Re: thoughts on small and on quality

July 12, 2006

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.I can think of many example of smaller is better outside of the human service arena.1) Your tailer making an outfit for you vs. going to the mall2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home DepotAdd in the human service element and things get even messier1) Homeschooling one child vs. sending a child into a classroom of 45 kids2) Parenting 2 kids vs. 17and....3) Caring for a patient panel of 400 vs. 2500I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc... With low overhead we can provide better service at a equal or lower price.We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...Pamela some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts? I struggle quite frequenlty with quality / mistakes in an arena that seems almost nit picky to me However my sense is that it is not nit picking but gets at the heart of how we do medicine What I mean focusses on the information we share with each other I do a lot of skilled nursing home work My patients come from 3 hospitals most of the time The dishcarge summaries are awful I am required in the NH setting to have a dx for each med( what a concept eh?!) and you know sometimes it is near impossible to figure out Now if the patient went on to that med during the stay from which they are being discharged well I think it should say so int he discharge summary Sometimes it will say BUN was 1 and this is a typo but can we allow typos?Saw a chart recently where it said a pregnant woman went to the er and "unfortunatley her pregnancy was not in jeopardy".Had a patietn admitted recently with a questin of Lyme disease Presented to the er with rash etc The H and P does not mention the rash No exam was recoreded. Etc etc WE have all seen this I cannot figure out to fix this My own hospital has been revamping its quality imporvement measures and these seem to have nothing to do with what I am talking about- you know what gets focussed on is did the pneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of the provider to get done and falls to their training-I get disch summaries from the tertiaty care hospital written by some poor resident who never met the patietn in their 3 week stay and then had to do the summary... Thoughts please? I had some other thoughts as the title of the e mail said but I will mostly skip them for now tillI think 'em out better It was about "small" Small works so much better in so many ways I see 's post on the IMPS1 cohort than in a prior small office it was still seen to beineffcient to a horroble degree but nevertheless i see that medicine gets bigger and bigger and though I mean small does nequal good/effcient it seems more likley to.. And other things I have to walk 1/4 mile to get milk inside the Shop n save. I liked it when the store was littler The Gore compnay in Delaware- makes goretex fabric a nd material for shunts and grafts has no factory over 150 people They have a lot of employees but never over 150 in a building People then know their collegues and are more responsible to eachother How/could we/should we? take medicien back to that? Wouldn't that get us to better care andless errros?

July 13, 2006

RE Small and quality and overhead.

So, if ultrasolo can only cover 400 pts, then "low overhead" with outsourcing for various services should be able to cover some more, and survive. Technology CAN help, but there must be a close balance between volume, technology and cost outlay.

I was just challenged with the choice of buying a new shelf unit for records, vs moving to scanning which I feel is a good choice for busier practices with more cash flow. I ran the numbers and bought the cabinet for $590, although if my cash flow was better, I'd have moved into the scanning solution, and fully intend to ultimately.

This choice was based on a slow but steady pt base of about 500, range of 25-40 pts per week with open access (but goal is about 60 pts/week), use of designated hospital rounder (another FP!), EMR which generates my notes and I use for various tasks (SOAPware), outsourced billing.

Each of us has their own restrictions and goals.

Dr Matt Levin

Pittsburgh, PA

Solo since Dec 2004.

FP residency completed 1988.

EMR SOAPware since 1997

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

July 13, 2006

RE Small and quality and overhead.

So, if ultrasolo can only cover 400 pts, then "low overhead" with outsourcing for various services should be able to cover some more, and survive. Technology CAN help, but there must be a close balance between volume, technology and cost outlay.

I was just challenged with the choice of buying a new shelf unit for records, vs moving to scanning which I feel is a good choice for busier practices with more cash flow. I ran the numbers and bought the cabinet for $590, although if my cash flow was better, I'd have moved into the scanning solution, and fully intend to ultimately.

This choice was based on a slow but steady pt base of about 500, range of 25-40 pts per week with open access (but goal is about 60 pts/week), use of designated hospital rounder (another FP!), EMR which generates my notes and I use for various tasks (SOAPware), outsourced billing.

