The Third Path

It is the eve of my Family Practice Boards Recertification exam. Once every 7 years, I and many of my fellow FPs take the test, and if we pass, we can proudly claim that we are "Board Certified" in our specialty. It will be my 2nd recert, and even though I haven't studied very much, I'm not worried. I answered some practice questions and got around 70% correct. Plus the pass rate for the ABFP boards averaged between 92-96% between 1986 and 1996. Although there was that one year in 1993 when only 85% passed. Whoops.

There are courses every year to help you review for the Boards, and I took one 7 years ago for my first recertification. But my opinion now is that for most FPs, they are probably unnecessary, given the high pass rate we already enjoy. It appears to be a lucrative enterprise, though.

In the past week, I've had to deal with a new kind of problem: what to do when established patients call with a new complaint?

One woman got rearended in a car accident, and developed whiplash-like neck pain. A patient's mother had a form that needed to be filled out so he can go on a summer educational cruise. Another patient had been having vertigo for a few days. Another patient's mother emailed me asking if her son should get orthotics for knee pain that began ever since he started training for cross country 2 weeks ago.

All of these problems could be handled, more or less, without an office visit. My dilemma is that, without an office visit, I won't get paid for my services or time. My choices are:

1) Encourage everyone to make an appointment to be seen by me in the office for a "proper" evaluation, and risk alienating each patient who may conclude that I am only making them come in to make money off them.

2) Help them out by phone or email, then charge them a separate fee to be billed later. One flaw with this option is that I have not established any kind of policy on charging for these services. Until I establish a more formal policy and inform patients beforehand that they will get charged, I think I will avoid doing this. I did read, however, that there is now a CPT code available for online consultations. Read about it here.

Even if I were to establish a policy of charging for telephone or email consultations, it might be seen as "nickel and diming" patients. I recognize that other professionals, such as attorneys, bill for their time, such as for telephone advice. As a physician trying to get a new practice off the ground, it might not be in my best interest. Maybe later, after I am more established. Which brings me to option number...

3) Help them for free, which is what I've been doing. It's building goodwill, and hopefully I'll get compensated for it later on with a new patient brought in by a good word from these patients I've helped for free.

This is in contrast to the transition of a local doctor's practice from a traditional office to a "concierge medicine" practice. I don't know who it is, but I've heard about it from a couple of patients or their relatives. I keep thinking that if people only knew about me and my practice model, they would realize that they don't have to pay that extra retainer fee to get good service and personal attention.

Unfortunately, this brand of medicine does not yet have a catchy buzzword name to describe itself. In my search for a suitable descriptor, I came up with "The Third Path". It sounds kind of mystical, like a spiritual movement, and I suppose to a certain extent it could be that.

The First Path of modern medical practice is what physicians do now. Reimbursements are fixed by third party insurers. Expenses keep going up. Those who follow the First Path try to make ends meet by seeing more patients to generate more income. This generates more work, more claims, more charts. So more ancillary help needs to be hired, which raises expenses more. Which means even more patients need to be seen. It's a hamster wheel.

Those who take the Second Path are boosting their income by charging patients more, an extra retainer fee to insure good service and to pay for all the services that don't get reimbursed. This is the "Concierge" or "Boutique Medicine" that seems to be getting more and more popular. More income means they don't have to see as many patients to cover their expenses, so they can spend more time with patients. Which means doctors can relax and enjoy practicing medicine again. Everybody wins. Except those unfortunates who can't afford the extra fees. This is medicine for the wealthy and well to do, and creates a second-class patient. Plus, Medicare will probably go after anyone who charges extra for what it considers covered benefits.

The Third Path is the way I've chosen, led by our prophet Gordon Moore. Instead of raising fees, we seek to control expenses by doing as much as we can ourselves, by streamlining operations with EMR's and email and cellphones and the Internet. And by thinking small, as in small offices, short waiting times, minimizing barriers and hassles as much as possible. The Third Path is not the Usual Way Things Are Done. Hopefully, it's better!

Bad Ads and Good Claims

A new record: 2 hrs 54 minutes.

