ACP Internist

Tuesday, March 9, 2010

What if Other Parts of Life Were Like Healthcare?

Health care is bizarre. Anyone who spends significant time in its ranks will attest to the many quirky and downright ludicrous things that go on all the time. But I am not sure people realize just how strange our system is. Perhaps it would be interesting to see what it would be like if other parts of our lives were like health care.

1. Get up in the morning

The first thing that happens in your day is that your alarm fails to go off. Although you have major things happening, nobody ever has explained to you exactly what you are supposed to do and when. You watch the morning TV show and it seems that some experts say you should go to school while others say you should avoid school at all cost. You call a friend who says that she knows someone who went to school and it destroyed their liver. Another friend goes to school every day and is just fine.

Confused, you turn to the Internet and go to a Web site that explains that you should base your schedule on the pattern of tea leaves in a cup. This site claims that your normal schedule is actually fraught with secret appointments that will, unbeknown to you, make you have cancer. It states that those people in power are making you go through this dangerous schedule so they can make money off of you. They don't care for you like the people who made this web page (and for $400 you can have six months of magic tea leaves).

Finally, you decide that you are going to go with the majority opinion and go to school.

2. School

You go to your bus stop and wait. You keep waiting. You know that the bus was supposed to come at 8 a.m., but after an hour you begin to wonder if you missed it. Calling the bus service, you find out that the bus got caught up doing some extra routes. There is a shortage of buses, and so the ones that remain have to do twice as many routes as is feasible. After a two-hour wait, the bus finally arrives to take you to school.

The first teacher comes into the classroom and looks very distracted. She teaches general studies and is staring at a curriculum that contains a huge amount of subjects. As she is doing her lessons, she furiously takes notes on her own teaching so that she can submit documentation to the school board and prove that she taught you. This is the only way she gets paid.

In total, she teaches for about 15 minutes and documents her teaching for 45 minutes. You want to ask questions, but the bell rings and you have to move on to your next class before any can be answered.

The next teacher only teaches a small specialized subject. This teacher is paid four times more than the first teacher. Instead of teaching and answering questions, however, he is constantly making you take tests. Apparently, the school system pays a huge amount for making you take tests, but very little for teaching lessons that would make you do well on those tests in the first place.

School is finally over, but you don't feel like you got much out of it (except for taking a lot of tests and getting more confused). You decide that a trip to the store would perhaps make you feel better.

3. The grocery

Upon entering the grocery store, you notice something odd. There are very few different brands of items stocked on the shelves. Your choice is limited to only the brands that have struck the best deal with the grocery chain. These brands have to send the grocery store a large "rebate" check because they are carried exclusively in this store.

When you go to the meat counter and ask for some steak, the butcher asks you if you have first tried the ground beef. You may not purchase steak unless you have first tried and disliked the ground beef. The ground beef, of course, is actually ground turkey, but the butcher says that these two are basically interchangeable and so the substitution is permitted.

The grocer can't post prices because all customers have different negotiated prices. Posting prices, in fact, would be considered collusion since other grocers could find out exactly what this grocer is charging. Some congressman in California decided that grocers are all crooks and should not be allowed to share what they charge for things.

You go to the cash register to pay. The total is $380, but the cashier informs you that your negotiated price is only $150. A poor person behind you has not had the chance to negotiate a price and so must pay full price for everything.

There are a few people in the store who don't have to pay anything. They have had the price negotiated for them by the government, and so will come to the store very often. They sometimes come for real food, but are often coming for candy and cigarettes--all paid for by the government.

This experience leaves you more tired and confused, and so you decide to go home.

4. Home

Coming home, you notice that your house is under construction. There is a new wing being built that contains all sorts of the newest and fanciest gadgets, such as flat-screen TVs, the fastest computers, and wonderful new kitchen appliances. Going into the house, you notice that there is no running water or heat. Apparently, there are all sorts of grants and low-interest loans to pay for the fancy gadgets, and so contractors find it much more profitable to do that instead of fixing water or heating.