Each of us has their own restrictions and goals.

Dr Matt Levin

Pittsburgh, PA

Solo since Dec 2004.

FP residency completed 1988.

EMR SOAPware since 1997

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

July 13, 2006

60 pt’s/week averages

out to be 13 pt’s/day if you work 4.5 days/week. So you anticipate

being able to earn at least an average income with that volume and still paying

someone else to do your billing? Your overhead must be very, very

low? I get by OK doing about that same volume now (open 2 yrs this past

April) but we do all of our own billing. I would have to see more than

that if I outsourced my billing. I pay only one front desk staff person

(non clinical).

Re:

thoughts on small and on quality

RE Small and quality and overhead.

So, if ultrasolo can only cover 400

pts, then " low overhead " with outsourcing for various services should

be able to cover some more, and survive. Technology CAN help, but there

must be a close balance between volume, technology and cost outlay.

I was just challenged with the

choice of buying a new shelf unit for records, vs moving to scanning which I

feel is a good choice for busier practices with more cash flow. I ran the

numbers and bought the cabinet for $590, although if my cash flow was better,

I'd have moved into the scanning solution, and fully intend to ultimately.

This choice was based on a slow but

steady pt base of about 500, range of 25-40 pts per week with open access (but

goal is about 60 pts/week), use of designated hospital rounder (another FP!),

EMR which generates my notes and I use for various tasks (SOAPware), outsourced

billing.

Each of us has their own

restrictions and goals.

Dr Matt Levin

Pittsburgh, PA

Solo since Dec 2004.

FP residency completed 1988.

EMR SOAPware since 1997

Re:

thoughts on small and on quality

Nice to hear your voice this morning! I totally

agree that small improves quality, especially in human services.

The assembly line " one size fits all "

mentality can give us truckloads of uniform and volume discounted lesser

quality products al a WalMart.

I can think of many example of smaller is better

outside of the human service arena.

1) Your tailer making an outfit for you vs. going to

the mall

2) Having a local artist design/make a stained glass

door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even

messier

1) Homeschooling one child vs. sending a child into a

classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who

are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service

at a equal or lower price.

We are not built to move at speeds beyond our

capacity. Even with computers and other gadgets we can not be pushed gracefully

to achieve more than a certain amount of volume per day. After all, we still

need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to

put more into practice

Wasson and Deb please your thoughts?

I struggle quite frequenlty with quality / mistakes in an arena that seems

almost nit picky to me However my sense is that it is not nit picking but

gets at the heart of how we do medicine What I mean focusses on the

information we share with each other I do a lot of skilled nursing home work

My patients come from 3 hospitals most of the time

The dishcarge summaries are awful I am required in the NH setting to have

a dx for each med( what a concept eh?!) and you know sometimes it is near

impossible to figure out Now if the patient went on to that med during the

stay from which they are being discharged well I think it should say so

int he discharge summary

Sometimes it will say BUN was 1 and this is a typo but can we allow

typos?Saw a chart recently where it said a pregnant woman went to the er and

" unfortunatley her pregnancy was not in jeopardy " .Had a patietn

admitted

recently with a questin of Lyme disease Presented to the er with rash etc

The H and P does not mention the rash No exam was recoreded. Etc etc WE

have all seen this

I cannot figure out to fix this My own hospital has been revamping its

quality imporvement measures and these seem to have nothing to do with

what I am talking about- you know what gets focussed on is did the

pneumonia patient get antibx within 4 hrs etc

Much of what I think about is " small " and falls back to the memories

of the

provider to get done and falls to their training-I get disch summaries from

the tertiaty care hospital written by some poor resident who never met

the patietn in their 3 week stay and then had to do the summary...

Thoughts please?

I had some other thoughts as the title of the e mail said but I will

mostly skip them for now tillI think 'em out better It was about

" small "

Small works so much better in so many ways I see 's post on the

IMPS1 cohort than in a prior small office it was still seen to

beineffcient to a horroble degree but nevertheless i see that medicine gets

bigger and bigger and though I mean small does nequal good/effcient it

seems more likley to.. And other things I have to walk 1/4 mile to get milk

inside the Shop n save. I liked it when the store was littler

The Gore compnay in Delaware- makes goretex fabric a nd material for shunts

and grafts has no factory over 150 people They have a lot of employees but

never over 150 in a building People then know their collegues and are more

responsible to eachother How/could we/should we? take medicien back to that?

