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Curbside Consult with Dr. Jayne 11/4/13

November 4, 2013 Dr. Jayne 2 Comments

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For the last few weeks, my email box bas been filling up with lots of comments and feedback. I particularly like hearing from other CMIOs in the trenches who are sharing the same experiences. Let’s dip into the reader mailbag and see what’s buzzing with our readers.


Dear Dr. Jayne,

What do you think is going to happen when folks have those big deductibles because their Bronze or Silver insurance operates that way? Won’t the docs delay billing by months so they don’t have to chase the deductible, especially if it’s the professional fee associated with inpatient or ambulatory surgical care? It used to happen only in January, but could it become a year ‘round phenomenon? Or do you have other thoughts?

No Sleep Till Brooklyn

Dear Brooklyn,

I hope this doesn’t happen. To me, waiting to bill until you think a patient has met his or her deductible is kind of like playing Russian Roulette. If you wait too long you could run up against timely filing deadlines and miss out altogether. Plus there is no guarantee of when the patient will be meeting his or her deductible.

I’m hoping that this pressure will improve the quality of services offered by eligibility vendors and encourage more adjudication and subsequent collection at the point of care. For elective or semi-elective services, this should be fairly straightforward as long as providers know their contracts and are willing to ask for payment. At a minimum, they can collect the patient portion of the post-deductible allowance. Providers could also elect to go for a higher amount and refund it later, or go ahead and set up payment plans for high-dollar services.

It’s a little trickier with inpatient since it’s not always planned and emergency services will be even tougher. I think the best strategy is to go ahead and bill as you have been doing (preferably as soon as possible) and get the charges in the system. We bill daily in our organization although statements only go out monthly. For patients who see multiple providers, this will help those deductibles be met faster. It’s not going to change how fast patients pay their bills, however, so there will still be the need to collect up front as well as to chase the rest of the payment.

I think there is also the possibility of more medical credit cards and debt programs like those we used to see only in the cosmetic and dental realms. Some can be a good deal, especially those that are low interest, but there have been some abuses recently and patients will have to protect themselves from predatory lending.

Jayne


Dear Jayne,

I’m outraged at a recent blog post from Evan Grossman at Athena. He talks about retail clinics “following guidelines” more often than the actual doctors’ offices. I always wondered what it would look like when we have all this “data” to look at. I am convinced that what we are measuring now is actually what is easy to measure – the low-hanging fruit. What we do with that data is going to be important, but all this data interpreted in silos is going to cause more harm than good. Like Einstein said, “Not everything that counts can be counted and not everything that can be counted counts.”

In reality, many of my patients may only get to see me when they come in with a “cold” and get to talk about their prevention, cholesterol, and BP or weight and now even that is not happening as we have an even more fragmented system for the sake of convenience. I cannot give the flu shots to my patients, but I am supposed to report on it? I am merely reduced to treating train wrecks who could have had a chance at a conversation for prevention but they dismissed it because the Walgreens was closer and cheaper. Penny wise and pound-foolish.

The Thrill is Gone

Dear Thrill-less,

I share your disappointment with this simplified analysis and agree that right now we’re looking at the low-hanging fruit. We’re also looking at many factors that I’m not sure make a bit of difference in the long-term outcomes for patients – factors like wait time and patient satisfaction scores. We also can’t just look at retail clinics as low-cost providers – we have to look at total cost of care. We know that comprehensive care by a single primary care physician can be very cost effective. That’s one of the reasons behind the patient-centered medical home pushes we’re seeing and is also important for the accountable care movement.

We’ve figured out though that we can’t get enough primary care physicians to operate in the way they need them to for the reimbursements they receive, so we end up with multiple care providers and locations and hope interoperability can patch it all together. I understand that the PCP can’t do everything and we need interoperability to put together the hospitalizations, post-acute stays, home health, and other data, but adding the equivalent of multiple PCPs to the mix is not the answer. I’m not opposed to retail clinics. As a solo PCP for a number of years, it was impossible for me to be open 24×7 and I’d much rather see patients have a low-cost alternative to the ER.

