re why provviding SNF care for specialists

[Guest guest]

sorry about earlier Sometiimes I type a whole note and it willnot send.

and i do not know how in teh em ail set up i have to save...

I think the trouble here is with Annie who has a heart of gold but needs a

script to avoid being a doormat.

Nurses are the first ones to protect their licenses Believe me they

understand

If the snf unit called me i would say oh my that is terrible the patietn

is in pain? Needs a commode? I can't legally do that since i am not the

admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?

Call me back if that does not help

(Another choice you have is to do the work then drop in in the am for a

minute or two and bill for the visit)

finally --call dr Oncology it is entirelyp ossible he has no idea the

nurses do not know his phone numbers or maybe he does not know how

incompetent his service is.

And finanlly rememebr the nurses-they --can call the m nusing home medical

director who assumes that responsibility

Next.patietn calls after seeing dr Heart about geting theirmeds " sure i can

hellp you with that . when can you come in? "

I fear for you Annie . you give it away all the time and then compalian

You may be enabling.

I understand that the medical situation in your neck of the woods is tougher

than here but you have more than twice as many patients as me and only see

the same number I do There is room .Respect yourself and patietns and

docotrs will respect you

I really am worried.

[Guest guest]

Hi

Thanks for your kind concern. I am with you on the “not

being a doormat”, and I too am REALLY worried.

The issue of refilling other doctors’

prescriptions is the most common problem (of the ones we are discussing here)

and I DO try to get people in to do this stuff. The newest twist (happened 4 times this

week) is that the Lexington market has been invaded by Medicare managed care plans as of the

end of 2005. Many of the local

specialists do not accept these plans (because they offered specialists only

85%of Medicare rates, tho’ they are paying PCPs

at 100% of MCR). So now, patients

are calling the specialists offices only to learn that they would have to pay

cash to go there. So they call me “Dr

Skaggs, Dr Bones won’t take my insurance anymore, so I need you to call

in my arthritis medicine and find me another specialist to go to. My pharmacy is….What?, why do I have to come in for that? I was just in your office in

January; that’s outrageous. I

shouldn’t have to come back to see you so soon!”

I try very hard to be non-confrontational

about this. I look in the charts

and see that I had told that person to come back in 3 months anyway, and remind

them that we need to recheck their elevated BP. I say “I understand that you are

getting frustrated. Why don’t

you think about what works best for you and call me back.” And even with all that pussy footing, I

got records requests from another PCP office

on 2 of those 4 people within 24 hours.

So now I have lost those 2 longstanding patients, have to give them

their “one free” copy of records (both over 200 pages) and have to

pay to mail them out. Needless to

say the next two got what they wanted: I just phoned in the refills.

The same thing happened about a year ago,

when a bunch of folks went on a mail order Rx plan that encourages the patient

to have the Dr’s office just

deal directly with the PBM. When I

continued my practice of giving the prescriptions to the patient and saying “You

need to place your own orders so you will have the info you need to track them

in case you orders don’t arrive”, boom, right off the bat several

people changed doctors (and two of them were “kind enough” to write

me letters to say they were sorry to leave because they think I am a great

doctor, but their lives are so busy that “good customer service” is

more important.) So now I just shut

up and manage their prescription services for them.

All that said, I

don’t want you to think that all my patients are jerks. Many are very kind, and are more than

willing to come in for any service. It just seems that they are the minority,

and they seem to be dying faster than I find new ones like them. (And of course they are all Medicare

beneficiaries)

As for the calls from Hospice and HH, my

new plan for that I that I will personally page Dr. So-and-so. I already tried it once this week and

the doc in question seemed genuinely shocked that I had been called. He went on

to say that he would take care of it and that if I got any other calls I should

direct them to him….we’ll see how well he follows thru, but it

seems a reasonable solution: let’s me stay a “good guy” to

the nurses and families by doing something for them, and gently redirects the

issue back where it belongs.

Hopefully over time it will cut down the calls to me.

Again, thanks for your concern Jean. I am really curious how you have more

visits out of the same size patient panel?

I am an outlier in my area in that I bring diabetics in Q3 months (even

the local endocrinologists only bring diabetics in Q6-12 months) and anybody

else on any prescription besides birth control pills or allergy meds Q6 months,

and I insist on a visit for any “sick” problem for which the

patient wants a prescription (never phone in Bactrim

for dysuria, or Zpack for

cough); “If you are sick enough to need a prescription, you are sick

enough to need a doctor visit.”

When I get pharmacy faxes to refill meds, I refuse, writing “Appointment

needed” on it and faxing it back. I don’t know how I could get

more visits unless I started saying “You scheduled today because you have

a cough. We will take care of that,

but you will have to come back to get your chronic medications refilled. I can’t do both today because your

insurance won’t pay me for two separate services on the same day.” As it is, most of my patients make

efforts to “dovetail” their services to get as much done in each

visit as possible. Makes perfect

sense to me, I try to do the same sort of thing in my life. Going to the store?

Take a list and get EVERYTHING in one trip, don’t run back 3 times a

week. But of course I expect to pay for every item in the cart…..Still, a PCP who

makes people come back next month for chronic care would be WAY outside the

norm in Lexington. How do

you get the number of visits up?

Annie

re

why provviding SNF care for specialists

sorry about earlier Sometiimes I type a whole note and

it willnot send.

and i do not know how in teh em ail set up i

have to save...

I think the trouble here is with Annie who

has a heart of gold but needs a

script to avoid being a doormat.

Nurses are the first ones to protect their

licenses Believe me they

understand

If the snf unit called me i would say oh my

that is terrible the patietn

is in pain? Needs a commode? I can't legally

do that since i am not the

admitting doc... Did you call teh hospital

operatro/ Dr Oncology's service?

Call me back if that does not help

(Another choice you have is to do the work then

drop in in the am for a

minute or two and bill for the visit)

finally --call dr Oncology it is entirelyp ossible

he has no idea the

nurses do not know his phone numbers or

maybe he does not know how

incompetent his service is.

And finanlly rememebr the nurses-they --can call

the m nusing home medical

director who assumes that responsibility

Next.patietn calls after seeing dr Heart about

geting theirmeds " sure i can

hellp you with that . when can you come in? "

I fear for you Annie . you give it away all

the time and then compalian

You may be enabling.

I understand that the medical situation in your

neck of the woods is tougher

than here but you have more than twice as

many patients as me and only see

the same number I do There is room .Respect

yourself and patietns and

docotrs will respect you

I really am worried.

[Guest guest]

Hi

Thanks for your kind concern. I am with you on the “not

being a doormat”, and I too am REALLY worried.

