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:

14164_z_mntybfc1u 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.

    montypythonfrenchNow 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 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 EMR, 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 AM and every evening from 5:30-7:00 PM.  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 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 Thousand 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 NCQA 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 US healthcare, 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.

      python4

      If we are, then perhaps we can start collecting shrubbery.

      python2

      I already have my EMR programmed to say "Ni!"

      Bonus points if you know the significance of the title.

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