…And I feel Fine

29 Comments / American Medicine, Being a Doctor / By

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.

    \"montypythonfrench\"Now 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.

      29 thoughts on “…And I feel Fine”

      1. Peggikaye

        Ni!!!Ok, I can’t believe I’m saying this to a blogging doctor!!

        I wish you were my doctor!!
        Mostly over the not tolerating people being rude to patients … ooooo if you only knew how rude “Thumper” was. No, that’s not her real name, but it’s close enough that if she read this she’ll know who she is so I should probably change it but I won’t. She already knows she treats me rudely. :p

      2. Peggikaye

        Ni!!!Ok, I can’t believe I’m saying this to a blogging doctor!!

        I wish you were my doctor!!
        Mostly over the not tolerating people being rude to patients … ooooo if you only knew how rude “Thumper” was. No, that’s not her real name, but it’s close enough that if she read this she’ll know who she is so I should probably change it but I won’t. She already knows she treats me rudely. :p

      3. Mrs. H

        Bonus points: “It’s the End of the World As We Know It”? I do like REM…
        The health group we use does a lot of this, and I will say that being able to see our own doctor the same day we call (most of the time, of course) has been huge for us. Also, having access to our records has been great – for instance, I was able to print a copy of my 5-yr-old’s immunization records for school without having to go to the office and pick one up. Today we’re taking our 3-yr-old to an ENT referral where they don’t have EMR. So I’m just going to print out the current meds, etc. from his record. Makes it so much easier for all of us!

      4. Mrs. H

        Bonus points: “It’s the End of the World As We Know It”? I do like REM…
        The health group we use does a lot of this, and I will say that being able to see our own doctor the same day we call (most of the time, of course) has been huge for us. Also, having access to our records has been great – for instance, I was able to print a copy of my 5-yr-old’s immunization records for school without having to go to the office and pick one up. Today we’re taking our 3-yr-old to an ENT referral where they don’t have EMR. So I’m just going to print out the current meds, etc. from his record. Makes it so much easier for all of us!

      5. Rob

        Yes. REM is actually from just down the road in Athens, GA.Again, I don’t want my practice to seem like it is paradise, but we have been quite successful for some reason.

      6. Rob

        Yes. REM is actually from just down the road in Athens, GA.Again, I don’t want my practice to seem like it is paradise, but we have been quite successful for some reason.

      7. The Happy Hospitalist

        Nice entry Two questions:

        “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. “

        1) Is this the Walmart model?

        2. How would you apply your model to internists who take care of patients with multiple time consuming medical problems?

      8. The Happy Hospitalist

        Nice entry Two questions:

        “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. “

        1) Is this the Walmart model?

        2. How would you apply your model to internists who take care of patients with multiple time consuming medical problems?

      9. AnnR

        You sound like a practice that a person with a job could deal with. If a person is sick they need to get fixed up so their life can keep operating.
        I’m sure you get your share of complex and interesting problems from your normally mundane patients.

      10. AnnR

        You sound like a practice that a person with a job could deal with. If a person is sick they need to get fixed up so their life can keep operating.
        I’m sure you get your share of complex and interesting problems from your normally mundane patients.

      11. Rob

        Happy: To some extent it is the Wal-Mart model (although I cringe to say it). Wal-Mart uses computers to control stock and responds to where there are needs. In some ways I am simply responding to demand. The simple math says that a 5 Minute visit for $50 is more profitable than a 20 minute visit for $100. Plus, there are no labs to follow-up on, etc. The hourly rate for the complex patients is significantly less than that of the simple problem. It is a flaw of the system, but it is the reality.
        We do enough of the quick visits that we don’t feel the need to rush the complex ones. In a sense, they subsidize the complex care we offer. Plus, they greatly increase loyalty in the patients we have. They love our practice because they can get seen.

        AnnR hit the nail on the head in that we want the working people coming to our practice and try to make it easy for them. I think internists need to market themselves to the well and not just the sick. To do so, however, they need to adjust their schedules to that of the target market. The simple way to do this is to schedule a sick visit work-in for every complex patient visit. Then when you are waiting on labs, EKG’s, etc, you can go see the sick person. Plus, you have something to fall back on if the complex patient no-shows (which is far more likely than a same-day scheduled sick patient). With Medicare doing what they do, I don’t think internists can survive without doing this.

        Again, for me about 70% of my schedule is pre-booked (not including walk-in hours), and the rest is same-day or walk-in visits.