Your mother is in the kitchen trying to make dinner, but instead of cooking she is staring into a cookbook and at the ingredients you brought from the grocery store. You assume she can make do with what you brought, but she just sighs helplessly. Despite the fact that your mother is incredible at improvising meals, she is required to follow a cookbook that doesn't fit the ingredients that are available. This makes dinner taste pretty bad. Your mother, obviously angry about this, gives you a weak smile and tells you to finish what is on your plate.

After dinner, you settle down to watch some television. As you are finally starting to relax, a knock on the front door breaks your peace. At the front door stands a police officer. "You are only authorized to be in the house for two hours today, so I am going to have to ask you to leave."

You try to explain that two hours is not enough to get the rest you need, but the officer threatens a stiff fine and forces you to leave. Before you can get your necessary things, you are forced to leave without an explanation of how you are supposed to survive on the streets.

If it doesn't make sense in real life, how can it make sense in medical practice?

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: health care delivery, humor, medicare, primary care shortage, reimbursement, Rob Lamberts

Once Upon A Time

AUTHOR'S NOTE: I am very frustrated with a system that increases cost dramatically and yet reduces what I get paid. The rest of the money is going somewhere, and since it is not improving the overall quality of care, it is mostly waste. We are enamored with MRI scans, stents, and expensive cancer treatments, with little to show for them except increased expenses and a lot of third parties getting rich off of this waste: drug and device manufacturers, medical imaging companies and other para-healthcare industries. This story, which originally appeared at Musings of Distractible Mind, is prompted by my frustration with waste and how it spurs unneeded health care delivery.

Once upon a time there was a land on the ocean. The people lived off of the food from the ocean and were very happy. But as they grew bigger, they had a problem: They made a lot of waste! Yuk! Nobody likes waste. What could they do about all of this that stuff that nobody needed?

Some said that they should find a way to make less waste. They said that the people of the land were not smart and should be making less waste. But most of the people in the land didn't like to change what they were doing. It's hard to change. So they built a large pipe that pumped the waste into the ocean.

The land was clean again and the people were happy!

As time went on, they had to build more and more pipes to handle their waste. Nobody ever tried to make less waste because they could just make more pipes and pump it into the ocean. This even built a very successful industry of pipe-workers. This helped the economy.

But then one day something terrible happened. The pipes pumping waste killed off several species of sea life. This made the environmentalists in the land cry out in protest. But as it stood, the number of species in the ocean were so vast that the killing off of a few of them was felt to be no harm. So the pipes kept pumping. The people still could be happy with a few less species.

And then came a day when something magical happened. New species of sea creatures formed around the pipes. These creatures fed off of the waste and thrived around these pipes. These new creatures became very big and very fancy, and this made the people of the land very happy. What were the environmentalists all worried about? So what if a few species had died off; there were new exciting species being formed! The people were so excited that they made even more waste and more pipes so they could make more new species of sea creatures.

What fun!

Now, these fancy new creatures were hungry. They ate all of the waste and wanted more. They ate most of the other sea animals and wanted still more. They couldn't get enough food. So they sent lobbyists to the government of the land to get them to build more pipes and send more waste. The creature lobby was very rich, and so poured lots of money at the government of the land. This made the politicians very happy. So the happy politicians told the companies of the land to make more pipes and send more waste out to the sea. And the sea creatures were happy.

And so it went for many years: more pipes sending more waste making more fancy sea creatures eating more waste sending more lobbyists to make politicians get more companies in the land to build more pipes. Everyone seemed to benefit from this nice arrangement! Maybe they'd be happy forever!

But one day, some of the people of the land got tired of putting all of their money into building pipes to send waste. They thought their land should stop making so much waste and start putting those resources into schools, food and fighting crime. The government was raising taxes more and more so that they could afford to make more pipes. This made these people mad because some people couldn't afford any more taxes. Paying for all of this waste was too much.

But the lobbyists from the sea creatures put commercials on television saying how good the waste was. In fact, having so much waste made the land one of the best lands anywhere. They pointed out how many new sea creatures came to be because of this waste and how other lands couldn't do this. The pipe manufacturers also made commercials telling about all of the jobs these pipes were creating. They all made so much sense!

They also sent more money to the politicians so they would ignore the people who couldn't afford paying for the waste.

