Home Forums Discussions General Discussion When do I stop taking new patients?

Hello fellow ACers. I need some very important help from my friends here on the boards.

As you know, I do computers for a living and am a solo pediatrician on the side. Just joking, I am a full time pediatrician. I opened my practice in December of 2006. I have today exactly 1500 active patients 50% Medicaid, 50% private insurance/self pay. We are seeing 25 to 35 patients a day which is all I want to see. We are solvent.

It is a bit confusing because a local pediatric office recently closed which had over 2,000 patients. As I worked there for six years, many of them are coming over. We have received 300 new patients in two weeks.

In the 11 years I have been here in the area, I have never said I don't take new patients, so it is new territory to me.

When do I say I don't take new medicaid? When do I say I don't take new private or both?

Thanks.

Hey, Bert --

Stop taking new Medicaid yesterday. In the future, as established Medicaid patients leave your practice, replace them with insured patients.

Medicaid patients take the same amount of time and often more, due to a combination of socio-economic factors and increased government red tape. Replacing them with insured patients gives you an instant pay raise without increasing your work hours.

Closing the practice is a tougher issue -- it can have unintended consequences. There is also a difference between the number of patient files you possess vs. the number of true active patients. There was an excellent article on this topic in FPM magazine last year:

http://www.aafp.org/fpm/20070400/44pane.html

HTH.

Excellent advice. I would love to hear more comments on the Medicaid issue based on what Brian writes and the following observations.

First, I wouldn't have been successful in my first year and a half without Mainecare patients as frustrating as the red tape and decreased reimbusement can be. Second, I always feel somewhat indebted to all patients even if the government doesn't seem to want to help in that regard. And, third, and more practical, if I can see 25 patients comfortably and I only see 20 patients per day because of not enough patient visits, then the Mainecare can only be more profitable.

I have always believed that Medicaid was a practice builder and a social obligation. The folks at Medicaid were able to persuade me otherwise over time. In California the Medicaid program, called Medi-Cal is administered by one medical group/IPA entity for the entire county. The intent is too direct all of the patients into managed care and stop them from using the Emergency Rooms as the after hours clinic. At the same time we have "must treat" legislation that completely bypasses all of these efforts. The result is penalties for the physician whose patients use the ER inappropriately, but no penalties for the patient. In spite of all that I am not completely insensitive to the issues here. Many of these patients have desperate needs, and no transportation, especially in Los Angeles. They must wait until a family member or neighbor comes home from work in order to get a ride, and this is usually after your office hours. But none of this stopped me from seeing Medi-Cal.
Several times a year they will send inspectors to our office to do a site inspection. I am really proud of the look and layout of our office. But they are the only one that has to come and inspect our office to see if we are good enough to see their patients. A few years ago we failed the inspection because we didn't have an employee first aid kit. Normally my office manager keeps me well insulated from these delightful little interludes in an otherwise busy and productive workday, but on this occasion I happened to be standing nearby when I heard the inspector ask to see our first aid kit. The office manager said, "OK we will get one" and I said whoa, hold on a minute. This entire office is a first aid kit. Or if need be, pick any of the eight exam rooms, they are all equipped better than any first aid kit. Or if you need a kit that you can take to the patient we can go look at the crash cart again, and I will even charge the paddles for you! Nope Nope and Nope again. After some heated debate the practical solution was to spend twenty dollars and buy a little plastic first aid kit with bandaids and not much else that can be fastened on the wall so the inspectors can check a box on the form.
But even that was not enough. The "final solution" came to me when they were here again telling us what is wrong with our office. We have a refrigerator for all the vaccines and biologicals (as opposed to the specimen refrigerator or the ones for our lunches) and it has a number of things to make it safe for the vaccines. It has a number of bottles of water in the frige and bottles of ice in the freezer to hold it over in the event of a power failure and it has a number of thermometers and we keep a log and pay an employee to log the temperature every morning so that the inspectors will have some more forms to sort through when they stop in for coffee and a chat. So on our last inspection they told us we were doing a brilliant job, "BUT" they just felt we needed to log the temperature TWICE a day because the temperature might not be maintained in such a busy practice as we opened the door too often throughout the door. My response was that we did not need to record the temperature twice a day, because we no longer take Medi-Cal. It took quite a while for the inspector to get the drift, she kept insisting that I had to log this twice a day, I was equally insistent that I did not need to log it twice a day, because I no longer needed to pass her inspection.
What annoyed me the most is that the really busy practice, where the door is open so much, will surely be too busy to record the number when it is busy. They will simply fill in the logs when the Doctor is out of the office and things slow down. The presence of bureaucracy DOES NOT assure quality. Any way we are done with Medi-Cal, I have finished my RANT and I feel much better now. Thank you!!