The issue of refilling other doctors’

prescriptions is the most common problem (of the ones we are discussing here)

and I DO try to get people in to do this stuff. The newest twist (happened 4 times this

week) is that the Lexington market has been invaded by Medicare managed care plans as of the

end of 2005. Many of the local

specialists do not accept these plans (because they offered specialists only

85%of Medicare rates, tho’ they are paying PCPs

at 100% of MCR). So now, patients

are calling the specialists offices only to learn that they would have to pay

cash to go there. So they call me “Dr

Skaggs, Dr Bones won’t take my insurance anymore, so I need you to call

in my arthritis medicine and find me another specialist to go to. My pharmacy is….What?, why do I have to come in for that? I was just in your office in

January; that’s outrageous. I

shouldn’t have to come back to see you so soon!”

I try very hard to be non-confrontational

about this. I look in the charts

and see that I had told that person to come back in 3 months anyway, and remind

them that we need to recheck their elevated BP. I say “I understand that you are

getting frustrated. Why don’t

you think about what works best for you and call me back.” And even with all that pussy footing, I

got records requests from another PCP office

on 2 of those 4 people within 24 hours.

So now I have lost those 2 longstanding patients, have to give them

their “one free” copy of records (both over 200 pages) and have to

pay to mail them out. Needless to

say the next two got what they wanted: I just phoned in the refills.

The same thing happened about a year ago,

when a bunch of folks went on a mail order Rx plan that encourages the patient

to have the Dr’s office just

deal directly with the PBM. When I

continued my practice of giving the prescriptions to the patient and saying “You

need to place your own orders so you will have the info you need to track them

in case you orders don’t arrive”, boom, right off the bat several

people changed doctors (and two of them were “kind enough” to write

me letters to say they were sorry to leave because they think I am a great

doctor, but their lives are so busy that “good customer service” is

more important.) So now I just shut

up and manage their prescription services for them.

All that said, I

don’t want you to think that all my patients are jerks. Many are very kind, and are more than

willing to come in for any service. It just seems that they are the minority,

and they seem to be dying faster than I find new ones like them. (And of course they are all Medicare

beneficiaries)

As for the calls from Hospice and HH, my

new plan for that I that I will personally page Dr. So-and-so. I already tried it once this week and

the doc in question seemed genuinely shocked that I had been called. He went on

to say that he would take care of it and that if I got any other calls I should

direct them to him….we’ll see how well he follows thru, but it

seems a reasonable solution: let’s me stay a “good guy” to

the nurses and families by doing something for them, and gently redirects the

issue back where it belongs.

Hopefully over time it will cut down the calls to me.

Again, thanks for your concern Jean. I am really curious how you have more

visits out of the same size patient panel?

I am an outlier in my area in that I bring diabetics in Q3 months (even

the local endocrinologists only bring diabetics in Q6-12 months) and anybody

else on any prescription besides birth control pills or allergy meds Q6 months,

and I insist on a visit for any “sick” problem for which the

patient wants a prescription (never phone in Bactrim

for dysuria, or Zpack for

cough); “If you are sick enough to need a prescription, you are sick

enough to need a doctor visit.”

When I get pharmacy faxes to refill meds, I refuse, writing “Appointment

needed” on it and faxing it back. I don’t know how I could get

more visits unless I started saying “You scheduled today because you have

a cough. We will take care of that,

but you will have to come back to get your chronic medications refilled. I can’t do both today because your

insurance won’t pay me for two separate services on the same day.” As it is, most of my patients make

efforts to “dovetail” their services to get as much done in each

visit as possible. Makes perfect

sense to me, I try to do the same sort of thing in my life. Going to the store?

Take a list and get EVERYTHING in one trip, don’t run back 3 times a

week. But of course I expect to pay for every item in the cart…..Still, a PCP who

makes people come back next month for chronic care would be WAY outside the

norm in Lexington. How do

you get the number of visits up?

Annie

re

why provviding SNF care for specialists

sorry about earlier Sometiimes I type a whole note and

it willnot send.

and i do not know how in teh em ail set up i

have to save...

I think the trouble here is with Annie who

has a heart of gold but needs a

script to avoid being a doormat.

Nurses are the first ones to protect their

licenses Believe me they

understand

If the snf unit called me i would say oh my

that is terrible the patietn

is in pain? Needs a commode? I can't legally

do that since i am not the

admitting doc... Did you call teh hospital

operatro/ Dr Oncology's service?

Call me back if that does not help

(Another choice you have is to do the work then

drop in in the am for a

minute or two and bill for the visit)

finally --call dr Oncology it is entirelyp ossible

he has no idea the

nurses do not know his phone numbers or

maybe he does not know how

incompetent his service is.

And finanlly rememebr the nurses-they --can call

the m nusing home medical

director who assumes that responsibility

Next.patietn calls after seeing dr Heart about

geting theirmeds " sure i can

hellp you with that . when can you come in? "

I fear for you Annie . you give it away all

the time and then compalian

You may be enabling.

I understand that the medical situation in your

neck of the woods is tougher

than here but you have more than twice as

many patients as me and only see

the same number I do There is room .Respect

yourself and patietns and

docotrs will respect you

I really am worried.

[Guest guest]

Hi

Thanks for your kind concern. I am with you on the “not

being a doormat”, and I too am REALLY worried.

The issue of refilling other doctors’

prescriptions is the most common problem (of the ones we are discussing here)

and I DO try to get people in to do this stuff. The newest twist (happened 4 times this

week) is that the Lexington market has been invaded by Medicare managed care plans as of the

end of 2005. Many of the local

specialists do not accept these plans (because they offered specialists only

85%of Medicare rates, tho’ they are paying PCPs

at 100% of MCR). So now, patients

are calling the specialists offices only to learn that they would have to pay

cash to go there. So they call me “Dr

Skaggs, Dr Bones won’t take my insurance anymore, so I need you to call

in my arthritis medicine and find me another specialist to go to. My pharmacy is….What?, why do I have to come in for that? I was just in your office in

January; that’s outrageous. I

shouldn’t have to come back to see you so soon!”

I try very hard to be non-confrontational

about this. I look in the charts

and see that I had told that person to come back in 3 months anyway, and remind

them that we need to recheck their elevated BP. I say “I understand that you are

getting frustrated. Why don’t

you think about what works best for you and call me back.” And even with all that pussy footing, I

got records requests from another PCP office

on 2 of those 4 people within 24 hours.

So now I have lost those 2 longstanding patients, have to give them

their “one free” copy of records (both over 200 pages) and have to

pay to mail them out. Needless to

say the next two got what they wanted: I just phoned in the refills.

