Is being in my practice something that saves money? Some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get. This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model). I realize that this does not constitute a proof of concept, but it is not without meaning.
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Sit down. Really, sit down. Trust me, please. You are going to be shocked with the news I am going to give you and I don't want any contusions, closed head injuries, street riots, or revolutions taking place in South American countries on my conscience.
Are you sitting? OK, here it goes:
Medicare got something right.
Pretty crazy, right? I am not sure if it was an accident, like the infinite monkeys typing on a keyboard producing the works of Shakespeare (they'd write all of the Harlequin romance novels too, by the way). They had to eventually do something right, something that really benefits people, makes my life better, and potentially cuts cost. The thing they got right? The Medicare preventive exam.
Up to a year ago, the only way I would ever get paid to see a Medicare patient was when they had a problem. If a person came in with the desire to keep from being sick, we would have to get a waiver signed and charge them full price. So at those visits we would fish for any problems to justify it as a disease-management visit or one for acute care. This meant that any prevention that I did perform on my Medicare patients had to be done on the side during problem-oriented visits. So the motivation to do prevention was dependent on the nature of the doc; if they are OCD, didn't care about getting home on time, or less concerned about getting paid, patients got better care, otherwise it was hit or miss.
Plus, the chart itself was often neglected. Any time a doctor took to make the chart accurate was time away from other patients or time away from home. This sounds petty, but it takes a large effort to keep things updated, and with the low reimbursement of primary care, only those things that were grossly inaccurate got corrected in most patients' records. I was never given the time to make sure the records were accurate.
In January of 2011 this all changed (at least for Medicare patients). The Medicare Preventive Care Visit came into effect, paying well for keeping people well. The visit follows a specific structure (and arduous documentation, of course), and making the proper templates on our EMR and getting them to put out a suitable handout at the end of the visit took a lot of effort. But the effort paid off; my patients are very happy with these visits and I am able to do some things I have never had time for. The end result is this:
- The patients are given their problem, medication, and allergy lists prior to the visit and correct them for us.
- We can compile the names of other physicians they are visiting and make sure they are accurate.
- We do a functional assessment on people, identifying those at risk for falls or those in bad home environments.
- We screen for depression.
- I get to discuss advance directives with people (living will and health power of attorney). This is probably the biggest change, as I rarely had the chance to talk about this before (and felt very guilty about it). In the past year I have talked to hundreds of people about this, and have probably saved a whole lot of trouble down the line because of it.
- I check when their last screening tests (colonoscopy, mammogram, bone density) and get a copy of them when they aren't in my records (which is distressingly common). I order tests that are due and discuss with the patient when the next screening test is due.
- More of my patients are getting pneumonia shots (pneumovax), and many more are getting the option to get the shingles vaccine (Zostavax).
- In the end, the patient gets a handout (see below) that gives a road map of their care: what was done in the past and when, what was done today, and when things are due in the future. In short, the patient suddenly knows where they stand regarding their health, something that was not common prior to this.
- I am actually being paid well enough for these visits to motivate me to schedule them on as many patients as possible. Certainly, the improvement to the chart itself and to the overall care of the patient is also motivation, but it's nice to be paid for doing good from time to time.
There are (of course) some negatives, including:
- The document created in the chart is enormously wordy and not really useful on its own. Again, since we are paid for documentation, we get exactly that: lots and lots of words to justify our pay. This isn't too hard if you own a gibberish generator.
- Some of the local GYN groups are billing for a Medicare preventive visit (although I seriously doubt they are meeting the cumbersome documentation guidelines), so some of our patients' bills are not paid for. We do our best to filter patients who may be in this situation, but some still get through. I cringe at the thought of these GYN's charts being audited.
- Some patients try to get a disease management visit rolled into the preventive visits. They don't understand at first why I can't talk much about their diabetes on this visit, but when they get the finished product they are almost always satisfied.
Here is the 1st page of the handout given to the patient:
It's not bad. There are still some bugs being worked out, but it is very satisfying to have time to make sure the records are right and to have a significant percentage of my patients with up-to-date preventive care. This is very much like the GPS device I mentioned in an earlier post.
I am a little anxious about posting this, as it may encourage the government to double the number of monkeys on typewriters (i.e. bureaucrats) and so negate any good that comes of this. Anyhow, some of the monkeys are already busy running for president. But for now, I say something I rarely get to say:
Thank you, Medicare.
You may resume standing.
Since I am self-employed (as part of a partnership), the easy answer would be to say I work for myself. That is not, however, what was meant by the question (and it would make a dull blog post if it was); the intent of the question was this: for whose interest am I most working for? Who am I trying to please? Who is my boss?
