Staying the Course

Last week was a pretty good week for my still fledgling practice: 9 office visits, 5 new patients who all had physicals. This week: 6 office visits, 5 more new patients. Six months into my solo practice, I've had 73 office visits with 60 unique patients, with an even 50-50 split between the sexes, 30 males, 30 females. The average age is 36, and I'm definitely seeing more children and teenagers than in my former practice at Kaiser. This means most of the patients tend to be healthy, which makes for easier and more enjoyable visits, too.

Compared to some of the other doctors who are trying the "low overhead" or "Gordon Moore" model of practice, I feel like an old tortoise racing against Olympic-caliber hares. Scott in Florida just opened a practice right out of residency and saw 45 patients in his first two weeks. Michelle in Colorado closed her practice to new patients after less than a year, capping her patient panel at 450 patients.

Getting approval for insurance participation should help my practice grow. I learned just last week that I have been approved as a participating provider in Blue Cross of California, which has been the most common insurance my patients have had: 36%. That makes two health plans I have joined, Blue Cross and Cigna. I called Blue Shield the other day to ask what the status of my application was and found out that somehow my application had "slipped through the cracks". My credentialing had been approved back in April, but my application was never sent to the appropriate department to finalize participation. Whoops.

Yesterday I received an approval letter from Medicare, which was very fast, compared to the others. Looking back, it took about 6 weeks from the time I mailed the application to the time I got the approval letter. The third party insurers took about 3 months (with some still counting.... )

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Even as my practice seems to slowly pick up steam, I recently got an offer to buy an existing practice in a neighboring city. It is a successful practice with about 1500-2000 active patients, and the doctor is able to make a good income despite having two part-time employees and seeing about 42 patients on the 4 days of the week he works. When I heard these numbers, my first reaction was, "How can he do that?" But in analyzing the numbers a little, it does seem credible. I think I'm still not used to seeing a lot of income because I have not been keeping up with the billing.

When I first considered going into private practice, it had occurred to me that buying an existing practice would be one way to become financially solvent faster. But at the time, no one was advertising a practice for sale, and I wasn't about to go from doctor to doctor asking them if any of them were thinking of retiring. But buying someone else's practice means you get a lot of things that you don't want, too. There would be his employees, who are probably very nice, but a new kind of responsibility to deal with. There would be all the paper charts, since he is not using electronic medical records. His patients might be used to a different style or philosophy of medicine. But I would probably be instantly busy, seeing 10-15 patients/day compared to the 3-9 patients/week that my practice currently enjoys.

It would also mean either:
1) moving my location to another city, which would force me to give up my goal of being my home town's one and only family doctor.
2) Or moving the other practice to my current location (and risk losing patients from that practice)
3) Or keeping both locations and shuttling between them.

I would not be able to keep as tight control over everything, since I'd be forced to delegate appointment scheduling, billing, keeping track of supplies, etc. Some of this would be desirable. It'd be nice to have someone else answer the phone when I'm busy with a patient, rather than a recorded message. And billing can be tedious, when you have a lot of bills to process or if you have to call the health plans to argue over a denied claim.

So today I thanked the other doctor for the generous offer, but I preferred to stay the course and continue building up my own practice. I hope I don't regret it.

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I recently read a newspaper article about another doctor in San Diego who has been practicing completely solo, but he seems to have come up with the idea independently of Gordon Moore. Great minds think alike, eh?

And what can I expect for the future? Hopefully a little of what Kelly is getting. Kelly in North Carolina opened her solo practice about a year ago, and recently provided an update to the members of the Practice Improvement listserv. She wrote:

"My practice is incredible...I knew how hard this would be, but there are so many things that come up which I could't have even imagined let alone plan for.  I finally had to hire someone to help with billing...actually allocating payments and keeping up with the insurance companies, as Alteer handles the actual billing beautifully.

I'm still getting many calls a day for new patients, I have started accepting two a week and am scheduling them into January.  It feels stupid, as I hold my open access system dearly (for my established patients only).  But my waiting list was daunting and I don't want the responsibility of that...so if the people aren't minding I guess I shouldn't.

