Rather interesting little soiree'

[JustPlainBill]

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So today I have someone from an ACO that my practice is a part of stop by since I'm newly credentialed with them to "show" me some of the quality measures as part of getting credentialed -- I'm thinking,"What are you talking about?" ---

In walks a non-clinician with "MS" bolded behind their name who breaks out a computer and launches into quality measures that PCPs are graded on ---- for bonus reimbursement --- I'm thinking,"this could get interesting" --

along the way, before I became exasperated and began asking sharp, pointed, uncomfortable questions ----

1) ED visits -- I'm judged by how many times my patients go to the ED -- umm, I can see that in some cases, in others, it's a behavior problem, not a result of bad medicine -- I get that we're supposed to keep them out of the ED but for the love of Pete, I have no control over adherence or ED use/misuse

2) labs -- so I'm judged negatively if the endocrinologist gets an A1C and I get an A1C although we have no access to each others records -- really? also impacts negative if, for instance, they go to an ophthalmologist and they get coded with a "diabetes screening eye exam" -- if I (key word there) don't get that changed on my patient's account, and I don't screen them for an A1C and nephropathy, I get dinged -- yo, genius, an eye exam does not diabetes make and I don't have the time to chase down every system upgefucht.

3) patient satisfaction surveys -- having worked urgent care, this makes my skin crawl -- some now, patient satisfaction - read,"did the doc treat me the way I wanted to be treated and give me all the meds I wanted and make all the risky decisions I didn't want to make so I could blame them for the outcome" -- now impacts me in terms of bonus reimbursement.

4) did I attend a group meeting or not -- yep, if I don't go down to the hospital in my copious spare time to attend a lecture and meet with the specialists, I get dinged....

5) if the patient moves elsewhere and becomes non-adherent and forgets to f/u, I still get dinged in spite of them moving out of the area UNLESS I go in and do the legwork ,contact the patient and have them call the insurance provider to get it changed...

given this, plus the repetitive death-by-powerpoint, I began asking questions like --

so when does patient adherence kick in -- I'm being judged for the actions of patients who may/may not be adherent and now you're telling me that in addition to treating patients to the tune of 20+ per day, I get to play admin and make sure all my patient's paperwork is up to date AND beg them pretty please to be adherent or I get penalized -- is that correct?

they tried to hem/haw their way out but I locked in on them and told them it was a yes/no question --- when they wouldn't answer, I thanked them for their time and returned to patient care ----

Now I understand why people are going to DPC -- this is nuts ----

 

[kbeitz]

Why would any physician willingly put themselves through this? It cannot be worth whatever bonus they're offering.

Can they penalize you for not cooperating?

 

[mabinante]

It is crazy. I'm sorry that you are going through that.

I am in the last year of my FM training. I have watched all of my colleagues go out to big groups like Kaiser with a huge contract and bonuses. Seems like they are a bit like lemmings. . . I hear the longevity of docs in these groups is around 2-3 years.

I agree...DPC is better for the patients, docs, insurance companies, employers, government, etc, etc, etc. And to think my classmates in med school wanted socialized medicine!! Could you imagine working for the government for the rest of your career?

 

[JustPlainBill]

It is crazy. I'm sorry that you are going through that.

I am in the last year of my FM training. I have watched all of my colleagues go out to big groups like Kaiser with a huge contract and bonuses. Seems like they are a bit like lemmings. . . I hear the longevity of docs in these groups is around 2-3 years.

I agree...DPC is better for the patients, docs, insurance companies, employers, government, etc, etc, etc. And to think my classmates in med school wanted socialized medicine!! Could you imagine working for the government for the rest of your career?

After yesterday, I'm half tempted to get my doctor bag, script pad and otoscope and start seeing people for $25/visit cash in the parking lot at wal mart -- don't handle anything big that I can't prescribe something off of the $4 list.....

 

[surrender903]

And to think my classmates in med school wanted socialized medicine!! Could you imagine working for the government for the rest of your career?

socialized medicine =/= an incentivized bonus. What you re implying is that social medicine is horrible, i don t see the connection to the original post.

 

[Bacchus]

Our residency office is the application office for PCMH accreditation. I think this is more so because we can be asked to slave away at data entry for these quality and value based measures compared to the other offices. It's terrible. I had a patient today who had a full page of quality measures to be addressed. Most of them were done and in the EMR but our EMR is so incompetent if the eye exam or foot exam or a1c or pmeumovax isn't entered in one specific way it doesn't get abstracted. Add to that, we don't have enough staff for previsit planning that it's now to the point my last few months of residency won't be learning medicine, but learning how to be a data entry clerk. It's ****ing terrible. Hate isn't a strong enough word.

