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Curbside Consult with Dr. Jayne 2/2/15

February 2, 2015 Dr. Jayne 1 Comment

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Although I still haven’t answered the "should I stay or should I go" question regarding my day job, I did make a decision to leave the practice where I’m currently providing urgent care services. I haven’t resigned yet since there’s enough strangeness that I want to have my final paycheck in hand before I do.

I didn’t really pay attention to the calendar when I sent my available days for this month, so I’m spending Super Bowl Sunday seeing patients. So far, sinusitis is leading otitis media 13 to 2 going into halftime, where we expect a rousing performance by indie rock band Motor Vehicle Accident.

I’m certainly not a job hopper. Prior to this job, I had been with the same emergency and urgent care staffing company for nearly six years. They had a huge portfolio of customers, which allowed me to experience quite a few different care settings and a variety of different inpatient and outpatient EHR systems, health information exchanges, and more. 

Last year, they lost their contracts with most of the facilities in my area when another staffing company underbid them. I’m not sure the facilities were aware that all the part-time and as-needed physician providers were going to be replaced with non-physicians, but they should have seen it coming based on the pricing model. Along with more than a dozen other part-timers, I was let go.

I didn’t see patients for a couple of months while I evaluated my options. Eventually I received a call from a recruiter which led me to this opportunity — an independently-owned urgent care with two locations. The facilities are recently renovated, the drive was reasonable, and the pay was in my range, so I gave it a shot.

The only downside was their lack of EHR. For some, that might be a bonus — the learning curve for charting is certainly very small. But for someone who is used to the safety features of an EHR (allergy and interaction checking, pediatric dosage calculation, etc.) it was a little rough. I dabbled with a freestanding eRx system for a while, but the dual data entry was a bear.

My employer is certainly nice enough, but he’s suffering from the same things that are impacting most small practices. They don’t run themselves. Without a dedicated physician leader or a hands-on management style, it’s easy to start a death spiral with staff unhappiness, turnover, patient unhappiness, and ultimately physician unhappiness. All of these conditions contribute to a negative impact on the bottom line, as does his obsession with the salt water aquarium in the waiting room.

He tends to manage from afar, yet micromanages at times. Policies and procedures are lacking, but he shows up unpredictably and criticizes how work is being done. Poor performance is not addressed and high performers are not rewarded. The staff is relatively young, and without consistent leadership or supervision, they tend to fall into the behaviors that college-age people do. Smartphone use is rampant, which not only hampers productivity, but leads to some interesting conversations that patients overhear. Staff regularly shows up either at the exact time the office is supposed to open or even after and management doesn’t seem willing to address it for fear of losing people.

Although I can put up with a fair amount of chaos, I recently figured out that there were some significant irregularities in my onboarding. Apparently I’m not fully credentialed with most payers (not even Medicare / Medicaid), which is surprising for the length of time I’ve been here. That’s a red flag right there. The next red flag was when he emailed me to let me know there was an error on my 1099 tax form and I’d have to handle it on my own. Running a practice, or any small business for that matter, is not for the faint of heart or those without education, experience, or solid advisors.

Before making the decision to leave, I put myself in his shoes and considered whether there was anything he could offer to make me stay. He’s not going to run out and implement an EHR tomorrow, so the patient safety issue remains. It’s also an efficiency issue (although a bad EHR would certainly be worse than handwriting on pre-printed paper templates). Then there’s the clinical quality issue. I have no way of sending copies of our notes to primary care physicians unless I personally fax them since there is no system in place unless there is a specific request for release of information. The primary care practices in the area have yet to embrace the patient-centered medical home model. Few of them are open outside the hours of 9 a.m. and 4 p.m. and I can’t name any that have evening or weekend hours, so we’re essentially the safety net. We don’t have access to the local HIE or the state immunization registry, so we’re actively contributing to the fragmentation of care.

I don’t see him hiring a strong office lead or spending more time at the practice himself, so the staff will continue to be relatively undisciplined. The owner isn’t clinical and there’s not a named medical director, so I don’t see any expansion of policies or procedure that could help bring things into line. Strangely enough, he’s opening a third location in a fairly dangerous part of town without commitment by providers or staff that they’re willing to work there. I’m sure that will further dilute his ability to manage the practice effectively and might make staff turnover even more of an issue than it already is.

Although I don’t see him embracing new technology like the HIE or immunization registry web portals, I also don’t see him abandoning some of the problematic technology we already have. The computer-assisted coding system is a concern since it codes the visits after documentation is complete and providers don’t have a chance to confirm or correct the E&M codes before they’re released to the practice management system. Although most of my coding has been consistent with what I would have manually coded, it’s just another red flag.

On one hand I feel bad leaving because the patients are genuinely appreciative and certainly need physicians who understand their needs. But on the other hand, knowing what’s at stake from a regulatory standpoint and that I could wind up personally liable for any creative coding or billing that is occurring, I can’t afford to stay. 

I’ve got a new clinical endeavor lined up, one where they’ll ensure I’m fully credentialed before I see patients and where an EHR is already in place. They’re using a system I’ve never worked with, so I am looking forward to the new challenge. If nothing else, learning a brand new system will surely make for some good stories.

What makes a new employee run shrieking? Email me.

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Currently there is "1 comment" on this Article:

  1. Good luck, Dr. Jayne! And thanks for your ongoing clear assessments of the current state “real world” of healthcare.







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