Medicare: "Do as we say, not as we do"

While Medicare officials advise seniors to shop around, I recall that the federal Medicare program itself is prohibited from shopping around for the lowest drug prices:

As written, the legislation complied with a drug industry demand that Medicare be prohibited from negotiating with manufacturers for lower drug prices. Among those helping the industry make its stand was Rep. Billy Tauzin (R-Louisiana), whose committee on energy and commerce oversaw Medicare. In an odoriferous development, Tauzin soon quit Congress to become president of the Pharmaceutical Research and Manufacturers of America – Big Pharma’s Washington lobbying group.

I think healthcare reform would proceed a lot faster if all members of Congress and their staff were required to use Medicare as their health insurance.

A Good Question

Via joyoftech.com

All of a Sudden

From Sen. Bernie Sanders at DemocracyNow.org:

For years now, they’ve told us that we can’t afford—that the government providing healthcare to all people is just unimaginable; it can’t be done. We don’t have the money to rebuild our infrastructure. We don’t have the money to wipe out poverty. We can’t do it. But all of a sudden, yeah, we do have $700 billion for a bailout of Wall Street.

It's rather sickening.

Via Daring Fireball.

How do doctors get paid?

The following was recently posted in a listserve that I subscribe to. It is insightful and published with the author's permission (plus it saves me the trouble of writing an entry myself).

Imagine going to your favorite restaurant. You are greeted at the door by the hostess, who seats you and takes your drink order. You order through your favorite waiter, Andrew, who recommends the special of the day: prime rib with a dinner salad and a chocolate tort for dessert. Soon after, the food is brought out and it is delicious. You have time to enjoy your food. You then receive the bill and pay for your meal, returning to your home satisfied, all your dining needs met. Let’s say you paid $75 for this meal:$50 for the steak, $10 for the salad and $15 for the dessert.

A change then occurs in the restaurant industry. A new form of eating out has been adopted. Your favorite restaurant has now contracted with over 30 different ”restaurant insurance companies.”

Anticipating another pleasant dining experience, your return to the restaurant with your new “subscribers card.” You pay your $5 “copay” and sit down in the foyer of the restaurant. After waiting an hour, even though you made reservations, a harried Andrew greets you and quickly takes your order after you briefly glance at the menu. The food arrives at your table, but before you have time to truly enjoy it, Andrew informs you that “your time is up” and the table is reserved for another party. You are escorted outside with your hastily boxed left-overs.

What has happened to the restaurant? Behind the scenes, the restaurant owner has learned some tough realities of the “new system.” During the first month of taking insurance, the owner submits the charges for the $75 steak dinner. The contract with this particular insurance company already states that they will only pay $45 for the $50 steak, but the owner decides that the extra customers brought to the restaurant by contracting with this insurance company will more than off-set this small loss.

The first attempt at collecting the $75 dollars for the full meal is returned unpaid due to a clerical error. The owner mistakenly used the number assigned by another insurance company. The owner mails the corrected form.

In response to the second request for payment, the insurance company does not send a check, but a detailed questionnaire: Was basil used in seasoning the steak? Was it necessary to use basil for this particular recipe? Did the restaurant ask for permission to use basil from the insurance company before serving the steak? The owner submits the answers, emphasizing that the basil is part of a family recipe that made the restaurant famous.

The owner waits another week (it has now been 3 weeks since the dinner was served). The check arrives three and a half weeks after the meal was served. The check is for $20 and states that it is specifically for the steak. The check also comes with a letter stating that no billing of the patron may occur for the salad, but no other explanation is enclosed. No mention is made of the $15 dessert.

The now frustrated restaurant owner calls the provider service number listed in the contract. After five separate phone calls to five different numbers (The harried voice behind phone call number four explains that the insurance company has merged with another insurance company and the phone numbers had all changed last week, sorry for the inconvenience…), the owner gets to ask why, when the contract says the steak will be paid at $45, has the check only been written for $20? And what happened to the payment for the salad and the dessert?

As it turns out, this particular patron’s insurance contract only pays $45 when the patron has reached their deductible, which this patron has not at this time. The remaining portion of the steak must now be billed by the restaurant to the patron directly.

