Tag: private practice

Immediate Changes Needed for Physicians to Stay in Business During the Pandemic

Mar 31, 2020• 4

Practices cannot survive the COVID-19 cash flow crisis

By JEFF LIVINGSTON, MD

Will doctors be able to keep their practices open during the worst pandemic in our lifetime? Our country needs every available doctor in the country to fight the challenges of Covid-19. Doctors working in independent practices face an immediate cash flow crisis threatening their ability to continue services.

The CARES Act was signed into law on Friday, March 27, 2020. The law offers much-needed help to the acute needs of hospitals and the medical supply chain. This aid will facilitate the production of critical supplies such as ventilators and PPE. The law failed to consider the needs of the doctors who will run the ventilators and wear the masks.

Cash flow crisis

Private-practice physician groups experienced an unprecedented reduction in in-office visits as they moved to provide a safe and secure environment for patients and staff. In compliance with CDC guidelines, practices suspended preventative care, nonurgent visits, nonemergent surgery, and office procedures.

These necessary practice changes help keep patients safe and slow the spread of Covid-19. The unintended consequence is an unreported and unrecognized cash flow crisis threatening the viability of physician practices.

Doctors Struggle to Make Ends Meet?

Dec 1, 2018

By Aaron Carroll, MD

I’m already preparing for hate mail.

So I open up my email this morning to find a gem from the WSJ, entitled, “Doctors struggle to make ends meet.” Usually, when I hear that phrase used, it’s describing the plight of the poor, unable to figure out how to make a mortgage payment, pay off medical bills, and still find enough left over to put some food on the table for the family. That’s what “struggling to make ends meet” means. This? Not so much.

To be fair to the author, I’m sure she didn’t choose the title. In my experience, editors do that, and they sometimes choose catchy titles that are inflammatory and don’t, perhaps, truly capture the flavor of the piece. That is sort of the case here. It’s not really an article about a doctor struggling personally, it’s an article on how a doctor is struggling to keep his practice profitable. That practice sounds like a very nice place to be cared for:

His family practice uses electronic health records, calls up patients at home to check on their progress, and coordinates with other specialists and hospitals—all the things that policy makers and insurers say should be done to improve patient care.

Recently, the practice has been upgraded to attempt to qualify for anticipated future incentives for a “medical home”. In essence, we’re talking about more accountable care and paying for “quality”, not “quantity”. But there’s a problem. Getting ready for those new incentives ain’t cheap:

For a five-doctor practice, the Advisory Board Co., a health-care research firm, projects the total first-year cost at between $126,000 and $346,500, including two added nurses.

The upshot: Doctors fear a squeeze as they try to ramp up changes in tandem with evolving reimbursement schemes. “You’re asking a practice that may be only marginally viable as a business to invest in significant infrastructure,” says Glen Stream, president of the American Academy of Family Physicians. “Is the payment model going to be there to support that?”

Continue reading…

Doctors Who Take Medicine Into Their Own Hands

Aug 1, 2014• 28

By RICHARD GUNDERMAN, MD

Many doctors are frustrated by pressures to practice a faster and more impersonal brand of medicine, but some are actually doing something about it. I recently spoke with one such doctor, Tom O’Connor, MD, who practices general internal medicine in central Connecticut. He and his partner, Paul Guardino, MD, believe they were the first US physicians to begin building a fully concierge medical practice the day they completed training. In the concierge model, their practice collects an annual fee of several thousand dollars from each patient, enabling better access, more personalized care, and even house calls.

But the real story about physicians such as O’Connor is not that they are opting for a different model of financing their practices. Instead it is the unmistakable sense of excitement with which they talk about the way they care for patients – an attitude that has become noticeably rarer in recent years. Says O’Connor, “I have been practicing medicine for nearly ten years this way, and I am happier than ever.” His enthusiasm stems largely from the fact that, unlike most physicians, he is not employed by a hospital or a large practice group. Instead, he works for himself. He is his own boss.