PS, Paul did not help me edit that post!

There are several issues. I, like Bert am both a Pediatrician and take a high amount of Public Aid. I have seen lots of referrals come when other offices either stop taking Public Aid or close.
Overall, I take it with the flow, but currently my NP is going on maternity leave, so... I have chosen to close the practice to new patients until she returns.

Bert, the majority of patients will find a new doc in the next 6 months, most need school PEs now and the issue will be different very soon. Those that chose not to follow you when you left the other practice have no loyalty to you, but you are a known quantity. Thus, I would recommend ONLY take new patients who are either newborns, relatives of current patients or exceptions that you choose. In six months, you can open the practice back up. You could limit it to no medicaid, this may have the same effect, but you may find that temporarily closing the practice may give you some breathing room.

My philosophy on closing the practice to new patients is not to. However, you can delay when they enter your practice (i.e. Dr B does not have a new patient appointment until December). If someone really wants to see you they will. Otherwise they will seek care elsewhere. When I did this I essentially stopped getting new patients for a few months. However, I had no choice since I was getting overwhelmed and could not service what I had (and subsequently lost some patients). Now I have a certain number of new slots each month to replace what I may lose (either through death, move, or dissatisfaction).

I would recommend trying to reduce your percentage of patients on MaineCare. I was like Martin and took Medicaid (called AHCCCS in Arizona) for the first several years (5) of my practice life. However, dropping those plans (there are 5 in my region) reduced the stress on my staff and the administrative burden, and I did not notice much of a drop in my income except for the first 1-2 months. It is a sad commentary that treating the indigent has to be such a hassle yet bureacracy has a way of doing that.

With regards to feeling indebted to patients, a good physician friend of mine once observed about a third of your patients love you, a third hate you, and a third are indifferent to you, and you'll never know who's who (though you think you may). (My friend by the way has one of the best bedside manners you'll ever see in a physician). So while many of us entered medicine to help humanity, the cold hard facts of practice life are you have to make business decisions on what is in the best interests of your practice and the type of lifestyle you want.

I hope this helps. Best of luck.

Martin, Wendell and Scott,

Thanks very much for your insight. Some of your advice is remarkably similar to others I have received. It is true that actually "closing" your practice can get around and make it more difficult to "open" when necessary. But, stating you are taking new patients but do not have any openings until....such and such....can be a way around that.

I have fought with the local, regional and national government about the FQHC across town who is seen for an ear infection on Monday, and they are reimbursed extremely well. The same patient, upset with seeing five different providers at five different visits, then transfers to me. I see the same ear infection and receive much less than the FQHC. That in and of itself, makes the Mainecare issue tough to swallow.

Not to mention that Mainecare patients receive their second Varivax, their TDap, RotaTeq, Menactra and Gardasil series at no cost while my private and self pay patients must purchase it themselves at the local pharmacy.

Bert, Good luck on coming to some peace about closing to new patients. Sounds like you really have your hands full with your full time job and your doctoring, LOL. I will be waiting to hear about everyone's experiences. It's so neat that folks are so willing to share.