Wouldn't that get us to better care andless errros?

July 14, 2006

I'm the Imp in the wings, facinated by the ultra - solo notation. no LNA/MA? what kind of space do you lease? ?sq ft? Exam rooms? also do you know Lee son MD a FP from Case Western....she and her husband are in pittsburg. Adam Levin wrote: RE Small and quality and overhead. So, if ultrasolo can only cover 400 pts, then "low overhead" with outsourcing for various services should be able to cover some more, and survive. Technology CAN help, but there must be a close balance between volume, technology and cost outlay. I was just challenged with the choice of buying a new shelf unit for records, vs moving to scanning which I feel is a good choice for busier practices with more cash flow. I ran the numbers and bought the cabinet for $590, although if my cash flow was better, I'd have moved into the scanning solution, and fully intend to ultimately. This choice was based on a slow but steady pt base of about 500, range of 25-40 pts per week with open access (but goal is about 60 pts/week), use of designated hospital rounder (another

FP!), EMR which generates my notes and I use for various tasks (SOAPware), outsourced billing. Each of us has their own restrictions and goals. Dr Matt Levin Pittsburgh, PA Solo since Dec 2004. FP residency completed 1988. EMR SOAPware since 1997 Re: thoughts on small and on quality Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services. The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart. I can think of many example of smaller is better outside of the human service arena. 1) Your tailer making an outfit for you vs. going to the mall 2) Having a local

artist design/make a stained glass door vs. buying a stained glass door from Home Depot Add in the human service element and things get even messier 1) Homeschooling one child vs. sending a child into a classroom of 45 kids 2) Parenting 2 kids vs. 17 and.... 3) Caring for a patient panel of 400 vs. 2500 I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc... With low overhead we can provide better service at a equal or lower price. We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve

more than a certain amount of volume per day. After all, we still need to sleep, eat, and play... Pamela some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from

3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did

thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in

Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

How low will we go? Check out Yahoo! Messenger’s low PC-to-Phone call rates.

July 15, 2006

RE Being a solo... trying to make it work after 18 months.

1) Space leased from gen surgeon-- using 2 exam rooms and a common area and an admin office for myself; rent is $1390 including space, cleaning, shared access to internet modem.

2) Don't know Lee son

Dr Matt Levin

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

How low will we go? Check out Yahoo! Messenger’s low PC-to-Phone call rates.

July 15, 2006

RE Being a solo... trying to make it work after 18 months.

1) Space leased from gen surgeon-- using 2 exam rooms and a common area and an admin office for myself; rent is $1390 including space, cleaning, shared access to internet modem.

2) Don't know Lee son

Dr Matt Levin

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

How low will we go? Check out Yahoo! Messenger’s low PC-to-Phone call rates.

July 15, 2006

RE Being a solo... trying to make it work after 18 months.

1) Space leased from gen surgeon-- using 2 exam rooms and a common area and an admin office for myself; rent is $1390 including space, cleaning, shared access to internet modem.

2) Don't know Lee son

Dr Matt Levin

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

How low will we go? Check out Yahoo! Messenger’s low PC-to-Phone call rates.

July 15, 2006

RE Outsourcing billing.

Ah, if I only saw that many-- still down around 25-30 and just making ends meet in the office and little take home for home expenses just now.

Numbers: I ave about $10,000 - $12,000/month overhead including EVERYTHING (rent, malp-- paying monthly with a loan, 2.5 FTE staff, AND billing).

Each visit take-home about $80/visit -- I'm very aggressive billing for well care, which fortunately is paid well by the major insurers in area, but you have to check on it. So, $80 x 60 pts/week = $4800/week, x 4 = $19,200/month - $12,000 = $7200 net/month, x 12 = $84,600 per year low end, if overhead would be $10,000/month, then

$9,200/month, x 12 = $110,400.