In my state, nurse practitioners can only practice independently for certain types of conditions unless the patient sees the collaborating physician first, so it’s important to understand that retail clinics cannot take over everything a primary care physician provides. Incidentally, I ran my office in an open access paradigm where same day appointments were the norm, so during business hours, there was no need to go elsewhere. Patients appreciated that and it made my practice grow quickly.

If I could have staffed my office the way retail clinics staff — with a rotating cast of part-time nurse practitioners (which is largely what I see in my area) — I could have had a lot more access, but it wasn’t what the patients wanted. They wanted a single person to get to know them and take care of them. That doesn’t come cheap, though. It requires smaller patient panels, high-quality staff, and efficient systems (both technical and operational) to ensure quality care.

Check out this story about Illinois physician Russell Dohner, who has been seeing patients for $5 per visit for decades. He had the luxury of doing that because of a family farming business that helped pay the bills. He also sounds like he oozes altruism from every pore and pretty much sacrificed most of his personal life to caring for his patients. Residents of his town “would line up in his office and wait as long as they needed to see him” but he would often be working until 9 p.m. (as would the local pharmacy who always waited for him to let them know he was done seeing patients). That’s just not a reality with many people today who seem to be taking “me-me-me” to the extreme. Now that you can track facility wait times on Twitter and go wherever is quickest (or to whichever retail pharmacy offers you a 20 percent off coupon for non-drug items after your visit) why bother waiting for someone who wants to care for you until you die?

I’ve had patients complain when I ran late after sending a patient out of my office via ambulance. Really? I guess they figured that patient who just rolled past them on a gurney to the big yellow vehicle with the flashing lights triple parked outside the waiting room didn’t need extra time, or maybe the complainers are just narcissists. Medical care should be first and foremost about quality and caring, not cost and convenience. Being a member of the human race should also be about getting over one’s self and putting yourself in the other guy’s shoes from time to time.

I’m not saying physicians should habitually run late because that is disrespectful to patients, but people need to understand that if you don’t want cookie-cutter medicine, you might have to wait now and then. I’m not giving physicians a blank check for outrageous charges, either – but being able to collect enough payments on a visit to actually pay a health coach, a social worker, and a diabetic educator to work with me would be nice since I’m now expected to provide those services on top of normal patient care. It’s rare to get the same kind of long-haul care in a walk-in clinic with a rotating staff as you would in a true medical home. If nothing else, I would almost bet the midlevel providers at a retail clinic aren’t having sleepless nights about their patients nearly as often as the average family physician, internist, or pediatrician.

Jayne


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2 Responses to “Curbside Consult with Dr. Jayne 11/4/13”

  1. 1
    Evan Grossman Says:

    You both bring up some very valid points and I appreciate you taking time to read through my analyses.

    I share your concern about these issues, and respectfully point out that my intention is simply to share trends that we’ve identified; the key issue beyond that is to either learn from retail clinics or figure out how to harness what they’re good at for the benefit of each practice’s patients – patients who do find the cost of care very important. Retail and urgent care clinics are a growing part of the health care landscape, and we wanted to share some of the data that’s surfaced on our network. For instance, we selected adherence to protocol as one example of quality care. We acknowledge that there are numerous metrics that can signify quality care and all demand further discussion and tracking – same as any measurable activity.

    We all need to ensure that patient data flows smoothly across settings so that transitions of care are smoother. Regardless of the data we share, we believe in the best possible care in the best possible setting for the patient, regardless of where that is. In fact, in my upcoming post (this contribution has always been planned as two parts), I will address some of the ways retail clinics and traditional care providers can work to support and benefit one another. Doing so could deliver far greater overall value than treating new care delivery options as contradictory in purpose.

    I hope this helps explain my intentions with my post.

  2. 2
    Mobile Man Says:

    You mean you have to pay for healthcare services?

    One of my favorite takes ever (from HIStalk of course!):

    “…Imagine the cost of homeowner’s insurance if it covered every possible problem with appliances, appearance, and the lawn and business were created around collecting inflated payments for providing those services. Not only would policies be priced out of reach, services would become so expensive that you’d have to have insurance to afford them, causing prices to just keep going up to everybody’s benefit except the person needing the service…”

    http://histalk2.com/2012/07/03/news-7412/

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