But then some of the people of the land ran out of money and stopped paying taxes. This made the government mad, and so it left these bad people to live in their own waste. Many of these people became sick in their waste, and some of them died. Finally, the cry of the people was loud enough that the politicians in the land took notice. They decided that all of this waste was a real problem. No other land had so many pipes sending so much waste. True, there were lots of fancy new sea creatures, but the people in the land were getting angry, and some were dying.

But the politicians started fighting. One group of the politicians decided that the pipe-making companies were the problem. They thought that the government should take over the pipe-making job and guarantee waste pipes for every home. Others thought that the government could never do as good of a job as the companies did. They said that those people who couldn't afford pipes were dead-beats and probably deserved to die.

They held town hall meetings to talk about who should be making pipes, and people got very angry.

Finally, someone who wrote a waste-pipe blog suggested that perhaps the problem wasn't the pipes, but instead it was the waste. He said that the people should find a way to cut back on the waste, and so need fewer pipes. The blogger was criticized sternly, because his suggestion would have very bad consequences. The new fancy sea creatures that made everyone so proud would die off if they cut back on waste, and the pipe-workers would lose their jobs and be very sad. Plus, people didn't want the government telling them how much waste they could make. It's a free country, and people should be able to make waste without the government rationing it.

But as the people of the land thought about what this blogger said, they saw the sense in it. Yes, the sea creatures and the pipe manufacturing companies put very moving commercials on TV about dying sea creatures and unemployed pipe workers. They were very sad commercials and they made a lot of people weep. But the people of the land realized that this land was for people to live in, not for pipe companies or fancy sea creatures. Yes, it would be sad to not have those fancy creatures, and they'd have to get new jobs for the pipe company workers, but it was the only way.

Oh, it was hard to cut back on waste and kill off the fancy sea creatures. People got very mad and lobbyist groups tried to change laws or pay off politicians. But this was a good and smart kingdom, and they didn't listen to the creatures any more. And finally the day came when the sea was clean again.

And everyone was happy.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: cardiology, climate change, drug companies, environment, health care delivery, humor, Rob Lamberts

Primary Care Physicians Are All One Breath Away From Dropping Medicare

This post by Rob Lamberts, ACP member, originally appeared at Better Health.

I am going to state something that is completely obvious to most primary care physicians: I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business.

In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance. If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit. This is totally obvious to me, and I suspect to most primary care physicians. A huge part of our overhead comes from the fact that we are dealing with insurance. A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge. As it stands, the percentage of my collections that goes to overhead is between 50% and 60% (depending on the month). A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing and documenting. If I dropped insurance and charged a fixed amount, I could:

--cut my billing staff nearly to zero (someone would still have to do bookkeeping),
--increase my payment per visit, which would allow me to see fewer patients per day,
--document for the sake of patient care, and not for the sake of getting paid, and
--add extra services like e-mail access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid (M/M)? Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me. There are several reasons why this is possible for insured patients:

--Insured patients generally have the option of filing for their own insurance (there are some that still don't allow this, but that number is dwindling with the decrease of HMO's); and
--Insured patients could choose to just pay me cash if they choose.

Can't Medicare/Medicaid patients do this? No, for several reasons:

--If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files;
--If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered). So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud; and
--If I drop M/M, I cannot sign up for it again for three years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still? Why would I continue to make my life so difficult? Two words: duty and calling. I view my seeing M/M patients as a social responsibility (especially Medicare). These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income. So far.

Plus, I just like to take care of the elderly and the poor. My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need. If I dropped M/M I would reject the calling for personal gain, which is something I can't do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care. The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system. I am personally willing to continue on this course as long as (it doesn't get too much worse) but I have complete sympathy for primary care physicians (PCP) who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP's. PCP's keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital. The system is just holding on with the PCP's we have; decreasing that number would be devastating and perhaps fatal to the system. It's a very bad sign when the best business model for PCP's is to do something that, if done by all PCP's, would wreck the system. Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors! They have to earn less money! They have to actually have a conscience! What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle and live by my conscience. At this time, most PCP's accepting M/M are doing the same. But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish. Pushing down M/M payments for PCP's will make a bad situation worse.

