Physicians

Dismantling the Cottage Industry

Last week I went to see a doctor about an EHR. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed “two and a half” days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene’s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn’t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Dr. Greene collects 99.6% of his charges and he never used a collection agency and he never will. Wait a minute…. This is impossible. Insurers deny payments all the time and they certainly don’t pay what you bill out. Not to mention that patients are not very quick to pay either. How can you collect 99.6% of charges? How about allowables and adjustments and write offs and all other administrative nightmares that are part and parcel of a medical practice? Dr. Greene walked out of the kitchen and returned with a piece of paper he picked up at the front desk: his fee schedule.

Dr. Greene’s fee schedule was neatly typed on a letter sized pink sheet of paper and carefully encased in a clear plastic protecting sleeve. The fee schedule contained about fifteen procedure codes, mostly E&M codes for various office visits. He doesn’t do any procedures in the office and if he does an “EKG or some other simple thing”, he doesn’t charge separately for it. The fee schedule had two columns for each code; the Medicare allowed fee and the actual fee he charges all his patients. I had to look several times at the column headings to understand – Dr. Greene charges less than Medicare is willing to pay him. For the most common visits, he charges a lot less than Medicare will pay. He bills these lower charges out to Medicare, to all private insurers and to his cash patients. Why????

Dr. Greene was laughing and Mrs. Green was smiling at my total lack of understanding. I guess city folks are not so bright after all. For Dr. Greene this is a matter of principle. It is an entire philosophy. This is about fairness and honesty. His patients are his neighbors and he knows all too well that most cannot afford to pay the Medicare deductibles. He charges what people can pay and he makes it simple, straightforward and fair. His fee schedule is displayed at the front desk. In return, his patients pay their bills promptly. Fairness in small communities is usually reciprocated. Medicare and commercial payers, probably assuming he is mad, are quickly paying his claims just like a quarterback quickly snaps the ball to avoid a challenge. That’s how you get 99.6% of your charges collected with very little overhead. And, no, he is not at all interested in changing things. He is making a very nice living, thank you.

Dr. Greene wants an EHR. Why? Because he wants to receive lab results electronically from the little hospital down the street, and because he wants to use templates. Templates??? You mean you want to click on boxes instead of writing those beautiful golden notes? He thinks a dozen or so customized templates would make him more efficient and allow him more time with his patients and perhaps he can go home a bit earlier too. He wants to send prescriptions to pharmacies and not have to write down the medication list each time. No, he doesn’t want to create documentation for higher billing codes. And he doesn’t want to be left behind.

Dr. Greene, unlike some of his colleagues in town, has no plans of running away and retiring early in the face of new challenges. He will get an EHR and he will exchange clinical information and he will advance with the times. He will be exploring quality improvements and medical homes and even accountable care organizations. Dr. Greene knows that EHRs slow you down and are well positioned for improvement, but he also knows that his grown children, who are themselves physicians, will expect an electronic office if and when they return to their hometown to continue the tradition. There was a faraway dreamy look in his eyes now. Lunch hour was over and there was one patient in the waiting room.

For all the pundits and the health economics experts, and for the political activists on either side, who are actively trying to dismantle our health care cottage industry and reconstitute its remains into large corporations of efficiently employed physicians, this is what you are attempting to dismantle – Dr. Greene, and the thousands of others like him who practice medicine four to five hours away from a major airport beyond miles and miles of cow pastures and fields of corn.

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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Louise Denton, MDpcpMGmaggiemaharDeterminedMD Recent comment authors
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DeterminedMD
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DeterminedMD

Hey, Doctor Urbach, here is a return quote, I think you’ll recognize it: (Me)”I want the truth” (obamacare supporters/defenders)”You can’t handle the truth” You don’t like what I have to say, well, solid feces to you to, sir. Don’t like what the majority of Americans said by voting last night, well, you have about 730 days to convince some of those voters to change their minds and vote for what you champion for in 2012. But, until then, let’s see what the Repugnacants come up with that just might make this legislation a bit more realistic and palatable, eh? Frankly,… Read more »

pcp
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pcp

“Larger groups have better negotiating power”
Exactly!
As Ms. Gur-Arie points out, what these studies show is that larger groups are better at being measured on parameters that have nothing to do with better outcomes (insurers have for years been telling me that I’m doing a lousy job of ordering mammograms on low-risk women in their 40s, and PSAs on men -and sometimes women- in their nineties).

Dan Urbach, MD
Guest
Dan Urbach, MD

To Dr. DeterminedMD,
A quote from James Joyce, just for you:
“Arrah, sit down on the parliamentary side of your arse for Christ’
sake and don’t be making a public exhibition of yourself. Jesus, there’s
always some bloody clown or other kicking up a bloody murder about
bloody nothing. Gob, it’d turn the porter sour in your guts, so it would.”