Of course, the idea of doctors running their own practice is not a new one. For much of the 20^th century, most physicians were self-employed, and many operated in solo practice. Today’s trend away from physician self-employment is driven by a number of factors, including increasingly complex and costly regulation of medical practice by government and insurance companies, the failure of medical schools and residencies to prepare physicians to manage their practices, and big financial incentives for hospitals and health systems to buy medical practices in order to capture patient referrals.

Enter a new breed of physician that includes O’Connor. He did not want someone else telling him who he could care for, what tests and medications he could order, or how long he could spend with each patient. In his practice, he and his partner – the doctors who actually see the patients every day – make such decisions themselves. He sees all his own patients, whether in the office, the nursing home, the hospital, or at home – wherever care needs to be provided. They do not go to walk-in clinics and they are not cared for by teams of hospitalists. O’Connor is their doctor in every context.

Rob’s New Economics of Practice Management

Jan 27, 2013• 20

By Rob Lamberts, MD

It has always been my assumption that my new practice will be as “digital” as possible. No, I am not going into urology, I am talking about computers. [Waiting for the chuckles to subside]

For at least ten years, I’ve used a digital EKG and spirometer that integrated with our medical record system, taking the data and storing it as meaningful numbers, not just pictures of squiggly lines (which is how EKG’s and spirometry reports appear to most folks). Since this has been obvious from the early EMR days, the interfaces between medical devices and EMR systems has been a given. I never considered any other way of doing these studies, and never considered using them without a robust interface.

Imagine my surprise when I was informed that my EMR manufacturer would charge me $750 to allow it’s system to interface with a device from their list of “approved devices.” Now, they do “discount” the second interface to $500, and then take a measly $250 for each additional device I want to integrate, so I guess I shouldn’t complain. Yet I couldn’t walk away from this news without feeling like I had been gouged.

Gouging is the practice of charging extra for someone for something they have no choice but to get. I need a lab interface, and the EMR vendor (not just mine, all of the major EMR vendors do it) charges an interface fee to the lab company, despite the fact that the interface has been done thousands of times and undoubtedly has a very well-worn implementation path. This one doesn’t hurt me personally, as it is the lab company (that faceless corporate entity) that must dole out the cash to a third-party to do business with me.

Doing construction in my office, I constantly worry about being gouged. When the original estimate of the cost of construction is again superseded because of an unforeseen problem with the ductwork, I am at the mercy of the builder. Fortunately, I think I found a construction company with integrity. Perhaps I am too ignorant to know I am being overcharged, but I would rather assume better of my builders (who I’ve grown to like).

Yet thinking about gouging ultimately brings me back to the whole purpose of what I am doing with my new practice, and what drove me away from the health care system everyone is so fond of. If there is anywhere in life where people get gouged or are in constant fear of gouging, it is in health care. Continue reading…

Progress

Jan 10, 2013• 4

By Rob Lamberts, MD

Finally.

I can finally see progress in what I am doing. Above is a photo of the front page of my new practice website (visit http://doctorlamberts.org).

There still is a little “Lorem ipsum” here and there – like having labels you missed on a shirt you are wearing – but I am very happy with the look. The pictures of the sepia photos with the iPad making it color were the genius of my web developer (with some suggestions from me), giving a perfect image of the use of technology to accomplish “old-fashioned care made new.”

I’ve spent good portion of the past few days writing the content (replacing most of the “Lorem ipsum”). Of what I’ve written, the strongest was in the section “Why It’s Different,” where I compare life in a traditional practice to what I intend to do. Here are a few examples:

“I Need an Appointment”

Traditional Practice

· Call the office, hear a message about calling 911, get placed on hold or leave voice message (after navigating automated attendant).
· Get called back to find out the reason for your appointment.
· Appointment is made around what is open for the doctor.
· Take time away from your schedule to meet doctor’s schedule.

Our Practice:

· Log on to portal and directly make your own appointment to fit your schedule.
Or
· Call the office and tell a human being that you need an appointment.

