Home Forums Discussions General Discussion Bad attitude (mine)

Hi all,

This is sort of hard for me to write. It is more or less a followup to this thread

http://amazingcharts.com/ub/ubbthreads.php/topics/38424/Maximizing_billing#Post38424

I would like to thank all who responded to that. EMUniversity has lots of useful info, my takehome is that I was doing way too much charting to justify a 99214. I think I'm getting comfortable coding more 99214s, with briefer (but adequate) charting.

But the whole process has caused much soul searching. This was largely provoked by 2 job offers, one from a Community Health Center in which I had worked in the past, the other from a very for-profit group that is being established. Both were for quite a bit more money than I am now making.

The process of considering these made me really ask why we do the things we do. And, while trying to decide that, I realized that I had developed a really really crummy attitude toward practice. Sort of a hopeless/helpless/it will never get better, only get worse/whats the point attitude (most of you are now reaching to rx the Lexapro, I know....) Not having the hassles of payroll, practice management, etc....

But when I really thought of giving up solo Family Medicine, something clicked.

Why do we do what we do? Because we do it well. Really, really well. Anyone who has been in practice a while knows what I mean. In terms of getting patients well, and keeping patients well, we are top notch. Can a doc-in-a-box, or an ER, or a large group where the patient sees a different provider each time do what we do? Can a specialist do what we do? Can a hospital system do what we do? Overall we save the system lots of money, avoiding unnecessary testing, avoiding hospitalizations, and so forth. And we really keep patients healthier.

This is worth keeping, and fighting for. A spark in me has been reignited. I am not going to feel guilty about coding mostly 99214s, if the documentation supports it, then we deserve it. If we can get paid for both an annual, and 99213/99214 on the same visit, so much the better.

But I think I will also value what we do a little more, too. Just that internal sense of "What I do is really important" has been recharged.

Finally, I would like once again to thank all the members of this board. This is a great group, extremely knowledgable, but equally caring. When I was considering other practice settings, one of the questions was whether I was willing to give up AC and this board. That would have been really hard, too.

So thanks again to all. And go Steelers! (Sorry JBS and DCubed.)

Gene

Gene,

Saw your note and wanted to respond while it was fresh in my mind.

I don't know your practice personally, but every Physician that I have met through this board have been the kind of folks I would take my own family to see; thoughtful, caring, innovative, pros that have time for the people they treat.

Besides that, these folks are accomplished individuals beyond just medicine, and have interesting stories worth hearing. Really.

I came away from ACUC this year realizing that for our line of business where we support providers and their practices, we are in the "Provider Care" business. Mainly because we get a lot of satisfaction from keeping the "magic in the box" so that providers can concentrate on practicing medicine.

Everyone knows it isn't the high margin business line, but it has all it own appeal.

Thanks for what you do, and consciously choose to keep doing, in-spite of all of the de-motivators. That goes double for the folks here that I have the pleasure of knowing personally. You know who you are.

Way to go, Gene! I am glad you decided to stick it out. Solo practice is indeed very, very difficult. But it beats the H*^^ out of group. Every day I whine and complain and think about how badly I wish I could retire. Then I have a patient like I did yesterday (in whom I diagnosed a head and neck cancer which even the ENT missed) come in for a cold and, before leaving, thank me again for saving his life. I do love medicine and (most of) my patients. I just wish the government would go away and let us do what we do best.

Indy, you also are one of the most sincere and kind people I know. And I love your dogs! Tahoe was a fantastic experience.

My experience with a group was like having to get up in the morning and put on someone else's underwear and brush my teeth with someone else's toothbrush. I nearly quit medicine because of it. If you can make enough money to have a decent life, the difference between that and lots more is small by comparison.

Regarding 99214, it is an artificial construction that has little to do with real medicine. While we do all the items usually required in a complete evaluation, charting it is a different process to make sure you jump through the right hoops. Templates help.

Burnout can be worse in a group, because you are not in control of your situation. When you are asked to do things that you do not agree, it only makes the situation worse.

