Enter the YOUR plan to improve your practice and win an Amazon Gift Card!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

Link Fest: Updates on group visits, RVUs, Medicare and the ‘Physician Shortage’

I’ve been storing up some links and today seemed to be a good time to have at ’em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ’em up!

AHIP Rides in to Save Health Care

America’s Health Insurance Plans (AHIP) has released a plan on how to reduce health care costs.  The platform is summarized below:

The new reform proposal would:

Ensure universal coverage by guaranteeing coverage for pre-existing conditions, fixing the health care safety net, giving tax credits to working families and enacting an individual coverage requirement;
Call on the nation to set a goal of reducing the growth in health care costs by 30 percent;
Enhance portability for people changing or in between jobs;
Provide more affordable health care options for small businesses; and
Increase value and improve quality.

An admirable statement indeed. But once again, one must look a little deeper. 

Reducing costs: AHIP points out “Respected studies have shown that patients do not consistently receive high-quality health care and receive care based on best practices only 55 percent of the time.”  Hmm, does  mean that we as physicians are giving ‘low qulaity’ care the other 45% of the time? Who is determining what is ‘high quality’ care?  They advocate using “evidence based standards.”  Aren’t we already doing this?  Furthermore, evidence based standards typically apply to ONE disease state, not the multiple chronic problems primary care physicians deal with.  C’mon give us something fresh!  Stop blaming the doctors for the problem.

AHIP also advocates “exploring” replacing medical liability with dispute resolution. No argument here!  Now who will reign in the powerful legal special interest groups that so effectively court congress?

The reform proposal also advocate controlling fraud.  Now really, how big of a problem is this?

AHIP also advocates pay for performance.  This is a little scary, given the current P4P mess.  I could see this as just another way to with hold payment to providers.  Based on my work as a hospitalist, I find it laughable when the 80 year old post op knee patient is expected to be discharged on day 3.  However, insurance companies don’t care to notice the hypoxia, anemia and confusion attendant with operating on the elderly. Instead, they leave a bright orange sticker on the chart demanding that I justify why the patient is still in the hospital.  Good thing I’m not currently paid for my performance in getting the total knee replacement patient out on time.  The heck with hypoxia!  Clearly I must be doing something wrong and my pay should reflect this!

They also advocate “streamlining” administrative costs.  Gosh, I’d love to streamline my claims, and not have to have extra office staff there to beg insurance companies to pay the bills, or jump through hoops for pre-authorization.  Insurance companies should begin immediately to streamline their administrative costs–they don’t need a government mandate or huge reform to do this–but, I suspect, this may take money from their own pockets.

AHIP states another priority: “Refocusing our health care system on keeping people healthy, intervening early, and providing coordinated care for chronic conditions.”  This is something the health insurance companies should be doing already!  It should not take a “crises” in health care for health care plans to make STAYING healthy a mandate.  They also advocate strongly for “patient centered homes”, a concept that I think is just repackaging of the current model, albeit more top heavy with “midlevel”  and ancillary providers.  

Information technology is embraced (how fashionable!) but no attempt is made as to explain WHO will pay for technology.  Why don’t we admit that the emperor has no clothes?!  There is no money to pay for an EMR and nationalized technology.  Putting it on the backs of primary care practices will drive more physicians out of primary care.  Perhaps insurance companies should pony up for this cost?

They also advocate that everyone should have insurance, regardless of condition.  AHIP also states there should be tax benefits to small businesses so they can offer health insurance, and “large markets should be strengthened.”  They even suggest that the government offer assistance to small businesses. They also advocate broadening SCHIP and medicaid eligibility, as well as offering tax credits to lower income families.    This completely ignores the fact that medicaid reimburses so poorly  that  physicians can’t afford to see medicaid patients!  AHIP also wants  “community health centers” to receive “adequate” support.  Ah yes, another bail out in the making!

American Health Insurance Plans close with a mandate that the feds should provide a “framework” for reform, and that state governments should follow suit.  They also pledge to “cooperate” with the effort.  After reading the entire proprosal, I am left with just one question: what are the health insurance companies going to do?  Are they going to fly to Washington in their private jets to ask the government to pay for the uninsured?

 Visit the complete reform platform at:

http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf

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.

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!!!)

Entering the Lions Den: Negotiating With Health Plans

Fighting with insurers isn’t something I anticipated doing when I was in my “save the world through medicine” phase (?haze?) during medical school, but none the less, here we are!  I came across an interesting article in Modern Medicine titled: “You Can Negotiate With Health Plans,” by Robert Lowes, from the Jan 4, 2008 edition.  I will summarize briefly:

1) Don’t be afraid to challenge insurance companies on their reimbursements, but go in fully armed with data.  Lowes suggests taking your top 15-25 codes and looking at what each insurer reimburses.  Also, obtain what medicare reimburses for each code.   They suggest, “set your fees well above the rates of your best payer.”  This is because if you set your rates LOWER than your best payer, your best payer will reimburse at the LOWER rate.

2) Make sure your fees are at or above the medicare allowable.  The author goes on, “if an insurer is paying your fee in full, that’s a sign that you’re undercharging. This happens when your fee is under or slightly above the Medicare allowable, and the insurer is willing to pay a higher multiple. Before you launch into negotiations, bring your fee schedule up to market levels.” 

3)  Make sure the insurance company is using a CURRENT medicare fee structure.  Some will use an older one, which will not reflect the (slight) increase in Medicare reimbursement.  Insist the insurance uses an up to date schedule.

4)  Make sure you actually GET a fee schedule from the insurance company!  If your top codes are not included, send them your top codes and ask for the fee reimbursement schedule.

5) Start your reimbursements negotiations at least 3 months ahead.  Many plans will automatically renew if you don’t cancel 90 – 120 days ahead of time.

6) Don’t be afraid to walk away, but make sure you can afford to.  If an insurer covers 20-30% of your patients, it may be hard to walk away.

7) Be persistent. The last part of the article is dedicated to ‘if they say…then you say’ scenarios, e.g.:

If they say, “I’ll get back to you,” you say, “When?”

If they say,  “I’m not authorized to make that decision,” you say, “Who should I be talking to?”

Lastly, (and I can’t imagine really saying this):

If they say, “We can’t afford that,” you say, “You earned__million (or billion) dollars last year.”

Go get’em! Go out there and get paid for the work you do, and remember YOU CAN’T SEE PATIENTS IF YOU CAN’T KEEP THE DOORS OPEN!