The $10 for the salad would have been paid if the patron had ordered it on a different day, but, per page 35 in the contract, because it was billed on the same day as the steak, it is considered to be part of the payment for the steak and no extra money can be collected from the patron or the insurance company.

The dessert should have had a “modifier” number put with its particular billing code in order to receive payment when billed with the steak and the salad.

Realizing that the billing is quite a bit harder than anticipated, the restaurant owner hires a person to specifically make sure these errors do not occur again. The owner must lay off the hostess and the bus boy to hire the biller, but feels these duties can be added to the waiter’s other responsibilities.

In the meantime, the restaurant owner has now had to have the waiter take on the job of answering the phones due to the now high volume of phone calls from patrons questioning why they are receiving bills for meals they ate over 2 months ago and why did their insurance company not pay for this portion of the meal. This extra work is now resulting in longer times patrons must wait to be seated and served, and grumblings from the waiters who “were not hired or trained to do this kind of work.”

The owner now realizes that, although the dinner originally cost $75 to make, only $22 has been paid. The remaining $30 billed to the patron has now cost $10 in overtime for the biller and mailing a second bill to the patron after the first bill went unpaid. By the third billing cycle, the owner realizes a collection agency must be employed in order to have any hope of receiving any portion of payment from the patron.

In order to meet costs, the restaurant owner now must seat twice as many patrons in the same amount of time. The owner has now over-extended the waiter, who was an excellent waiter, but is now taking on the roles of host, phone answering and table bussing, as the pay for these employees has been shifted to the biller and the collection agency.

What was once an outstanding business that focused on fine dining and customer service has now been turned into a business in the business of trying to get paid.

Alas, I wish this were a fictional tale, but it is not. The only fictional portion is that this is not your favorite restaurant, but your favorite doctor’s office, who is responsible not for meeting your dining needs, but those of your health.

Megan Lewis, M.D.
A family doctor in rural Colorado.

This analogy reminds me of a similar one that I read a few months ago in the Los Angeles Times: "Dollars to doughnuts diagnosis":

Imagine one morning you're craving something sweet, so you stop by the corner doughnut shop. Turns out the wait is half an hour, the clerk is rude and, when you finally get it, the doughnut is stale. Would you buy doughnuts there again? Of course not.

Yet, every day, millions of Americans put up with just that kind of service in their physicians' offices. And they keep going back.

Anyone who has visited a primary care doctor lately knows the drill: You show up on time, only to wait 45 minutes or even an hour. In the examination room, the physician (who offers no apology) seems distracted, harried and eager to get to the next patient. Then you're referred to a specialist -- who doesn't have an opening for a month.

Every politician and his Aunt Martha has a scheme to overhaul American healthcare. But not one of them will solve this problem: Most doctors are awful at serving their patients. The typical hair salon pays more attention to customer service than the typical doctor.

Why?

Because not enough people are pissed off enough with the current system to demand a change - yet.

But the two authors above, Dr Megan Lewis and Dr. Albert Fuchs, are. They both decided that they would rather be paid by their patients than by insurance companies, and don't take any insurance at all. Now all we need are some patients who would rather pay their doctor to do a good job than pay a health plan that gets in the way of doctors trying to do a good job.

Virginia FP of the Year = IMP!

From the Newport News Daily Press, an interview with this year's Virginia Family Physician of the Year:

When was the last time that your family physician made a house call? Or you were able to make a same-day appointment, see the doctor without waiting -- and then spend a half hour talking over your treatment plan?

These seemingly old-fashioned images are at the core of practicing medicine for Dr. John Brady of The Village Doctor. Working and living in the Hilton Village area of Newport News, Brady and nurse Jeannie Arado provide preventative care, management of chronic illnesses and special care coordination for nearly 1,500 patients.

As he developed his business model, Dr. Brady became active in a national movement known as the "Ideal Medical Practices, " or "IMP," which focuses on managing practice work-flow and communications to increase quality in primary care. Brady's efforts and those of other IMP practices around the country, gained national attention in 2006, with an article in The Wall Street Journal.

For more articles about Ideal Medical Practices, go here.