Though the insurance companies were definately NOT worth the hastle from November until July, they definately ARE now.  The reimbursement has been excellent this month.  Now that I have my pattern established with the ten biggest companies here I'm not having to call much anymore.  What a relief, and I'm getting paid much better than if I charged cash.  I also like the variety of patient's that it allows.

Have to go pick up my kids, who are also very happy with the life this practice allows, and have dinner with my husband (also a doctor at a local clinic) who is getting very jealous of the time I get to spend with my patients."

This gives me hope for a financially viable practice. I already am enjoying the time I spend with my patients - a practically obscene 60-90 minutes with a new patient has been my norm. And it's certainly gratifying to get comments such as this from my patients: "Thank you for being someone who wants to bring the caring quality back into Doctoring!"

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On a final note, I passed my Family Practice Boards (like 90+ percent of the doctors who took it). Yay. Now I have an excuse to send off a press release to the local paper and try and drum up some more business. I may be slow, but I'm not dumb.

Patch vs. Crash vs. ... Switch

I originally sent my Cigna application on 5/13/04. I got a letter back last week informing me that I had been approved as a participating provider. About 3 months, which is what others had told me. I am no longer in the limbo world of out of network providers. I am now a Participating Physician!

Or not...

I looked on Cigna's website and I am not listed in the online Physician Directory yet. So more waiting. Hopefully, I'll be hearing from Blue Cross, Blue Shield and Aetna in the next few weeks as to whether I'm accepted into their plans as a participating provider.

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Stop me if you've heard this one before. Complex system and infrastructure integral to providing healthcare has numerous flaws and obstacles to providing excellent care. Patches and fixes are like applying bandaids to plug leaks in Hoover Dam. You can keep tinkering with the system even as more and more problems arise. Or keep up with the status quo and crash and burn. Or you can try a radical change in the way things work.

The Gordon Moore Model? No, this time I'm talking about computers.

Eventually, if you wait long enough, everything converges. I ran into an article on Slashdot.com which discusses two of my favorite topics: medicine and computers. Fed up hospitals defy patching rules.

Problem #1: WIndows-based PCs are vulnerable to new viruses and worms. This is bad for hospitals that use PCs, ie. ALL hospitals.
Solution #1: Apply system patches and updates to plug vulnerabilities.

Problem #2: System patches often render software programs inoperable, including medical devices and instruments.
Solution #2: Software vendor tests their program with system patches to make sure they are compatible first.

Problem #3: Testing takes several months.
Solution #3a: Software vendor finally produces a product compatible with patched operating system. Repeat Problem #1.

or

Solution #3b: Hospitals apply patches anyways, and roll the dice, hoping their medical software and devices will still work. This leads to...
Problem #4: Vendor voids warranty because they didn't promise it would work on a patched system.

"When Microsoft recommends we apply a critical patch, the vendors have come back and said 'We won't support you,'" says Dave McClain, information systems security manager at Community Health Network in Indianapolis.

So the hospital has gone ahead and applied critical Microsoft patches to vulnerable patient-care systems when vendors wouldn't, McClain says. The hospital views the failure to apply patches as a possible violation of the federal Health Insurance Portability and Accountability Act (HIPAA ). "We have HIPAA regulatory issues, and you can't hold us back from compliance," he says.

Sometimes, the software vendor itself is the source of the virus infection:

There have been several instances in which viruses originated from medical instruments straight from the vendors, says Bill Bailey, enterprise architect at ProHealth Care, a Milwaukee healthcare provider. Medical equipment arrived with computer viruses on it or service technicians introduced the viruses while maintaining the equipment, he says.

(Getting on my soapbox)

As medical systems become more and more dependent on computers and electronic medical records, the information confained within them is only as safe as the operating system they run on. Increasingly, the Windows-based operating system is being exposed for its poor design and lack of security. As a physician, I feel that we should not trust our vital data and patient care to a buggy system, especially when there are safer alternatives. Either a Mac or Linux-based computer is a more secure solution.

This is not going to be a viable solution for everyone. There are not as many medical EMR/software/practice management options for Macs as for PCs. But for a solo physician, this is certainly something that is affordable and feasible. I'm living proof that it can be done.

