I’ve had two jobs since I completed a fellowship is gastroenterology over 20 years ago. For the first decade, I was a salaried physician. Afterwards, I promoted myself to private practice. Each model has its advantages and drawbacks, but for me the private practice model wins out. The climate in Cleveland is extremely inhospitable to private practice, because of two mega-medical institutions that incinerate private practices as their boiling lava flows across the region. So far, our practice is still viable, but the prospects for its long term health and welfare are questionable.
One of the advantages of working for a straight salary is that income dies not depend upon productivity. (My employer maintained that we had a productivity bonus, but in reality there wasn’t much the physicians could do to adjust their salaries in either direction.) One of the disadvantages of private practice, particularly where I practice, is the need to hustle aggressively for patients, a task I neither enjoy nor do particularly well. In my present professional world, an empty schedule means empty collections.
So, when a patient decides to miss an appointment, the ramifications are quite different for me now than it was during my first job. At least when I was reading The New York Times during a gap in the schedule while I was on salary, my paycheck didn’t change. Not so these days.
My partners and I are forever lamenting the empty spaces in our schedules when patients do not show up or call in advance to notify us that they will not be coming.
These acts hurt us economically and forfeit an appointment slot that another patient would have happily occupied. Moreover, not showing up is downright inconsiderate. Sorry, if some readers find this latter view to be harsh, but I don’t wish to sanitize it as a venial sin.
Of course, sometimes life happens and an appointment is missed or forgotten. As a member of the human species, I get this. However, many of the patients who are AWOL at appointment times have been contacted a day before by a living, breathing member of our superb staff. Here, the absence is inexcusable.
Should these patients be assessed a fee for failure to appear? If a patient does call to cancel, how much notice is reasonable? 24 hours? 10 minutes? What if their insurance companies prohibit us by contract from charging patients these fees? Then, what leverage do we have?
Should we leave a heartfelt flyer in the waiting room pleading for cooperation on this issue? What good would that do? The ones who really need to read it aren’t there.
Sunday, July 28, 2013
Sunday, July 21, 2013
Electronic Medical Records Save Money! (Never Mind)
Electronic medical records (EMR) were supposed to rewire the
medical grid. It would increase
efficiency, reduce redundancy, improve quality and reduce costs. On
these measures I offer a grade of 0 for 4. Ask any practicing doctor how EMR has
impacted on his practice and be prepared for some remarks that differ from the
government’s Kool Aid talking points. EMR,
thus far, hasn’t been ball bearings for the system. More often, it gums up the works.
The EMR Maze - Enjoy!
The government spent billions of dollars with cash
payments to induce hospitals and doctors
like me to jump on board the EMR express.
The Rand Corporation helped to fuel this euphoria in 2005 when it
predicted exaggerated benefits of EMR. By
the way, this study was financed in part by EMR companies whom, I politely
suggest, had a vested interest in the study’s conclusion. Rand denies that they were unduly influenced
by their backers, and I don’t claim that they caved on their principles. Nevertheless, the propriety of taking money
from folks whose survival may depend upon the study’s outcome is ethically
problematic. But, Rand was wrong and has
publicly admitted it now. The Rand folks
are now back flipping across the countryside with new and improved pronouncements
stating that EMR has added to medical costs and hasn’t delivered on its other
rosy promises.
This wasn’t an epiphany.
Many folks in 2005 didn’t swallow the Rand bait. The Whistleblower was blowing hard but
apparently the frequency was above what human ears can perceive. EMR is a money pit that has made many
companies rich. EMR systems are
expensive, clumsy to use and do not communicate easily with other EMR
systems. Patients have the notion that
the hundreds or more EMR systems out there can easily communicate with each
other. They can’t. I have a few posts on EMR, and they’re not
pretty.
The point here transcends the EMR mirage. How many other promises of Obamacare will
crumble in the years ahead? Again, this
won’t be a revelation. Many of us were
shouting about this on day 1. No one could
hear us above the din of health care reform.
Will these reformers, like Rand, admit that they were wrong as the
evidence piles up? Wouldn’t that be the fair
and balanced thing to do?
We’re in the Era of Medical Ridiculousness. Call it EMR.
Sunday, July 14, 2013
A U.S. Marine's Gift to a Doctor
I saw an elderly patient a few months back for a
gastrointestinal issue that fortunately led to a benign outcome. He was a modest man who spoke softly and used
few words. As has been my custom for as
long as I’ve sat across patients, I was interested to learn something of the
man beyond the issue that brought him to see me. Indeed, it is these vignettes that I regard
as the gems of my practice. Without them,
I would be left only with the practice of medicine, and this would not be sufficient.