And business is paying my health insurance, which I was paying almost all of when working for a hospital owned practice, I'll be ahead here.

Outsourcing billing helps me by having 8 hour/day coverage for billing questions, having maintenance of billing system and software by others. Yes, 8% per collected dollar sounds like alot, but I'd be paying way more to do the same myself.

Right now, with my cash received, it works. If I had another doc also seeing 60 pts/week, may not be.

Economies of scale work if you have "enough" work throughput, otherwise, outsource.

My opinion-- share more with you off list if you want.

Best to you!!

Dr Matt Levin

Pittsburgh, PA

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

July 15, 2006

Matt and : You both hit on very good points. Matt, if you performed billing tasks you would have to either invest more time or give up some clinic time. Both may be unacceptable for you to choose to do in-house billing. , you may have extra time to invest or see patients for higher reimbursement or lower overhead. You can both be right in your own situation. For someone to consider outsourcing or in-sourcing a function, you need to know the details of the operations and the opportunity cost of each. I am struggling with these issues now. As my numbers increase, seeing 8-13 patients some days with 4-5 others, but the time for administration is diminishing as the time for clinical activity and revenue increases. I estimate my time at $2.00 per minute. This

pays my salary at current level and would pay all the overhead. So when I perform the billing functions of say posting payments, it takes me 3-4 hours to post $3-6,000 in accounts receivable. This costs me $360 - 480. 8% of $3-6000 is $240 - 480. The later is a real expense while the former is only lost time unless I could be seeing patients, then lost revenue. Abbout cost neutral for posting alone. There are other functions of invoicing, data collection, statements, collections activities, appeals, but most of my time is spent between posting payments, depositing payments, and printing statements to mail. I don't like the idea of paying someone to collect money for something I did. I do not like the idea of working 3-4 more hours seeing patients to pay someone to collect "my" money. It could be used for other medical related services like a vial of Tuber-sol, or go to a salary, mine or

staff. However, technically no difference between in house vs. outsourcing based on my availability of time. That said, I always try to close the gap or improve on efficiency. My EMR does most of the coding and billing work for me,if I keep good data on patient insurance and addresses and phone numbers etc. It takes me very little time at each patient visit to generate the invoice one minute or less usually, except for the exotic code or the preventive physical with shots, labs, E & M , and preventive services. As for posting, my biggest sources of revenue are medicare and Blue-Cross Blue-Shield. These two sources of payments can be deposited electronically and automatically. I do this now without a trip to the bank. They have a new service that my EMR supports for auto-posting or ERA electronic remittance advice. This service costs $50 per month, but will save me

time. 2.5-3.5 hours per $3-6000 of posting. It will save $$$ if I have patients to see. The cost to my practice last year on 8% collections would have been $12,000. I paid my wife and I a salary of around $72,000 including FICA MEDICARE and STATE TAXES. This is 12000/72000 or 16.7% of my gross salary. 12,000/60,000 or 20% if I had revenue and time contant neutral costs. . I believe technically then that you could spend 16.8%-20% or your time in billing and collection activities and remain goss profit neutral. You would have lower overhead because I would presume you would actually see fewer patients and require less staffing. Please challenge my assumptions here because I am not certain they are100% valid. I encourage all who would save time by doing it yourself to calculate the actual cost of doing it yourself both in terms of time, money, and opportunity. Sincerely: D. Egly, M.D. P.S. Until I contemplated your posts I had not calculated my true costs of posting manually. I will actually set aside time to fill out the forms to implement ERA. It will cost me $600 this year, but will save me 40-120 hours of time this year. I imagine spending more time with my kids or a two week vacation. Levin wrote: RE Outsourcing billing. Ah, if I only saw that many-- still down around 25-30 and just making ends meet in the office and little take home for home expenses just now. Numbers: I ave about $10,000 - $12,000/month overhead including EVERYTHING (rent, malp-- paying monthly with a loan, 2.5 FTE staff, AND billing). Each visit take-home about