 

[KnuxNole]

I agree, it's what made me hate outpatient medicine. I told my program director this personally, and although it's disappointing, it's a reality. If I ever decide to do outpatient medicine in the future, I might do DPC or urgent care. Otherwise, hell no!

 

[deleted87716]

Most of this stuff should be delegated to staff. If you're the one getting stuck doing it, there's something wrong. Physicians shouldn't be data-entry clerks.

 

[KnuxNole]

Most of this stuff should be delegated to staff. If you're the one getting stuck doing it, there's something wrong. Physicians shouldn't be data-entry clerks.

At least in our residency clinic, we are severely understaffed, and the current staff are resistant on doing most stuff anyway....it's like pulling teeth to get simple tasks done. I think that asking them to put in vaccine info or diabetic measures would get my head chopped off 😱

Of course, it's probably easier in private practice with 1-2 MAs per physician vs. 1 MA for 2-3 physicians.

 

[deleted87716]

Agree, most residents don't have much control over their practice environment. However, once in private practice, if you find yourself in the same situation, you only have yourself to blame.

 

[deleted480308]

Go work for atlas or vahopeful... Your place sounds horrible

 

[JustPlainBill]

Agreed...most of these measures are data mined by the emr. What exasperates me is that non-clinicians gave cooked up their data points so they can insert themselves into patient care.... I dislike bean counters of almost any stripe and listening to this person who struck me as an ex-stripper who finished college really frosted my cookies....I've got enough on my plate without adding thus non-sensical BS.....

 

[deleted87716]

If you're going to go the ACO (or pay-for-performance) route, know that reimbursement is a game. Learn the rules, play by the rules, and you'll do fine. Ignore the rules, fail to play by the rules, and you'll suffer. Don't like the game? Get out. While you still can.

I should add, for those of you who may think that direct pay is some sort of panacea, think again. Direct pay makes significant demands on you. You have to constantly deliver on the promise of something better than what patients can obtain in the insurance model. It sounds simple enough, but it's still a game, just with different rules. You're going to earn your money regardless of which model you choose to follow.

 

[NurWollen]

I agree, it's what made me hate outpatient medicine. I told my program director this personally, and although it's disappointing, it's a reality. If I ever decide to do outpatient medicine in the future, I might do DPC or urgent care. Otherwise, hell no!

Just out of curiosity, if you're not going to do outpatient, what are you going for? Hospitalist?

Sent from my SM-N910V using SDN mobile

 

[HipsterLorax]

I should add, for those of you who may think that direct pay is some sort of panacea, think again. Direct pay makes significant demands on you. You have to constantly deliver on the promise of something better that what patients can obtain in the insurance model. It sounds simple enough, but it's still a game, just with different rules. You're going to earn your money regardless of which model you choose to follow.

Do you think as the DPC movement picks up pace that it will receive more legislative backlash? It sounds much more ideal than working through the beaurocracy of large group practices, but I'm worried that once lobbyists sense it as a threat it'll be game over. Obviously the proponents of it are very enthusiastic and optimistic, but it's hard to predict the future..

 

[KnuxNole]

Just out of curiosity, if you're not going to do outpatient, what are you going for? Hospitalist?

Sent from my SM-N910V using SDN mobile

Yep 😀

 

[NurWollen]

Yep 😀

Nice.

 

[deleted87716]

Do you think as the DPC movement picks up pace that it will receive more legislative backlash?

Hard to say. Right now, it's generally tolerated, if not exactly encouraged. I'd be concerned, however, that if there's a move towards single-payer (which I've long believed is the Democrats' ultimate goal), DPC may fall into disfavor by the PTB.

 

[Doctor4Life1769]

Yep 😀

Ew

 

[KnuxNole]

Ew

Don't hate!

 

[Doctor4Life1769]

Don't hate!

Not my issue, have fun with that 😉

 

[deleted87716]

Don't think for a minute that being a hospitalist will get you away from quality measures. Not even a little bit.

 

[VA Hopeful Dr]

If you're going to go the ACO (or pay-for-performance) route, know that reimbursement is a game. Learn the rules, play by the rules, and you'll do fine. Ignore the rules, fail to play by the rules, and you'll suffer. Don't like the game? Get out. While you still can.

