Robert Gleeman: I wish you would start a new thread to explain HOW implementing EMR/PM enabled you to become a low-cost provider. Could you help us see the connection, how EMR helped this come about? Great post, by the way!
I wish you would start a new thread to explain HOW implementing EMR/PM enabled you to become a low-cost provider. Could you help us see the connection, how EMR helped this come about? Great post, by the way!
It worked for us because we started on day #1 with patient #1 with EMR/PM. Thus we didn't have to buy the charts/files/and filing cabinets. We've never had a chart-pulling employee. Most importantly, the space normally allocated to paper storage became an extra exam room - the only place we really make money. And Dragon Naturally Speaking means we have never paid for typing/transcription.
But the key is to start on day #1. If I had to convert 25,000 patient encounters, I would not do it.
Brendon: Dagmar, I cannot see how the 10% cut is good for anyone, however, as the access to PCP is extremely hard here in South Florida. Therefore, the cost is in the Health Care Providers not being available to those who need them because they are off becoming a specialist.
Dagmar, I cannot see how the 10% cut is good for anyone, however, as the access to PCP is extremely hard here in South Florida. Therefore, the cost is in the Health Care Providers not being available to those who need them because they are off becoming a specialist.
Hi Brendon,
You are indeed correct. And this post illustrates quite nicely one of the very big problems in our current health care system. For removing a simple skin lesion on that medicare patient, Dagmar makes several times what a primary care doc makes when seeing that same patient for their 8 medical problems, prescribing their 12 meds, reviewing their labs, getting them DME supplies, getting the CT approved, the referral to a specialist, fill out the handicapped license plate form, FMLE paperwork for their kids, etc. The patients visit to Dagmars office takes 15 minutes and has very little risk associated with it. The patients visit to the primary care doc may take an hour of the doctors and staff time or more, and has a very high risk associated with it. That does not include all the phone stuff that is supposedly included in the office visit fee. Yet Dagmar makes a lot more for the visit to his office than the primary care doc does. A 10% cut for most specialists doesn't mean a whole lot in the scheme of things, but that same cut can be devastating to a primary care doc operating on thin margins to begin with. It doesn't take a genius to figure out why doctors don't want to go into primary care anymore.
By the way, nothing against Dagmar at all. He is just being practical and smart. He is merely following the system as it is set up. I just used him as an example because he made the post. The bottom line is as a country we will get the type of healthcare that we incentivize. And that is procedures, and sick care. The government and insurers can talk all they want about the importance of primary care and preventative medicine, etc. but the reality is it is only lip service the way our current system is set up. Actions speak a lot louder than words. We are currently witnessing the demise of primary care medicine as we know it. It is being dismantled piece by piece by the very entities that talk about how important it is. I'm afraid if we continue down this road we will soon be past the point of no return.
I know this is off topic but the nature of the post struck a nerve. Ok, now I'll get back to how crappy todays EMR UI's are.
Regards,RoyF
The posts on this I have made over at the blog have probably been the heaviest hit stories since I started the site. I have even had a few doctors take time out and write to appreciate the posting and bringing it to the forefront.
What surprised me a bit more was the fact that Reuters picked up this one (link below) with my quip about what the insurance companies are doing, complete with the flag. I thought I was a bit out there on this one for it to be posted, but they went with it.
http://www.reuters.com/article/blogBurst/politics?bbPostId=BAfMYODD5A1mB4i22hiR9pHlBDMGSROJ4qqnBBEGFZ4LS7Be
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There are so many questionable ideas floating around on this thread, that I do not know where to begin. Everyone is entitled to his or her own opinion, but there appears to be a lot of short sightedness in some of them. The biggest is of course RoyF’s comment, “A 10% cut for most specialists doesn't mean a whole lot in the scheme of things, but that same cut can be devastating to a primary care doc operating on thin margins to begin with. It doesn't take a genius to figure out why doctors don't want to go into primary care anymore.”
RoyF is the kind of doc the bureaucrats like to hear from. The perfect person to work the age old divide and conquer scheme. Little does he realize that we are all in this together. Just as Dagmar can handle skin lesions, specialists can also handle the easy PCP stuff. We all trained as physicians and specialists cannot absorb a 10% cut. You may not remember that in the past, specialist procedures were cut to increase PCP rates and we both were losers. You base your opinion on one procedure. Maybe that one procedure can stand a 10% cut, or maybe that procedure is over performed. Who knows? This cannot be said for the thousands of other procedures when specialists like myself are no longer willing to perform these procedures at such low rates. RoyF have you ever paid $50K-120K for malpractice insurance?
How about this statement, “Simple. Medicare patients, since they are older, require more biopsies and skin cancer surgeries than a typical younger patient.” “I would love to have 90% Medicare patients on my schedule. Even at reduced rates.” What an argument for lower reimbursements. You take a group of people the require more and want to pay less. They are slower to move, slower to understand and have more issues for the same 99213. 10% is across the board.
The system needs improving, not further destruction.