That's how long it took from the time the patient walked through the door till the time I submitted her claim electronically. I think I'm getting the hang of it. She needed a refill of meds for HTN and BCP, otherwise felt fine. I went over her 2 page history form (it used to be 3 pages but I trimmed it down) and we talked a bit about what works best to lose weight. As she said, she knows what to do, she just needs to do it: eat less, exercise more. A detailed physical exam (but no breast or pelvic exam since she had a Pap done 6 months ago), then I wrote out her prescriptions, and an order for a mammogram. In all, her face-to-face time with me lasted 45 minutes.

The medical student working with me got to contrast how I see patients at Kaiser vs. seeing one in my own office. At Kaiser, I would've spent a lot less time on the history and done an abbreviated physical exam, probably taking 20 minutes instead. Which system is better? It depends on whose money is being spent, and if the patient is in a hurry or not. The net outcome is probably the same as far as mortality. A better patient-physician relationship: how much is that worth? If it means sowing the seeds for eventual weight loss and prevention of related illnesses through better motivation and encouragement, then it may be worth a lot. But it's not an easy thing to measure.

I would've gotten done sooner if I hadn't been interrupted in the middle of my progress note. Someone had called me earlier about placing an ad in a weekly flyer that would be handed out free to all Blockbuster Video customers. He guaranteed that I would be the only medical doctor listed, and even better, that they were running a contest where people could win gift certificates for $50 or $100. All they had to do was write down the names of all the advertisers in the flyer and send it in, guaranteeing that someone would remember my business. It didn't sound like a bad deal so far. I was interested so he arranged for someone to come by my office at 3:30 PM.

But when his associate came to my office an hour early, I got a different impression. Their company does the ads that show up on the back of the grocery market receipts, on the shopping carts and on bus benches (hmmmm...). The flyer, which lists new movies and TV shows of the week, looked like the throwaway flyers that you get when you go to the grocery store, except it was on glossy paper. The people that advertised in it didn't seem like the kind of businesses that I would be interested in going to. It would cost $18 a week or $936 a year with a minimum one year contract. Plus I had to tell him yes or no...NOW! That was a bit offsetting, plus the way he kept smiling and telling me repeatedly, "You are gonna make so much money from this!" I didn't have a good feeling from this.

So I pulled my trump card. "This sounds really interesting, but I'm going to have to check with my wife first." He called my bluff and said, "Can you call her right now?" I asked him to have a seat in the waiting room, and made a call to my wife's cellphone and then her brother, whom she is visiting this week in Connecticut (hi honey!). Fortunately, she was unreachable, having gone to the city to paint the Big Apple red with my daughters. I relayed the bad news to the salesman who shrugged it off and left, while I silently rejoiced at my narrow escape.

While there may be no such thing as bad publicity, I do believe there is such a thing as bad advertising.

The other noteworthy thing that happened today was that, after much hemming and hawing, I finally sent in my Medicare Enrollment form. I also heard from someone at the local Medicare contractor's office that I am able to retroactively bill Medicare for any patients I have seen since I opened my practice 4 1/2 months ago, even though I didn't submit my enrollment form until today. That seems kind of unbelieveable to me, so I hope it's true.

I officially joined the local Kiwanis chapter this week, but I consider this a form of Good Advertising. There are a lot of local business and community leaders involved in this, and I think in the long run, it will be better for my practice. This Sunday morning I will be resuscitating my old waitering skills and try not to spill any syrup on top of anybody's head at the Annual 4th of July Kiwanis Pancake Breakfast.

Finally I want to mention how helpful the people at Medrium have been so far in helping me sort out my billing snafus. My first 5 claims were rejected because I forgot to enter my medical license number in the appropriate (but non-obvious) location. My next 2 resubmissions were rejected for different reasons. The first because "v70" is not an billable code, but "v70.0" is (missed the point zero, which I should have known, having taken a medical billing class). The second rejection was for an arcane reason, however. It turns out Blue Shield doesn't like my medical license number unless it has two zeros preceding it and one zero trailing it. Don't ask me why. Those are the kind of picayune yet real obstacles to getting paid. I consider myself lucky for being able to send the claims electronically. Instead of waiting one month to find out I made a mistake, it took a week. At this rate, I'll probably get paid in one month. If I had used snail mail, I probably wouldn't get paid for 4 months, if I was lucky.