FQHCs receive a flat reimbursement of $115 per patient. The max allowable for a 99213 from MoHealth Net is $32 and EPSDT garners a whopping $20.

Doc Martin-loved your approach to dealing with idiocy of the bureacracy. Sounds like one of those moments that we all wish we had the courage to step up and do what you did.

Ditch the Mainecaid now! Do as adviced above replace cheap paying plans and patients with better paying commercial ones, and the ones with the least amount of red tape and prior auths. Time wasted by you and staff on such things is also lost money.

We are starting to look thru our contracts and see who gets the "boot" next plan wise. It is so empowering to call these folks up and tell them "you simply don't pay my wife what she is worth so we are leaving" and then watch them start falling all over themselves to bump your fee schedule and try and keep you on board. Even the evil UHC, who is not very big in our area is trying to appease us...

So if you are full or close to it, start cutting out the worst payors and the bigest pains, and give your self a raise and a break all at the same time... Heck some of those same patients may even choose to stay on. Some of ours have...

Paul

Paul, that raises an interesting possibility. I think most plans have some room to negotiate. So should you start with the worst? If they offer 10% more would you keep them? Negotiate with the middle of the pack. Tell them you are going to cut out your three worst payors, (or whatever). They know that they are not paying the highest rate. If they offer a little more, take it! Then move to the next on your list. You probably will still can the same ones, but you might get a raise on some of the others. Good luck!

Bert,

Just another side. Several years ago when I grew tired of bowing to the excessive needs of most Medicaid patients I tried delaying any new appointments as ScottM suggested. Funny though how patients heard from other patients who did not have Medicaid that we made them an appointment for that week or that day! So, I got double calls from angry want-to-be-patients asking why we could not see them for 2 months. It is simply easier to say we are not accepting any new Medicaid patients. As the ones I have move or die or get ticked that I won't refill their pain meds or write them a script for Tylenol and go elsewhere I have over the last few years eliminated all but one Medicaid patient. I have also started this with United Health Care and Aetna. I chose not to boot out the ones I have but won't accept new ones. When a prospective patient asks why, I am very happy to tell them their insurance does not compensate fairly and/or is a pain in the jackass to deal with. Most of the primary care doc here in my market are not taking any UHC and booted the ones they had. Perhaps the Human Resources Directors will stand up and take notice when their employees cannot find a doctor taking their insurance. Well, we can dream, can't we?

Leslie

Thanks everyone. Leslie I was waiting for you to weigh in as I know you have a lot of experience with this. Not that the others don't.

I have been out of commission on the boards for a bit with some major computer problems. No lost data. Just all of a sudden my server decided not to talk to my clients. So, then my client workstations got passive aggressive and decided they wouldn't ping the server. 103 comments on Experts-Exchange later, and they still aren't talking. Very stubborn these computers.

In the normal world when I accept any patient with any insurance, I have no idea what the patient will be like until a few dealings with them. Well, not usually. But, with the transfers, it is a different matter. I see some patients come in that I had long since forgotten and go, "Oh, geez, I should have stopped taking patients." I guess it's a good place to be. A year ago, I was very worried about the bottom line. Now....

We have had two docs either retire or die here in the last few months. My staff has been instructed to ask the following questions when patients call wanting to transfer records to me:
1. What kind of insurance do you have?
2. How old are you? (If they are under 65 and on Medicare, that is often a bad sign...disability issues, pain meds, etc.)
3. Have you ever been a patient of Dr. Strouse's before? If so, why did you change doctors? (I will not accept a patient back who transferred records for reasons other than they moved out of town and then came back or their insurance changed and I did not accept it. I do take it personally. Once a patient leaves me they are generally gone forever. I was at the grocery the other day and ran into a former patient who transferred records because I no longer go to the hospital. She was one that I had gone out of my way numerous times for through the years. She made a bee-line towards me when she saw me and I knew what was coming. She told me how she really did not like her new doctor and that their office was so inefficient and would I take her back? "Gee, I am really sorry to hear that but I do not think re-establishing our relationship would be in your best interest as I do take offense to patients who do not feel a loyalty to me when I have tried very hard for many years to see to their medical and often personal needs").
4. Do any of your relatives see Dr. Strouse? Some families are genetically programmed to be difficult patients.

