Sunday, August 31, 2008

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.