ask me how you are to accomplish that!)
2. Have frequent meetings on how to improve HEDIS measures such as screening for cancer and diabetic monitoring.
3. Send reminders to patients to get their screening done.

Right now, that’s all that has been studied and shown to work.  What works for your practice?

Forgive me if this adds to H1N1 hype. For those of you who feel that forewarned is forearmed, here is a simple check list to help your practice in what could be a busy influenza season, both with seasonal influenza and “swine flu.”

• Lay in a supply of alcohol based hand sanitizer and surgical masks.  Have signs on your office door along with a supply of both, advising patients with flu symptoms to use them.
• Remove non-essential items such as toys and magazines from the waiting areas and exam rooms.  These can serve as a mechanism to transmit the viruses.
• Have a place were symptomatic patients are separated from other patients.  Some practices triage over the phone and have symptomatic patients enter through a different door and go directly to an exam room.
• Encourage staff AND their families to get influenza vaccines.
• Have a plan so employees can work from home if possible.
• Cross train employees to cover for each other.
• Have a defined sick policy.  The federal government is recommending those with suspected or confirmed H1N1 stay at home for seven days or until they are well, whichever is longer.  (See flu.gov.)
• Physicians should develop a plan of what to do if they are sick.  (My group, ExtraMD, has already been called in to fill in for one doc out with the flu.)
• Have a plan of how your practice will handle extra patients.  Consider finding an extra practitioner temporarily, or sending patients to another office.
• Current recommendation on treatment: (verify this for yourself, please) tamiflu for those hospitalized with suspected or confirmed influenza, those with high risk from complications, e.g. children younger than 5, adults 65 and older, pregnant women, those with chronic medical/immunosuppresive conditions. Start monotherapy with tamiflu within 48 hours of onset of symptoms.

Hope that helps.  Take good care of yourselves–doctors are people too!

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According to MGMA, physicians’ number one concern right now is falling revenues.  Especially concerning is collecting copays. Copays are tricky–this is the part of the revenue that the physician is directly responsible for collecting.  Making it even more challenging is the fact that physicians didn’t go in to medicine to become business people, but rather to help and heal people. Some physicians find it abhorrent to even think about the business of medicine.

If you are one of those, I suggest you think about an important concept: you can’t practice medicine if you can’t keep the doors of the practice open.

If on the other hand, your practice is so well run that patients run in carrying cash for the copays and insist on leaving a tip at the front desk, read no further.

Here’s the deal: you must get paid for the work you do, you must meet the financial obligations of the practice, and you must take home some sort of paycheck to keep bread on the table, a roof over your head and clothes on your body.  Your dependents would probably appreciate this as well.  Health insurance and retirement funds are optional.

So what to do:

1. Set the expectation from the get go that a copay is  expected at the time of the visit.  Have a sign to this effect, and train your staff as to the importance of collecting the copay from the beginning.
2. The front desk should check the insurance card for the amount of the copay every time.  (I was at my ob/gyn office, and they tried to convince me to pay the “specialist” copay of $50.  Since when is a gyn visit for a pap smear a “specialist” visit?!)
3. The front desk person should ask, “how will you be paying the copay today?”  (Notice: not “will you be paying the copay today?”)
4. Take credit cards if your office can afford it.  Credit card companies take a 2.5 -3% of each transaction.  When your margins are really tight, this can be significant!
5. Ask for partial payment.   Getting even some of the copay and billing the rest is better than getting none at all.
6. Be diligent in following up on missed copays with billing.  Again, have the option of putting it on a credit card when you send out the bill.
7. Make sure you have a system for logging copays. 
8. Keep the goal in mind: doors open=practice medicine. 

Good luck out there!

Today I was at a primary care office and walked in to a mountain of paperwork and charts.  I was in an office of a solo internist, and he was gone for a total of 1.5 days.  In one day, he had FIFTY charts worth of labs, x rays and reports accumulate for him to view and sign.

It took me an hour and half to go through them, sign them, make the appropriate dispos: e.g. patient needs follow up  appointment, needs phone call etc.  Of course, that one and half hours isn’t paid for.  I tried to make it quick, making piles of charts to file, piles of charts of patients to be called, piles of those needing follow up appointments etc.  I racked my brain for ways to make this more efficient, but couldn’t come up with much.  It just needed to be done, and it required a physician to do it.

In keeping with the guidelines on abnormal labs I just blogged about, I had the patients notified on every test if it was normal, and scheduled appointments for those that weren’t.  Same with x-rays etc. An EMR may have helped as results could have routed through the EMR, but it would still require review.

I don’t have a solution for how to wade through the endless paperwork.  Maybe this is why we desperately need to reform how we give health care, and how it is reimbursed.  Thoughts on improving efficiency?

The hospitalist groups I work for are both trying to cut costs as hospitals are clamping down on the payment to hospital owned groups. Both groups are stretched thin, and rely heavily on locums to fill the gaps. Here are some ideas on how hospitalist groups can save some mula as we continue to weather the economic storm. I admit some are ridiculous, but others should have happened long ago.