Computer: Powerbook G4 12 inch 867 mHz
Scanner: HP Officejet 6110 All-in-one
Printer: HP Laserjet 1150
EMR: SpringCharts
Billing: Medrium
Financial: Quickbooks
Web browser: Safari (no pop-ups!)
Other software: Microsoft Office, Mail
Backup: daily automatic backup to offsite storage site, once a month complete backup of entire hard drive to external Firewire drive.
No known viruses for Mac OS X as of this time.

For ideas on how to switch to a Mac, go here.

(Getting off soapbox now)

Long Distance Medicine

It's nice to see that even though I am on vacation in Banff, Canada, I am still getting requests for appointments. 4 this week so far (one by email). Because of the distance, however, it's been a little trickier in calling people back and scheduling appointments.

First of all, I changed my answering machine message to note that I will be out of the office for the entire week, and that I would be returning on Monday, August 2nd. If they needed to be seen before then, I gave them the names and phone numbers of two local FPs who agreed to let me post their info. Since I've only seen about 50 patients, I told them it was unlikely they would get a call from one of my established patients. And I threw in the bit about, "If you think you have a medical emergency, call 911." Lastly I gave my cellphone number for anyone who really wants to get a hold of me, otherwise they could just leave a voice message.

Cellphone reception hasn't been bad, considering we're high in the Rockies. But for some reason, my cellphone often switched over to voicemail before I had a chance to answer it. The only calls I got were from a local magazine asking to verify the size of an ad I was placing, and a patient who was returning my call.

Internet access has been more difficult. At first, we were led to believe that there was free internet access in our hotel room, but that wasn't the case. They charge $15 (Canadian) for 1 hour of laptop hookup to the internet, which is cheaper than $20 for using one of their computers. After being spoiled with wireless access throughout our house, my wife and I find it a little inconvenient to trek downstairs just to access our email. It's still a heckuva lot cheaper than using our dialup service. The closest phone access is in Spokane, WA. While I was able to dialup and connect from our hotel room, the 45 minutes I connected ended up costing $57 in hotel long distance access fees. Ouch!

And for some reason, I'm not able to send outgoing email even though I can receive it. I'm sure it has something to do with the fact that I'm trying to access my ISPs email servers which I'm not connected on my ISPs network. So to send outgoing email, I have to use a web-based email server, like Yahoo or Hotmail.

My dream is to someday get an iSight web camera and be able to see and hear people from long distance, like a videophone, and be able to have a long distance doctor's visit that I can still charge for. That would be real long distance medicine.

Billing for Dollars

I've been spending a lot of time billing and trying to catch up on submitting bills for visits from 1, 2, even 3 months ago. I use Medrium, which I've found to be very helpful. I will write a little review of it later.

A couple of days ago I got my first two checks from patients who have insurance. Their insurers didn't cover the entire charge for their visit, so I sent them a bill. I've been setting my fees higher than Medicare's, using the rationale that Medicare's fees are the "baseline". I remember reading somewhere that you should set your fees higher because each insurer has their own individual "allowed amount" for each E&M code, and if you undercharge them, you could be losing out on some money.

For instance, a level 3 visit for a new patient (code: 99203) would be paid $104.46 by Medicare. Blue Cross's allowed amount is 101.02. My stated amount is $155. Unfortunately, if the patient's deductible hasn't been met yet, then the patient gets charged $155.

Another example, a preventive health visit for someone aged 18-39 (code: 99385). Medicare doesn't pay for preventive health visits so nothing to compare with there. I found some other fee schedules on the internet and chose a fee of $165. Blue Cross's "allowed amount": $165. That suggests to me that this is not their highest allowed amount, and I probably could have charged for more money. In this patient's case, however, his insurance only pays for 60% of the visit. So it's kind of a game to figure out how much money to charge to maximize reimbursement from the insurers without gouging the patients.

Yesterday I received a letter for denial of payment for a sports physical for a teenaged boy because their coverage does not include preventive health visits. I resubmitted it as a level 2 new patient visit ($105) because otherwise his family would be responsible for the entire charge of the sports physical ($160). I'd rather have the insurer pay for part of the visit, even if I get a lower total amount. I think the patient's parents would appreciate that, too.