He wore a military baseball style cap, emblazoned with a
U.S.M.C. label. To those who do not
immediately recognize what these letters stand for, then I suggest that you
apply to medical school, become a physician, see patients so you also will have the
opportunity to learn stuff that really matters.
I learned that he served in the Pacific theater in World War
II and asked him about his service there.
While my father served in the war for 39 months, he remained in the
United States, far from harm’s way. As
he was so mechanically incompetent, perhaps the government kept him home as
they were fearful of placing a firearm in his hand. He was stationed in California and likely
would have been deployed to Japan had President Truman not ended the war in
August 1945.
My patient described how he was shot in the head, with the
bullet piercing the front of his helmet and then exiting out the rear. No vital structures were injured. He described the event as casually as one
who had sprained an ankle in the parking lot.
I find that older veterans are characteristically modest and understated,
two virtues that I wish were more contagious.
When I learned that he served on Iwo Jima, my eyes flickered
wondering if he had witnessed the scene that has become America’s most iconic
military image. Yes, he had
witnessed the legendary flag raising on Mount Suribachi. I felt as if I were in the presence of an
important man, though he would likely dispute that.
I saw this man back in the office recently, and at the
conclusion of the visit, he gave me an envelope containing a gift. It was his U.S.M.C. pin that he wore
throughout his service.
“I want you to have this, doctor,” he told me.
I accepted this important gift from an important man with
deep appreciation.
We give what we can to our patients. They have just as much to give back to us.
Semper fi, Elmer.
Sunday, July 7, 2013
The Cost of Colonoscopy: A New Payment Model
There is a steady push to change the way that physicians are
paid. No compensation model is
ideal. The fee-for-service (FFS) model
has become Public Enemy #1 as it is felt to be responsible for overtreatment
generating excessive costs and utilization.
Salaried physicians may be freed
from the FFS conflict of interest, but it has other drawbacks including a
diminished incentive to provide exemplary service to patients and to referring
physicians. Since physicians did not
initiate compensation and health care reform decades ago when we should have,
we are now being squeezed hard by external forces that will overcorrect on the
system’s deficiencies. It’s always
better to fix your own house. There
should be a lesson here for other professions who are in need of some reform
and repair. Teachers, in my view, were
dragged into the education reform arena, and will suffer because of it. Attorneys have been smug and cavalier about
the legal profession’s obscene excesses and I believe that they will rue their
inaction.
What do patients think about how their doctors should be
paid?
I’ve done over 20,000 colonoscopies. As I have written in this blog, I’m not even
sure how much I charge for the procedure.
It’s not simply because I have little interest in the business of
medicine. It’s also because
colonoscopies are like air travel. No
two passengers pay the same price.
Which system would you favor for pricing a colonoscopy?
(1)
Flat fee for the procedure for every insurance
carrier.
(2)
Hourly rate.
If a colonoscopy is tough and takes twice as long, the physician should
get double the dough.
(3)
Graduated rate depending upon experience. Should a 20 year gastro veteran be paid the
same as a green newbie?
(4)
Airline model.
We now know that various airline seats have been designated as premium
seats because they afford an extra centimeter of leg room or the oxygen mask
actually works. Similarly, certain
colonoscopy time slots could be subject to a surcharge, such as the first
appointment of the day when the physician is energized and not yet running
behind. The 5 pm slot, in contrast, would be discounted as the
physician is fatigued and is trying to make a 6 pm dinner reservation.
(5)
Name your own price model as is done with air
travel, car rentals and hotel rooms. Patients
offer an on-line price in advance and the GI practice decides to accept this or
wait for a higher bidder. This adds a
fun element to the colonoscopy adventure.
(6)
Patients decide after the procedure to pay the
doctor what they feel the training, knowledge, experience and judgment are
worth. Some patients, I fear, may
valuate the colonoscopy only by the 10 minutes duration. This is not quite fair. Once in Cape Cod, I saw a beautiful sand
sculpture of a mermaid. I asked the
artist how long it took him to create the art.
His response was ’30 years and 7 hours’.
Get the point?
(7)
Barter system as functioned well
historically. One colonoscopy = 6 Box
seats at sporting event = set of luggage = last year’s iPhone model = 1 hour
plumbing service = 5 car gas fillups
(8)
No charge at all. You can’t put a price on your health, and we
shouldn’t try.
While I’ve never regarded myself as business savvy, perhaps
I’m onto something here. What do
readers think? Is it time to take off the rubber gloves and wear suits and ties or should I keep my day job?
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