I should add, for those of you who may think that direct pay is some sort of panacea, think again. Direct pay makes significant demands on you. You have to constantly deliver on the promise of something better than what patients can obtain in the insurance model. It sounds simple enough, but it's still a game, just with different rules. You're going to earn your money regardless of which model you choose to follow.

This is definitely worth revisiting. I love doing DPC, but it definitely has its own stresses.

 

[VA Hopeful Dr]

Hard to say. Right now, it's generally tolerated, if not exactly encouraged. I'd be concerned, however, that if there's a move towards single-payer (which I've long believed is the Democrats' ultimate goal), DPC may fall into disfavor by the PTB.

A thought that does worry me. It depends on what form our single payer takes. If it allows private practice, I think DPC will expand even more since rarely does single payer result in shorter waits and longer visits. If we are all government employees with no other real option, DPC is in trouble.

Fortunately, the latter doesn't seem likely to fly in American anytime soon.

 

[SuckySurgeon7]

This is definitely worth revisiting. I love doing DPC, but it definitely has its own stresses.

Sounds like the kind of stuff we students need to know! Feel like being more specific (if it's not hijacking the thread)?

 

[VA Hopeful Dr]

Sounds like the kind of stuff we students need to know! Feel like being more specific (if it's not hijacking the thread)?

Well it comes in 2 varieties.

First, there's the usual stress of actually running a business. Payroll, employee management, paying bills, being responsible for getting patients in the door - physicians historically don't like doing any of that. Why do you think so many of us are employed by hospitals?

Second, there are unique challenges to DPC. I don't get bothered too much after hours and on weekends, but its not zero either. During cold and flu season (ie. now) I usually get around 10 texts/e-mails per day on the weekends, around 5 after hours during the week. I don't mind it too much, but many people these days like the idea of leaving work at work. In the last 8 months, I've had to come into the office I think 4 times on the weekend. That's not terrible, but its also not zero. Also, as you might suspect, we get more uninsured patients that most FM practices. This leads to difficulty with getting any advanced diagnostic testing or referrals (as both are expensive). Some of that has been fun - I've had to expand my comfort zone markedly (MTX therapy being the most recent example, or the patient I'm about to start IV iron on outpatient). Some of it less so - patients who really need CT scans who refuse to get them, for example. There is also the initial stress of a new model. You spend a good bit of time explaining why what you do is better than the status quo. The upside to that is that since its new, word of mouth will help you more here than in traditional practice.

 

[HipsterLorax]

Well it comes in 2 varieties.

First, there's the usual stress of actually running a business. Payroll, employee management, paying bills, being responsible for getting patients in the door - physicians historically don't like doing any of that. Why do you think so many of us are employed by hospitals?

Second, there are unique challenges to DPC. I don't get bothered too much after hours and on weekends, but its not zero either. During cold and flu season (ie. now) I usually get around 10 texts/e-mails per day on the weekends, around 5 after hours during the week. I don't mind it too much, but many people these days like the idea of leaving work at work. In the last 8 months, I've had to come into the office I think 4 times on the weekend. That's not terrible, but its also not zero. Also, as you might suspect, we get more uninsured patients that most FM practices. This leads to difficulty with getting any advanced diagnostic testing or referrals (as both are expensive). Some of that has been fun - I've had to expand my comfort zone markedly (MTX therapy being the most recent example, or the patient I'm about to start IV iron on outpatient). Some of it less so - patients who really need CT scans who refuse to get them, for example. There is also the initial stress of a new model. You spend a good bit of time explaining why what you do is better than the status quo. The upside to that is that since its new, word of mouth will help you more here than in traditional practice.

What's your opinion on larger groups using the DPC model? I'm wondering if by the time I finish residency it will be a little more accessible.

 

[cabinbuilder]

Don't think for a minute that being a hospitalist will get you away from quality measures. Not even a little bit.

So true. There are so many quality measures that there is an actual "quality measures police" (usually a nurse) who checks all the charts to make sure you have checked all the boxes and are doing your job. It's very annoying and they are in your face to "explain yourself" if you are outside the box even a little bit. Sigh.....

 

[Bacchus]

So true. There are so many quality measures that there is an actual "quality measures police" (usually a nurse) who checks all the charts to make sure you have checked all the boxes and are doing your job. It's very annoying and they are in your face to "explain yourself" if you are outside the box even a little bit. Sigh.....

I'm on the Sepsis QI committee. There's 65 "boxes to check" for CMS. 64/65? You fail!