Contrarian: Everyone is entitled to his or her own opinion, but there appears to be a lot of short sightedness in some of them. The biggest is of course RoyF’s comment, “A 10% cut for most specialists doesn't mean a whole lot in the scheme of things, but that same cut can be devastating to a primary care doc operating on thin margins to begin with. It doesn't take a genius to figure out why doctors don't want to go into primary care anymore.” .....specialists cannot absorb a 10% cut.
Everyone is entitled to his or her own opinion, but there appears to be a lot of short sightedness in some of them. The biggest is of course RoyF’s comment, “A 10% cut for most specialists doesn't mean a whole lot in the scheme of things, but that same cut can be devastating to a primary care doc operating on thin margins to begin with. It doesn't take a genius to figure out why doctors don't want to go into primary care anymore.”
.....specialists cannot absorb a 10% cut.
Contrarian,
You couldn't have misunderstood my comments more if you tried. Or perhaps you didn't read the entire thread to understand their context? My comment above was a response to dagmars post where he said:
"The Medicare cuts will probably be beneficial for this practice. Maybe the situation is different for dermatologists. I would love to have 90% Medicare patients on my schedule. Even at reduced rates."
dagmar is obviously a dermatologist and his post says that not only didn't the 10% cut bother him, it might turn out to benefit him. No where did I say I agreed with the cuts or felt that specialists should be cut and not primary care docs. What I said was that of the 2 groups specialists would be able to withstand a cut better than primary care docs. This is just simple math. If 1 group of people make twice as much as another group, you tell me who the cut will effect more? Again, I'm not saying I agree with a cut for anyone but given that the cut happened I don't think it's very difficult to see who it is going to be more painful for.
What I also said is that dagmars post illustrates quite nicely one of the very big problems in our current health care system. Our current system is set up to incentivize procedures and sick care. Primary care medicine is grossly undervalued and underpaid relative to other specialties. And that is a big reason why doctors don't want to go into primary care anymore. What about that is so "short sighted"? Once again, I think the cut stinks for everyone, but I also believe it is one more nail in the coffin of primary care medicine in this country.
Contrarian: Just as Dagmar can handle skin lesions, specialists can also handle the easy PCP stuff. You take a group of people the require more and want to pay less. They are slower to move, slower to understand and have more issues for the same 99213.
Just as Dagmar can handle skin lesions, specialists can also handle the easy PCP stuff.
You take a group of people the require more and want to pay less. They are slower to move, slower to understand and have more issues for the same 99213.
Once again I think you are misinterpreting this. Dagmar is a dermatologist. Of course he can handle skin lesions. His point is that he wants to handle more of them, in spite of the medicare cuts. My point is exactly as you say above about the group of people that require more and want to pay less, and that they have more issues for the same 99213. And once again I think that is illustrative of the unsustainable mess that our health insurance system has become.
Contrarian: .....specialists can also handle the easy PCP stuff. We all trained as physicians.... You base your opinion on one procedure. This cannot be said for the thousands of other procedures when specialists like myself are no longer willing to perform these procedures at such low rates. RoyF have you ever paid $50K-120K for malpractice insurance?
.....specialists can also handle the easy PCP stuff.
We all trained as physicians.... You base your opinion on one procedure. This cannot be said for the thousands of other procedures when specialists like myself are no longer willing to perform these procedures at such low rates.
RoyF have you ever paid $50K-120K for malpractice insurance?
Oh please... give me a break. While what you say is technically true, I don't know many specialists that want to "handle the easy PCP stuff". For the most part they want to avoid it like the plague. As a matter of fact, unless they are in an area saturated with their specialty and are hurting for business, the last thing they seem to want to do is any "PCP stuff". And I can't blame them a bit. Why would they want to take on additional risk and assume a large downside with very little upside?
If there are procedures that are reimbursed so low that you don't want to do them anymore, then don't. One of the reasons we are in the mess we are in today, is because physicians allowed it to happen. And I put myself squarely in the crosshairs of that criticism along with every other doctor out there. Rather than put our foot down and say enough is enough, we allowed ourselves to be bullied, coerced, and cajoled into accepting the insurers agenda on their terms. They have already played the "divide and conquer scheme" as you say and have been very successful with it.
We have willingly abdicated our power and have become reduced to arguing amongst ourselves and begging for tablescraps, while insurance company executives take home millions in bonuses. We will be so happy just to find some way to avoid this cut, that we lose sight of the fact that there hasn't been any meaningful increase in years. Ultimately this isn't about me or you, or specialists or primary care docs, it's about the commoditization of american medicine. And that is bad for doctors, patients, and everyone involved except the corporations and big government who control the game.
And no I have never paid $50K-120K for malpractice insurance. I think that is an absolute crime, but it really has nothing to do with this discussion.
Contrarian: The system needs improving, not further destruction.
I don't know that it is even possible to improve the system in any meaningful way at this point. It is so dysfunctional that it may be like putting a bandaid on a spurting artery. Our system of health insurance is fast becoming like a gangrenous appendage. There comes a point where if you don't remove it, the person dies. Contrarian, we are all in this together. It does no one any good to bicker over who deserves a pay cut and who doesn't. Obviously no one does, and I sincerely hope that you don't take my comments to mean that I believe one group should be cut over another. This current pay cut is just one symptom of a far greater problem.