Questions and Answers

Dec 20, 2012• 6

By Rob Lamberts, MD

Things have been crazy. It’s much, much more difficult to build a new practice than I expected. I opened up sign-up for my patients, getting less of a response than expected. This, along with some questions from prospective patients has made it clear that there is still confusion on the part of potential patients. So here is a Q and A I sent as a newsletter (and will use when marketing the practice).

About My New Practice

Q. Why did I do this?

A. I get to be a doctor again (perhaps for the first time). I got tired of giving patients care that wasn’t as good as it could be. I got tired of working for a system that pays more for bad care than for good. I got tired of forcing patients to come in for care I could’ve given over the phone. I got tired of giving time that should be for my patients to following arduous regulations. I got tired of medical records not meant for actual patient care, but instead for compliance with ridiculous government rules. Making this change gives me the one thing our system doesn’t want to pay for: time devoted for the good of my patients.

Q. How can I afford to do this?

A. I have greatly decreased my overhead by not accepting insurance and keeping my charges simple. My goal is to have 1000 patients paying the monthly fee, which will limit the number of staff I need to hire.

Q. When will it open?

A. My office will open in January, 2013, but the exact date is still not set. I had initially hoped to be already seeing patients, but things always are harder than they seem.

Q. What makes this better for patients?

A. The main advantage is that I am finally able to give them the care they deserve: care that is not hurried, not distracted by the ridiculous complexity of the health care system, and not driven by the need to see people in person to give care. This means:

I don’t ever have to “force” people to come to the office to answer questions. This means that I will let people stay at home (or work) for most of the care for which I would have required an office visit in the past.
I will be able to give time people deserve to really handle their problems
I won’t have to stay busy to pay the bills, so I can take care of problems when they happen (or when they are still small), rather than having to make people wait to get answers
Patients won’t get the run-around. They will get answers.
I won’t wait for patients to contact me to give them care. I will regularly review their records to make sure care is up to date.
I will help my patients get good care from the rest of the system. Avoiding hospitalizations, emergency room visits, unnecessary tests, and unnecessary drugs takes time; I will have the time to do this for my patients. This should more than make up for my monthly fee.

What If Success Sucks?

Nov 27, 2012• 15

By Rob Lamberts, MD

“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees. I pay him to give me the stark reality of things, but his optimism made me uncomfortable. ”You’ve got to go for this. I know you don’t feel ready for it yet, but this could really be huge for your business, and I don’t think you should pass this up.”

I sighed. Yes, this is a victory of sorts (still only theory, not reality), but what if I can’t deliver? What if I fail?

“You know,” a colleague told me during another phone conversation, “you are the buzz of the medical community right now. We talked about you for half an hour at lunch today…and it was all good!” He went on to use phrases like “our only hope,” and “the way out,” to describe the potential for my practice model.

“No,” I thought, “I am not Obi-Wan. I’m not your only hope.” I sighed. I don’t want that kind of pressure on me before I even see my first patient. What if I fail?

Even worse: what if I succeed?

One of the main things that separates good clinicians from the rest is the ability to think through contingencies. When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z. Or, here’s the plan if you get better on the medication, and here’s the plan if you don’t. The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem. I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.

Tough Hard Decision: What To Do About Medicare

Nov 19, 2012• 15

By ROB LAMBERTS, MD

It seems both ironic and inevitable: I won’t be getting any more “meaningful use” checks. It’s not that I didn’t qualify for the money; I saw plenty of patients on Medicare and met all of the requirements. I was paid for my first year money without much hassle. The problem I am facing is this: I am probably going to be “opting out” of Medicare, and once I do that I will cease to exist as far as HHS is concerned, and they are the ones who write the “meaningful use” checks. No existence equals no money.

This is ironic because I have gotten famous for how well I’ve used electronic medical records, have written advice for physicians trying to qualify for “meaningful use,” and am esteemed enough to be often asked for my opinion on the subject (culminating in a presentation last year for CDC public health Grand Rounds). I have spent much of the past 16 years disproving the myths that small practices couldn’t afford EMR, that EMR decreases profitability, or that they reduce quality of care. We not only could afford EMR, we flourished, using it as a tool to increase both productivity and profitability. Not to overstate the issue, but my practice (and others like it) paved the way for the existence of “meaningful use.” I don’t know if that’s a good or a bad thing.

