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

FP/IM Physician wanted for local Locums (Denver)

Family Practice and Internal Medicine physicians wanted to join ExtraMD, Denver’s local locums.  ExtraMD, in practice for 7 years, specializes in placing FP/IM physicians in short and long term assignments in the Denver/Boulder area.  ExtraMD covers family medicine and internal medicine clinics, urgent care and hospital medicine groups.  Benefits include flexible schedule, ability to have extended time off, and the ability to work in the situation of your choice.  Please do not apply if you are not boarded, and don’t have malpractice coverage.   Physicians who value interesting clinical work, balanced with home and family life should apply.  Slackers need not bother!

Who qualifies?

Must be board certified family medicine or internal medicine physician.

Must have Colorado License, DEA and proof of malpractice.

Must be committed to the flexible schedule and mind candy that go along with fill in work, and who honor their commitment to work and family.

Must have ACLS if doing urgent care or hospital medicine.

Signing bonus: to applicants that commit to working 10 shifts with ExtraMD.

Reply to info at extramd dot com.

In my last post, I was a bit dark with the factory worker analogy.  However, this is status quo for primary care.  But, given my promise that if I complain about a problem, I will seek to find solutions. So here goes:

Physicians must become leaders and team players.  Sometimes, when I am wearing my EMR consultant hat, I have to remind myself that I am not the boss, I’m a team member, and not necessarily the most important team member!  (I think we physicians love to be the boss–after I told my daughter what I did at work, she commented, “so basically, you bossed people around all day.”  Ouch!) Being the boss is not the same as being a leader!

So what’s a physician leader? Here are things you don’t hear from a physician leader:

• “That’s not how we do things”
• “We’ve always done it this way.”
• “I don’t have time.”
• “You can’t teach an old dog new tricks.”
• “It will never work.”
• “That’s of no benefit.” (I think this was heard at the introduction of hand washing and sterilizing instruments!)

So what are what does a physician leader say?

• “Show me the data.” (We love data!)
• “How we will do this?”
• “Does it improve patient care?”
• “How much does it cost–in terms of time, money and will power, and what resources do we have for this?”
• “Who can I work with to get this done?”

So if you really want to stop being a factory worker physician, get out of your silo. Learn to lead, not to boss, open your mind to new ways of thinking and doing things, and learn to collaborate. And lastly, listen much, speak little!

As a hospitalist, I hate direct admits, especially from doctors I don’t know well.  The direct admits always seem to get called to me at 4:45, just as the busy clinic doc is wrapping up, and I’m throttling up for the admitting race. The clinic doc will call us with the patient info and ask us to go on faith that the patient is stable.  Cases that make me queasy and reject the patient as a direct admit:

• chest pain–I don’t care if the EKG is normal. Don’t ask me to direct admit a patient to tele, with the potential that they are having an acute coronary syndrome.  If the doc is concerned enough to admit someone with chest pain, they deserve a timely eval, something that may have to wait for several hours until I get to them.
• the physician hasn’t seen the patient, and is calling in based on a lab, or a report from a visiting nurse.  (I see this a lot with anemia–the patient will have a low hematocrit, and the PCP will assure me the patient is “stable.” How can you know the patient is stable if  you are not looking at them?)
• marginal vital signs.  Again with the assurance that the patient looks fine, “they not septic!”  Ha, I say.  My criteria is that a patient must be stable enough to wait two hours in a hospital bed before someone sees them to be a direct admit.  I will ask the PCP if the patient meets this criteria. 
• hypoxia–I hate admitting “stable” hypoxia.  If they are that stable, why do they need  to be admitted? I see this with chronic COPD patients on oxygen who are going up on their oxygen requirements.  The PCP will assure me that they are not in extremitis from their COPD exacerbation or pneumonia, but it takes a lot to convince me.  This type of patient can go down hill fast, and you can’t under rate breathing!
• TIA evaluation.  Patients like this may need a rapid CT scan and neuro exam before I am certain it’s “just a TIA.”

So why do PCPs direct admit? For a good reason–it saves the patient a lot of money and hassle not to have to go through the ED.  I’m all for cutting down costs, but only on verifiably stable patients.  I know that a direct admit gets labs and study results a lot slower than a patient in the ED.  Therefore, a direct admit patient may have treatment started much later than a patient that comes through the ED. This may be acceptable in very stable, slightly ill patient, but for many patients, the delay in diagnosis and treatment can lead to an extended stay and increased morbidity.  So, no, when I question the PCP, I’m not a lazy bum, I’m actually on medically solid ground.

My suggestion: develop a rock solid criteria for direct admits.  My proposed rules:

1. No chest pain or hypoxia direct admits.  Don’t care how stable the PCP says they are.
2. No one with marginal vital signs–and I get to be the arbiter of this.  If I think the patients is not stable enough, then they aren’t. It’s my name (and malpractice!) that is on the line, so, sorry, but I rule.
3. PCPs must have the patient physically in the office.  No one can get called in from home after a lab done yesterday, or last week, or last month.
4. Cellulitis is okay.
5. Social admits are okay.  Why waste all that ED time and money?  This is the one case I really think IS a direct admit.
6. No mental status change evals as a direct admit. C’mon, would you do that to your mom?

Lastly, my friendly PCP, I’m right there with you trying to take good care of patients, in a timely and cost effective manner.  My world is a little different than yours, and I hope you understand I’m not argumentative–I just see patients a little differently, and in a different time frame than you may.

Through a series of unfortunate events, I spent a fair amount of time in my local ED and pediatrician’s office. Tweenager Daughter broke her arm at gymnastics, with just one week to go before the state championships.  Needless to say, there are a lot of long faces at my house, including my own.  Watching her compete this season has been a joy, as it has lifted me up just watching her.