That's bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: health insurance, Medicaid, medicare, primary care, reimbursement, Rob Lamberts

It's Not Our Fault

This post by Rob Lamberts, ACP member, originally appeared in Musings of a Distractible Mind in September 2008.

Dear Patients:

I know you get frustrated with our office. We make you come in for visits when you think we should handle things over the phone. We seem more focused on your chart sometimes than on you. Sometimes you may even wonder if money has become more important than patients.

To this, I say: I'm sorry. It's not our fault.

We are part of an insane system that requires us to do things in a way that makes life harder for us both. We would love to practice medicine differently, but we simply can't. Here are some examples:

1. Making you come in all the time

I would love to handle your simple problems on the phone or via e-mail. The problem is that if I do this, I am giving free care for which I am liable. People are being sued for nearly everything. If we give you a medicine without seeing you, we are actually more at risk than if you come in. Plus, the only way we can get paid is to bring you in. Insurance won't pay me for handling your problem any other way. Even if we both agreed, we couldn't have you pay for a phone call or e-mail, because we would be breaking our contract with our insurance company.

2. Not ever giving discounts

If I choose to give you a break and not charge you for a visit, I am being nice. Right? Well, according to our government, I am actually committing fraud. That's right, fraud. You see, I can't offer anyone a discount that I don't offer to Medicare patients; and not charging you would mean I have to not charge my Medicare patients. Ridiculous, isn't it?

3. Getting lost in notes

Why do we spend so much time taking notes and not talking to you? Is it so that we can do better medicine? No, we actually think that all this charting is stupid too. The problem is that we don't get paid to see you, we get paid to chart about you. We are paid based on a complex set of rules of documentation and if we are able to document more, we are paid more. If we cut corners so we can spend time with you, we are again viewed as committing fraud.

4. Obsessing about money

When you get your bill from us, you may wonder what all those charges are. And why are we forcing everyone to pay up front and sending people to collections? The problem is, while health care insurance premiums have gone up and inflation has raised everyone's cost of living, our reimbursement has dropped. We get paid less and less for taking care of you, so we have to become much stricter in how we run our business. The practice of medicine has turned into the business of medicine. We didn't do that, nor do we like it. But we have to stay in business, so we do what we must.

5. Not seeing you in the hospital

It seems like the time you most need your primary care doctor is when you are in the hospital, yet we don't see adult patients in the hospital. Believe me, we hate that as much as you do. It is very hard to give your care over to others who see you as "another patient." They don't know your history like we do and are often too busy to answer your questions. We try to communicate with them, but it is just a hard thing to do.

The problem is that we can't afford to see patients in the hospital. The amount of time it takes for the money we get is just not worth it. It came down to what was the least-bad thing to do: stop seeing patients in the hospital, see our families less or see our salaries drop. As primary care providers, we are not paid enough to let our salaries drop, so we chose our families. It was one of the hardest choices we ever made.

6. Acting paranoid

Why does the nurse always tell you to go to the ER when there is even a small chance there may be a problem? Why are you treated like a criminal if you ask for pain medications? The answer? Lawyers. Lawsuits are so rampant in our culture and so it makes us practice "defensive medicine." This means that we can't do what makes sense, we must do what minimizes risk.

And if we are ever thought to be giving pain medications too liberally? We can lose our licenses and even go to jail. It's a dangerous business we are in, but we don't want to do anything to make it more dangerous.

I am truly sorry for the state of things as they are. Perhaps better days are ahead of us. Some politicians are actually talking about paying primary care doctors more. Some people are suggesting that they stop paying just based on charting, but actually reward better work. And some people are even talking about limiting malpractice rewards.

These all sound promising, but remember who it is that is making the decision: It isn't the doctor or the patient, the two people who the whole thing is about; it is the politicians, bureaucrats, and insurance companies controlling this stuff. Unfortunately, with them in charge it is probably not wise to hold our breath.

Stay healthy, and have a great day!

Sincerely,

Dr. Rob

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: health care reform, health insurance, reimbursement, Rob Lamberts

...and I Feel Fine

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.

Primary care is dead. Long live primary care.