I'm getting ready to take a week off, as my family will be going out of town. In the past, I've never been busy enough to even worry about patients calling while I was away. This time, I plan to change my answering machine message to let callers know that I am gone for the week, but they can still reach me by cellphone. Plus, I made arrangements with a couple of local FPs who agreed to let me give out their names and phone numbers if there are any patients who need to see someone before I get back.

I Got Paid Today!

A momentous occasion has arrived! I got a check from Blue Cross for $149.61 today.

This represents my first successful 3rd party reimbursement. Yippee! Of course, it's not what I charged for my services, but I didn't really expect full payment. That would be just ludicrous in this day and age. This amount breaks down to a $99 payment for a $165 charge for a physical on a healthy 30-something male; and a $50.51 payment for a $155 charge for a level 3 visit for a new patient (maximum allowed amount = $101.02. Where do they come up with these amounts???).

It only took 15-17 days from the time I first submitted the claim until the date they cut the check. Not bad.

This means that I can start submitting all my other pending claims with the reasonable expectation that not all of them will be automatically rejected. This also bodes well for my future income projections since my initial estimates were for an average payment of $78 per visit. According to my Quickbooks program, I have about $3500 in accounts receivable, ie, this is how much money is owed to me. This is with an average of about 3 patients/week over the past 5 months. When and if I ever build up my patient visits to what I hope (10-12 patients a day), then I see myself finally able to make a living from my solo practice.

For now, I look forward to just being able to break even. For that, my estimates call for at least 3 patients/day. I have a long way to go.

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FP Boards came and went uneventfully. They gave us 7 hours to answer all the questions. I used 4. I wasn't even the first one to finish. Some stuff was easy, some was hard. Either you knew it, or you didn't. All I can remember now is Lewy Body dementia and Henoch-Schonlein purpura. Or more specifically, I remember wishing I knew more about them.
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Over the weekend, while having dim sum in Chinatown with my family and some friends, I got a call from a friend who was sitting in the emergency room with her husband, who was not my patient. He had accidentally severed part of a finger off with a power saw and they were waiting for a callback from a plastic surgeon. She was hoping I knew someone who might be able to respond faster. Unfortunately, I didn't. I still don't know very many specialists in the local area, since I haven't ever had to deal with them or refer to them before. But I'm going to have to.

My first instinct was to call UCLA, since that is where I have a teaching appointment, plus it is one of the premier medical institutions around. The ER nurse connected me to the page operator who said she would page someone. While I was waiting, my wife paged a plastic surgeon she knew. He gave me the name of someone at USC, which is a lot closer than UCLA, but unfortunately no one answered at that number. So USC's page operator said she would page a hand surgeon from their facility. All this took place as we walked through the streets of Chinatown, with my cellphone clinging to its one bar of battery power left. I knew I should have charged it up before, but before that day, nobody ever called me on a Sunday!

In the callback race, the USC hand fellow called me back first (while taking the metro train back home). I explained the sketchy details I knew, and he explained that usually you had up to six hours to reattach a severed digit, depending on how bad the cut was. After some initial reluctance, I ended up convincing him to call my friend on her cellphone so she could talk directly with him. I figured they wouldn't want to just up and leave from one ER to go to USC's ER, but it might make them feel like they had a chance to have everything possible done.

UCLA's surgeon didn't call until after I had gotten home, but he explained that he had been in the middle of surgery and had asked a nurse to try calling me back earlier (but I hadn't gotten any calls from them). I thanked him for calling, and said it had been taken care of already.

We found out later that night, that my friend's husband ended up going to a Kaiser facility, and underwent skin graft surgery, but apparently they were unable to reattach the digit because of the severity of the cut.

While I was very much on the periphery in this case, it reminds me that in the not too distant future, I will probably be in the thick of things, taking care of hospitalized patients and calling the shots. I need to admit and attend at least 6-8 patients and be proctored by a current hospital staff physician in order for me to receive full hospital privileges. So far, I haven't had any, mainly because the local hospital ER doesn't know about me yet. But I plan to drop by and introduce myself and tell them I'm available for inpatients, but not until after summer's over. It may be the last quiet summer I have for a while.

As for now, my cellphone needs recharging...

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!