The ED visit was a complete disaster.  We waited for an hour and a half in an empty ED  before being seen.  I looked at the Xrays with the ED doc, and we both noted the fracture.  The radiologist at the hospital called while we were there and confirmed the break.  The ED doc sent her home in a sling, with an instruction sheet on “sprains”!  No splint was applied, no pain medications given, no warmth to a young girl whose entire season concluded with a misplaced hand on a vault table.  The nicest person to us was the lady who took our registration information and handed us some warm blankets as we waited in the cold, empty lobby. 

The next day I came to my senses and called Tweenager Daughter’s pediatrician. By some miracle, he was in the office on the Saturday after Thanksgiving.  He told us to come right in.  The good doctor applied a splint, gave a prescription for pain medication, and applied a soothing balm to the soul. 

Tweenager Daughter is still horribly depressed about missing the state championships.  However, she is in less pain, and actually slept last night.  Thank you Dr. W. for that!

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?

As a small business owner, I buy my own health insurance. Two and a half years ago, my husband went to work at a small cutting edge company that offered only one health insurance option.  It wasn’t a good option for us, so I made the fateful decision that we would pay for our own insurance, believing fervently that the freedom provided by the insurance we would buy would be worth it.

In reality, it was something out of the movie Sicko.

My husband had a screening colonoscopy and removal of two benign polyps.  He was deemed “uninsurable” by several insurance companies I contacted.  (Now, mind you, this is not a obese, tobacco spewing, french fry chewing middle aged man!  This is someone that plays hockey every Sunday with former NHL players, bashes down black diamond ski slopes and jumps out airplanes for fun!)

My daughter was diagnosed with reactive airway disease at age 3, and had 2 ED visits at that age.   Nothing since, and she is now 12 years old.  She was deemed uninsurable because she was on flovent and singulair.  At one time I remember saying to the faceless entity on the other end of the phone, “it’s not like she’s on a vent for God’s sake!  She’s a gymnast.”

Click. Dial tone.

So we ended up buying one insurance policy for my husband, and a second for my daughter and me.  Our combined deductible is $7500/year and we pay approximately $500/month in premiums.  According to NPR, since my husbands lay off, we are under insured as we now pay over 10% of our income to health insurance.

Yesterday we got a notice saying that my husband’s insurance would go up $200/year.  This is the second such notice we have gotten in two years.

So, yes, I support insurance reform.  I pay heartily for the coverage I have, and I have no other options.  I am not saying that all we should have is a single payor system, but I think there should be more options then what is out there.  Health insurance for 3 healthy people is the largest percentage of our budget.  Something needs to change!

Today I was covering in a small two doctor practice.  The patient population was largely female, and had problems scattered across the health care board.

The problems was, so were the records.

Each patient had a chart with appropriate blanks for a SOAP note, a check off scheme for physical exam and another blank area for the assessment and plan.  There was an area at the top where someone would check “meds unchanged.”  The problem was, when I went to look at the medication lists, there weren’t any. There was just a blank piece of paper where the doctor (or whoever!) was to list the meds.

But no one was doing that.  Many times I had to rely on the patients to tell me what they were taking, or reschedule the patient, telling them to bring in all their pill bottles.

In addition, I spent a lot of time leafing through labs, in one case trying to verify a clotting disorder, and a hospital work up.  Didn’t find either.

A pharmacy called, and I tried to verify a medication dose and couldn’t because I couldn’t find it.

This is the kind of stuff that causes duplication of tests, patient mismanagement and rising health care expenditures.  Yes, I have finally drunk the kool-aid, and feel that we all MUST have an EMR that communicates with other physicians, hospitals and pharmacies.  HOWEVER: I do NOT believe we should have 10 different EMRS that don’t talk to each other (kind of like our current health insurance, don’t you think?!)  I believe  we have got to have effective, efficient EMRS that communicate to all the arms of the health care delivery system.

But I’m not holding my breath.  So, if you need me, I will be leafing through charts trying to figure out exactly WHAT clotting disorder the patient has, and considering redoing the whole dang work up to verify it, and appropriately treat it.  Just how much will that cost?

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!

Annals of Internal Medicine had a great article on so called retail clinics.  The article looked at three acute diseases that make up 48% of the retail clinics’ business, and compared the cost of treating these three illnesses to costs at a physician office, urgent care center and Emergency Department.  The authors also looked at quality scores at the retail clinics in comparison to physician offices, urgent care centers and EDs.  The three acute illnesses studied were pharyngitis, otitis media, and urinary tract infection.

And the winner was…retail clinics!  “Retail clinics seem to provide reasonable quality of care for 3 common acute illnesses, at a competitive price.”  Retail clinics cost significantly less, coming in at $110/visit.  This compares to physician offices at $166, urgent care centers at $156 and the highly priced ED at $570.  And guess who used these clinics?  Those that were young and had health insurance!

Why was the retail less? Primarily because the care was provided by nurse practitioners. 

What does this mean to you; oh savvy physician/business owner?  Open a “quickcare” clinic in your practice! Hire a nurse practitioner and have him see patients for UTIs, sore throats and ear aches.  (Immunizations are a big item for retail clinics as well.)  Have open access to the practitioner, and make appointments short–these are by nature very uncomplicated illnesses. Make sure you limit the NPs visits to these illnesses, however, in order to make this model work.

Market the fact that you have a “quickcare” clinic in your own office, and get the word out.  Your patients will appreciate the familiar surroundings, the quick service and appropriate level care.  Your benefit:  you can supply good, cost effective care, keep your patients happy, and increase revenues, rather than have those revenues go to the local Wal-Mart MinuteClinic.

This is a classic win-win situation for all! What’s not to like?