Wait a minute, I am in primary care. I am not dead. Not yet, at least.

Which reminds me of this Monty Python skit:

CART MASTER:
Bring out your dead!
[clang]
Bring out your dead!
[clang]
Bring out your dead!
[clang]

CUSTOMER:
Here's one.

CART MASTER:
Ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
What?

CUSTOMER:
Nothing. Here's your ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
'Ere. He says he's not dead!

CUSTOMER:
Yes, he is.

DEAD PERSON:
I'm not!

CART MASTER:
He isn't?

CUSTOMER:
Well, he will be soon. He's very ill.

DEAD PERSON:
I'm getting better!

CUSTOMER:
No, you're not. You'll be stone dead in a moment.

CART MASTER:
Oh, I can't take him like that. It's against regulations.

DEAD PERSON:
I don't want to go on the cart!

CUSTOMER:
Oh, don't be such a baby.

CART MASTER:
I can't take him.

DEAD PERSON:
I feel fine!

CUSTOMER:
Well, do us a favour.

CART MASTER:
I can't.

CUSTOMER:
Well, can you hang around a couple of minutes? He won't be long.

CART MASTER:
No, I've got to go to the Robinsons'. They've lost nine today.

CUSTOMER:
Well, when's your next round?

CART MASTER:
Thursday.

DEAD PERSON:
I think I'll go for a walk.

CUSTOMER:
You're not fooling anyone, you know. Look. Isn't there something you can do?

DEAD PERSON: [singing]
I feel happy. I feel happy.
[whop]

CUSTOMER:
Ah, thanks very much.

CART MASTER:
Not at all. See you on Thursday.

Now I would never suggest that the cart master who clubs the dead person represents, say, Medicare. It would not be in my nature to make such a suggestion.

But that is not the point of this post. While many complain of the death of primary care and declining reimbursement, some practices are experiencing quite the reverse: growth in income. I should know, because I am in such a practice.

We are not business geniuses in any stretch of the imagination, but we have been quite successful and raising our incomes substantially. Since I started 13 years ago, my income has doubled, and most of that increase has happened over the past five years, just the time that the death of primary care has been announced.

Our practice is almost totally outpatient (we still see inpatient pediatrics), and we earn very little at this point from labs and procedures. The vast majority of our income comes from regular office visits.

Here are some of the ways we have accomplished this:

We have focused on process. Using our electonic medical record, we try and find the most efficient ways to perform tasks in the office, involving the lowest possible number of staff. This has been a passion (see also: obsession) of mine.

We have focused on our patients. Our patients are our business, and so trying meet their needs (instead of the needs of the doctors) has resulted in a booming business. Here are some ways we have done this:
1. We have extended office hours. with a walk-in clinic (for acute problems only) every morning from 7:30-9:00 a.m. and every evening from 5:30-7:00 p.m. People don't get sick on a schedule and so we allow them to come in when they are sick. To do this, we had to drop most of our inpatient care (or have no life). This accounts for about 25% of our revenue that we would have otherwise lost to prompt cares or ERs.
2. We allow work-in visits. The patient likes to be able to see their doctor when they are sick (they get whoever is in clinic if they use our walk-in clinic). So even with a full schedule, I allow one "quick sick" visit every hour.
3. We do not tolerate patients being treated poorly. Doing so is considered a fireable offense. If a physician does so, they talk to the senior partner (which is me, but this really has not happened).
4. We strive for timeliness. Although we can never guarantee being on-time, we have done our best to have patients out the door within an hour of their arrival. This goal was modest enough to be possible, while allowing for the obvious emergencies.
5. We have a modified "open access" schedule. While I have too many chronic disease patients and scheduled follow-up visits to want to go completely open access, we do leave an hour of each afternoon open until the day of, so even complex patients can possibly be seen on the day they call.

We understand what is most important. While many practices focus on the complex higher-priced visits, we have understood from the start that the money we can earn per hour is much higher for ear infections and urinary infections. Plus, the majority of our patients are only going to use us episodically, so we want our office to cater to the larger population rather than the minority who are sick all of the time.