      12. Rob

        Happy: To some extent it is the Wal-Mart model (although I cringe to say it). Wal-Mart uses computers to control stock and responds to where there are needs. In some ways I am simply responding to demand. The simple math says that a 5 Minute visit for $50 is more profitable than a 20 minute visit for $100. Plus, there are no labs to follow-up on, etc. The hourly rate for the complex patients is significantly less than that of the simple problem. It is a flaw of the system, but it is the reality.
        We do enough of the quick visits that we don’t feel the need to rush the complex ones. In a sense, they subsidize the complex care we offer. Plus, they greatly increase loyalty in the patients we have. They love our practice because they can get seen.

        AnnR hit the nail on the head in that we want the working people coming to our practice and try to make it easy for them. I think internists need to market themselves to the well and not just the sick. To do so, however, they need to adjust their schedules to that of the target market. The simple way to do this is to schedule a sick visit work-in for every complex patient visit. Then when you are waiting on labs, EKG’s, etc, you can go see the sick person. Plus, you have something to fall back on if the complex patient no-shows (which is far more likely than a same-day scheduled sick patient). With Medicare doing what they do, I don’t think internists can survive without doing this.

        Again, for me about 70% of my schedule is pre-booked (not including walk-in hours), and the rest is same-day or walk-in visits.

      14. pcb

        Dr. Rob,
        How many patients do you see, on average, in a day?

        How long is your workday?

        Do you do your doumenting along the way or let it build up due to time constraints? What about patient calls, lab results, etc? (If it builds up, how much time spent after clinic hours finishing your work?)

        Are you dictating? Using templates? Free type? How do you think other doctors would rate your notes? (concise, high signal/noise ratio, yet containing the “essence” of the visit and your thinking?)

        How well are you able to stay “on schedule” in your practice? Do you aggressively limit how many patient concerns you will address on a given visit?

        I think your model sounds ideal, but I suspect there are some devils in the above details, given my experience trying to carve out similar sanity in our practice.

        Or maybe you’ve found nirvana. 🙂

      15. pcb

        Dr. Rob,
        How many patients do you see, on average, in a day?

        How long is your workday?

        Do you do your doumenting along the way or let it build up due to time constraints? What about patient calls, lab results, etc? (If it builds up, how much time spent after clinic hours finishing your work?)

        Are you dictating? Using templates? Free type? How do you think other doctors would rate your notes? (concise, high signal/noise ratio, yet containing the “essence” of the visit and your thinking?)

        How well are you able to stay “on schedule” in your practice? Do you aggressively limit how many patient concerns you will address on a given visit?

        I think your model sounds ideal, but I suspect there are some devils in the above details, given my experience trying to carve out similar sanity in our practice.

        Or maybe you’ve found nirvana. 🙂

      16. Rob

        See my previous post on how my day goes with EMR.
        I see an average of 25 patients per day, 4.5 days per week. Plus I see an average of 15 walk-in clinic patients per week.

        We use an EMR and use templates. We are mostly done with our notes at the end of each visit, but I usually have a few to follow-up on. We do not dicatation

        We always limit the number of concerns for the work-in or walk-in visits (this is necessary). The routine visits have no such limit.
        If they want to add on concerns to this type of visit (to “trick us” into doing a regular visit), we make them schedule a longer visit. The HPI and PMH are free text typed, while the rest is templated.

        Honestly, the biggest thing for us was that our system was easily scaled up and the addition of more physicians did not add much incremental cost. This is when I saw the biggest gain in my income – when my relative overhead dropped, as most of my overhead is fixed and not variable.

      17. Rob

        See my previous post on how my day goes with EMR.
        I see an average of 25 patients per day, 4.5 days per week. Plus I see an average of 15 walk-in clinic patients per week.

        We use an EMR and use templates. We are mostly done with our notes at the end of each visit, but I usually have a few to follow-up on. We do not dicatation

        We always limit the number of concerns for the work-in or walk-in visits (this is necessary). The routine visits have no such limit.
        If they want to add on concerns to this type of visit (to “trick us” into doing a regular visit), we make them schedule a longer visit. The HPI and PMH are free text typed, while the rest is templated.

        Honestly, the biggest thing for us was that our system was easily scaled up and the addition of more physicians did not add much incremental cost. This is when I saw the biggest gain in my income – when my relative overhead dropped, as most of my overhead is fixed and not variable.

      18. TBTAM

        At least you didn’t use the dead parrot sketch.
        Kidding aside, I cou’dnt agree with you more on the urgent care visits. I learned a lesson from my dentist on that one – see them just for the urgent issues, and have them come back for the annual. Most patients are exceedingly grateful to be seen on the day they call.

        I do make an exception, however, for the patients I see out of network who pay cash for their visits. (about 20% of my practice at ths point). If I see them for an urgent problem, I will do whatever they need. I am their happy slave.