But, as fate would have it, I am leaving the practice in which I did all of this work and am starting a new practice with a different payment system. Instead of charging for office visits or tests done in my office, I am charging a monthly “subscription” fee for access to my care and to the other resources I offer. But there isn’t a Medicare code for a monthly subscription fee, and the rules of Medicare are such that, as far as I can tell, I cannot have the practice I intend to build and be listed as a Medicare provider. This is the case even if I never charge Medicare for any of my services.

Regarding my status as a Medicare provider, there are three options:

Accept Medicare as a “participating” provider – This means that I see Medicare patients and accept what they say I will be paid. I bill CMS for my services, which are based on my “procedure codes.” My main procedure is the office visit, but I can also bill for things like immunizations, lab tests, and office procedures. The more procedures I bill for, the more I get paid, but I must justify this billing in my documentation or run the risk of being accused of fraud.
Become a “non-Participating” Medicare provider – In this scenario, I am paid by the patient for the encounter and then they are reimbursed for what they paid me. The choice of what I bill happens the same way, and I still must set fees based on what CMS tells me (although I can bill a little bit more than I would if I was a participating provider). Billing is, once again, based on the documentation of the visit.
“Opt out” of Medicare altogether – Opting out means that I am no longer in the Medicare database as a provider and won’t get paid by them at all. Patients are free to come to me, but they must pay what I charge, and I set my fees based on what I think is best.Continue reading…

Doctorology: Communication. It’s All Good

Nov 3, 2012• 6

By Dinosaur, MD

“Doctor’s office; please hold.”

You’ll never hear that when you call me. Never. You’ll also never get an automated answering system (I’m just referring to office hours, of course. Evenings and weekends the phone goes to Google Voice. More on

that below.) We are also in the middle of a communication revolution. There are now so many other ways patients can contact me other than the telephone, the silly thing is almost becoming obsolete. I took amoment the other day just to go through all the various ways patients contact me.

Telephone

Still the most reliable fallback. Most synchronous form of communication: both parties willing and able to talk in real time. After hours, Google Voice (free) transcribes messages and texts them to my smart phone. As a rule, patients do not call my cell phone, although I’m not shy about giving out the number. Then again, those who have my cell number usually use it for…

Texting

At the moment, it’s just a few patients, but I anticipate more and more of them will partake as time goes on. It doesn’t happen very often, and so far it’s never been inappropriate. Med refill requests and pictures of kids’ rashes have been the mainstay so far. I like it. By it’s very nature, the people choosing to text me understand the limitations of synchronicity, ie, they don’t get bent out of shape if I don’t answer them right away, and they understand that it’s just for relatively minor issues. I also use it to communicate simple quick questions to specialists with all the same mutual understandings (minor issues only; response time unimportant).

The Good Doctor Learns to Fly

Oct 26, 2012• 37

By Rob Lamberts, MD

This is my new office. I signed the lease for this property yesterday – another big step in the process of getting my new practice off the ground. I should feel good about this, shouldn’t I? I’ve had people comment that I’ve gotten a whole lot accomplished in the 4 weeks since I’ve been off, but the whole thing is still quite daunting. Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.

I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don’t know what I want done, and nobody can tell me what I should do. Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don’t really know which of my ideas about the practice will work, I don’t know what my needs will truly be. How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse? I want a space for group education, but how many resources should I put toward that? I also want a place to record patient education videos, but some of my “good ideas” just end up being wasted time, and I don’t know if this is one of them.

I come across the same problem when I am trying to choose computer systems. I know that I want to do that differently: I want the central record to be the patient record, not what I record in the EMR. I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their PHR. So do I build a “lite” EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product? Do I use an EMR company’s “patient portal” product, or do I have a stand-alone PHR which is fed by the EMR? I have lots of thoughts and ideas on this, but I don’t really know what will work until I start using it.