We are growing. My income went up when my share of the overhead went down. While our system worked fine for three physicians, it requires very few additional staff and space to run it with six. Adding new physicians and/or mid-levels has cut our overall overhead per provider dramatically.

We are planning. We know that pay-for-performance (P4P) and the "medical home" concept are probably going to happen. We have tried hard to keep our data good enough to be able to pounce on this once it is offered. So far, I have personally collected over $5,000 from P4P programs already, and their penetration is minimal. We know that once that wave starts, we will be in the front of it.

Quality is not compromised. We have done what we can to run the business well, but have tried not to forget that we are offering healthcare. The physicians in our practice agree to certain care standards and common practices. If we can all agree to what good quality care is, then we are far more likely to achieve it and we can engineer our process to accomplish it. For example, when National Committee on Quality Assurance certification became a means to increasing income, we were already exceeding the standards to become certified in diabetes care within a matter of weeks.

Admittedly, it has not been a smooth road to where we are now, and we are not without our problems (there is always a crisis somewhere), but from what I can tell, we have remained one of the less dysfunctional practices around. Given the unstable ground of U.S. health care, we certainly have no guarantees that this trend will continue, but I am doing my best to anticipate any trends in the system and set us up for capitalizing on this, rather than being caught off-guard.

Hopefully we are not facing any bridge of death in the near future. If we are, then perhaps we can start collecting shrubbery. I already have my electronic medical record programmed to say "Ni!"

Bonus points if you know the significance of the title. The answer is here.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: electronic medical records, humor, medicare, patient communication, patient-centered medical home, primary care, quality reporting, Rob Lamberts

Facing the Future

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.

The following is an actual fictional conversation that took place in the doctor's lounge at a local hospital.

Internist: Dang, these Medicare cuts are coming and I doubt that Congress has the wits to avoid them. I am not sure I can go on practicing if they cut them anymore.

Family Physician: Yeah, we already get paid so little by Medicaid and the private insurers, we have had to start to look for other sources of revenue.

Internist: Really? We have been looking into that as well. What are you thinking about doing?

Family Physician: We thought about doing cosmetic procedures, but we have an especially good-looking population, so we really can't make it work.

Internist: Bummer.

Family Physician: Yep. Instead, we have decided to open a kiosk for Krispy Kreme donuts. We figure we can make money off of the donuts, plus we can get more of our patients obese. Then we can treat worse diseases and code a higher level for each visit.

Internist: Genius. Plus, you can get all of the kids hyperactive on the sugar and treat their ADHD.

Family Physician: And the "Hot Donuts Now" sign along with the scent of fresh-baked donuts will really draw in new customers ... I mean patients.

[Click on the More link below to read the full post.)

Internist: One of the GI doctors in town is doing the same sort of thing, opening a Starbucks in his office. He figures he gets walk-ins, gets people with worse dyspepsia, and gets free WiFi to boot.

Family Physician: Brilliant. What have you been thinking of?

Internist: We have noticed the interest our patients have in holistic medicine, and thought we should capitalize on that.

Family Physician: So you are hiring a homeopath?

Internist: No, they wouldn't set foot in our office because of the "evil" immunizations we use. We tried to get all sorts of alternative providers, but they would always sneer at our practices. And so we finally opted for two things: First, we are doing aromatherapy, which has our staff so relaxed that they don't seem to have noticed that we cut their pay by 50%.

Family Physician: Great.

Internist: Second, we have a psychic who goes around in our lobby doing palm reading and tea leaves on our patients as they wait. There are two positive outcomes from this: the patients who get bad fortunes told are so anxious that their blood pressure is up and they are ripe for anxiety treatment; the ones with good fortunes are happy enough that we can order all sorts of tests on them and they don't seem to care. There is a downside, however.

Family Physician: What's that?

Internist: My partner now thinks that we should take our entire budget for next month and invest it in Power Ball lottery tickets. He says it is a "sure thing."

Hospitalist: Hey guys, what's up?

Family Physician: We're just discussing what we are going to do to offset the impending Medicare cuts. Do you have plans?

Hospitalist: Oh yes. I don't like the idea of increasing the load to 70 admissions per day. Fifty is plenty. Instead, we are capitalizing on the fact that our patients are a "captive audience."

