Tuesday, April 26, 2005

How much is perfection worth? $60/hr

Last month I called a plumber to come fix a garbage disposal unit that had been broken for the past few months. The first thing he did was flick a switch on the bottom (the reset button) and it worked. 15 seconds. Done. Since he was already there, I had him fix a leaky faucet and a slow running drain. His bill for an hour of work: $80.

When I work at Kaiser, as a per diem family physician, I get paid $60 an hour. Which brings me to something I've come to realize: that somehow, people don't seem to place a high value on the services of primary care physicians anymore. I see it when I get the reimbursement checks from the insurance companies, and they knock off $50 from the $150 charge I billed for spending 1 hour doing a complete physical. I see it in myself when I feel guilty because I ask a patient to pay me for my services. When I first started my solo practice, I would spend an hour with a patient. Then because I felt sorry that they had no insurance, I would only charge them for 30 minutes. And even then I would give them a 20% discount for paying me at the time of service, so a $200 visit dropped to $100 down to $80. I was doing to myself what the insurance companies are doing to me.

This article describes how primary care is often undervalued:
Most experts agree that something should be done to get more sensible pay for primary care doctors.

''Just think about it,'' said Penny Tenzer, head of the family medicine residence program at the University of Miami. ``They want to pay very little to a doctor treating a diabetic so he doesn't lose his foot from gangrene, but then they'll pay a lot to the surgeon who would cut it off.''

The American healthcare system traditionally puts little value on primary care. About a third of America's doctors focus on this basic treatment, compared to about two-thirds of doctors in Europe.

''Other places pay primary care much better than we do in the United States,'' said Gerard Anderson, a Johns Hopkins professor who compares healthcare systems.

Dartmouth researchers have found that healthcare costs are extremely high in South Florida because patients get bounced between many specialists, which often results in ''uncoordinated care'' with repeated tests and other duplications that could have been more economically handled by primary care doctors.

''The importance of the primary care doctor doesn't have societal backing,'' said Robert Forster, a primary care physician who works for Blue Cross Blue Shield of Florida. ``The problem is that it's hard to measure the value of talking to a patient.''

Experts at the American Academy of Family Physicians and elsewhere have developed proposals that would pay for telephone and e-mail consultations, which are frequently not covered now.

Others point to pay-for-performance concepts, so that primary care doctors would receive more if they did well in controlling patients' diabetes and blood pressure, and if they kept them out of emergency rooms and hospitals.

Ultimately, primary care doctors would like insurers simply to recognize the value of time spent with a patient, but that may not be easy.

''Since the 1950s, American medicine has emphasized specialties and procedures over primary care,'' Forster said. ``It's going to take some major changes in our society and our thinking to turn that around.''

So I guess I should be proud of myself the other day. I spent 30 minutes with a returning patient and charged her for 30 minutes. Except for some reason she thought I charged $100/hr. I politely stated that my usual fee was $50 for 15 minutes with a 20% discount for payment at the time of service. And she paid me. I think with more practice, I will get better at this.

So public devaluation of physician services is one major problem I see in our broken healthcare system. To be more specific, poor compensation for cognitive physician services is a major problem, specifically for primary care. As has been stated elsewhere, there is an unbalanced emphasis towards procedures. If I spend 30 minutes talking to a patient, I'll get paid $40 by insurance companies. If I take 3 minutes to freeze a skin tag, I'll get paid $77. It's a messed up system.

Because of poor reimbursement, primary care physicians can't raise their prices to offset their rising expenses. The only other options are to start charging an extra retainer fee like a concierge practice or see more patients (and spend less time with each patient). But this places a lot of pressure on primary care physicians (registration required), some of whom burn out:
When Audrey Martinez's former patients in South Miami-Dade run into someone who knows her, they ask when she's coming back to practice. They loved her because she devoted so much time to them.

In fact, that was Martinez's problem. She insisted on spending at least 15 minutes with each patient, when her payment levels afforded her only nine or 10 minutes. That didn't make economic sense. ''We are in a crisis, but no one seems to understand,'' she said.

Crushed financially, she became part of a growing trend of primary care doctors in South Florida who are abandoning their private practices.

They closed their doors because they couldn't overcome the squeeze between low fees from insurers and soaring costs. Or they refused to survive by cutting their time with patients.

I used to feel this pressure to be productive, too, when I worked at Kaiser, although my paycheck didn't depend on it. Just my sense of duty.

The other pressure that doctors (primary care and specialists) feel is that we have to be perfect, even though this is, of course, totally impossible. The recent news stories about Celebrex and Vioxx are clear-cut reminders that there is no such thing as a free lunch. And yet, many patients expect safe and effective drugs with zero side effects. They (okay, I'm generalizing) expect perfect answers, perfect results. On a local news radio show, I heard a woman complain about how she went to the doctor for a UTI, received an antibiotic which made her feel better, but then did a home test on herself 3 days later and found out she was pregnant. The implication is that the doctor was somehow negligent because this was "missed".

In contrast, a few months ago one of my patients developed an allergic rash after taking a sulfa antibiotic for an infection. Even though I could not have foreseen it, I felt badly. I suppose in another kind of patient-physician relationship, the patient's parents might have blamed me. Perhaps even sue me. But in this case they understood that these things happen. They appreciated it when I came to their house to check their son. And fortunately his rash cleared up 3 days later.