For his accomplishments, Brady was recently selected by the Virginia Academy of Family Physicians as the 2008-2009 Virginia Family Physician of the Year. This statewide award, which is the academy's highest honor, is presented to "a family physician who gives compassionate care, is active in the community, and serves as a role model to medical students and other medical professionals."

An article from 2 weeks ago about Dr. Brady's practice can be found here.

When my solo practice grows up, I want it to be just like Dr. Brady's.

Good News, Bad News

The good news is from today's Portland Press Herald: "Smaller is better, say doctors who reduce practice"

Dr. Jean Antonucci says a physician can learn a lot by meeting a patient in the waiting room. She notes how difficult it is for the patient to get out of the chair, how easily he walks, whether his speech is slurred and whether his mind is confused.

Antonucci, a family practitioner in Farmington, does these waiting-room observations every workday.

She has no staff, practices out of one room, performs duties typically handled by a nurse or medical assistant and offers patients a $10 discount for handling their own insurance claims. She also has fewer appointments a day than most of her peers and is available to her patients around-the-clock.

Antonucci says she's never had such a good time practicing in her 21-year career as a doctor.

"It's not only good care for patients. It's just joyful to do it," said Antonucci, who opened her current practice three years ago.

Antonucci is among a small but growing number of doctors who are radically paring down their practices. They reason that if their overhead costs are lower, they can get by with fewer patients.

Besides making practices smaller, another trend for some primary care practices seems to be going "insurance-free":

Dr. Karen Hover opened a new cash-based solo practice in Bangor in July. She uses a menu of services with set fees that charge $50, for example, for a single-issue visit and $100 for a full physical.

"It's supposed to be really simple. They can look at it and decide what they want," Hover said. "That's our contract for the visit. I don't go over that and they don't go over that."

Hover said she was troubled that the uninsured pay more for the same services than insurance companies. Insurers negotiate discounts but individuals are at a disadvantage, she said.

Because billing requires a lot of staff resources, cash payments allow her to cut her expenses. She employs only a receptionist.

I like simple. Simple is good.

Dr. Hover knows how bad our overly complex medical system can get. She wrote this editorial which was published a few weeks ago in the Bangor Daily News about the unfortunate experience of "Jane" who literally fell through the cracks of the system, "How our health care system failed Jane":

As a family doctor, I am reminded daily that American health care is broken. A local administrative assistant, "Jane," was working on her roof on a Wednesday afternoon when she fell. X-rays showed two elbow fractures. She was put in splints that immobilized her arms from the armpits to the fingers. She went home at midnight in the care of a friend with instructions to call her doctor in the morning for home services.

Nobody considered that home services are structured to provide only a few hours of support a day. She recalled: "I couldn’t scratch my nose, or feed myself, or get a glass of water, or pull my pants down." She needed around the clock care. Jane called her insurance company, which told her that her plan included 100 days of skilled care.

Arrangements were made to go to a rehabilitation facility on Friday, which was good because Jane’s friend had to go back to work. When Jane arrived, around noon, administrators told her that the insurance company had denied her claim and that she could not be admitted because she had no need for skilled medical care. After a couple of hours on the telephone, no one had a better idea, so she was sent back to the emergency room. By this time, she needed to go to the toilet, but staff refused to take her because of fear of liability. Her ex-husband helped her.

The good news is that Jane recovered and went back at work. The bad news is that there were no consequences for her insurance company and it is still business as usual for them. That's bad news for the rest of us.

Making Practices Perfect

Yet another article on an Ideal Medical Practice from today's Washington Post: "Making Practices Perfect":

The waiting room of Ramona Seidel's family medicine practice is empty, and she works hard to keep it that way.

After several years in a traditional suburban group practice that blended pediatrics and family medicine, Seidel quit to start her own micro-practice in Annapolis: a low-overhead, high-tech office that gives her more control over how she treats patients and more time to spend with them. She's happier. Her patients are happier. And she's pretty convinced they are healthier having a physician who knows them well.

Okay, no practice can be perfect. But "Making Practices Better" doesn't sound as sexy.

I wish the writer had included a link to the IMP Map because you just know that people are going to want to find something like this near them.

Dr. Seidel's web site can be found here.

What's in a name?

Anonymous recently wrote a comment:

Are you sure you want to call youself "IMP" ? The word imp has a negative connotation in its definition.

