If anyone wants to know why we need healthcare reform yesterday, all they have to do is read this
newspaper article about a patient who spent 12 hours at the
Fort Walton Beach Medical Center in Florida and racked up charges totaling
$211,941.50 before being transferred to a 2nd hospital where an additional $400,000 in charges were run up in 12 more hours.
Granted, this case sounds like the patient was very ill because they ended up dying. But still. These charges are ridiculous.
I mean, $354 for 2 mg of Lorazepam? You can get a 2 mg tablet of Lorazepam
at Costco for 37 cents.
When Dr. Atul Gawande wrote about the
high healthcare costs of McAllen, TX, who knew there were actually places even more expensive to get medical care?
One of my patients posted
this article about my practice, I am sorry to confess, back in February. I have been meaning to post a link to it, but always put it off, waiting for an opportune time to write a decent entry for this well-written article about alternative practice models, including the Ideal Medical Practice movement:
There is a revolt afoot across the land.
Doctors are rebelling against the burden of health care insurance paperwork. They are rebelling against having to deal with upward of 12,000 procedure and drug codes that add expense and time to their practices, keeping them from giving full attention to patients.
This means fewer and fewer doctors are going into general practice, opting instead for specializations, which double their income and insulate themselves, to some degree, from the burden of health insurance paperwork.
He compares and contrasts my practice vs. a traditional medical office.
Your doctor: you have to wait some time for an appointment. Your doctor spends less than 15 minutes with you before referring you to a specialist who, in turn, takes a long time to see.
My doctor: I can have an appointment the same or next day or whenever is convenient for me. My doctor will spend as much time with me as we both feel is necessary.
Your doctor: You check in with a receptionist who gives you forms to fill out. You stew in the waiting room for some period of time before being ushered into an examination room by a nurse who asks all the same questions you already provided. You wait for another interminable time (without the out-of-date medical journals and golf magazines that were outside).
My doctor: He meets me at the door since he has no nurse, receptionist or other staff, which keeps overheads -- and his charges -- low.
He has been a big supporter of my practice for years, and I appreciate his efforts in helping to spread the word about alternatives to the current dysfunctional healthcare system we have now. He is a much accomplished man, a veteran, a captain of the financial industry, a man of letters with a sharp wit, a loving husband, a doting father and grandfather, and a friend.
Unfortunately,
all good things must come to an end. And so, I say, "Well done, Mr. Sharp."
It is not necessary to change. Survival is not mandatory.
--W. Edwards Deming“The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness.” --Ancient Chinese quotationI haven't been posting regularly for a while because, well, it takes a lot of work to keep up a blog. I mean, I do have a day job. And that day job has changed a little.
I started this blog on
September 25, 2003 in order to "chronicle my attempt to replicate what family practitioner Dr. Gordon Moore has pioneered in his "solo-solo practice" (
Going Solo: Making the Leap) in the hopes of regaining some control and sanity in my professional (and personal) life" and to "help anyone else who might be attempting the same
foolhardy stupid insane brave endeavor".
I am as surprised as anyone that this blog has survived. For those of you who are considering, or have started your own medical blogs, know that, like everything else in life,
medical blogging is not without risks.
For those who are interested in starting your own solo micropractice, there are risks, too, but I still think it is possible under the right conditions and with
a lot of help.
I am still a solo family doctor. I started off as a solo-solo operation (aka the Gordon Moore model) about 5 1/2 years ago, in February 2004, and have been trying to figure out how to make this thing work for me and my patients ever since. I signed up with a bunch of PPO insurance plans and Medicare, but chose to avoid Medicaid and HMO because of the low reimbursement/high hassle factor.
What have I learned?1. Submitting claims to insurance companies is easy, but collecting payment from them is sometimes very, very difficult, and in some cases, impossible.
2. The more time you spend with a patient, the more there is to document in the progress note.
3. Perfect progress notes are the enemy of timely progress notes.
4. EMRs don't save time in charting, but they do when retrieving notes.
5. There is no perfect EMR so get the cheapest one that does what you need it to do.
6. The ideal personality to run a solo-solo office is someone who is either in a permanent manic phase or who has the energy of a hyperactive kid on
Pixy Stix and caffeine.
7. I live in a "
dead zone", an area with conditions (in my case, high cost of living and low insurance reimbursement) that makes it very difficult, if not impossible, for an Ideal Medical Practice to survive.