I know it's not really fair to generalize about "those patients" as if they are all the same, just as it is unfair to generalize about "those doctors". When you get down to one on one experiences, these generalizations fall away. Because of the trust my patients place in me, I learn to trust them back. I know they value my services by the words of appreciation they give, the smiles and the handshakes. A few of my patients have even called or sent me e-mails reminding me to bill them, so I know they value my services. (Either that or they feel sorry for me.)

One of my physician colleagues commented the other day that he'd read that malpractice lawsuits were unheard of before the advent of x-rays. And ever since then, the number of malpractice suits has risen as we've become more and more technologically advanced.

American society demands perfect medical care, but isn't willing to pay for it. Ultimately, it will cost society more in the long run.

Monday, April 25, 2005

Monthly Mail Bag

Since it has been over a month since I last posted, I thought I would be lazy unoriginal creative and post an e-mail I recently received along with my reply as a way of re-introducing the low-overhead practice model for Ideal Health Care:

Q: I am an internist in private solo practice in Mesa, Arizona. I am very interested in your practice model. I would like to be able to spend more time with patients, but my overhead mandates a higher volume of visits. Would you mind telling me how things are going for you and any suggestions you may have. For example, which EMR are you using? How do you cover patients while out of town? How did you find your space, and what kind of space are you in? Any online resources to which you would direct me?

A: Thanks for your e-mail. In answer to your questions, I got the idea for this practice model after reading an article about Dr. Gordon Moore, who sort of pioneered this concept of a low-overhead type of practice. You can read about him here:

Other physicians around the country have also tried to emulate his practice, and there is an e-mail listserve started by Dr. Moore which exchanges information between those who are actively practicing this way or who are just interested in learning more about it. There are at least 30 doctors around the country who are using some variation of this practice model. The website for the Practice Improvement Group is here. To subscribe to the listserve, just send a blank e-mail to "Practiceimprovement1-subscribe@yahoogroups.com".

I have been in practice a little over one year, and business is relatively slow but steadily growing. I am currently seeing an average of 13-15 patients per week, which is actually my break-even point. My goal is to see no more than 12 patients a day (30 minutes appointments) 5 days a week. I use open access scheduling so people can almost always get an appointment the same day they call, unless they prefer a later date. It is very gratifying to be able to spend a lot of time with patients and get to know them. The biggest downside for me (besides the low income) has been the large amount of administrative work. I have no employees (to keep overhead low) so I chose to do everything myself, including medical billing, copying, filing, scanning, shredding. Of all these, the billing part has been the hardest for me to learn, but I am gradually getting better at it. It has been very educational seeing what it takes to get paid. But most of the doctors who are doing "low overhead" practices have at least one staff person to help them out, so their experiences are probably better than mine.

My EMR is a little-known program called SpringCharts. I chose it because:
1. It runs on my Mac. There aren't that many EMRs that run on Macs. Macs are easier to use, plus more secure than Windows-based PCs.
2. It is inexpensive. When I first got it, it cost $500. Now the newest version costs $895 for a single user version.
3. It allows me to store all my data locally. This enables me to keep my patient's data private and secure, plus I always have access to it even if the Internet is not available, unlike ASP programs which store the data at a remote location.
It is very nice to have all the medical history available a few mouse clicks away, and in my small office, there isn't much room for paper charts. Other EMRs that some of the other doctors on the listserve use are Amazing Charts (also cheap), eClinicalWorks, SOAPware, Alteer (very expensive), e-MDs, Praxis. No EMR program is perfect, but I would encourage everyone to at least start looking at what is out there. This article is a good place to start.

My office space is very small. A total of about 600 square feet, including waiting room and hallway that I share with a chiropractor and psychologist. I basically use one exam room (8 x 9.5 feet) and one 8 x 8 ft room that serves as my office. It is in a small 2 suite 1 story medical building that looks more like a house. It is about a block from my house. The rent is $1000/month.

As far as out of town coverage, I haven't gone out of town very much plus I don't have very many patients (261 unique patients to date) so that also reduces the number of calls I get. When I went to Banff, Canada for a week last summer, I recorded a message on my answering machine that explained that I would be out of town for a week but that they could still call me on my cellphone if they needed to speak to me. On my recorded message, I left the names and phone numbers of two local family physicians who agreed to cover for me if any of my patients needed an urgent visit (but no one called them). Otherwise, I'm always available by cellphone 24 hrs/day 7 days a week. I've only had two calls in the middle of the night so far. One from a patient with psychiatric problems who was having trouble coping with recurrent chest pains (I told her to call 911 and go to the emergency room) and another from the hospital ER informing me that I had an admission (whom I had expected to show up earlier that day).

It has not been easy to transition from Kaiser, where I worked before, to solo private practice. But I do get a lot of satisfaction knowing that I am in control (well, as much as anyone can say they are in control when they are dependent on third party insurers for payment) and can spend quality time with patients. And I am optimistic that my practice will continue to get busier and busier as more and more people find out about me.

I hope this information above helps you. And again, please subscribe to the listserve to get more information. Let me know if you have other questions. Good luck!