$80/visit -- I'm very aggressive billing for well care, which fortunately is paid well by the major insurers in area, but you have to check on it. So, $80 x 60 pts/week = $4800/week, x 4 = $19,200/month - $12,000 = $7200 net/month, x 12 = $84,600 per year low end, if overhead would be $10,000/month, then $9,200/month, x 12 = $110,400. And business is paying my health insurance, which I was paying almost all of when working for a hospital owned practice, I'll be ahead here. Outsourcing billing helps me by having 8 hour/day coverage for billing questions, having maintenance of billing system and software by others. Yes, 8% per collected dollar sounds like alot, but I'd be paying way more to do the same myself. Right now, with my cash received, it works. If I had another doc also seeing 60 pts/week, may not be. Economies of scale work if you have "enough" work throughput, otherwise, outsource. My opinion-- share more with you off list if you want. Best to you!! Dr Matt Levin Pittsburgh, PA Re: thoughts on small and on quality Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services. The assembly line "one

size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart. I can think of many example of smaller is better outside of the human service arena. 1) Your tailer making an outfit for you vs. going to the mall 2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home

Depot Add in the human service element and things get even messier 1) Homeschooling one child vs. sending a child into a classroom of 45 kids 2) Parenting 2 kids vs. 17 and.... 3) Caring for a patient panel of 400 vs. 2500 I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc... With low overhead we can provide better service at a equal or lower price. We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play... Pamela some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home

workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what

gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was

littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

See the all-new, redesigned Yahoo.com. Check it out.

July 16, 2006

RE Time IS money.

"I don't like the idea of paying someone to collect money for something I did. I do not like the idea of working 3-4 more hours seeing patients to pay someone to collect "my" money. It could be used for other medical related services like a vial of Tuber-sol, or go to a salary, mine or staff. However, technically no difference between in house vs. outsourcing based on my availability of time."

If you can make MUCH more money in same amount of time that it takes SOMEONE ELSE to do lower expertise work, then it makes MORE sense to outsource it.

For ex, I didn't set up my billing system, don't support the software for it, don't do the mailings, don't pay the person. I pay a service to DO ALL THAT WORK for me while I generate income at a much higher level/hour than I could afford to pay someone to do this.

All depends on volumes. It's not just the cost you'd pay to the billing service, but ALSO the cost to support what you're doing already. For ex, YOU have to pay the $50/month for the direct billing system for some of your work. If that cost you $500/month, you might not do it.

If I was billing 3x as much, I might want to bring it in-house.

Self-sufficiency is one thing-- you may want to grow all of your own food, cut your own wood, or dig your own coal.

At this point, I'd buy it.

And I buy the billing service, for now at least.

Each setup is different... principles are similar.

Dr Matt Levin

Pittsburgh, PA

Re: thoughts on small and on quality

Nice to hear your voice this morning! I totally agree that small improves quality, especially in human services.

The assembly line "one size fits all" mentality can give us truckloads of uniform and volume discounted lesser quality products al a WalMart.

I can think of many example of smaller is better outside of the human service arena.

1) Your tailer making an outfit for you vs. going to the mall

2) Having a local artist design/make a stained glass door vs. buying a stained glass door from Home Depot

Add in the human service element and things get even messier

1) Homeschooling one child vs. sending a child into a classroom of 45 kids

2) Parenting 2 kids vs. 17

and....

3) Caring for a patient panel of 400 vs. 2500

I think better is smaller especially with patients who are not uniform in physical ailments, emotional state, spirituality, etc...

With low overhead we can provide better service at a equal or lower price.

We are not built to move at speeds beyond our capacity. Even with computers and other gadgets we can not be pushed gracefully to achieve more than a certain amount of volume per day. After all, we still need to sleep, eat, and play...