Plus these kinds of mistakes I figure I'll only make ONCE. After I learn the secret of filing clean claims, I'll be able to RULE THE WORLD! BWA! HA! HA! Or I may get paid in less than a Mercurian day. Either would be good.

I think one day it'll be possible for me to see a patient and submit their claim in less than an hour. How many doctor's offices can do that, I wonder? Happy 4th of July!

Catching Up

Sunday, a day of rest, a day to catch up.

I had 2 more patients on Friday, both kids. The first one I scheduled at 7:30 AM when his mother called. She probably thought she'd leave a message at the office, but instead I answered since I still had calls forwarded to my cellphone. Since I was giving a talk at the Senior Center at 10 AM, I thought it'd be better to schedule him a little later at 12 noon, just in case it ran long.

The second one was a walk-in. As I was driving back to my office at 11:30 AM, I got a call from the Ob-GYN doctor's office next door to mine, and they asked me if I was open today because a patient wanted to see me. I assumed they had referred one of their patients who walked next door, only to find nobody there. I told them that I would be there is 2 minutes, and to just ask the patient to wait. I only figured out later that they were not the Ob-Gyn doctor's patient. They had been referred by the "chemist" aka pharmacist up the street because they were looking for a doctor to check out the 4 year old's earache. (I must remember to thank Dr. Chan!) The mother and her 3 children were visiting for 7 months from England while her husband taught at a local college. I gave her the usual paperwork, which she found amusing/annoying since medical care is free in England through the National Health Service, which she loved. I quickly diagnosed a swimmer's ear and got them on their way, because my 12 o'clock patient had come early.

His mother had learned about me through my sister, who is a co-worker. He came with his father, who was worried that his son might have West Nile Virus, because he had spent time at his grandmother's who lives very close to where a lot of WNV cases were recently discovered. Fortunately, I had recently read about WNV though information provided on a CD-ROM provided by the CDC. (I don't know if every doctor is getting one, but I received two CD's in the mail. Anyone want an extra?) I reassured him that 80% of people infected with WNV are asymptomatic, that about 20% will get fever, headache, rash, and less than 1% actually needed hospitalization. Anyways, he had swollen tonsils with an exudate so I did a rapid strep test on him. Unfortunately (or maybe fortunately?) it came up negative, so I send off a throat culture and put him on Amox for 5 days pending the report.

As always with these new disease outbreaks, there is a lot of concern, but also some overconcern (hyperconcern?). About two weeks ago at Kaiser I saw a patient who works in the department of public health who developed fever and a rash. She told an epidemiologist there who told her to get tested for West Nile Virus. When I saw her she had a classic rash for shingles. But because an "expert" in WNV (who I suspect is not an M.D.) told her she should get tested for it, I could not reassure her that her symptoms were only due to shingles, and that testing for WNV would not change her management. I should try to find out what her WNV test showed.

Earlier last Friday morning I gave a talk at the Senior Center on Nutrition, Exercise and Supplements. And even earlier that morning/night, I was working on that talk. Being a chronic procrastinator, I always wait until the last minute to prepare these talks. It's hard for me to get motivated to write them any earlier. Anyways, I'm wondering if it's worth it for me to continue these talks. I've given 3 so far. This talk was attended by 9 people (but 2 left early). My last talk was attended by 4, so it's an improvement. I haven't gotten any patients from doing these so far, but one person said he is planning to see me sometime. I do enjoy giving them, plus I feel that I do learn a lot from researching the various topics. Because of the informality of the small group, there are frequent interruptions and questions, which always prolongs things. But some people ask very good questions.

I'm not signed up for any more talks so far, and I think I'll take a break for the summer. Besides my Board Recertification is coming up next month and I really should study. But, it's hard for me to get, you know – motivated.

My wife (hi honey!) and children are out of town this week visiting relatives back East. So I spent 2-3 hours yesterday scanning in papers from previous patients. For the longest time I couldn't get the scanning program to communicate with the scanner (an HP 6110 All-in-One), so I had to hold on to the papers. About a month ago, I figured out how to get it working but just didn't have time to scan papers in. Unfortunately, I had to manually scan each sheet by hand. Even though it has a automatic sheet feeder, it only works with faxing and copying, not scanning. Grrrrr! But it is satisfying to know that I can now shred all those papers (when I get around to it).

