Friday, January 29, 2010
...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
posted by Dr. Rob at
1:00 PM
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Wednesday, May 27, 2009
Watch out, bad doctors.
The interest group Public Citizen is launching a new campaign to get hospitals to step up their reporting of physician wrongdoing. Under a federal law, hospitals are required to submit to a database the names of any physicians who have lost their admitting privileges for more than 30 days. However the database has gotten very few reports; more than half of hospitals have never submitted a single name.
So either physicians have been being very, very good, or the hospitals are covering up their wrongdoing. Public Citizen suspects the latter and is urging the Obama administration to crack down on the failure to report. Doc are also on the hook: the organization's press release specifically calls them out for "lax peer review, including a culture among doctors of not wanting to 'snitch' on a colleague."
That's right; snitching isn't just for elementary schoolers and TV characters anymore. Let's hope that the next steps don't involve hair-pulling or cootie-catching.
Labels: quality reporting
posted by Stacey Butterfield at
1:37 PM
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Tuesday, March 10, 2009
No performance for peanuts
This time, we're actually talking about doctors, not elephants. A new RAND study (published in Health Affairs) is the latest to assess the impact of pay-for-performance. Participating practices reported increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened organizational focus and support for improvement.
BUT, they didn't see the P4P programs having any impact on quality. As researchers told Reuters, that might be because the performance bonuses were too small--about $1,500 to $2,000 per physician annually. "They suggested the incentives needed to be two to five times higher in order to achieve quality improvements."
Sounds like the payers need to find another zero if they want to get everyone's attention. Or just wait for the economic crisis/deflation to make the existing incentives sound relatively appealing.
Labels: pay-for-performance, quality reporting
posted by Stacey Butterfield at
12:46 PM
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Thursday, February 26, 2009
Best care doesn't always get best ratings, doc finds
Medicare's Hospital Compare Web site attempts to help the public compare hospitals based on quality of care, but it can also make good doctors look bad, WhiteCoat blogs.
Case in point #1: Docs are required by offical quality indicators to give thrombolytics within 30 minutes of a heart attack patient's arrival. But what if that patient also just suffered a significant head injury? Does the doc try to meet the 30-minute window by skipping the CT scan, thus risking the patient's life if there is internal bleeding? Of course not, says WhiteCoat, but according to Hospital Compare, "my decision made me a bad doctor."
Don't trust everything you read on the comparison site, WhiteCoat concludes.
But how do patients separate the wheat from the chafe?
Labels: hospital medicine, quality reporting
posted by Janet Colwell at
1:02 PM
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Monday, December 1, 2008
Ever wonder what people are saying about you on the web?
A new investigation conducted by Slate provides some interesting insight into online physician-rating systems. You know, those things that pop up when you Google a doc and then ask you to "click and pay here" to get all the dirt on him or her. So what's it all worth? Nothing, according to the article. The sites provide almost no information and even less that is useful. But, if you're a doctor with some spare websurfing time on your hands, you might want to try fixing your stats just in case, the author suggests.
Labels: health information technology, quality reporting
posted by Stacey Butterfield at
4:06 PM
3 Comments
Tuesday, September 9, 2008
More kinks in quality reporting
Practice managers are reporting more trouble with the Physician Quality reporting Initiative (PQRI) results, citing a lack of data, administrative burdens, and an 18-month delay in learning results.
Nearly 70% reported low or no satisfaction with how the program's results improved patient care outcomes. Nearly 93% reported problems accessing their results, according to a survey conducted by the Medical Group Management Association.
Specific complaints cited by the MGMA survey include the lack of data for improving patient outcomes and difficulty accessing and downloading the 2007 feedback reports. On average, respondent practices spent five hours downloading their final 2007 PQRI feedback reports from the Web site. In addition, 63% of respondents reported difficulty capturing and submitting data.
ACP members had previously reported their own difficulties. ACP is collaborating with a survey being conducted by the American Medical Association to assess physician experience with PQRI to further bolster arguments that Medicare needs to improve the program quickly. Look for details in upcoming issues of ACP InternistWeekly.
Labels: quality reporting
posted by Ryan DuBosar at
9:47 AM
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Thursday, August 21, 2008
Working out the kinks of quality reporting
Medicare released its first round of bonus payments to physicians who reported quality care data. But physicians say the actual payouts are relatively small and might not be worth the record-keeping, and report problems learning how well they performed.
The Centers for Medicare and Medicaid Services (CMS) introduced the Physicians Quality Reporting Initiative in July 2007. The program awards a bonus payment of 1.5% of allowed charges for Medicare patients to physicians who submitted quality measure codes. Since then, between 10 and 15 percent of internists reported at least one quality measure code, and slightly more than half earned a bonus. ACP will report more specific outcomes to members in the near future.
Internist William E. Fox, FACP, an internist in Charlottesville, Va., writes that his practice received a bonus payment below the average amount that Medicare had reported. He said that's probably because his practice is four years old, with a smaller patient panel and fewer Medicare patients.
But established internist W. James Stackhouse, MACP, of Goldsboro, N.C., received his bonus payment and questioned if it's worth continuing participating, even using simplified alternative reporting shortcuts that were released this year. He writes, "It took a lot of paperwork and screwed up billing because we had to charge 1 cent per code so that the Medicare carrier's computer would pick up the charges, and then had to manually write off that charge afterward."
His back-of-the-envelope math estimates a physician could reasonably recoup $6,000 in bonus payments, "which represents an extra 99213 visit only about 120 times in year, or about one every other day of office hours." He added that's little motivatation for the extra record-keeping.
Also, physicians who participated in the 2007 PQRI are supposed to be able to find out how they performed on a secure Web site. However, Dr. Fox has been so far unable to access his reports, a complaint voiced by users during a public forum CMS conducted, according to ACP's Regulatory and Insurer Affairs staff. Since doctors who have a bad first experience may not continue, ACP is reporting its members' frustrations back to Medicare.
Dr. Fox asked, "I wonder what results others have had?" ACP is working with the American Medical Association to survey internists about their experiences, as detailed in a report here.
Labels: quality reporting
posted by Ryan DuBosar at
10:00 AM
3 Comments
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