My answer? I have many bosses:
- My patients
- The insurance companies
- My patients' employers
- Our business
- The government
So who really is my boss?
We all, in the end, work for Oprah. That's a given. I won't add any more to that as it is self-evident.
Being a primary care doctor, I would like to say that I work for my patients. I would like to say that the only thing that matters is the health and happiness of the people in my care; but that would not be true. I fight to keep this focus in my office, but sadly it's still not the reality I live. The reality I live is that of a planet being torn out of its orbit by larger, more powerful celestial bodies, all trying to make themselves the center of my universe.
Who is my boss?
They certainly write a big chunk of my paycheck, commanding an increasing amount of my time. I have contracts with insurance companies, agreeing to what they pay. I follow rules of insurance companies to get the patients the care they need and what the insurers dictate, (which are sometimes at odds). Insurance companies have more access to patient records than patients do, or at least they have easier access. Insurance companies can decide if they will pay me or not, while the patient doesn't have that option.
Clearly, the pull of the insurers' gravity is stronger than that of the patient. Clearly my patients are not my real boss.
But who writes the check for the insurance companies? Employers do. Employers dictate just how strict of rules the insurance companies will keep me under. When they choose an insurance plan for their employees, employers dictate how much I can charge at each visit, what services I offer will be covered, what payment structure I will receive (capitated, fee-for-service, or high-deductible). Much of what I can or cannot do is dependent on this decision.
If you asked employers, however, they would tell you that they are "at the mercy" of the insurance companies. Despite the fact that the employer is writing a check to the insurer, the relationship is hardly one of control on the part of the employer. As owner of a my own business I can attest to the one-sided nature of my relationship with my employees' insurance carrier.
Are my patients' employers my boss? No, it's not really close. Insurance carriers win that contest with ease.
So what about my business? Is my practice my boss? Since I am a part-owner of my business, it is not quite as clear as it would be for physicians employed by a practice or hospital. But the reality is the same in many ways. My practice decides what contracts we will accept or reject. It tells me if I am seeing enough patients, dictating how much time I am spending on each patient. The practice pays for the medical record system, tells me when I can have time off and, in extreme cases, could fire me. I certainly feel like a factory worker at times, punching in at the start of a long day with a conveyor belt of patients coming in so I can make money for "the man."
But who am I fooling? Our practice is also totally dependent on insurers, going to great lengths to make what I do come out in a format that will please insurers enough to pay us. Our practice could go broke should the government go through with its threatened cut to Medicare reimbursement. We are a service industry, totally at the mercy of our "customers," or "clients." Our business is but a pass-through vehicle for me to be paid by insurers and a front to let me see patients.
I work at my practice, but not for my practice. My practice is not my boss.
A significant percentage of my patients are either Medicare or Medicaid, so a large chunk of my paycheck comes from the government. Many of the contracts I get from private insurers are based on a percentage of Medicare's rates, so the government is a very powerful force in determining what I get paid. In addition, while I can opt out of any insurance plan if I don't like the rates, and have the option of negotiating a better rate, dropping out of government contracts is much, much harder. There is also no chance for negotiation; I either take what they offer or don't have their patients.
- The government set up our procedure-driven model of care that has so favored the specialist over primary care.
- They pay for enormous hospital bills but not (up until very recently) for me to prevent those enormous hospital bills.
- The government sets the rules for documentation - those rules that force me to put so much meaningless information into the record that I can't find the useful information I need.
- The government says that I can't send many kinds or e-prescriptions, even though doing so would be more secure and less prone to abuse.
- The government sets malpractice laws that favor the accuser and so makes my nurses quick to send people to the ER unnecessarily and makes me increase my test-ordering and documentation to avoid litigation.
- The government doesn't just tell me to get on electronic medical records (which I had already done), but gives me a large number of hoops I must jump through to prove that I am using them "meaningfully."
- The government promises to make those rules more invasive and onerous as time progresses.
- The government is supposed to regulate the insurance carriers, drug companies, and device manufacturers, many of whom are making huge profits during a time of economic crisis. They "regulate" the drug industry, letting companies gouge with generic drugs, set prices inordinately high, and advertise directly to patients information that tricks them into believing things that aren't proven or that are patently false.
- The government does nothing while more and more people outside the doctor-patient relationship plunge onto the system and plunder it for what they can get.
In short, the government stands watch while the health care system crashes and burns, the end result of which is that my patients are able to afford less and less care and I am too busy dealing with pleasing the system to give them the attention they deserve.