The same thing happened about a year ago,

when a bunch of folks went on a mail order Rx plan that encourages the patient

to have the Dr’s office just

deal directly with the PBM. When I

continued my practice of giving the prescriptions to the patient and saying “You

need to place your own orders so you will have the info you need to track them

in case you orders don’t arrive”, boom, right off the bat several

people changed doctors (and two of them were “kind enough” to write

me letters to say they were sorry to leave because they think I am a great

doctor, but their lives are so busy that “good customer service” is

more important.) So now I just shut

up and manage their prescription services for them.

All that said, I

don’t want you to think that all my patients are jerks. Many are very kind, and are more than

willing to come in for any service. It just seems that they are the minority,

and they seem to be dying faster than I find new ones like them. (And of course they are all Medicare

beneficiaries)

As for the calls from Hospice and HH, my

new plan for that I that I will personally page Dr. So-and-so. I already tried it once this week and

the doc in question seemed genuinely shocked that I had been called. He went on

to say that he would take care of it and that if I got any other calls I should

direct them to him….we’ll see how well he follows thru, but it

seems a reasonable solution: let’s me stay a “good guy” to

the nurses and families by doing something for them, and gently redirects the

issue back where it belongs.

Hopefully over time it will cut down the calls to me.

Again, thanks for your concern Jean. I am really curious how you have more

visits out of the same size patient panel?

I am an outlier in my area in that I bring diabetics in Q3 months (even

the local endocrinologists only bring diabetics in Q6-12 months) and anybody

else on any prescription besides birth control pills or allergy meds Q6 months,

and I insist on a visit for any “sick” problem for which the

patient wants a prescription (never phone in Bactrim

for dysuria, or Zpack for

cough); “If you are sick enough to need a prescription, you are sick

enough to need a doctor visit.”

When I get pharmacy faxes to refill meds, I refuse, writing “Appointment

needed” on it and faxing it back. I don’t know how I could get

more visits unless I started saying “You scheduled today because you have

a cough. We will take care of that,

but you will have to come back to get your chronic medications refilled. I can’t do both today because your

insurance won’t pay me for two separate services on the same day.” As it is, most of my patients make

efforts to “dovetail” their services to get as much done in each

visit as possible. Makes perfect

sense to me, I try to do the same sort of thing in my life. Going to the store?

Take a list and get EVERYTHING in one trip, don’t run back 3 times a

week. But of course I expect to pay for every item in the cart…..Still, a PCP who

makes people come back next month for chronic care would be WAY outside the

norm in Lexington. How do

you get the number of visits up?

Annie

re

why provviding SNF care for specialists

sorry about earlier Sometiimes I type a whole note and

it willnot send.

and i do not know how in teh em ail set up i

have to save...

I think the trouble here is with Annie who

has a heart of gold but needs a

script to avoid being a doormat.

Nurses are the first ones to protect their

licenses Believe me they

understand

If the snf unit called me i would say oh my

that is terrible the patietn

is in pain? Needs a commode? I can't legally

do that since i am not the

admitting doc... Did you call teh hospital

operatro/ Dr Oncology's service?

Call me back if that does not help

(Another choice you have is to do the work then

drop in in the am for a

minute or two and bill for the visit)

finally --call dr Oncology it is entirelyp ossible

he has no idea the

nurses do not know his phone numbers or

maybe he does not know how

incompetent his service is.

And finanlly rememebr the nurses-they --can call

the m nusing home medical

director who assumes that responsibility

Next.patietn calls after seeing dr Heart about

geting theirmeds " sure i can

hellp you with that . when can you come in? "

I fear for you Annie . you give it away all

the time and then compalian

You may be enabling.

I understand that the medical situation in your

neck of the woods is tougher

than here but you have more than twice as

many patients as me and only see

the same number I do There is room .Respect

yourself and patietns and

docotrs will respect you

I really am worried.

[Guest guest]

RE Appropriate follow up and appropriate visits.

1) I do NOT refill meds of specialists, EVER. IF that doc is following the condition, THEY need to write the refills. Period. If you rewrite those meds, it's YOUR responsibility to FOLLOW THAT CONDITION.

I won't write for rheumatrex, placquinil, etc. I don't write or start pts on Coreg, risk of hypotension is in the literature, I'll leave it to the Cardiologists. If a local cardiologist would tell a pt after seeing them for ME to write the meds, I send the pt BACK to that office; THEY need to follow their pts for those conditions, NO EXCEPTIONS.

At times, a pt may have an upcoming appt with a specialist, and if I have a letter from the specialist, and pt seeing me, RARELY I'll write a 1 month refill. My medication lists in my EMR are annotated with WHICH DOC is following which medication, pts get a copy of this. Pharmacies DO call (or fax-- we usually call anyway) for refills of specialist meds-- we call the pt and have THEM call the specialist.

Others in my area do differently. That's up to them. My area has a deficit of accessable primary care docs, so perhaps things are different for me than Annie.

2) Recheck visits and volumes-- I do try whenever possible to have pts see me for acutes, and we'll do chronic care at the same time, time permitting. Using an EMR makes this possible, as I can address the acute problem extensively, then upgrade the chronic problem, like checking HTN, high cholesterol, hypothyroidism if due for recheck within a month, let's say.

Well care-- we check with the major insurers (2 of them we can check on-line) to see what the benefit covers. I don't check AT the time of acute visit, but am compulsive with my office staff to check that status yearly. I mark in the chart as a "problem" when the well care was last updated, and do this about 1 year and a day to be sure I don't get rejected. Perhaps I'm more fortunate than most, but am able to get paid for many of these.

So for those that will pay "either or," I'll follow up on the chronic issue peripherally, then do the well care as the main issue for the visit. I DON'T write a separate note.

3) Others don't do well care at 3 months for unstable conditions? SHAME ON THEM!! You should. Those pts who don't want the regular care SHOULD GO ELSEWHERE. If you look at your entire patient panel, probably not many of these "problem pts" and should cull them out. Don't be surprised if some come back to your door when they can't get in with their "new doc" if they get sick-- and if they don't, too bad for them.

4) Mailorder accommodation-- I've unfortunately had to "cave" for faxing for some of these pts, BUT I INSIST that we get a "fax master" from the company. Pts NEED to do their part, by contacting that company and have them fax a refill request TO us. MANY MANY TIMES, these have errors (still my old address on many of them since I started out in Dec 2004 on my own). We found that no matter HOW we altered these masters, they were NOT changed by the Mailorder Pharmacy, so we will NOT fax order without a corrected master.