8. The fixed low reimbursement of primary health care coupled with relatively high expenses means that the current American Healthcare System forces primary care doctors to continue following the business plan of the
Underpants Gnomes:
Phase 1: Provide primary care (or collect underpants, your choice)
Phase 2: ???
Phase 3: $Profit$!
It's that Phase 2 part that's killing off primary care.
Changes I have made in my practice since 2004:1. I got a part-time biller. My first biller was a lifesaver for me in that she is able to follow up on denied and "forgotten" claims that I didn't have the time or energy for. I call her my "pitbull" because once she gets hold of a claim, she doesn't let go until they pay up or all options have been exhausted. She has since moved on due to other obligations, and I have a new biller who is still learning the ropes. Still, it is better than when I was submitting (or not submitting) claims on my own.
2. Changed my practice name from a "Family Practice" to "Family Medicine". I should have done this at the very beginning, but that was right around the time that
AAFP was changing our specialty name and I guess I didn't have the foresight to see what a hassle it would be later to change business cards, stationary, phone book listings, insurance contracts, etc. People still aren't really sure what Family Medicine is, but it's better than being confused for a daycare center.
3. I opted out of Medicare. I had been thinking about opting out of Medicare for a long time, basically ever since I opened my solo practice. Medicare's reimbursement level was low but usually no lower than the PPO payers and sometimes even higher than them, which is pretty depressing. They usually paid quickly and it wasn't that difficult to talk to a live person when we had a problem. But after my first 3 years in practice, only 4% of my patients had Medicare.
My main concern with Medicare has always been about accidentally running afoul of Medicare regulations and being tossed in jail or fined. When you first enroll with Medicare, they send you a CD with their rules and regulations. I have never opened that CD. In book form, it is
over 500 pages long.
Medical coding is probably 2nd only to income tax calculations in complexity. In a study with 300 coding experts given 6 hypothetical cases to code, there was
only 57% agreement on the correct E/M code. And this was with coding
experts. It's got to be even worse when physicians do it but as physicians, we are ultimately responsible for any errors.
Medicare can fine you
if you waive a patient's copay. They even sell
Medicare supplemental fraud insurance in case you get hauled in. Under the False Claims Act, you can be fined up to $11,000 per claim and liable for 3 times the actual damages. Kind of like having a rich, beautiful and famous girlfriend who will cut your arm off because you didn't compliment her new shoes.
And while I realize that the few
horror stories are rare and unlikely to ever affect me, they were enough to make me question, as
for this physician, whether I should continue taking Medicare. Since dropping Medicare wouldn't affect my income significantly, I decided it wasn't worth it for me so I opted out.
4. I started charging an extra fee to help me survive the dead zone. More on this next time.
So anyways, both my practice and this blog are
not dead yet.
In fact, I'm a lot happier and more satisfied as a physician, with the freedom to practice medicine the way I was trained to. I have the flexibility to pick up my kids from school every day and drive them to get braces, or wait for the plumber, or run errands. I don't make as much as I used to at Kaiser, but my income has been growing every year and I anticipate it will keep growing.
One of the reasons I went into medicine was because I knew I didn't want to go into business. But when I got into medicine, I discovered that it had turned into big business. So I started my own business to rediscover the art of medicine. Funny how that worked out, huh?
Even as physicians, patients, insurers, business leaders and politicians converge on Washington, DC to focus on healthcare reform, Ideal Medical Practices are making the news,
this time in Anchorage, Alaska:
During a typical visit to the doctor, most people spend more time in the waiting room than in the examination room.
On average, a physician spends about 10 minutes with a patient, according to one doctor in Anchorage who's working to change that.
At Steward Family Medicine, Dr. Daniel Steward makes time for every patient -- the shortest appointment lasts 30 minutes.
"You have so much time to talk with him and can cover any issue that you could possibly have because he doesn't rush you out of the office," patient Tahneta Stroh said. "He's a fantastic doctor."
Steward has jumped on board a grassroots movement sweeping across the nation known as an "ideal medical practice."
Unlike the glacier-like progress of healthcare reform taking place in Washington, DC, Ideal Medical Practices are bringing a better and more satisfying experience to patients
NOW and will continue to do so regardless of what changes eventually take place.
To see where other Ideal Medical Practices are in the lower 48, go to the
IMP Map.