Indy, you are right. The ACUC group are thoughtful physicians who care about their practices and their patients. Otherwise they would not have invested the time and energy to learn and improve AC.

Leslie, you are right, Indy is very wonderful. He actually understands how docs think. Very rare. The dogs were great too.

Gene,
We all suffer from periods where we get ground down. A couple of years ago, I wondered how I could continue, my attitude had gotten bad. It helps to set limits on medicine and have others interests that make you happy. It also helped me to try to find new things that I could learn to be of help to patients, I found a stress reduction course that I took and now recommend, and then I took on the AC conversion which I had been thinking about for quite some time. It is worth the effort to be able to share our patients' lives and take good care of them in a very personal way.

Think of your worth as a plumber, electrician or (God forbid) lawyer would. What is the hourly rate that you should be paid for your effort and expertise? I think that we are all going to have to move toward a "retail" practice where we provide a service and get paid for it, without the interference of insurers or the government.

I wish you were a little closer, and could join us in the Baltimore AC group. (Even though you are a Steelers fan, we would let you in, right JBS?) The comraderie is a big help. Maybe we could meet halfway sometime for a get together.

Donna

I wish somebody could tell me how it is that group doctors make so much more money than I can make in solo practice.

My only experience with groups (outside the government)was many years ago when I sold my practice to a large private group which then sold itself to a hospital. After interminable "staff" meetings at which nothing was ever accomplished, and in which nobody ever did anything but whine, I would go to the clinic to try to see patients that had been scheduled by a scheduling clerk who knew nothing about medicine, nothing about the patients --and certainly didn't try to let me see my "own" patients. In fact, the whole point was to commodify patients and doctors, and make them interchangeable parts in an industrial enterprise -- allegedly to make "healthcare" more "efficient". The result was predictable.

I put my tail between my legs and left, and thankfully had not signed a exclusionary agreement, and opened my own practice again in the same town -- although the hospital tried to enforce a nonexistent geographic exclusion clause, and that caused more heart ache, but finally went away. That all turned out to be a bid by a regional hospital to take over the local hospital, and it failed. Ultimately, though, the local hospital has bought up or otherwise employed most of the doctors in town and is running a sort of half-assed "group."

The point of all this is that there was nothing very efficient about the way I was practicing in that group, and there's nothing very efficient about the way I see the local hospital group is practicing, and yet they make twice or 3x as much money.

That can only be possible if they are seriously "overcoding", or I am seriously "undercoding" or they have a source of revenue I can't tap into.

Bottom line for me, though -- solo practice is the only possible way for physicians who value their relationship to their patients above their loyalty and relationship to their employer. Independence has a price -- or as the Tea Party says, "freedom isn't free" (thought I doubt their understanding of that slogan is the same as mine.)

I am in solo practice and prefer to be that way but...

1)Docs in group practice usually see more patients per hour (if you do not get to know them, you do not spend time asking about relatives and mental health and the like)

2)Groups use economies of scale with employees, so that benefits and time can be cross covered more easily.

3)Docs are usually working more hours seeing patients. If you do not have to to any administrative duties, you can "produce more product." This combined with #1 makes a big difference.

4)Especially now, groups are covered by hospitalists. No more giving time for rounding,couple hours to see 2-4 patients, now it's 4-6 patient per hour not couple of flex hours.

5)Groups often have more expanded hours, which IS good for patients. It's easier to cover late nights and early mornings when you have a group. Truly a benefit on the group side here. Expanded hours mean more utilization of the facility and lower cost.

6)Costs are often underwriten by writing them off for the entire corpooration. So IT costs get floated to other areas. How else can they have 100K programs before or even after the gov'mt involvement.

7)Your senario about buying and selling practices and hospitals not quite knowing what they are doing is common. They see us as revenue streams, to bring patients in the hospital. This will increase as they see the focus shift to the outpatient world and outpatient medicine becomes more important. The money is in the hospital, not the office. That may shift (I sincerely hope so) Then we will become more "valuable." Look for another round of buying. We have our ear to the ground so we know the community. Even community hospitals do not understand patient behavior as well as we. But then again, they sometimes treat them like cattle. Not all, but enough that I can make the statement.