Pamela

some things i am thinking about and not sure how to put more into practice Wasson and Deb please your thoughts?I struggle quite frequenlty with quality / mistakes in an arena that seemsalmost nit picky to me However my sense is that it is not nit picking butgets at the heart of how we do medicine What I mean focusses on theinformation we share with each other I do a lot of skilled nursing home workMy patients come from 3 hospitals most of the timeThe dishcarge summaries are awful I am required in the NH setting to havea dx for each med( what a concept eh?!) and you know sometimes it is nearimpossible to figure out Now if the patient went on to that med during thestay from which they are being discharged well I think it should say soint he discharge summarySometimes it will say BUN was 1 and this is a typo but can we allowtypos?Saw a chart recently where it said a pregnant woman went to the er and"unfortunatley her pregnancy was not in jeopardy".Had a patietn admittedrecently with a questin of Lyme disease Presented to the er with rash etcThe H and P does not mention the rash No exam was recoreded. Etc etc WEhave all seen thisI cannot figure out to fix this My own hospital has been revamping itsquality imporvement measures and these seem to have nothing to do withwhat I am talking about- you know what gets focussed on is did thepneumonia patient get antibx within 4 hrs etc Much of what I think about is "small" and falls back to the memories of theprovider to get done and falls to their training-I get disch summaries fromthe tertiaty care hospital written by some poor resident who never metthe patietn in their 3 week stay and then had to do the summary...Thoughts please?I had some other thoughts as the title of the e mail said but I willmostly skip them for now tillI think 'em out better It was about "small"Small works so much better in so many ways I see 's post on theIMPS1 cohort than in a prior small office it was still seen tobeineffcient to a horroble degree but nevertheless i see that medicine getsbigger and bigger and though I mean small does nequal good/effcient itseems more likley to.. And other things I have to walk 1/4 mile to get milkinside the Shop n save. I liked it when the store was littlerThe Gore compnay in Delaware- makes goretex fabric a nd material for shuntsand grafts has no factory over 150 people They have a lot of employees butnever over 150 in a building People then know their collegues and are moreresponsible to eachother How/could we/should we? take medicien back to that?Wouldn't that get us to better care andless errros?

See the all-new, redesigned Yahoo.com. Check it out.

July 16, 2006

Matt,

What I find is that although time is

money, the time I spend doing billing is not during traditional clinical time.

In other words, I think its kind of comparing apples to oranges. For instance,

I am getting ready to do billing now (at 8:30pm on a Saturday after the kids have gone to bed). There is no way I

would be seeing patients at this time. Now you certainly could argue the point

about working all time, but I collected $220,000 last year with a collection

rate of 97.2% of allowable. Outsourcing would have cost me 8% of collections ($17,600),

but, given it would have been subtracted off my salary, it would have decreased

my salary 16.7% ($106,000-$17,600). Yes, I spend $100/month for autoposting through Gateway EDI, but that makes up less

than one tenth the difference. I also feel that a lot of billing companies go

for the low hanging fruit and will not work for the extra claims like I might. All

told, I hate billing, but until I feel like I am losing more than say $10-$15

thousand a year, I will continue doing it. Note for comparison: I see about 65-70

patients a week (4 ½ days).

Re:

thoughts on small and on quality

RE Time IS money.

" I don't like the idea of paying someone to

collect money for something I did. I do not like the idea of working 3-4

more hours seeing patients to pay someone to collect " my "

money. It could be used for other medical related services like a vial of

Tuber-sol, or go to a salary, mine or staff. However, technically no

difference between in house vs. outsourcing based on my availability of

time. "

If you can make MUCH more money in

same amount of time that it takes SOMEONE ELSE to do lower expertise work, then

it makes MORE sense to outsource it.

For ex, I didn't set up my billing

system, don't support the software for it, don't do the mailings, don't pay the

person. I pay a service to DO ALL THAT WORK for me while I generate

income at a much higher level/hour than I could afford to pay someone to do

this.

All depends on volumes. It's

not just the cost you'd pay to the billing service, but ALSO the cost to

support what you're doing already. For ex, YOU have to pay the $50/month

for the direct billing system for some of your work. If that cost you

$500/month, you might not do it.

If I was billing 3x as much, I might

want to bring it in-house.

Self-sufficiency is one thing-- you

may want to grow all of your own food, cut your own wood, or dig your own coal.

At this point, I'd buy it.

And I buy the billing service, for

now at least.

Each setup is different...

principles are similar.