Internist: This I've gotta hear.

Hospitalist: We figured that we have enough turnover that some sort of direct marketing scheme to our patients could be quite lucrative. We are now certified Amway sales representatives.

Family Physician: I love it!

Hospitalist: Yep. We have these patients in a position where they can't move, and we sell them cleaning solvents, vitamins, and skin care products. Instead of taking cash, we just add it on to their hospital bill, so they usually buy a bunch.

Internist: As an added bonus, the families of your patients will be so scared that you will try to sell them Amway products, that they steer completely clear of the hospital.

Hospitalist: Bingo! It works like a charm. We got this idea from the intensivists who were holding Tupperware parties in the ICU. The patients were sedated "just enough" so that they left the hospital with all sorts of cups, jugs, and bowls.

Family Physician: Any complaints?

Hospitalist: Not yet. You figure, what we charge for the solvents is 1/4 of what the hospital charges for an aspirin. The patients really don't notice a little more charge. We have even had some insurances mistakenly pay for some of our Amway products!

Internist: You know, maybe this Medicare cut may just be a good thing. Look at how it has pushed us to open new frontiers in medicine. Our children will look back on this time as being one of the real turning-points in American healthcare.

Family Physician: Yeah, today Amway ... tomorrow ...

Hospitalist: Healthcare reform? Higher reimbursement? A fair payment model?

Family Physician: Used cars.

Internist: I am so glad I went into medicine.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: health care reform, health insurance, humor, Rob Lamberts

An open letter to consultants

Thank you for agreeing to see my patients. I send them to you with confidence that you can help me in the overall care for them.

While I understand that you had a few extra years of training above me, and certainly have extensive knowledge in the area of your expertise (that is why I send people to you in the first place), I would like to share with you a few important points about our relationship. Understanding these things will help you better care for the patients I send your way and will greatly help me get what I want from the consultations I send to you

I am not a moron. I typically try to anticipate what you will do for the patient and order all appropriate tests before sending them to you. There are almost always has been a number of visits and several tests ordered that may greatly help you in managing the problem for which I send you the patient. When I send you a patient, I typically want a specific question answered. Please ask yourself: "What does Dr. Rob want me to answer?" and answer that question for me.

My patients are not morons. Overall, my patients are very nice and reasonable people. Even those with very strange histories are seldom coming in to simply waste their doctor's time. Rest assured that I won't send you a consult that simply gets a patient off of my hands. Please listen to what they have to say, and if you are confused as to what is expected, please call me and I will explain what I want from you.

You represent me. Please understand that when I refer a patient to you, their experience with you will reflect back on me. I sent them to you for a reason, and if they think you are incompetent or that you are a jerk, it makes me look bad.

These patients consider me as "their doctor," not you. I am the one who is ultimately responsible for their care, not you. If they are dissatisfied with you, they come to me and I will send them somewhere else. I am trying to take care of their medical care as a whole, so please communicate to me what I need to know to better their overall care. You play a very important role, but not the central role in their care. That is my job. Your job is to help me do my job to the best of my abilities

I can send my patients elsewhere. Most of my patients require a referral for them to see you. On top of that, most want to know my opinion of specialists. I essentially have complete control over whether my patients see you or not. This means that a major part of your job is to keep me satisfied. If I don't like the care you give my patients, I will send them to someone who gives me what I want. This is not a veiled threat, it is the reality of the relationship between primary care and specialty physician. I control a portion of your pipeline, so it is good business to keep me happy.

Please be brief. I really don't care about 90% of the stuff you put in your letters. Just answer my question and put it in a letter. I know you have to appease the E/M gods to get paid properly, but I really don't want to read that stuff.

Please communicate. It is useless for me to send patients to you and not get the consult note back. Make sure you get my name right (notes are often sent to the wrong office) and get it to me in a timely fashion. Like it or not, your job is to help me manage the patient, not the reverse. It is no help to have patients see you and not know what went on.