DeterminedMD
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DeterminedMD

Gee, Ms Mahar pads her sources to defend her thinking. Uncomprehendible she would do such a thing! I do commend you, Ms G-A, for deflating her last response. Wonder what else will come out post election that will embarass the Democrats in cramming this legislation down the throats of Congress and the people? Hey, what will one expect as the reply once caught: denial, projection, minimization, and rationalization. Hey, if narcissists and antisocials use these defenses so well, why not politicians? Oh, that’s right, these are the basic personalities in Washington in the first place! Makes you wonder why Ms… Read more »

Margalit Gur-Arie
Guest

Maggie, I just skimmed through the Health Affairs article, and I will read it carefully later today, but a couple of things attracted my attention: 1) By the authors own admission, the population served by the larger groups was younger, healthier and more affluent, which could affect the findings, even when adjusting for these factors. 2) A savings of 3.6% for Medicare could easily translate into a larger loss for commercial insurers. Larger groups have better negotiating power and can more than make up for this small savings to Medicare. This is why I suggested a similar study for non-Medicare… Read more »

Dan Urbach, MD
Guest
Dan Urbach, MD

Regarding real estate, in my area it would have made sense 20 years ago to buy my office. Now it doesn’t. Rent is fairly high, but nothing compared to Manhattan, so the comparison isn’t apples to apples in that case. Regarding best practices, collaboration, medical record, etc, all I can say is that I am an evidence based medicine practitioner, and when I don’t know what to do and can’t find it in the literature, I call my specialist colleagues. They’re usually a block or two away. It doesn’t matter if they are in the same office space nowadays. I… Read more »

maggiemahar
Guest

Margalit– People have done reserach on quality and practice size– lots of it. See this piece about a Health Affairs article published in May http://www.healthcarefinancenews.com/news/large-multi-specialty-medical-groups-offer-higher-quality-lower-cost-care The reserachers include Bill Weeks, Larry Casalino, Steve Shortell, Elliott Fisher– all excellent. Larger mutlispecialty practices win hands down–higher quality care as well as lower cost. Better co-ordination and collaboratoin among PCPs and specialists who all are looking at the same chart; better adherence to “best practice” guidelines (docs are looking over each others’ shoulders–no one is doing things the way they did them 25 years ago becuase “I’ve always done it that way”) -and… Read more »

Barry Carol
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Barry Carol

I take exception to the idea that large group practices are necessarily more efficient than solo and small group practices. While large groups offer doctors advantages including better ability to afford IT and other equipment, the ability to more easily collaborate with colleagues, and freedom from the business aspects of running a practice, such organizations are more complex and therefore require more administrative infrastructure. I remember a few years back hearing from a couple of doctors that there are modest economies of scale until you get up to 5 or 6 doctors. After that, you need a practice manager and,… Read more »

Louise Denton, MD
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Louise Denton, MD

“Extremism is being rejected now by those like me who realize that either party does not represent us, but just resents us to have to come to the public every 2-6 years to keep their cushy jobs, insulated from the realities that even doctors deal with every day!” Many share this view. The happenings in DC and in most state capitols are despicable. The needs of the people are neglected by all of the parties, including the Tea Party. I never saw an election in which so many felons and inbeciles ran and gor elected. The populace of this country… Read more »

DeterminedMD
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DeterminedMD

This isn’t about random trauma, Ms G-A, but just partisan politics that ruin it for the independents and moderates who are a sizeable voting majority now, and we are telling the Democrats tonight to stick it where the sun don’t shine, your “progressive” rhetoric is not going to progress this country any further than the Republican garbage of 2003 selling war in Iraq. Oh yeah, the Democrats didn’t support the Republican agenda to send American soldiers to either die in the Middle East or come home and be scarred for life and have the highest rates of suicide since statistics… Read more »

Margalit Gur-Arie
Guest

I’m sorry… I know I shouldn’t say this, but I can’t resist… 🙂
“what about those who are in good health, responsible with choices and life style decisions, who HAVE to buy health care insurance…”
The chances of getting hit by a bus are equally distributed amongst saints and devils.

DeterminedMD
Guest
DeterminedMD

I’ll take you on one at a time, as I am staying up to watch the mayhem and carnage of this election, hoping for as many incumbent losses as can happen! So, for every person who is sick without insurance, what about those who are in good health, responsible with choices and life style decisions, who HAVE to buy health care insurance as this democrat bs demands, at prices that will be higher than what they could have pursued without this intrusion? What do you, as entitled dictators mandate by this legislation, say to these people, who are not a… Read more »

DeterminedMD
Guest
DeterminedMD

“MS. Mahar, your unconditioned love for large medical groups (which, in my experience as a former employee of several, are much less efficient than small ones) is really preventing you from seeing that there are other effective ways in which to deliver quality health care. It’s not one size fits all, either for the doc or for the patients.” Hence how slavery is manipulated and sold to the public as acceptable and viable. If the elections play out as polling potentially indicates, Ms Mahar’s backers will be scrambling to try to enforce this legislation before the other party can try… Read more »

MG
Guest
MG

The HSR on small practices vs. larger practices on an array of quality and safety outcomes is pretty scant. It has mainly focused instead on efficiency instead.

Margalit Gur-Arie
Guest

Maggie, as pcp writes, New York City is rather different than most of the country. There are very efficient and successful solo practices in urban areas, and yes, owning your real estate is probably the right thing to do. Perhaps, Dr. Urbach can comment on his urban solo practice. My concern is that we are pushing one particular model of practice, which may seem efficient on the surface, without examining the side effects. It would be very interesting if someone did some research on cost & quality based on practice size in various geographical regions. I understand that contractual cost… Read more »