So who am I working for? The one for whom the system is designed, the patient, is not just competing for my attention but is on the periphery looking in while I deal with these other entities. The patient waits for an hour while I see extra patients and document profusely. The patient can't afford prescriptions I write because the cost of drugs is too high or the drugs are denied due to insurance formularies. The patient is afraid of me making a diagnosis for fear of losing their insurance. The patient pays more and gets less. I work harder and get less.
Who am I working for? Far too many people who are making it far too hard to do my job.
I wonder what care would look like if I actually did work for my patients? What would real care, not care that is torn apart by competing gravitational forces, be? What would the chart look like? How long would the visits last? How much would the visit cost, and how much would drugs cost?
What would care look like if the patient was really who I was working for?
I'll ask Oprah the next time I get a chance.
The following is an actual fictional conversation that took place in the doctor's lounge at a local hospital. Internist - Dang, these Medicare cuts are coming and I doubt that congress has the wits to avoid them. I am not sure I can go on practicing if they cut them any more.
Family Physician - Yeah, we already get paid so little by Medicaid and the private insurers, we have had to start to look for other sources of revenue.
Int - Really? We have been looking into that as well. What are you thinking about doing?
FP - We thought about doing cosmetic procedures, but we have an especially good-looking population, so we really can't make it work.
Int - Bummer.
FP - Yep. Instead, we have decided to open a kiosk for Krispy Kreme donuts. We figure we can make money off of the donuts, plus we can get more of our patients obese. Then we can treat worse diseases and code a higher level for each visit.
FP - And the "Hot Donuts Now" sign along with the scent of fresh-baked donuts will really draw in new customers...I mean patients.
Int - One of the GI doctors in town is doing the same sort of thing, opening a Starbucks in his office. He figures he gets walk-ins, gets people with worse dyspepsia, and gets free WiFi to boot.
FP - Brilliant. What have you been thinking of?
Int - We have noticed the interest our patients have in holistic medicine, and thought we should capitalize on that.
FP - So you are hiring a homeopath?
Int - No, they wouldn't set foot in our office because of the "evil" immunizations we use. We tried to get all sorts of alternative providers, but they would always sneer at our practices. And so we finally opted for two things: first, we are doing aromatherapy, which has our staff so relaxed that they don't seem to have noticed that we cut their pay by 50%.
FP - Great.
Int - Second, we have a psychic who goes around in our lobby doing palm reading and tea leaves on our patients as they wait. There are two positive outcomes from this: the patients who get bad fortunes told are so anxious that their blood pressure is up and they are ripe for anxiety treatment; the ones with good fortunes are happy enough that we can order all sorts of tests on them and they don't seem to care.
There is a downside, however.
FP - What's that?
Int - My partner now thinks that we should take our entire budget for next month and invest it in Power Ball lottery tickets. He says it is a "sure thing."
Hospitalist - Hey guys, what's up?
FP - We're just discussing what we are going to do to offset the impending Medicare cuts. Do you have plans?
Hos - Oh yes. I don't like the idea of increasing the load to 70 admissions per day. 50 is plenty. Instead, we are capitalizing on the fact that our patients are a "captive audience."
Int - This I've gotta hear.
Hos - We figured that we have enough turnover that some sort of direct marketing scheme to our patients could be quite lucrative. We are now certified Amway sales representatives.
FP - I love it!
Hos - Yep. We have these patients in a position where they can't move, and we sell them cleaning solvents, vitamins, and skin care products. Instead of taking cash, we just add it on to their hospital bill, so they usually buy a bunch.
Int - As an added bonus, the families of your patients will be so scared that you will try to sell them Amway products, that they steer completely clear of the hospital.
Hos - Bingo! It works like a charm. We got this idea from the intensivists who were holding Tupperware parties in the ICU. The patients were sedated "just enough" so that they left the hospital with all sorts of cups, jugs, and bowls.
FP - Any complaints?
Hos - Not yet. You figure, what we charge for the solvents is 1/4 of what the hospital charges for an Aspirin. The patients really don't notice a little more charge. We have even had some insurances mistakenly pay for some of our Amway products!
Int - You know, maybe this Medicare cut may just be a good thing. Look at how it has pushed us to open new frontiers in medicine. Our children will look back on this time as being one of the real turning-points in American healthcare.
FP - Yeah, today Amway...tomorrow....
Hos - Healthcare reform? Higher reimbursement? A fair payment model?
FP - Used Cars.
Int - I am so glad I went into medicine.