Biggest problem is pts that read "your doc CAN reorder UP TO 1 YEAR" as your doc MUST reorder 1 YEAR OF MEDICINE. This of course results in a pt NOT coming back for a year!!! I had one recently telling me "sure, doc, I'll come back in 3 months, but give me 6 months -- AFTER they showed up last time 8 months later. I expect this pt will NOT be coming back, and I have reconciled that I'll loose that one.

But 1 pt is NOT equal to 5. My objective review of these outliers is that for every 1 inappropriate pt, there's 5 we forget about, that are respectful, and appropriate. I'll be there for THEM, the others can get lower quality care, as that's really all THEY care about anyway.

Annie just caught me at a pragmatic time!

Dr Matt Levin

Pittsburgh, PA

re why provviding SNF care for specialists

sorry about earlier Sometiimes I type a whole note and it willnot send.and i do not know how in teh em ail set up i have to save...I think the trouble here is with Annie who has a heart of gold but needs ascript to avoid being a doormat.Nurses are the first ones to protect their licenses Believe me theyunderstandIf the snf unit called me i would say oh my that is terrible the patietnis in pain? Needs a commode? I can't legally do that since i am not theadmitting doc... Did you call teh hospital operatro/ Dr Oncology's service?Call me back if that does not help(Another choice you have is to do the work then drop in in the am for aminute or two and bill for the visit)finally --call dr Oncology it is entirelyp ossible he has no idea thenurses do not know his phone numbers or maybe he does not know howincompetent his service is.And finanlly rememebr the nurses-they --can call the m nusing home medicaldirector who assumes that responsibilityNext.patietn calls after seeing dr Heart about geting theirmeds "sure i canhellp you with that . when can you come in?"I fear for you Annie . you give it away all the time and then compalianYou may be enabling.I understand that the medical situation in your neck of the woods is tougherthan here but you have more than twice as many patients as me and only seethe same number I do There is room .Respect yourself and patietns anddocotrs will respect youI really am worried.

[Guest guest]

RE Appropriate follow up and appropriate visits.

1) I do NOT refill meds of specialists, EVER. IF that doc is following the condition, THEY need to write the refills. Period. If you rewrite those meds, it's YOUR responsibility to FOLLOW THAT CONDITION.

I won't write for rheumatrex, placquinil, etc. I don't write or start pts on Coreg, risk of hypotension is in the literature, I'll leave it to the Cardiologists. If a local cardiologist would tell a pt after seeing them for ME to write the meds, I send the pt BACK to that office; THEY need to follow their pts for those conditions, NO EXCEPTIONS.

At times, a pt may have an upcoming appt with a specialist, and if I have a letter from the specialist, and pt seeing me, RARELY I'll write a 1 month refill. My medication lists in my EMR are annotated with WHICH DOC is following which medication, pts get a copy of this. Pharmacies DO call (or fax-- we usually call anyway) for refills of specialist meds-- we call the pt and have THEM call the specialist.

Others in my area do differently. That's up to them. My area has a deficit of accessable primary care docs, so perhaps things are different for me than Annie.

2) Recheck visits and volumes-- I do try whenever possible to have pts see me for acutes, and we'll do chronic care at the same time, time permitting. Using an EMR makes this possible, as I can address the acute problem extensively, then upgrade the chronic problem, like checking HTN, high cholesterol, hypothyroidism if due for recheck within a month, let's say.

Well care-- we check with the major insurers (2 of them we can check on-line) to see what the benefit covers. I don't check AT the time of acute visit, but am compulsive with my office staff to check that status yearly. I mark in the chart as a "problem" when the well care was last updated, and do this about 1 year and a day to be sure I don't get rejected. Perhaps I'm more fortunate than most, but am able to get paid for many of these.

So for those that will pay "either or," I'll follow up on the chronic issue peripherally, then do the well care as the main issue for the visit. I DON'T write a separate note.

3) Others don't do well care at 3 months for unstable conditions? SHAME ON THEM!! You should. Those pts who don't want the regular care SHOULD GO ELSEWHERE. If you look at your entire patient panel, probably not many of these "problem pts" and should cull them out. Don't be surprised if some come back to your door when they can't get in with their "new doc" if they get sick-- and if they don't, too bad for them.

4) Mailorder accommodation-- I've unfortunately had to "cave" for faxing for some of these pts, BUT I INSIST that we get a "fax master" from the company. Pts NEED to do their part, by contacting that company and have them fax a refill request TO us. MANY MANY TIMES, these have errors (still my old address on many of them since I started out in Dec 2004 on my own). We found that no matter HOW we altered these masters, they were NOT changed by the Mailorder Pharmacy, so we will NOT fax order without a corrected master.

Biggest problem is pts that read "your doc CAN reorder UP TO 1 YEAR" as your doc MUST reorder 1 YEAR OF MEDICINE. This of course results in a pt NOT coming back for a year!!! I had one recently telling me "sure, doc, I'll come back in 3 months, but give me 6 months -- AFTER they showed up last time 8 months later. I expect this pt will NOT be coming back, and I have reconciled that I'll loose that one.

But 1 pt is NOT equal to 5. My objective review of these outliers is that for every 1 inappropriate pt, there's 5 we forget about, that are respectful, and appropriate. I'll be there for THEM, the others can get lower quality care, as that's really all THEY care about anyway.

Annie just caught me at a pragmatic time!

Dr Matt Levin

Pittsburgh, PA

re why provviding SNF care for specialists

sorry about earlier Sometiimes I type a whole note and it willnot send.and i do not know how in teh em ail set up i have to save...I think the trouble here is with Annie who has a heart of gold but needs ascript to avoid being a doormat.Nurses are the first ones to protect their licenses Believe me theyunderstandIf the snf unit called me i would say oh my that is terrible the patietnis in pain? Needs a commode? I can't legally do that since i am not theadmitting doc... Did you call teh hospital operatro/ Dr Oncology's service?Call me back if that does not help(Another choice you have is to do the work then drop in in the am for aminute or two and bill for the visit)finally --call dr Oncology it is entirelyp ossible he has no idea thenurses do not know his phone numbers or maybe he does not know howincompetent his service is.And finanlly rememebr the nurses-they --can call the m nusing home medicaldirector who assumes that responsibilityNext.patietn calls after seeing dr Heart about geting theirmeds "sure i canhellp you with that . when can you come in?"I fear for you Annie . you give it away all the time and then compalianYou may be enabling.I understand that the medical situation in your neck of the woods is tougherthan here but you have more than twice as many patients as me and only seethe same number I do There is room .Respect yourself and patietns anddocotrs will respect youI really am worried.

[Guest guest]

RE Appropriate follow up and appropriate visits.

1) I do NOT refill meds of specialists, EVER. IF that doc is following the condition, THEY need to write the refills. Period. If you rewrite those meds, it's YOUR responsibility to FOLLOW THAT CONDITION.