Hello, Anonymous. You are absolutely right. From FreeDictionary.com, the definitions of "imp" are:
1. A mischievous child.
2. A small demon.

While it may sound like a medical office run by small demons, IMP (short for Ideal Medical Practices) is a practice model that focuses on enhanced doctor-patient relationships, increased face-to-face time between doctors and patients, reduced physician workloads, and cutting wasted dollars from the healthcare system by reducing overhead and using technology to streamline communication and administrative functions. This is a kind of disruptive technology that is meant to demonstrate an alternative to the usual kind of medical office.

There aren't enough of us to overturn, much less challenge, the current system. We just want to stir the pot, make some waves, shake things up and just get people to see that there is a better way than the direction we are now headed. Medical care doesn't have to suck.

So "mischievous little demons" sounds about right. We're here to bedevil the broken US healthcare system, and hopefully one day put it out of its misery. Heh heh heh! ;-)

Gone Cruising

One common question that comes up with doctors looking into doing an IMP/solo model practice is: how do you take vacation?

This is a problem encountered by all solo physicians, not just those doing the IMP model. For myself, when I first went solo 4+ years ago, I didn't know any FPs in the local community and didn't know who to ask for coverage. So that first summer, I took my own call when my family went on vacation to Banff, Canada for a week. Since I was only seeing about 5 patients a week at that time, I figured no one would even really notice that I was even gone, especially when they could still reach me by phone and e-mail. And no one did. I scheduled patients for physicals the following week while sightseeing, just as if I was back in my own office.

Later on, I met some other solo family physicians through the local hospital medical staff meetings, and asked if they would be interested in doing reciprocal coverage, where I would cover them if they would cover me. It has worked out so far. It helps that our practices generally take the same insurance plans as each other. It also helps that:
1) I have less than 1000 patients so that means fewer calls.
2) My patient population tends to be younger so again that means healthier patients and fewer calls.
3) I still continue to take cellphone calls and e-mail so I can take care of issues quickly and easily that the covering physician might take longer to handle.

Having no employees the first few years of my practice meant not having to worry about paying for their services when I was away. I now have a part-time biller, but she can do her work even when I am away.

This coverage system has allowed me to travel with my family to Palm Springs, Yosemite, Walt Disney World in Orlando, Bar Harbor in Maine, New York City. This summer I have taken my longest vacation yet of 2 weeks. In fact, I am still on vacation, writing this from a Mediterranean cruise ship en route from Sicily to Naples.

While there is Internet access available, it is slow and expensive, so I have not been able to receive and respond to e-mail as quickly as I usually do. Also, I have no cellphone access, so that has resulted in more isolation, which is good for vacationing, but not so good for continuity of care. I know I should be grateful for being cut off from work. There is a tendency among many physicians (me included) to never let go of work, which I am always telling patients that they have to do to reduce stress. I should follow my own advice.

I know there are other solo physicians who take their own call whenever they go on vacation, without arranging for any kind of coverage. I think it depends on how far you go, and what your patient panel is like. If you are a doctor in a rural area with no other primary care physician nearby for coverage, that may be your only option. Hiring a locums doctor is another solution, but I think running a solo IMP model, even temporarily, might freak out your usual locums doctor who is used to the usual set up of having someone else answer the phones, do the scheduling and give the shots.

Since there seems to be a growing number of doctors interested in the IMP model but who are not ready to make the "leap" themselves yet, I think it would be ideal and mutually beneficial for a pre-IMP doctor to do locums coverage for an IMP doctor just to get their feet wet, and at the same time, help out an solo IMP doctor who might not otherwise feel confident about leaving their practice for much-needed R&R time. Something like a Craig's List for IMPs.

Anyways, I hope that all primary care physicians get a chance to take some time to rest, relax and recharge this summer.

Ciao bella!

Comic-con Relief

OK, I meant to post these last week when I went to Comic-con. Better late than never.









Sick, but funny. Trust me, I'm a doctor.

Old Fashioned Touch

From The Olympian in Washington State: "Old-fashioned touch: Micropractice helps doctor humanize modern medicine"

Dr. Marius Laumans strives to run an old-fashioned medical practice with modern-day conveniences.