• Wash own coats. (I already take mine home because I don’t like the starch!)
• Print on white paper (for some reason the administrative staff prints our patient lists on blue paper-more expensive then recycled white!)
• Cut CME money-go ahead and give the time off, but reduce the amount for educational expense.
• Cheaper business cards-go cheap on the ones we give out to  patients.
• Cut excess staff. The two groups I work for have way too many administrative staff.
• Avoid locums staff-this may sound downright stupid coming from the owner of a locums staffing service, but here is my point: all my docs (including me) are local and more reasonably priced then the big companies. See if you can find physicians like me who fill in for less, live in your area and provide great patient care. (A little shameless self promotion,eh?)
• Buy cheaper pens.
• Cut down on computers. One office I work in has way too many computers for the EMR-the computers seldom get used to capacity.
• Consider ER hospitalists. Let me explain myself. Many of our admission are the so called “garbage” admissions-those patients that are admitted for social reasons, or because the ED is too busy to work them up fully. Admissions cost money. Why not have an ED Hospitalist that does the “borderline” or “garbage” admissions and tries to get those home that don’t belong in the hospital? This would cut back on physician staffing requirements, and heck, would even save health care dollars!
• No more free food. Sorry, don’t kill the messenger.
• Look for cheaper phone systems and pager systems.
• Up staff during day to take the 2 pm ED patient bolus. Evening and night time physician coverage is usually more expensive than day time coverage. Up staff the rounders during the day, with the expectation that with fewer patients to see rounders will also do 2 or 3 admits. This will help take care of the 2:00 pm patient bolus most hospitalists get from the ED. (There are usually two bolus times: 11:00 and 2:00 pm-with the 2 pm bolus being the biggie.)

I need to bleach my coat, so I gotta go.

In the last two weeks I have spent time at two completely different hospital system, and by default, spent a lot of time in their EDs.  One ED is efficient, the other over orders and under delivers, and easily becomes overwhelmed.  So what is the difference?

First, the two EDs serve two very different populations.  One is the go to hospital for a large HMO in the area.  The other is a large, urban trauma center, serving a significant population of the homeless as well as weekend warriors that are getting fancy hip replacements.  Guess which one is more efficient and effective?

If you guessed the HMO hospital, you guessed wrong.  The large sprawling hospital with “we take ‘em all” attitude is more efficient at healing and dealing with patients.  They don’t have a fancy EMR, they don’t have smarter docs, or better nurses, or fancier equipment.  (It’s actually kind of an arm pit of an ED.)  What they have is a culture where patients are fully worked up and all avenues are explored before a patient is admitted.  Let’s call this ED “A” (for armpit!) and the second ED at the fancy HMO ED “F” (for fancy.)

Differences:

ED A values disposition, looking at hospital admission as a last option.  This is based on the fact that with such a significant homeless population, hospital A would go out of business if ED A admitted everything. 

ED F, on the other hand, values through put.  ED F will get paid on every patient they see, and the hospital will get paid by the HMO for every patient that is admitted.  There is no incentive to not admit patients.  Rather, there is incentive to clear the decks of the ED and move patients through to the hospital.

ED A must complete work ups so they can dispo patients effectively.  ED F frequently will call and say, “Mr. Oldtimer can’t walk, and I don’t know why, so he needs to come in.”  Work ups stop as soon as patient is admitted because, for ED F, it is easier just to admit patients than work them up and attempt a disposition.

Hospital A has a powerful hospitalist group that has a lot of clout.  The hospitalist group and hospital don’t want to admit patients for social reasons.  Again, finances play a large part in this culture of disposition.  Hospital F has a hospitalist group that has no clout, and is viewed as a baby sitting service by the ED.  ED A will hear about it from the hospitalist group if work ups are incomplete.  ED F will hear nothing.

So, if you are looking for an efficient, effective ED group, don’t look at the fancy ED with the fancy EMR and state of the art equipment.  Look at the ED group who understands that a hospital is not a hotel, and that it is for sick people only.  This is how to save health care dollars!

 As the Wall Street Journal announces that decreased reimbursement for physicians appears imminent under the Health Care reform that President Obama is pushing, it is time to make sure that your practice is maximizing collections.  So how do you know if your billing company is a bull dog or a pussy cat?

• Check the days in accounts receivable.    Current national average for all practices is 43 days.  The longer it takes to get your money, the more kittenish the billing company!
• Check gross and net collections.
• Check encounter averages: i.e. the amount billed vs. the amount collected.
• Check bad debt amount and amount turned over to collections companies.  Transferring 2 -3 % of  Accounts Receivable to collections is reasonable.    One practice I know of was NOT aware that their billing company was writing off a whopping 30% of the accounts receivable!
• Check references from other physicians.  Make sure the billing company has been in business for several years. 
• Benchmarks to check: total AR in the 31-60 day category should not be greater than 15 % of monthly charges, AR in the 61-90 day category should not be greater than 10% of monthly charges and AR in the 91-120 day category should not be greater than 7% of monthly charges.
• Exceptions to benchmarks: practices that are academic, hospital based, or have a significant portion of medicare/medicaid/workers comp will have longer time in AR.