I can add a couple of things to your list
1. Our phones are answered by a person, not a machine -- money we could pay the doctor.
2. Our employees are paid a living wage -- a silly, sappy idealistic notion.
3. Almost certainly the hospital subsidizes the clinic side with its monstrous lab and imaging fees. Accounting rules seem to be quite flexible.
4. Our hospital is a "critical access" hospital, which for now, is some sort of license to coin money.
5. 20 years ago the hospital refused to consider subsidised rent for doctors, or paying them above market salaries -- the bogy-man IRS was always invoked, something about "private inurement". Nowadays, not a word about that.

I agree with everything above, but there is something to be said for auto-attendants.

Tom,
That is not my experience at all. My take-home is much higher in my solo practice than it ever was in a group. I think the distinction is "group" vs "hospital-owned, employed physicians". When the hospital owns the group, it can charge both a "professional component" and a "facility fee", then share part of the total largess with their employee docs, resulting in higher income. Remember, no one is ever going to pay you more money than you can generate. Either you make more money by the sweat of your own brow, or by forfeiting your independence and control over your destiny. As a solo doc, I know how to increase my income. I just need to decide if I want to trade more time for money. But, I have that option. Employees do not.
Dave

Dave --
I am sure you are right, at least in principle. I could make more money with the same effort if I did things a little differently, and I theoretically could.

I have infinitely more control over my income -- and maybe more importantly, my schedule -- than I ever did during my brief fling with a group. And you are entirely correct about the distinction between "hospital owned" and private group, though around these parts the hospital made sure that there would never be such a choice.

I am well aware of choices I make that negatively affect money income, but positively affect my enjoyment of the practice. These choices are going to have to be very critically examined as Medicare prepares to cut us 30%, and private insurance will most likely follow right along.
Thankfully, because I am solo, and because my EMR is AC, I feel like I am in a good position to make those difficult choices and to survive in the coming storm.

Tom and others,

I was musing about this last night, and remembering years ago when I was in a group. There would be the monthly meetings to discuss production. The envy of the lower producers, the anger of the higher producers that the low producers were not pulling their weight. And, always, the subtle and not so subtle pressure to produce more. Practicing better or more cost effective medicine never came up.

That group also had its own lab and x-ray (much like hospital employed MD's). So, imagine what would happen if you were a lower producer, trying to good medicine, and you came out of that meeting feeling like you let your partners, your wife and your kids down. The next patient you saw with a cough for two weeks; why, it isn't tough to justify a CBC and 2 view chest. Maybe even an EKG if their BP is a little up. Maybe spirometry. Chest percussion from physical therapy? Sure, why not. Can't hurt. Sputum culture for sure, even if it is just saliva they're bringing up. No reason not to be creative. Certainly no one will criticize you next month if your numbers come up.

The point, Tom, is that you and I are free to do the most effective, compassionate, and cost-effective medicine we know how. Yes, our reward may only be in heaven. Yes, I resent all those who flaunt their greater income. But, I no longer go home feeling slightly sick to my stomach.

David
Welll said.
I have been offered money for various reasons- selling my practice to a hospital, setting up Heart echos, stress test, and all kinds of gadgets to BOOST my income.
I ask them who pays for my income boost- ofcourse it is our patients.
I feel I am blessed being a private family physician and decisions are made by myself , my staff and my patients.
I am not willing to sacrifice my freedom which no amount of money can buy.
In the end ,patients appreciate the time you spend with them ..ofcourse there will be very few who do not appreciate anything you do.
To them I say " You have a choice to find a better caring practice
which can take care of you"
Grenville

For me, it is short and simple. I was in two groups. They both ended with two simple words: You're fired.

I can never thank Adam Lauer enough for getting me my own practice in less than two months. One of the hospital groups went belly up. I sent them a card.

Ah, Bert......

A fellow child of the 60's. Makes me proud.