Doing the math, if I eventually see 12 patients a day, and each patient has 9 sheets of paper (2 registration, 1 financial responsibility, 1 email consent, 3 patient history, 1 insurance card, 1 statement of benefits) to scan, that works out to 108 papers to scan a day! Of course, that's the worst case scenario. Hopefully, I'll have some returning patients who won't need anything scanned. But I am beginning to see the benefits of a high-speed scanner (and high-speed shredder). At this point, I don't have the money or space so manual scanning it is for now.

After sending 5 claims through Medrium, I have gotten back 5 rejections. Hmmm. The reasons for rejection are all the same: "NETWORK ID:REQ: LCNSE # IN NETWK ID FOR PAYER". I think that means they are rejecting the claims because I did not give them a network ID#. That's because I don't have one. I clearly checked off that I was not a participating provider - yet. But I hope to be soon. I hope this doesn't mean that I have to wait until I'm approved as a participating provider before I can submit ANY claims. There has to be a way for non-participating providers to bill the insurance companies. I'll call Medrium on Monday to see if they can help me figure this one out. I knew it wouldn't necessarily be easy to get a claim paid, but why can't I ever be wrong about these things?

Finally, last week I received an email from Dr. Bob Nelson, a pediatrician stationed in Afghanistan, who is thinking of opening his own solo practice after he gets out of the army. I connected him with Gordon Moore's Practice Improvement Group, and told him about this blog, which he has found helpful. I hope he doesn't mind me posting his comments. He wrote: "On 14 FEB you wrote that if your blog helps one person start a solo practice, you'd be happy. You should be happy." Thanks, Bob. I hope we'll both be happy. Godspeed and good luck!

See One, Do One, Teach One

One patient so far this week, a young woman with anxiety disorder who wanted to be reassured that her shortness of breath wasn't a sign of impending asthma. And it wasn't. I was able to see her at 8PM after she initially called in the afternoon for an appointment, but changed her mind. Twice.

I spent some time discussing anxiety disorders with her, and encouraged her to consider trying anti-anxiety medications as her psychiatrist suggested. Hopefully, she'll get better. And even though she didn't have any insurance (because she is a graduate student), she told me she would come back and see me when she got insurance coverage.

I hope I get some patients in my practice in the next 3 weeks since I am precepting a 2nd year medical student as part of the California Academy of Family Physicians' Summer Preceptorship Program. It pairs an practicing family physician with a newly minted 2nd year medical student who is interested in family medicine as a possible career choice. They spend 4 weeks shadowing the physician, and at the end, get a $1000 stipend. Having done this many summers over the past several years, it is always fun for me and hopefully inspires a student to go on to FP. This year's student is from USC, and even though I am a UCLA alumni, I am treating him like any of my other past students. I'm just that kind of guy. (For those of you who have no idea what I'm talking about, read this.)

For those of you who have not tried teaching medical students or residents, I highly recommend it as the experience can be quite rewarding.

I started inputting data into Medrium yesterday and have submitted 5 claims so far for a net total of $780. Of course, I don't expect to get all of that, but even some of it would be helpful seeing as I'm down to about $2000 in my checking account. We'll see how long it takes to process these electronic claims, or whether any claims get kicked back to me. Even though entering the info is kind of tedious, I can see myself getting faster as I learn what needs to be entered. I was one of the faster coders in my medical billing class, after all. I even toyed with the idea of trying to get some work as a medical coder (incognito, of course) just to see if I could code as well as a "real" coder. But before I got the chance, the instructor found out I was a physician, so that blew my cover.

But I am a believer in learning new things and doing things myself. And after I learn them, then I can teach someone else. Knowledge is power. A medical records file clerk has power over me as long as I don't know how to find a chart. A medical assistant has power over me if I have to wait for her to get vitals on the patient before I can see him. A medical coder has power over me if he can take 8% of my charges in return for writing some numbers on a piece of paper. Now, I am getting some of that power back, as I learn my way around the business end of medical practice. It may not be a pretty end, but it's the end that makes this beast called Medicine go.

