Curbside Consult with Dr. Jayne 11/28/16

It was a busy holiday weekend for me, with several days of patient care. I saw several extended families with a “stomach bug” that was more likely to be food-borne illness. It’s never fun to suggest that Aunt Tillie’s cooking make everyone sick, but it does happen. At one point, we had so many patients receiving IV fluids that we had to call for more supplies to be sent from another location.

Although I think I won the prize for fluid administration, several other locations broke records for the number of patients seen in a single day. Not every patient was in need of such urgent attention, though. Dozens had conditions that could have waited or didn’t need to be seen at all. I’ll have fun analyzing the statistics once we complete our month-end close, but the potential root causes are interesting.

Over the last several years, we’ve seen greater patient empowerment, which is generally a good thing, especially when you’re talking about shared decision-making and improved health through greater patient involvement. But it’s less of a good thing when patient empowerment loses the “patient” piece and becomes more of an exercise in instant gratification.

To be clear, I’m not talking about patients with urgent medical needs, such as shortness of breath, chest pain, lacerations needing stitches, strep throat, etc. I’m talking about the folks who have had a cough for one day, who haven’t tried any over-the-counter remedies, and who expect the physician to work magic and get mad when we don’t have much to offer.

We had one patient come in as we were closing on Friday who stated that she was “miserable” with her symptoms, yet she came in at closing time because she was too busy with her Black Friday shopping to be seen earlier. Even her $50 co-pay wasn’t a deterrent. She could have called the after-hours line at her primary care office and received the same advice that I gave her, which was to treat the symptoms using over- the-counter remedies since it was most likely a viral infection. She ended up being upset with my treatment plan and demanded an antibiotic, which I refused to give her. I’m sure she’s going to call our administrators and complain.

I used to become more aggravated at situations like that, but they’ve unfortunately become par for the course. When my administrators look at the overtime that was paid out handling her care, I’m sure they’ll be a bit less sympathetic to her complaints.

I also had several patients who were there because they were worried about symptoms they did not yet have. One was a college student planning worried about getting sick before finals, because she had been having a runny nose for a few hours. Her mother was more concerned about “what could possibly be causing those dark circles under her eyes?” than listening to my discussion of needing plenty of rest, plenty of fluids, and some over-the-counter medication from Target. I recommended that she obtain a flu vaccine when she gets back to school on Monday (we have already exhausted our supply) and she stated that she refuses to go to the student health service because they didn’t have “real doctors” there. Her mother heartily agreed. I knew at that point there was no reasoning with them.

Some of these situations are the unforeseen consequences of shifting healthcare policy. My practice is big on price transparency. That’s part of our marketing since we’re significantly more affordable than the local hospital emergency departments. We’re not cheap, though – self-pay physician visits are right around $100 with testing and treatment on top of that.

Patients paying out of pocket tend to have better judgment when deciding to come in, and most of them have conditions that legitimately need a prescription treatment or other intervention. The majority of patients who don’t really need to be there have insurance and are somewhat insulated from the real cost of care. Even those with high-deductible plans tend to come to care a little more frequently than I’d expect, knowing that the charges will be billed through to insurance first so there isn’t a direct correlation between care and payment.

My dad recently found some old physician office fee tickets from the 1970s that made for interesting reading. I remember going to those physician offices. They didn’t have big billing staffs or revenue cycle management agreements or contracts experts or any of that overhead. They had a physician, a nurse or assistant, and a receptionist who also collected the payments at the time of service. Even adjusting for the wages of the day, the charges were reasonable.

I look at my practice (which is right at MGMA benchmarks) and see how many people are supporting me from a revenue cycle standpoint compared to how many are actually helping me deliver patient care and it’s disheartening. We have so many layers between the patient and the payment that are contributing to costs, and yet no one seems intent on reforming the insurance industry or their extreme profits. Back when I ran my own practice, I once calculated that the costs of managing the payer-related workflows in my practice (charge entry, payment posting, working denials, collections, office management functions related to those workflows, etc.) were nearly 30 percent of my overhead.

People are working hard in the realm of healthcare technology to streamline those processes and make them efficient as possible. The practice management system I use now leaves the one I had in 2005 in the dust and it’s significantly easier to use as well. We’re automating ways to get the most out of the healthcare system, but the underlying problems aren’t getting much better. In some ways they’re becoming more complex, as we now have to manage prospective payments, capitated payments, fee-for-service, increased patient-pay amounts, and other arrangements.

I recently watched a practice spend nearly $100,000 in staff and consulting hours on a project to address write-offs and refunds largely related to inefficiencies in payer processes. I guarantee that practice had more patient-centric priorities they could have spent that money on, but they were hemorrhaging money with their previous process and needed to fix things so they could move forward.

Even with our major shifts in healthcare policy, it often doesn’t deal with some areas of urgent need. I saw one patient who was actively delusional, yet had nothing to offer her because she wasn’t a danger to herself or others. Mental health services are so strapped in our community that unless you meet the latter criteria, it may take months to see someone. I spent nearly an hour trying to come up with a plan for her, which ended up being pretty pathetic compared to the care she really needed. But at least I was able to refer her electronically and with an associated C-CDA so when she does finally have an appointment, the receiving care team will have my data.

My next few patient care shifts are in non-holiday, non-weekend time blocks, so maybe I’ll see more typical urgent care cases that will help reset my psychology around the work I do and how it plays into the grand scheme of things from a healthcare reform standpoint. In the mean time, I’ve got some last minute HIPAA-related security risk assessments to work through for consulting clients that like to wait until the last minute to get things done. After that, I’ll start helping clients get ready for end-of-year data gathering and preparing their attestations for various payer programs as 2016 winds to a close. The end of the year used to be a slow time, but no more.

What’s your busiest time of the year? Email me.

Email Dr. Jayne.