I understand that this is a somewhat odd relationship, since I am paid far less than you and yet am the central player. Truthfully, it galls me a bit that you get triple my income while I play the lead role and you support me in my job. Yet I realize that this is not your fault and that overall you value my role in the health care system. I promise to do what I can to make your job easier. Please help me in my quest to do what is best for my patients.

Sincerely,
Dr. Rob

[This post appeared in Musings of a Distractible Mind in July 2007. Since that time, my frustration with my interaction with specialists has grown, not improved. Our system seems to discourage communication when it should be promoting it.]

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: health care delivery, Rob Lamberts

Blogging gives voice to doctors in the trenches

My name is Dr. Rob, and I am the newest contributor to the ACP Internist blog. (That sounds a lot like a 12-step meeting, doesn't it?) Perhaps that's appropriate, as many of us internists feel powerless at this point in time, and we could certainly use help from a higher power (or at least from Washington, D.C.)

Since I will be a regular contributor, I thought a little bit of background information is appropriate:
--My full name is Rob Lamberts, ACP Member, and I am part of a private practice in suburban Augusta, Ga. I grew up in New York and went to medical school at Jefferson Medical College in Philadelphia. Read between the lines: I get called "Yankee" a lot.
--I did a combined internal medicine/pediatric residency at Indiana University and my practice is a mix of both. Read between the lines: I have a masochistic streak.
--Our office has been on electronic medical records since 1996, and was recognized by Health Information and Management Systems Society for our excellent implementation, receiving the Davies Award for 2003. Read between the lines: I am a geek.
--Since 2006, I have authored the blog Musings of a Distractible Mind, which is a mix of personal musings about life as a doctor, an insider's view of our ridiculous system, and humor (with the inexplicable appearance of llamas in an inordinate number of posts). Read between the lines: I write whatever strikes me at the time.
--Since July of 2009, I have hosted The House Call Doctor podcast, part of the Quick and Dirty Tips family of podcasts. My goal is to give concise and accurate medical information that the general public can understand. Read between the lines: the apocalypse may already be upon us.

One of my main passions--and what I will concentrate on in this blog--is to give a voice to the practicing internist. The health care debate rages in Washington, lobbyists vie for influence, and bills are passed; yet, the people who are at the center of the whole debate have very little voice. Doctors do have their advocacy groups (ACP is among the best), but even those representatives don't truly understand our situation.

I make my living off of seeing patients in my office. I have to meet payroll, pay rent, and cover my other expenses before I can get paid at all. This means that I don't have time to spend in Washington giving my very important perspective. I only get paid for days I am at work.

Blogging has given the doctors "in the trenches" a voice. I have been honored to be able to actually have some influence on the debate through my blog. I have been cited by the New York Times and Los Angeles Times, and have appeared on NPR. I contribute to the website MedPage Today. It boggles my mind that a practicing doctor in the deep south could actually have the opportunities to voice my views before such a large audience; but, the reason I have gotten this opportunity is that I voice a very important perspective that is rarely heard.

So I hope you enjoy my contributions to this fine blog. I am going to start out re-posting some of my more popular posts. Read between the lines: I am being a little lazy but will cover hot topics when they come up. I am truly honored to be part of ACP, and relish the opportunity to contribute on this blog. I doubt llamas will come up much. Read between the lines: It's irony.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: advocacy, health care reform, health information technology, humor, Rob Lamberts, social media

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

Everything Health
EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Getting Better with Dr. Val
Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

HealthHombre
A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

Kevin, MD
The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

LSUHSC-S Medical Library Evidence Alert
Major guidelines, systematic reviews, meta-analyses and/or major reviews by national and international organizations.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by a doctor.

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Related ACP Resources:

ACP EHR Partner Program

ACP Internist

Tuesday, March 9, 2010

What if Other Parts of Life Were Like Healthcare?

Monday, March 1, 2010

Once Upon A Time

Wednesday, February 17, 2010

Primary Care Physicians Are All One Breath Away From Dropping Medicare

Wednesday, February 10, 2010

It's Not Our Fault

Friday, January 29, 2010

...and I Feel Fine

Friday, January 22, 2010

Facing the Future

Thursday, January 14, 2010

An open letter to consultants

Tuesday, January 12, 2010

Blogging gives voice to doctors in the trenches

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