I won't write for rheumatrex, placquinil, etc. I don't write or start pts on Coreg, risk of hypotension is in the literature, I'll leave it to the Cardiologists. If a local cardiologist would tell a pt after seeing them for ME to write the meds, I send the pt BACK to that office; THEY need to follow their pts for those conditions, NO EXCEPTIONS.

At times, a pt may have an upcoming appt with a specialist, and if I have a letter from the specialist, and pt seeing me, RARELY I'll write a 1 month refill. My medication lists in my EMR are annotated with WHICH DOC is following which medication, pts get a copy of this. Pharmacies DO call (or fax-- we usually call anyway) for refills of specialist meds-- we call the pt and have THEM call the specialist.

Others in my area do differently. That's up to them. My area has a deficit of accessable primary care docs, so perhaps things are different for me than Annie.

2) Recheck visits and volumes-- I do try whenever possible to have pts see me for acutes, and we'll do chronic care at the same time, time permitting. Using an EMR makes this possible, as I can address the acute problem extensively, then upgrade the chronic problem, like checking HTN, high cholesterol, hypothyroidism if due for recheck within a month, let's say.

Well care-- we check with the major insurers (2 of them we can check on-line) to see what the benefit covers. I don't check AT the time of acute visit, but am compulsive with my office staff to check that status yearly. I mark in the chart as a "problem" when the well care was last updated, and do this about 1 year and a day to be sure I don't get rejected. Perhaps I'm more fortunate than most, but am able to get paid for many of these.

So for those that will pay "either or," I'll follow up on the chronic issue peripherally, then do the well care as the main issue for the visit. I DON'T write a separate note.

3) Others don't do well care at 3 months for unstable conditions? SHAME ON THEM!! You should. Those pts who don't want the regular care SHOULD GO ELSEWHERE. If you look at your entire patient panel, probably not many of these "problem pts" and should cull them out. Don't be surprised if some come back to your door when they can't get in with their "new doc" if they get sick-- and if they don't, too bad for them.

4) Mailorder accommodation-- I've unfortunately had to "cave" for faxing for some of these pts, BUT I INSIST that we get a "fax master" from the company. Pts NEED to do their part, by contacting that company and have them fax a refill request TO us. MANY MANY TIMES, these have errors (still my old address on many of them since I started out in Dec 2004 on my own). We found that no matter HOW we altered these masters, they were NOT changed by the Mailorder Pharmacy, so we will NOT fax order without a corrected master.

Biggest problem is pts that read "your doc CAN reorder UP TO 1 YEAR" as your doc MUST reorder 1 YEAR OF MEDICINE. This of course results in a pt NOT coming back for a year!!! I had one recently telling me "sure, doc, I'll come back in 3 months, but give me 6 months -- AFTER they showed up last time 8 months later. I expect this pt will NOT be coming back, and I have reconciled that I'll loose that one.

But 1 pt is NOT equal to 5. My objective review of these outliers is that for every 1 inappropriate pt, there's 5 we forget about, that are respectful, and appropriate. I'll be there for THEM, the others can get lower quality care, as that's really all THEY care about anyway.

Annie just caught me at a pragmatic time!

Dr Matt Levin

Pittsburgh, PA

re why provviding SNF care for specialists

sorry about earlier Sometiimes I type a whole note and it willnot send.and i do not know how in teh em ail set up i have to save...I think the trouble here is with Annie who has a heart of gold but needs ascript to avoid being a doormat.Nurses are the first ones to protect their licenses Believe me theyunderstandIf the snf unit called me i would say oh my that is terrible the patietnis in pain? Needs a commode? I can't legally do that since i am not theadmitting doc... Did you call teh hospital operatro/ Dr Oncology's service?Call me back if that does not help(Another choice you have is to do the work then drop in in the am for aminute or two and bill for the visit)finally --call dr Oncology it is entirelyp ossible he has no idea thenurses do not know his phone numbers or maybe he does not know howincompetent his service is.And finanlly rememebr the nurses-they --can call the m nusing home medicaldirector who assumes that responsibilityNext.patietn calls after seeing dr Heart about geting theirmeds "sure i canhellp you with that . when can you come in?"I fear for you Annie . you give it away all the time and then compalianYou may be enabling.I understand that the medical situation in your neck of the woods is tougherthan here but you have more than twice as many patients as me and only seethe same number I do There is room .Respect yourself and patietns anddocotrs will respect youI really am worried.

[Guest guest]

I'm not clear on what you mean by point #1, I think maybe I'm misunderstanding.

It would be difficult to be a primary care doctor and never refill any meds,

ever, that some other specialist started the patient on. Actually, I find the

reverse to be most common: a patient wants a refill of a med while at the

specialists & they say to follow up with your regular doctoir for that. I can

see certain meds, like methotrextate in RA, chronic opioids, etc, that I would

not prescribe. But if you refer to a cardiologist, they start the patient on

Lipitor & Norvasc & tell them to follow up with you, then you would not refill

those? If you have a patient that sees an endocrinologist 1-2x/yr for thyroid,

then you would not refill their Synthroid, ever? I could never get away with

that where I'm at.

>

>

> Date: 2006/03/12 Sun AM 09:56:40 EST

> To: < >

> Subject: Re: re why provviding SNF care for specialists

>

> RE Appropriate follow up and appropriate visits.

>

> 1) I do NOT refill meds of specialists, EVER. IF that doc is following the

condition, THEY need to write the refills. Period. If you rewrite those meds,

it's YOUR responsibility to FOLLOW THAT CONDITION.

>

> I won't write for rheumatrex, placquinil, etc. I don't write or start pts on

Coreg, risk of hypotension is in the literature, I'll leave it to the

Cardiologists. If a local cardiologist would tell a pt after seeing them for ME

to write the meds, I send the pt BACK to that office; THEY need to follow their

pts for those conditions, NO EXCEPTIONS.

>

> At times, a pt may have an upcoming appt with a specialist, and if I have a

letter from the specialist, and pt seeing me, RARELY I'll write a 1 month

refill. My medication lists in my EMR are annotated with WHICH DOC is following

which medication, pts get a copy of this. Pharmacies DO call (or fax-- we

usually call anyway) for refills of specialist meds-- we call the pt and have

THEM call the specialist.

>

> Others in my area do differently. That's up to them. My area has a deficit

of accessable primary care docs, so perhaps things are different for me than

Annie.

>

> 2) Recheck visits and volumes-- I do try whenever possible to have pts see me

for acutes, and we'll do chronic care at the same time, time permitting. Using

an EMR makes this possible, as I can address the acute problem extensively, then

upgrade the chronic problem, like checking HTN, high cholesterol, hypothyroidism

if due for recheck within a month, let's say.