From these 4 questions we can glean a lot of information. Although my practice is not completely closed, at this stage of my game I am in a position to be a little more selective in the kinds of patients I want in my practice. I would just as soon sit and twiddle my thumbs and not get paid as to have a practice full of patients whose insurance does not pay.

Leslie

Leslie,
Thanks so much for your thoughts. I am being deluged by patients right now and we need some way to sort things out.
Really appreciate you and the other folks who are so generous with their time and support. This community is just amazing!!
Thanks vr

I have never in my 14 years of being a practioner heard anything more lovely and closer to my heart than that. Thank you, Leslie, for sayng that. I am crushed beyond belief when a patient leaves, and it hurts. I don't think they have any idea. I basically have three rules for taking a patient back. 1) They left to go out of town, 2) they left because of insurance reasons, I have even been known to treat them for free or for a lobster or a few chickens since they were loyal to me or 3) they had the guts, courage or fortitude to sit down with me and look me in the eye and say, "You have been great, but....." Granted, I probably wouldn't do that with my doctor, but I wouldn't expect him (he is a he) to take me back.

Thanks.

Amen.

Thanks to all. I would like to think that after 21 years I would be beyond the pettiness of taking offense to patients who choose to leave me but, damn it, I am not. I have a tremendous staff who protects me emphatically from potential problematic new patients and from those who left and want to come back. And so, to reward them for their loyalty and hard work I am taking them to the Tetons and Yellowstone week after next. This has become an office tradition. We take a trip together every year. We spend weeks in planning and therefore "bonding" and weeks upon return reliving our expeditions. It is a great way to boost office moral as I cannot provide them health insurance or other benefits.

Leslie

Fascinating discussion. I think you should stop taking new patients when the average number of patient visits requested per day exceeds the number you offer per day. I work using a slightly modified open access schedule. Most of the patients I see called that day requesting the visit.

Medicaid in my county used to pay me $30 for adults and $36 for children. Now all the children have 'mandatory managed medicaid' which enrolls them with fee for service HMOs. Those HMOs are no worse than any other plan and in some cases pay better so I'm in a better place than I was a few years ago.

I recently had an inquiry from a new managed medicaid provider, Fidelis who will provide insurance in our county. They offered me 90% of Medicare's fee schedule. I emailed back that I was already getting 110% of Medicare from their main competitor GHI and so, didn't see any reason to join. Much to my surprise, the representative took it to her committee and in a few days they offered to match the 110% rate. I was AMAZED. I guess it comes down to supply, demand and the insurance company's situation. I would never again hesitate to at least ask for a raise!

Jay

Jay,

Nice post. Can you do me a favor and send an email to Mainecare for me?

J/K of course.

So it turns out EVERYTHING is negotiable. It's just that no one told the Doctors we might negotiate for something better. Go get 'em!

I still can't believe we don't force negotiations. And, as I have stated before, I am not too concerned that this post is inciting anything that would be considered antitrust. It just seems that ultimately we hold all the cards.

I would weed out the patients that don't fit your practice so that you only have patients that pay on time, are coming to there appointments regularly, that have good insurance reimbursement(determined by you), pay there no show fees, and respect the policies of your office. Everyone else needs to get a new doctor. Life is too short to have frustrating patients.

I appreciate the advice that once the patient is gone, the patient is gone.

Vicki, Where did that come from?

From me, I suspect. I posted that attitude a while back and that is how my practice operates.

Leslie

Oh. I thought Vicky was being facetious. (sp?) LOL