From the blog...TV ads on the way...sounds like from both sides...
It has taken a while to boil, but the revolution is slowly starting with not only the AMA wanting answers, but all the citizens of the US, we do need a new plan. Related Articles below from recent posts. BD
http://ducknetweb.blogspot.com/2008/06/senate-democrats-attack-republicans-on.html
http://ducknetweb.blogspot.com/2008/06/where-money-isn-family-practice.html
http://ducknetweb.blogspot.com/2008/06/temporary-halt-to-medicare.html
http://ducknetweb.blogspot.com/2008/06/american-medical-association-outraged.html
http://ducknetweb.blogspot.com/2008/06/new-medicare-bill-fails-in-senate.html
The American Medical Association and America’s Health Insurance Plans — the big groups representing doctors and insurers, respectively — are both rolling out TV ads this week in the fight over Medicare.
What surprised me a bit more was the fact that Reuters picked up this one
Be careful Barbara: they might pick you up one of these days and take you to UK.
RoyF
Clarification appreciated.
I can't comment much about specialty issues but I can comment about primary care. I don't think primary care will go away but I think we will see a change in who is doing it and where it occurs. For example, nurse practitioners are positioning themselves nicely to assume the role of PCP. It very well may be that a common scenario is that there are 2-3 NPs working with 1 MD. Also, the retail clinincs appear to be well positioned due to their excellent access and ability to handle common medical problems.
The primary care workforce issue is only going to become more apparent as we enter the era of chronic care management. chronic care clearly takes more time and with a smaller workforce the problems become obvious.
I do not expect to see a dramatic close in the divide between primary care and specialty salaries. Taht's not to say that the medical home is anot a good idea and the money eventually associated with it will be signifiant.
To me the answer is to become good at managing people and learning how to best run a medical office that can handle large volumes of people without sacrificing care and service. That allows me to work with several NPs and to do a good job for my patients.
Lowell
Lowell Kleinman, MD www.drkleinman.com www.old-fashionedhousecalls.com
Brendon that is an awesome deal!
I was happy to find out that my local burger chain store did not raise their prices despite the cost of gasoline, meat, crops etc. When I received my favorite philly steak burger I noticed the meat was smaller and lighter as is the bread and cheese. I figure it is healthier.
My threshold will be 50% pay cut from hereon forward (2008), after that it may not be viable (i.e 51% and above cut). Will need to trim the services I offer after hours, will turn off faxed preauthorization and will need to see all med clarifications from every insurance. No more phone consults, call ins etc. No more samples, or what my associate calls, cost sharing. it is also our time keeping an open concept for med reps so we can get volumes of samples. We give almost 6 months of samples and I estimate that samples cost more than a million a year.
Use Physician extenders, technology with EMR, patient portals, education via web media etc., to allow volume. Assembly line medicine.
Meanwhile the appropriate medical organizations and individual primary care physicians have to educate the public that in a "cognitive" field, accuracy of diagnosis requires a reliable history (75 to 85%). History and evaluation = more time spent. I wonder if more expenses will result, to compensate less time spent with patient by ordering more tests.
Rogerven: I wonder if more expenses will result, to compensate less time spent with patient by ordering more tests.
I wonder if more expenses will result, to compensate less time spent with patient by ordering more tests.
I believe this happens. I think it is worse here because the tests are free.
Interesting, but when I was a resident at a VA system, I was laughed at when I practiced defensive medicine, doing more tests. they told me no one sues as nobody can win suing the government.
I think the nurses are going one step beyond - the 'doctor of nursing degree'.Why work with a doctor when you can practice independently. I really don't think the public cares and the insurers will be glad to get a weaker class of primary care provider that will be even more pliant to their plans.
Other options would be to:
I didn't know about the 2 year wait to re-enroll. That could be a problem!
Al Borges, M.D.
● Oncologist in a Small Group Practice in Virginia
● My website URL: http://msofficeemrproject.com/
gratch6: I think the nurses are going one step beyond - the 'doctor of nursing degree'.Why work with a doctor when you can practice independently.
I think the nurses are going one step beyond - the 'doctor of nursing degree'.Why work with a doctor when you can practice independently.
I agree. I have spoken to a few at various meetings, in a non-doctor capacity, and many absolutely want autonomy and to throw off their physician overseers.
Another possiblity - The Medical Home with doctor 'middle managers' coordinating the care of physician extenders is a possible future. Maybe doctors can carve out a niche - specializing in "chronic care" within the medical home. Maybe. Otherwise, I suspect the CNPs will take over all of primary care. They might also become the 'procedurists of the future with physician specialists referring patients for colonoscopies and the like. If we do not avail ourselves of technology (EMR) to bring our standards into the 21st century, you can bet that other entities will - and doctors will be perceived as part of the problem rather than part of the solution.
Disclaimer: I am the founder of e-MDs. Highest rated by doctors. All posts are opinion only