Moo.

Use a Pen, Go to Jail

Back to a slow week, just 2 patients. That's the way it's going to be: unpredictable. It's been 4 months since I opened my solo practice and I've seen 36 patients so far. I've got a long way to go...

I signed up for an online billing service today called Medrium. It's about time I got paid for seeing some of these patients. We'll see how easy (or difficult) it is to use.

Here's an article from today's WiredNews.com site on doctors and computerization, appropriately title: "Dragging Doctors to the Info Age" that suggests a topic for a rant:

Since 1999, then, hospitals have slowly brought in more computers, focusing largely on so-called Computerized Physician Order Entry systems that force doctors to type in prescriptions instead of writing them on paper. Not surprisingly, some deadly errors occur when pharmacists misinterpret physician handwriting. In one 1995 case, a Texas man died because a pharmacist thought his doctor had ordered the high-blood-pressure medication Plendil instead of another drug called Isordil. The patient got eight times the safe dose of Plendil. (Wachter showed the handwritten prescription to 158 doctors and only a third thought it was for Isordil.)

"Only" a third? That's not very reassuring. And this:

Computers, of course, have limits. Notwithstanding computerized physicians on Star Trek, technology won't turn an incompetent doctor into a competent one or provide the intuition that nurses rely upon when they treat patients.

The point, Wachter said, is to provide backup systems to warn hospital employees before they make mistakes. "We're not going to fix these sorts of screw-ups by advising people to be more careful. They'll just blow it again," he said.

Computerization may help, but typos happen to (sic).

You'd think that highly educated doctors could learn to be more careful. But I agree that that is not likely to be the answer.

As studies (here, here and here) have shown, doctors as a group do have bad handwriting. I have personally known a select few whose penmanship was so illegible that even they have trouble re-reading what they wrote. So, as a profession, it's our own fault.

While some think the solution is forced computer entry, preprinted prescription pads or "aggressively educating" patients what medications they take and why, I think a simpler solution is at hand, yet one that will rarely be followed: handwriting classes. It is such a simple and low tech idea and addresses the root of the problem. As an English major, I have always prided myself in my handwriting, or rather my printing (I haven't used cursive writing since high school). One of the nicest compliments I get is from patients who look at their prescription and say, "Gee, you sure don't write like a doctor. I can read what you wrote."

Admittedly, my handwriting has gotten worse through the years. Plus I realize that lack of time plays a role in how quickly doctors scribble their notes and prescriptions. But are careful doctors also more careful about their handwriting? Or vice versa, are doctors who are careful about their handwriting also more careful in their medical practice?

I confess that I have a prejudice against bad handwriting. I sometimes feel that, rightly or wrongly, a doctor's handwriting correlates with his or her competency, or more specifically, their attention to detail. Whenever I read a consultant's report or progress note that is illegible, I think, "This doctor didn't take the time to give me a comprehensible note, so he probably didn't take the time to do a good job evaluating the patient either." I realize that this is probably not true, that there may be excellent doctors with chicken scratch handwriting. But it is certainly not something that bolsters a lot of confidence for me.

So write neater or the alternative is this.

A Good Week

This has been an unusually good week so far. So good, I'm finding it hard to post an entry. A quick summary:

Last week: 0 patients
This week: 9 patients (so far)

My ad appeared in The Quarterly, a locally distributed magazine that is mailed free to all residences in the area. I believe it goes out to about 30,000 households. But none of the 9 patients called because of the ad.

I met with the local Kiwanis group, and there are a lot of local business leaders. Seems like a good way to network.

I did 45 sports physicals on Tuesday at the local high school in 3 1/2 hours. It was the assembly line model, with me and a physical medicine doctor doing the doctorly duties. Quite exhausting! But I got paid $15 for each physical. With this week's income, I actually generated enough income to pay for my office rent this month. Whoopee!

Did my first pap smear today in my office. The patient did not want to bring along anyone she knew to chaperone, so I enlisted our children's nanny to step in for chaperoning duties, which she cheerfully performed. I also paid her $10 for 15 minutes of work, which is worth it to me.