Dr. John Brady runs a successful micropractice in Newport News, VA, and was Virginia's 2008 Family Physician of the Year. He has written a letter to his state legislators and President Obama regarding the healthcare crisis that is so well written that I am reposting it here, with Dr. Brady's kind permission:
-----
Dear President Obama,
I feel obligated to express my opinions on health care reform. I am a solo family physician working in Newport News, Virginia and am part of a nationwide collaborative of physicians dedicated to providing great care to their patients (
www.impcenter.com).
I am experienced working on the front lines of health care for the past 15 years, and I have dedicated my last six years to trying to understand how to provide superior care to my patients. I am independent, I have no axes to grind, and I represent no interests except those of my patients.
There is no question we need reform. The health care system is disintegrating daily and taking a lot of wonderful patients and doctors with it. Patients are literally dying from both not having access to good primary care and from the poor quality care they receive once they get through the door. Doctors are imprisoned by mounds of administrative minutia which strip away their freedom to practice medicine individualized to the patient’s wants and needs (patient-centered collaborative care) and serve as a wedge between them and their patient.
Study after study has shown that
the stronger the relationship between a doctor and his patient, the greater the quality and the lower the costs, but our system is set up not to enhance but to destroy this cornerstone of medicine. Unless the reform ideas being proposed address this fundamental flaw in our system, they are doomed to increase healthcare costs while remaining unable to enhance quality. Indeed, it is the failure of the doctor-patient relationship over the past twenty years which has been the true reason behind the cost escalation and the quality chasm.
Doctors are paid for quantity. The faster we push our patients through, the more money we make. The problem is that the faster we push our patients through, the less we know each one and the less we know each one, the more we rely on testing and specialty referrals to augment our clinical judgment.
Over the past 20 years, reimbursement has not kept up with overhead costs and so doctors have had to see more and more patients a day. The number of tests being done has exploded with the resultant explosion of costs. Insurance companies, seeing this trend, have tried to put roadblocks up to halt testing and referrals, but all this does is increase the administrative costs of the office forcing the doctors to see even more patients per day.
Harried doctors become burned out and begin to lack empathy leading to worsening quality and increased liability. Medical students see the trend of increasing workload, flat salary, and miserable physicians and have begun to avoid choosing primary care as a life choice. All this is occurring at the exact time the population is aging, which puts the country on the precipice of a complete meltdown of the medical system.
Clearly, the toxic reimbursement system needs to be fundamentally changed such that policies are adopted which enhance the relationship between doctors and patients. A simple solution would be to offer doctors the ability to opt out of the current nightmare payment scheme into a new system where the physician gets a dollar a day for every patient who chooses him/her as their primary care doctor. That reimbursement is then adjusted up or down quarterly based on the patient’s experience of care. Questions surrounding access, efficiency (waiting time), continuity, information exchange, and coordination can all be easily attained through a simple survey like How’s Your Health (
www.howsyourhealth.com).
By doing this, doctors will be encouraged to provide the best service to their patient, and the resulting happier, healthier patients will be much less likely to go to the ER or have to get admitted to the hospital. Doctors, vying for high satisfaction grades, will quickly adopt quality initiatives like secure e-mail, online appointments, etc. Primary Care salaries will become much closer to that of the specialists, but more importantly as the relationship with their patients strengthen, overall medical costs will decrease, physicians will have higher job satisfaction, and medical students will flock to primary care. Truly this becomes a win-win situation for everyone.
I know this solution does not involve covering the uninsured or forcing the implementation of new tools or cool (expensive) technology, but that is why it will work. Covering the masses is a laudable goal, but doing this prior to fixing primary care is the equivalent of giving everyone a car and not building any roads.
Turning to computers and electronic medical systems to try and make a medical office a “medical home” is similar to thinking that adding the internet or a flat screen TV to a house will make it a home. It is the relationships, not the furniture, which makes a house a home. Similarly, to encourage the development of medical homes, we have to start by encouraging the development of strong relationships and only then worry about where the furniture (computers, integrated systems, etc) should go.
I appreciate you taking the time to read this letter, and I hope it resonates with you. I fear the potential harm to my patients and my country if we decide to do what might be politically easy instead of what is right. I remain willing to discuss any part of this in more depth if you desire and I can forward many good studies supporting everything I have stated.
Providing high quality, cost effective care is possible in today’s environment—I do it every day. But, in order to encourage quality care to become mainstream, we have to change the way doctors are paid. If that cannot be accomplished, nothing else will matter.
Sincerely,
John E. Brady, MD, FAAFP
The Village Doctor
2008 VAFP Virginia Family Physician of the Year
