Resuscitating Primary Care: Part II

All right, pencils out, notebooks at the ready!  Quiz to follow!  Here is Part II of Resuscitating Primary Care.  At our last session, we noted the primary care was indeed a “code-blue/COR-0”.  As promised, I will apply my laser sharp focus to “fixing” this problem.

Buckle up!

You are a shrink. This is another unavoidable issue.  You must learn effective ways to help these patients, which make up a large part of medical practices.  In our medical school and residency programs there needs to be a greater emphasis on psychiatry, as mental illness is so pervasive.  As to your own practice, several things will help: learning and using the counseling codes, scheduling enough time for these patients, and having on hand the cards of your favorite psychiatrists, psychologists, and social workers.  Also, you must become well versed in the plethora of antidepressants out there.  Key point: you have limits too, and remember that most mental health professionals have the phrase down, “I’m sorry, but our time is up.  When should we schedule our next visit?”

Insurance companies make life miserable.  We must fight back!  As group, we physicians have laid down and played dead!  From a macro level, we physicians need to lobby for appropriate reimbursement and STOP accepting what ever insurance companies offer.  (See related post: “Entering the Lions Den”.)  At a practice level, your job is to ensure that your coding, billing and collections are top notch.  That means knowing which insurers are paying in a timely fashion, at an appropriate rate. It means dumping the ones that aren’t!  It also means negotiating for the reimbursement your work deserves. It means having a strong stomach, and realizing that this problem is not going to go away unless you make it go away! 

It’s not good mind candy anymore.  Ahh, to find the random pheo and look like a hero!  The reality is we are managers of chronic disease, cheering patients on when they lose weight, lower their A1-C and actually exercise.  Yes, you will still make the occasional brilliant diagnosis, but your focus will be on medical coaching.  You need to learn how to coach, and find joy in it.  Another avenue to explore would be group sessions, which can be energizing and exciting.  Next, you could market your practice as “the practice for the seriously ill” — meaning you WANT complicated medical patients.  This has ramifications for billing/collections, but could be a viable model.  (Note: I haven’t run the numbers, but remember, you will code higher for more complicated patients.  If you really market your practice to get these patients, it may be fairly interesting. Any one out there have a practice like this?)  Lastly, consider leaving slots open for urgent care visits.  There is no reason to give this business away to Urgent Care clinics, and these visits can be fun and interesting.  (Yeah, I know, you will see a lot of URIs, but you will also see the occasional thyroid storm and aplastic anemia!  Been there, done that!)

The environment is hostile.  But you don’t have to be!  If you are on time, sit down, look AND listen to the patient a lot of hostility will vanish.  We have perpetrated some of this, and it is completely fixable by physicians!  Bedside manner, (Marcus Welby, not House!) is where it’s at.  Please, do not hide behind your computer.  Yes, use that high falutin’ super expensive EMR, but set it up so that you can look at the patient and type.  For pity’s sake DO NOT write notes and type them in later! Talking about a huge time waster!!!  Make your exam room and waiting room comfortable, and a friendly receptionist and nurse are a must.  Sourpusses need not apply!

Not everything is fixable.  Yup.  However, our mind set must be that our job is to guide patients toward health, and that there are no quick fixes.  Part of the job is to move patients towards this mind set as well.

Key point of this post:

Make it fun!

We spend too much of our time at work not to have fun. Have a good time with your patients and staff.  When the end of the day comes, I think the one that had the most fun, wins!  Hang in there, send comments on how to make it better, lobby for change, and keep doing the good work!

PS:  I will put up a page with a resource list in the next few days.

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Resuscitating Primary Care, Part I

 
As promised, I will turn my laser like focus to the task of “fixing” primary care.  I will examine both micro and macro ways of doing this, coming up with to do lists that physicians can implement in their practices as well as global suggestions that will take shifts in health care policy.  (Which only we as a group of physicians can enact!)

1.  The pay stinks. Yes it does.  Physicians do not get pay raises because they are more experienced or incredibly good.  The only way to increase the pay is to do one of three things: see more patients, add more services and globally lobby for getting paid for thinking (which is what primary care physicians do best).  At the practice level, you need to examine patient flow, appropriate billing for services rendered (example: are you billing/coding appropriately for immunizations?) and decide on an appropriate number of patients to see.  Calm down, I am NOT telling you to become a patient care mill, rather to be realistic and set a REASONABLE number of patients you could see.  Also realize that the pay is limited, and it will take a major change in reimbursement to get paid appropriately for what you do.  (Sorry, it is what it is.  Get out there and lobby for change!)