>

> Well care-- we check with the major insurers (2 of them we can check on-line)

to see what the benefit covers. I don't check AT the time of acute visit, but

am compulsive with my office staff to check that status yearly. I mark in the

chart as a " problem " when the well care was last updated, and do this about 1

year and a day to be sure I don't get rejected. Perhaps I'm more fortunate than

most, but am able to get paid for many of these.

>

> So for those that will pay " either or, " I'll follow up on the chronic issue

peripherally, then do the well care as the main issue for the visit. I DON'T

write a separate note.

>

> 3) Others don't do well care at 3 months for unstable conditions? SHAME ON

THEM!! You should. Those pts who don't want the regular care SHOULD GO

ELSEWHERE. If you look at your entire patient panel, probably not many of these

" problem pts " and should cull them out. Don't be surprised if some come back to

your door when they can't get in with their " new doc " if they get sick-- and if

they don't, too bad for them.

>

> 4) Mailorder accommodation-- I've unfortunately had to " cave " for faxing for

some of these pts, BUT I INSIST that we get a " fax master " from the company.

Pts NEED to do their part, by contacting that company and have them fax a refill

request TO us. MANY MANY TIMES, these have errors (still my old address on many

of them since I started out in Dec 2004 on my own). We found that no matter HOW

we altered these masters, they were NOT changed by the Mailorder Pharmacy, so we

will NOT fax order without a corrected master.

>

> Biggest problem is pts that read " your doc CAN reorder UP TO 1 YEAR " as your

doc MUST reorder 1 YEAR OF MEDICINE. This of course results in a pt NOT coming

back for a year!!! I had one recently telling me " sure, doc, I'll come back in

3 months, but give me 6 months -- AFTER they showed up last time 8 months later.

I expect this pt will NOT be coming back, and I have reconciled that I'll loose

that one.

>

> But 1 pt is NOT equal to 5. My objective review of these outliers is that for

every 1 inappropriate pt, there's 5 we forget about, that are respectful, and

appropriate. I'll be there for THEM, the others can get lower quality care, as

that's really all THEY care about anyway.

>

> Annie just caught me at a pragmatic time!

>

> Dr Matt Levin

> Pittsburgh, PA

> re why provviding SNF care for specialists

>

>

>

> sorry about earlier Sometiimes I type a whole note and it willnot send.

> and i do not know how in teh em ail set up i have to save...

>

> I think the trouble here is with Annie who has a heart of gold but needs a

> script to avoid being a doormat.

>

> Nurses are the first ones to protect their licenses Believe me they

> understand

> If the snf unit called me i would say oh my that is terrible the patietn

> is in pain? Needs a commode? I can't legally do that since i am not the

> admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?

> Call me back if that does not help

> (Another choice you have is to do the work then drop in in the am for a

> minute or two and bill for the visit)

> finally --call dr Oncology it is entirelyp ossible he has no idea the

> nurses do not know his phone numbers or maybe he does not know how

> incompetent his service is.

>

> And finanlly rememebr the nurses-they --can call the m nusing home medical

> director who assumes that responsibility

>

> Next.patietn calls after seeing dr Heart about geting theirmeds " sure i can

> hellp you with that . when can you come in? "

> I fear for you Annie . you give it away all the time and then compalian

> You may be enabling.

> I understand that the medical situation in your neck of the woods is tougher

> than here but you have more than twice as many patients as me and only see

> the same number I do There is room .Respect yourself and patietns and

> docotrs will respect you

>

> I really am worried.

>

>

>

>

>

>

[Guest guest]

I'm not clear on what you mean by point #1, I think maybe I'm misunderstanding.

It would be difficult to be a primary care doctor and never refill any meds,

ever, that some other specialist started the patient on. Actually, I find the

reverse to be most common: a patient wants a refill of a med while at the

specialists & they say to follow up with your regular doctoir for that. I can

see certain meds, like methotrextate in RA, chronic opioids, etc, that I would

not prescribe. But if you refer to a cardiologist, they start the patient on

Lipitor & Norvasc & tell them to follow up with you, then you would not refill

those? If you have a patient that sees an endocrinologist 1-2x/yr for thyroid,

then you would not refill their Synthroid, ever? I could never get away with

that where I'm at.

>

>

> Date: 2006/03/12 Sun AM 09:56:40 EST

> To: < >

> Subject: Re: re why provviding SNF care for specialists

>

> RE Appropriate follow up and appropriate visits.

>

> 1) I do NOT refill meds of specialists, EVER. IF that doc is following the

condition, THEY need to write the refills. Period. If you rewrite those meds,

it's YOUR responsibility to FOLLOW THAT CONDITION.

>

> I won't write for rheumatrex, placquinil, etc. I don't write or start pts on

Coreg, risk of hypotension is in the literature, I'll leave it to the

Cardiologists. If a local cardiologist would tell a pt after seeing them for ME

to write the meds, I send the pt BACK to that office; THEY need to follow their

pts for those conditions, NO EXCEPTIONS.

>

> At times, a pt may have an upcoming appt with a specialist, and if I have a

letter from the specialist, and pt seeing me, RARELY I'll write a 1 month

refill. My medication lists in my EMR are annotated with WHICH DOC is following

which medication, pts get a copy of this. Pharmacies DO call (or fax-- we

usually call anyway) for refills of specialist meds-- we call the pt and have

THEM call the specialist.

>

> Others in my area do differently. That's up to them. My area has a deficit

of accessable primary care docs, so perhaps things are different for me than

Annie.

>

> 2) Recheck visits and volumes-- I do try whenever possible to have pts see me

for acutes, and we'll do chronic care at the same time, time permitting. Using

an EMR makes this possible, as I can address the acute problem extensively, then

upgrade the chronic problem, like checking HTN, high cholesterol, hypothyroidism

if due for recheck within a month, let's say.

>

> Well care-- we check with the major insurers (2 of them we can check on-line)

to see what the benefit covers. I don't check AT the time of acute visit, but

am compulsive with my office staff to check that status yearly. I mark in the

chart as a " problem " when the well care was last updated, and do this about 1

year and a day to be sure I don't get rejected. Perhaps I'm more fortunate than

most, but am able to get paid for many of these.

>

> So for those that will pay " either or, " I'll follow up on the chronic issue

peripherally, then do the well care as the main issue for the visit. I DON'T

write a separate note.

>

> 3) Others don't do well care at 3 months for unstable conditions? SHAME ON

THEM!! You should. Those pts who don't want the regular care SHOULD GO

ELSEWHERE. If you look at your entire patient panel, probably not many of these

" problem pts " and should cull them out. Don't be surprised if some come back to

your door when they can't get in with their " new doc " if they get sick-- and if

they don't, too bad for them.