      19. TBTAM

        At least you didn’t use the dead parrot sketch.
        Kidding aside, I cou’dnt agree with you more on the urgent care visits. I learned a lesson from my dentist on that one – see them just for the urgent issues, and have them come back for the annual. Most patients are exceedingly grateful to be seen on the day they call.

        I do make an exception, however, for the patients I see out of network who pay cash for their visits. (about 20% of my practice at ths point). If I see them for an urgent problem, I will do whatever they need. I am their happy slave.

      20. Carol

        Baby’s good to me, you knowShe’s happy as can be, you know
        She said so
        I’m in love with her and I feel fine

        (And I personally adore my primary care doc – can’t imagine getting by without him.)

      21. Carol

        Baby’s good to me, you knowShe’s happy as can be, you know
        She said so
        I’m in love with her and I feel fine

        (And I personally adore my primary care doc – can’t imagine getting by without him.)

      22. Ian Furst - Wait Times

        Fantasic post Rob,Hospitalist – FYI we use the exact same models as Rob. His plan works for specialist or generalist because he hasn’t instituted open-access for everything I think. Open-Access works if you have very low variability in appt types, chronic care isn’t needed and you can muster 30-50% additional personal to handle the variation in appointment need (compared to allowing waiting lists). Rob has a combo of block booking and open-access and that’s why it works well. BTW Rob — you’ve summed up pretty much every post of my blog in a single post — thanks a lot now I’ll have to take the blog down. Ian.

      23. Ian Furst - Wait Times

        Fantasic post Rob,Hospitalist – FYI we use the exact same models as Rob. His plan works for specialist or generalist because he hasn’t instituted open-access for everything I think. Open-Access works if you have very low variability in appt types, chronic care isn’t needed and you can muster 30-50% additional personal to handle the variation in appointment need (compared to allowing waiting lists). Rob has a combo of block booking and open-access and that’s why it works well. BTW Rob — you’ve summed up pretty much every post of my blog in a single post — thanks a lot now I’ll have to take the blog down. Ian.

      24. Rob

        I am glad I could ruin things.
        The funny thing is, despite the fact that this is our reality, some don’t believe me. My experience is entirely practical. Reading your blog, you have nothing to worry about.

        As far as appt types, the other thing we did was get rid of most of our appointment types. We have new peds, new adult, established peds, and established adults. That made things much easier and made the rest possible. It took some working with the EMR to make it happen.

      25. Rob

        I am glad I could ruin things.
        The funny thing is, despite the fact that this is our reality, some don’t believe me. My experience is entirely practical. Reading your blog, you have nothing to worry about.

        As far as appt types, the other thing we did was get rid of most of our appointment types. We have new peds, new adult, established peds, and established adults. That made things much easier and made the rest possible. It took some working with the EMR to make it happen.

      26. Sandy

        Hi Dr Rob, I’m from south asia and have no idea about the health care system in USA.I wanted to know how much a physician earns if he sees 25 pts per day. Is the pay any different from when you sees medicare pt vs young insured pt. Thanks in advance for the reply.

      27. Sandy

        Hi Dr Rob, I’m from south asia and have no idea about the health care system in USA.I wanted to know how much a physician earns if he sees 25 pts per day. Is the pay any different from when you sees medicare pt vs young insured pt. Thanks in advance for the reply.

      28. Rob

        The earnings vary widely, depending on: 1. The part of the US that the doctor works in – the reimbursement for even Medicare varies widely depend on this. 2. The payor mix – Medicare (for Seniors) and Medicaid (for the poor) pay much less than private insurance, and the insurance contracts vary from doctor to doctor. 3. The ages of the patients – pediatric patients pay differently (less in general) than older patients. 4. The complexity of the visits – 25 ear infections is different than 25 diabetic rechecks. You bill differently based on this.
        But, to answer your question, the average family doctor with an even mix of all of these in an average part of the country would earn from $120K-$140K seeing 25/day (that is my best guess). Perhaps that is a little high, but it is not far off.

      29. Rob

        The earnings vary widely, depending on: 1. The part of the US that the doctor works in – the reimbursement for even Medicare varies widely depend on this. 2. The payor mix – Medicare (for Seniors) and Medicaid (for the poor) pay much less than private insurance, and the insurance contracts vary from doctor to doctor. 3. The ages of the patients – pediatric patients pay differently (less in general) than older patients. 4. The complexity of the visits – 25 ear infections is different than 25 diabetic rechecks. You bill differently based on this.
        But, to answer your question, the average family doctor with an even mix of all of these in an average part of the country would earn from $120K-$140K seeing 25/day (that is my best guess). Perhaps that is a little high, but it is not far off.

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