The practice I mentioned in which the billing company was writing off a 30% of the AR now does their billing in house.  I don’t necessarily recommend this as billings/collections is complicated and requires dilligence and great understanding of the draconian coding/insurance morass we currently find ourselves in. 

Lesson: look carefully at what your billing company is doing, and apply benchmarks to judge the company’s effectiveness.  Don’t let your hard earned money go in to the insurers pockets!

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I’m going to be honest here.   Sometimes work is just no fun.  Sometimes it’s just darn right stressful and I can’t wait til the day is over.  Sometimes I wish I had gone ahead and opened a coffee shop, and the other day I was wondering how I could get a job testing Black Diamond climbing gear.  There are two trains of thought involving work: #1 it’s called work for a reason or #2 you spend most of your life doing it, so it should be fun.  I go back and forth between the two, depending on my mood, my caffeine level, and how much time I’ve spent outdoors recently.

I think we in medicine have been regulated out of fun and in to seriousness.  Yes, health care is a serious business, but we are human beings, and enjoying ourselves is part of our make up. So to that end here are ways to make the day fun:

• Go outside at least once during the day and breathe.
• Joke with a coworker.
• Carry around a picture of your kid/dog/S.O./next vacation spot.
• Have something to look forward to.
• Treat yourself to a great cappuccino before work.  (Don’t forget the post coffee mint!)
• Look up something you don’t know. 
• Spend some time making light chit chat with a patient or family.
• Say hi to the house keeping staff.
• Have a pot luck, and PARTICIPATE.  C’mon, you can bring in a crock pot full of beans ‘n’ weenies!
• Keep the candy jar stocked in the lounge.
• Have a themed Friday, say Hawaiian, and wear that crazy shirt.  Let your staff play Hawaiian music, and decorate the lunch room.  Give  plastic leis to the patients.
• Have a barbecue at lunch and play basketball.  I love it when I see a bunch of people playing basketball in the parking lot where they work. Kids aren’t the only ones that need recess!
• Go to your hospital’s lunch ‘n’ learn and yuck it up with your colleagues.  Sometimes we are so locked in to our little routines we miss the importance of spending time with our friends.  Besides, you might learn something!

Get out there and have some fun! Leave your responses on how to have more fun and email pictures to blogatextramddotcom and we’ll see if we can up load ‘em!

Now, does anyone have an in with Yvon Chouinard?

As promised, here is the quick and dirty primer on motivating patients to change unhealthy habits to healthy habits.  I found a good piece on behavior change on the AMSA website.  It seemed fitting, as we are all students in this area!  Let’s get schooled!

Here are the “5 A’s” as developed by the Brown School of Medicine  (I have added my notes in parentheses):

• Agenda: attend to the patient’s agenda, and then explain your agenda of helping the patient change an unhealthy behavior. (Note: I would prefer a visit JUST to address the unhealthy behavior but…)
• Ask: what does the patient know about the behavior, it’s health risks, and does the patient have interest in changing the behavior? Have they tried to change before? What’s worked or not worked?  (Note: then listen!)
• Advise: tell the patient you strongly advise a behavior change. Personalize why the patient should change, and discuss short and long term benefits of change.  (Note: this should be the shortest section of the entire encounter!)
• Assist: address patients feelings about change, and address barriers. Discuss steps to be taken to change, and provide support.  Provide information for the patient to take home, and other resources if you have them. (Note: the website suggests written information be given if available. This may be okay, but I advocate a DVD in addition, if available.  More on this in a later post.)
• Arrange follow up: reaffirm the plan and then arrange for a follow up visit or phone call.

Most of us use this outline, in some form or another, but my sense is that we tend to be heavy on the advising and light on the asking and follow up.  This type of patient may benefit from group visits.  Send in your success stories and techniques!

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There is a blog similar to this one, called Making It, written by Douglas Iliff, MD, a family practitioner. He blogs on the American Family Physician website. Here is what he says about patients and non-payment of debt:

“I have only tossed a couple of patients out of my practice face-to-face. One of them was a pretty good friend who kept verbally abusing my staff. I’ve never done it for non-payment of debt. But lots have been booted out by a process that I consider both just and merciful…The key is that I make it clear that no one will ever be dumped for inability to pay. If they ask for their debt to be forgiven, it will probably be forgiven. If they want to pay $5 per month, that will be fine. Here’s the key paragraph from the letter patients get before they are turned over to collections:

“I’ve tried to be human about debts. Anybody who tries to make arrangements to pay, and then follows through without our badgering, will make us happy. I don’t care if your monthly payment will never retire the debt. Just don’t make us keep sending you bills. That’s all we ask.” ”

I have one issue with Dr. Iliff’s post: how do you keep the doors open if your revenues are not greater than expenses, no matter how noble your intentions are? Remember PookieMD’s number one rule of practice: you can’t see patients if you can’t keep the doors open.
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