>

> 4) Mailorder accommodation-- I've unfortunately had to " cave " for faxing for

some of these pts, BUT I INSIST that we get a " fax master " from the company.

Pts NEED to do their part, by contacting that company and have them fax a refill

request TO us. MANY MANY TIMES, these have errors (still my old address on many

of them since I started out in Dec 2004 on my own). We found that no matter HOW

we altered these masters, they were NOT changed by the Mailorder Pharmacy, so we

will NOT fax order without a corrected master.

>

> Biggest problem is pts that read " your doc CAN reorder UP TO 1 YEAR " as your

doc MUST reorder 1 YEAR OF MEDICINE. This of course results in a pt NOT coming

back for a year!!! I had one recently telling me " sure, doc, I'll come back in

3 months, but give me 6 months -- AFTER they showed up last time 8 months later.

I expect this pt will NOT be coming back, and I have reconciled that I'll loose

that one.

>

> But 1 pt is NOT equal to 5. My objective review of these outliers is that for

every 1 inappropriate pt, there's 5 we forget about, that are respectful, and

appropriate. I'll be there for THEM, the others can get lower quality care, as

that's really all THEY care about anyway.

>

> Annie just caught me at a pragmatic time!

>

> Dr Matt Levin

> Pittsburgh, PA

> re why provviding SNF care for specialists

>

>

>

> sorry about earlier Sometiimes I type a whole note and it willnot send.

> and i do not know how in teh em ail set up i have to save...

>

> I think the trouble here is with Annie who has a heart of gold but needs a

> script to avoid being a doormat.

>

> Nurses are the first ones to protect their licenses Believe me they

> understand

> If the snf unit called me i would say oh my that is terrible the patietn

> is in pain? Needs a commode? I can't legally do that since i am not the

> admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?

> Call me back if that does not help

> (Another choice you have is to do the work then drop in in the am for a

> minute or two and bill for the visit)

> finally --call dr Oncology it is entirelyp ossible he has no idea the

> nurses do not know his phone numbers or maybe he does not know how

> incompetent his service is.

>

> And finanlly rememebr the nurses-they --can call the m nusing home medical

> director who assumes that responsibility

>

> Next.patietn calls after seeing dr Heart about geting theirmeds " sure i can

> hellp you with that . when can you come in? "

> I fear for you Annie . you give it away all the time and then compalian

> You may be enabling.

> I understand that the medical situation in your neck of the woods is tougher

> than here but you have more than twice as many patients as me and only see

> the same number I do There is room .Respect yourself and patietns and

> docotrs will respect you

>

> I really am worried.

>

>

>

>

>

>

[Guest guest]

I'm not clear on what you mean by point #1, I think maybe I'm misunderstanding.

It would be difficult to be a primary care doctor and never refill any meds,

ever, that some other specialist started the patient on. Actually, I find the

reverse to be most common: a patient wants a refill of a med while at the

specialists & they say to follow up with your regular doctoir for that. I can

see certain meds, like methotrextate in RA, chronic opioids, etc, that I would

not prescribe. But if you refer to a cardiologist, they start the patient on

Lipitor & Norvasc & tell them to follow up with you, then you would not refill

those? If you have a patient that sees an endocrinologist 1-2x/yr for thyroid,

then you would not refill their Synthroid, ever? I could never get away with

that where I'm at.

>

>

> Date: 2006/03/12 Sun AM 09:56:40 EST

> To: < >

> Subject: Re: re why provviding SNF care for specialists

>

> RE Appropriate follow up and appropriate visits.

>

> 1) I do NOT refill meds of specialists, EVER. IF that doc is following the

condition, THEY need to write the refills. Period. If you rewrite those meds,

it's YOUR responsibility to FOLLOW THAT CONDITION.

>

> I won't write for rheumatrex, placquinil, etc. I don't write or start pts on

Coreg, risk of hypotension is in the literature, I'll leave it to the

Cardiologists. If a local cardiologist would tell a pt after seeing them for ME

to write the meds, I send the pt BACK to that office; THEY need to follow their

pts for those conditions, NO EXCEPTIONS.

>

> At times, a pt may have an upcoming appt with a specialist, and if I have a

letter from the specialist, and pt seeing me, RARELY I'll write a 1 month

refill. My medication lists in my EMR are annotated with WHICH DOC is following

which medication, pts get a copy of this. Pharmacies DO call (or fax-- we

usually call anyway) for refills of specialist meds-- we call the pt and have

THEM call the specialist.

>

> Others in my area do differently. That's up to them. My area has a deficit

of accessable primary care docs, so perhaps things are different for me than

Annie.

>

> 2) Recheck visits and volumes-- I do try whenever possible to have pts see me

for acutes, and we'll do chronic care at the same time, time permitting. Using

an EMR makes this possible, as I can address the acute problem extensively, then

upgrade the chronic problem, like checking HTN, high cholesterol, hypothyroidism

if due for recheck within a month, let's say.

>

> Well care-- we check with the major insurers (2 of them we can check on-line)

to see what the benefit covers. I don't check AT the time of acute visit, but

am compulsive with my office staff to check that status yearly. I mark in the

chart as a " problem " when the well care was last updated, and do this about 1

year and a day to be sure I don't get rejected. Perhaps I'm more fortunate than

most, but am able to get paid for many of these.

>

> So for those that will pay " either or, " I'll follow up on the chronic issue

peripherally, then do the well care as the main issue for the visit. I DON'T

write a separate note.

>

> 3) Others don't do well care at 3 months for unstable conditions? SHAME ON

THEM!! You should. Those pts who don't want the regular care SHOULD GO

ELSEWHERE. If you look at your entire patient panel, probably not many of these

" problem pts " and should cull them out. Don't be surprised if some come back to

your door when they can't get in with their " new doc " if they get sick-- and if

they don't, too bad for them.

>

> 4) Mailorder accommodation-- I've unfortunately had to " cave " for faxing for

some of these pts, BUT I INSIST that we get a " fax master " from the company.

Pts NEED to do their part, by contacting that company and have them fax a refill

request TO us. MANY MANY TIMES, these have errors (still my old address on many

of them since I started out in Dec 2004 on my own). We found that no matter HOW

we altered these masters, they were NOT changed by the Mailorder Pharmacy, so we

will NOT fax order without a corrected master.

>

> Biggest problem is pts that read " your doc CAN reorder UP TO 1 YEAR " as your

doc MUST reorder 1 YEAR OF MEDICINE. This of course results in a pt NOT coming

back for a year!!! I had one recently telling me " sure, doc, I'll come back in

3 months, but give me 6 months -- AFTER they showed up last time 8 months later.