2.  You got an MD instead of an MBA.  I am addressing this early in the game because it is probably the most important.  In my neck of the woods, massage therapists, as part of their curriculum, learn marketing and accounting.  They are better equipped to set up a practice then a physician who has spent 4 years in medical school then 3 more in residency! (Academic medicine, are you listening?) Here is the big message of this post:

You must learn the business of medicine.

But how?  There are books on practice management, seminars on practice management, journals on practice management, and a good accountant and bookkeeper are essential.  But YOU must understand the financial underpinnings of your practice, even if you have God’s gift to office managers.  (For more on seminars, visit my website: www.extramd.com.)  Later this week, after I do my nights shifts, I will put up a page with a list of resources I found helpful.  C’mon, as a physician, you are used to soaking up knowledge like a sponge, you can do it!

 3.  Coding is really fun.  Sorry, but this is another one you MUST learn.  I don’t care that it is boring, picky and strong medicine even for the most confirmed of insomniacs.  Once again, avail yourself of every resource you can to learn it.  Think seminars, books, consultants.  No whining, just do it.  (And remember, ICD-10 is coming.  Sheesh.)

 4.  You are a hamster on a wheel.  You will have to weigh revenues vs. practice style here.  Of course, you will need to maximize revenues, billing and collections no matter what you do.  However, if you choose to see fewer patients per day, then you need to reconcile yourself to less revenues, and ultimately less income.  Your practice partners may have some input on this (!), but if you are solo, consider the micro practice model that is getting a fair amount of hype.  Whatever you do, be very clear in your mind what your expectations are.

All right, enough for today.  We will continue PookieMD’s crash course on primary care resuscitation in my next post.  Until then, keep the doors open, and get out and learn a little about the business of medicine!

Black Tuesday For Primary Care: Why Physicians Would Rather Do Anything Else

I have been in practice for 15 years, and most of my colleagues hate primary care.  (Remember, I come from a cohort of internists, the ones that should be the defenders primary care!)  In my rovings as the ExtraMD I still do some primary care, to keep me honest, and to remind me how hard primary care is.  Here are 9 reasons why most of my doc pals don’t do primary care:

1. The pay stinks. Consider this, my fellow refugees from primary care,: the average primary care physician in the U.S. earned $183,332 in 2007. A nurse anesthetist makes about $160,000 per year. (Think about the differences in school and training, as well as life style.)

2. Coding is really fun. Just to perk you all up, starting October 11, 2010, there will be a brand spanking new ICD, the ICD-10! According to Medical Economics October 3, 2008 (page 17) ICD-10 will have about “10 times the number of codes as ICD-9″.

3. You are a hamster on a wheel. The average physician spends just over 50% of their office time with patients, with 25% of their day taken up by answering calls and writing refills and reports.

4. You are a shrink. Here’s what it’s like in the trenches: “Even conscientious physicians …face many obstacles in delivering mental health services to their elderly patients who are depressed and suicidal.” (J Am Geriatr Soc. 2007;55(12):1903-191. And it’s not just the elderly that are depressed, “reliable estimates suggest that symptoms consistent with depression are present in nearly 70% of patients who visit primary care providers.” (The Journal of the American Board of Family Practice18:79-86 (2005). Hmmm, how much time can a physician spend with a depressed patient and get paid for it? Yes, you can code for counseling, but gosh, a colonoscopy sure pays better!

5. Insurance companies make life miserable. A typical primary are office has several staff members devoted to teasing out the tangled web we call health insurance. How much overhead does this add?

6. It’s not good mind candy any more. One of my favorite things about medicine is the diagnostic puzzle. Those days are limited to viewing episodes of “House.” Rather, we are mangers of chronic diseases, trying to find joy in motivating patients to change. (We are not well trained to motivate behavior change, but should be!)

7. You got an MD, rather than an MBA. Primary care medicine requires understanding the intricacies of practice financial management, insurance companies, marketing, HR, and ambassadorial level negotiating skills. Last time I checked, this wasn’t included in the standard medical school curriculum.

8. The environment is hostile. Patients have been fed a steady diet that physicians are uncaring sharks. We spend a fair amount of time dealing with patient anger, and more time yet dealing with re-education. Patients do have real grounds for complaints about waiting times, rushed physicians and lack of continuity of care, but this just adds to why physicians hate primary care.

9. A lot of stuff is unfixable. We’ve come a long way, baby, but we can’t fix everything. As a physician I want to make it all better, and patients certainly want it too! But I can’t, and boy is it frustrating.

So, keeping with my philosophy that if I complain about something, I should have ways to make it better, my next post will be on practice level AND global ways to make primary care better.   (I will have to do a lot of thinking on this, so send me some comments to get me started!!!)