I think I'm going to have to start sending out bills soon. Most patients I've been seeing lately have insurance, but I haven't gotten around to filling out those HCFA-1500 forms. Should I do it by hand, or sign up for Medrium at $25 a month? Hmmm...

I have to finish my talk on Anti-Aging for tomorrow's Senior Center lecture. Plus I have been continuing to work half-day shifts at Kaiser (12 patients in 3 1/2 hours). Busy, busy, busy. I hope it stays this way.

A change in plans

Last Thursday night I was all set to stay up late working on my talks ("Anti-Aging and Longevity" for the local senior center and "The Musculeskeletal System" for my daughter's 5th grade class) for the next day, when I got a call from my dad. From the emergency room. It turns out he'd been having melena for the past 3 days, and the doctor thought he should stay overnight and get scoped in the morning. He was feeling fine and was more worried about getting a hold of my mom so she could pick up his wallet and car keys.

To say the least, I was surprised, as my dad has been the epitome of good health even at age 75. He liked to brag about how he continues to play basketball 3 times a week with men who are 1/3 of his age. I spoke briefly to the admitting doctor and learned that my dad had only a mildly decreased hemoglobin count. I told my dad what to expect and apologized for not being able to be there with him tomorrow because I had to give these talks.

After I hung up, I thought about it. Even though I knew that the odds were more likely for a stomach ulcer, this could be really serious if it turns out he has an esophageal or gastric cancer. I decided that I really didn't need to give those talks tomorrow, and I would request that my afternoon shift at Kaiser be cancelled the next day. I decided it was more important for me to be there with my father when he got endoscoped, and when the doctor explained what he saw. This was about realizing where my priorities should be, similar to what led me to go solo in the first place. I was disturbed that I didn't see this immediately.

Fortunately things turned out as well as could be expected. My dad was diagnosed with a gastric ulcer, probably brought on by daily aspirin which he had been taking for the past few months. The senior center rescheduled my talk for next Friday. The 5th grade teacher said I could give my presentation on the musculoskeletal system next week. I assumed Kaiser managed to find someone to take my place for the afternoon shift.

It's funny how life works. I hadn't had any appointments all this week. But while I was sitting with my dad in the recovery room, I got two calls for appointments. I had to quickly step out of view of the nurses because the first time I used my cellphone, one of the nurses yelled at me to turn it off because of hospital rules. I ended up calling patients back using the phone at the desk. I got a call to schedule physicals for a family of three while I was sitting by my dad's bed back in his hospital room. I kept hoping that the patient wouldn't ask me about that loud snoring sound in the background and luckily she didn't.

I'll end with my opinion that the wholesale ban of mobile phones in hospitals is ludicrous. This article calls for a loosening of mobile phone restrictions in hospitals.

Mobile phones (cell phones) are a source of irritation for some but undeniably useful for many, and over 50% of the population of the United Kingdom possess one. Their use in hospitals, however, is mostly banned as they are considered potentially hazardous in medical environments. But the evidence for serious harm is flimsy, and the hysteria that surrounds the use of mobile phones in hospitals is unjustified.

So how dangerous are they? The evidence for harm is limited. Anecdotal reports exist of interference with medical electrical equipment, which led to a study by the Medical Devices Agency in the United Kingdom. In this study, 4% of medical devices suffered from electromagnetic interference from digital mobile phones at a distance of 1 metre. This compared with 41% from emergency services' handsets and 35% from porters' handsets. Most of the interference related to disturbance of the signal on monitors, such as electrocardiographs, confirmed by data from the United States.

It does seem hypocritical for hospitals to tell patients and visitors not to use their mobile phones, while the nurses and transporters are free to use theirs. It seems to be one of those rules that nobody follows anyways, like how the speed limit is 65 mph while everyone on the freeway is going at least 75 mph (in Southern California, that is).

The one situation with cellphones that drives me nuts is when I walk into an exam room and the patient is talking on their cellphone. And they keep talking. And keep talking. I use to wait until they were done. Now I just say, "I'll be back." and see the next patient in the other exam room. Of course, this only happens now when I'm working a shift at Kaiser. Because in my solo practice, nobody waits. Nobody but me, and that's only because these registration forms take at least 15 minutes to fill out.