Need a same-day appointment? Patients can go to his Web site, check his availability and schedule one.

Wondering if an over-the-counter allergy drug could mix poorly with prescription medication? All of Laumans' patients have his cell phone number and e-mail address and are encouraged to use them anytime.

Too sick with a stomach bug to get out of bed and drive to his office? Not to worry, he makes house calls, too.

"Thirty years ago, this was what a regular practice looked like," Laumans said.

The 34-year-old family physician is one of a growing number of doctors who are opting to go solo - without the support of receptionists, nurses, medical assistants, billing clerks and cleaning staff.

Dr. Laumans is indeed part of a growing movement of IMP (Ideal Medical Practice) doctors that seeks to improve quality of care as well as quality of life for patients and physicians alike. However, this article perpetuates the old concept of "micropractices" being completely solo-solo operations. Many IMPs start out without any employees, then add staff later as the practice grows.

And there aren't 500 micropractices/IMPs in the country...yet. But hopefully there will be. To find an IMP, go to http://www.impmap.com.

The Hopeful Future of Medicine

IMP Camp 2008 is underway and full of bright-eyed and bushy-tailed (and even tail-deficient) doctors!

From Soma's blog

I had started my medical practice in Manhattan in the summer of 2006. They say if you can make it there you can make it anywhere…Oh boy is that true. I started my business before I even knew the existence of the IMP group. I didn’t realize that the same concepts and the similar reasons why I wanted to go into business for myself was why several other physicians all over the country did the same. Most of the topics at the conference are things that I have already been developing in my own business. The spirit of the people is what gives me inspiration to continue what I am doing. Some have been in business longer than I have, some work in areas that are considered to be dead-zones for effective health care. But they continue. They get over the hurdles, take every day one day at a time and remain true to their souls. The magic of this is this is something that you cannot learn in medical school. It already has to be there. And most of the people here have it.

Speaking as one of those "dead-zone" doctors, I agree with Soma's sentiments about the enthusiastic spirit and idealism of the 80+ attendees. We want to save the world, one patient at a time.

IMP Evolution

From the June 2008 issue of Medical Economics, "Small practice evolution: The medical micropractice":

Every so often, a new patient of internist Jean Antonucci in Farmington, ME, looks puzzled when the doctor herself—and not a medical assistant—walks into the waiting room and escorts him to a 125-square-foot room.

In that room, which looks out on pine trees and a stream, Antonucci takes vital signs, asks the patient what's bothering him, diagnoses and treats that problem, and collects the copay. By the time the patient leaves, he realizes that Antonucci is truly a one-woman show.

"I really don't need staff," says Antonucci, who rents the space from another physician. "I'm amazed at how well this method works."

The method is known as a micropractice, and it defies the conventional wisdom of practice management experts who urge doctors to boost their productivity by delegating nonphysician chores. A micropractice doctor typically works without employees in a space that's drastically smaller than what the average soloist has. Such austerity reduces the customary overhead by 40 to 50 percent, thereby lowering the break-even point and enabling micropractitioners to spend more time with fewer patients.

Speaking of evolution, the official name is now "Ideal Medical Practice" or IMP, and not micropractice. That's because you don't have to be solo/small to achieve ideal health care.

Psst!

From The New Yorker Magazine

Pass it on.

Franco is Still Dead

From the NY Times: "Number of US Primary Care Doctors Down".

Fewer American doctors are focusing on primary care, but the decline is being covered by physicians from other countries. The General Accountability Office said Tuesday that as of 2006 there were 22,146 American doctors in residency programs in the United States specializing in primary care.

That was down from 23,801 in 1995, the research arm of Congress told the Senate Health, Education, Labor and Pensions Committee.

''It is troubling to me that the number of Americans pursuing a career in primary care has declined,'' said Sen. Bernie Sanders, I-Vt.

The Senator's solution? Doubling the funds for the National Health Service Corps. That's like trying to get people to buy a Zune by pricing it less than an iPod. Hello? It ain't gonna work with primary care either.

The only way to get more doctors going into primary care is to make the career and lifestyle *more* attractive than going into a specialty. Paying them more and abusing working them less would be a great start.

I'm not holding my breath on this one.