I expect this pt will NOT be coming back, and I have reconciled that I'll loose

that one.

>

> But 1 pt is NOT equal to 5. My objective review of these outliers is that for

every 1 inappropriate pt, there's 5 we forget about, that are respectful, and

appropriate. I'll be there for THEM, the others can get lower quality care, as

that's really all THEY care about anyway.

>

> Annie just caught me at a pragmatic time!

>

> Dr Matt Levin

> Pittsburgh, PA

> re why provviding SNF care for specialists

>

>

>

> sorry about earlier Sometiimes I type a whole note and it willnot send.

> and i do not know how in teh em ail set up i have to save...

>

> I think the trouble here is with Annie who has a heart of gold but needs a

> script to avoid being a doormat.

>

> Nurses are the first ones to protect their licenses Believe me they

> understand

> If the snf unit called me i would say oh my that is terrible the patietn

> is in pain? Needs a commode? I can't legally do that since i am not the

> admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?

> Call me back if that does not help

> (Another choice you have is to do the work then drop in in the am for a

> minute or two and bill for the visit)

> finally --call dr Oncology it is entirelyp ossible he has no idea the

> nurses do not know his phone numbers or maybe he does not know how

> incompetent his service is.

>

> And finanlly rememebr the nurses-they --can call the m nusing home medical

> director who assumes that responsibility

>

> Next.patietn calls after seeing dr Heart about geting theirmeds " sure i can

> hellp you with that . when can you come in? "

> I fear for you Annie . you give it away all the time and then compalian

> You may be enabling.

> I understand that the medical situation in your neck of the woods is tougher

> than here but you have more than twice as many patients as me and only see

> the same number I do There is room .Respect yourself and patietns and

> docotrs will respect you

>

> I really am worried.

>

>

>

>

>

>

[Guest guest]

RE Specialty care ongoing.

IF a pt has been seeing a Cardiologist for his/her CAD, and says to me, in midst of caring for DM, other issues, the Cardiologist needs to do their OWN refills, ie, I didn't see them for that issue, so I'm not refilling their meds for them.

Esp if pt wants mailorder refills which the cardiologist doesn't want to bother with? If pt wants (and I offer, most of the time, unless unstable) to see ME for their HTN, then, fine. But if Cardiology is seeing for ischemic cardiomyopathy, they're deciding which med to give them, Cardiology needs to refill the meds for THAT condition. Not just use me as their refill "scut puppy" as we used to say in med school/internship. He who sees the pt for that problem NEEDS to follow the labs, AND the meds.

As far as hypothyroidism, DM, depression, most HTN, sure, I follow most of these pts. If cardiology does care and refers them back to me, with follow up if needed, sure, I do that. But many of pts see Cardiology every 6 months, but pt tries to get me to refill med when they're relatively unstable. So specialist should follow up with refills, just like labs, etc.

ABSOLUTELY if a pt sees an Endocrinologist once, twice a year for hypothyroidism, WHY would I REFILL that medicine for them????? What is the Endocrinologist seeing them for if not for monitoring their med? (Most hypothyroid pts in my area are stable, and followed by primary care, as Endocrinology has its hands full with insulin pumps and brittle diabetics).

Dr Matt Levin

Pittsburgh, PA

re why provviding SNF care for specialists>> >> >> >> sorry about earlier Sometiimes I type a whole note and it willnot send.>> and i do not know how in teh em ail set up i have to save...>> >> I think the trouble here is with Annie who has a heart of gold but needs a>> script to avoid being a doormat.>> >> Nurses are the first ones to protect their licenses Believe me they>> understand>> If the snf unit called me i would say oh my that is terrible the patietn>> is in pain? Needs a commode? I can't legally do that since i am not the>> admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?>> Call me back if that does not help>> (Another choice you have is to do the work then drop in in the am for a>> minute or two and bill for the visit)>> finally --call dr Oncology it is entirelyp ossible he has no idea the>> nurses do not know his phone numbers or maybe he does not know how>> incompetent his service is.>> >> And finanlly rememebr the nurses-they --can call the m nusing home medical>> director who assumes that responsibility>> >> Next.patietn calls after seeing dr Heart about geting theirmeds "sure i can>> hellp you with that . when can you come in?">> I fear for you Annie . you give it away all the time and then compalian>> You may be enabling.>> I understand that the medical situation in your neck of the woods is tougher>> than here but you have more than twice as many patients as me and only see>> the same number I do There is room .Respect yourself and patietns and>> docotrs will respect you>> >> I really am worried.>> >> >> >> >> >>

[Guest guest]

RE Specialty care ongoing.

IF a pt has been seeing a Cardiologist for his/her CAD, and says to me, in midst of caring for DM, other issues, the Cardiologist needs to do their OWN refills, ie, I didn't see them for that issue, so I'm not refilling their meds for them.

Esp if pt wants mailorder refills which the cardiologist doesn't want to bother with? If pt wants (and I offer, most of the time, unless unstable) to see ME for their HTN, then, fine. But if Cardiology is seeing for ischemic cardiomyopathy, they're deciding which med to give them, Cardiology needs to refill the meds for THAT condition. Not just use me as their refill "scut puppy" as we used to say in med school/internship. He who sees the pt for that problem NEEDS to follow the labs, AND the meds.

As far as hypothyroidism, DM, depression, most HTN, sure, I follow most of these pts. If cardiology does care and refers them back to me, with follow up if needed, sure, I do that. But many of pts see Cardiology every 6 months, but pt tries to get me to refill med when they're relatively unstable. So specialist should follow up with refills, just like labs, etc.

ABSOLUTELY if a pt sees an Endocrinologist once, twice a year for hypothyroidism, WHY would I REFILL that medicine for them????? What is the Endocrinologist seeing them for if not for monitoring their med? (Most hypothyroid pts in my area are stable, and followed by primary care, as Endocrinology has its hands full with insulin pumps and brittle diabetics).

Dr Matt Levin

Pittsburgh, PA

re why provviding SNF care for specialists>> >> >> >> sorry about earlier Sometiimes I type a whole note and it willnot send.>> and i do not know how in teh em ail set up i have to save...>> >> I think the trouble here is with Annie who has a heart of gold but needs a>> script to avoid being a doormat.>> >> Nurses are the first ones to protect their licenses Believe me they>> understand>> If the snf unit called me i would say oh my that is terrible the patietn>> is in pain? Needs a commode? I can't legally do that since i am not the>> admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?>> Call me back if that does not help>> (Another choice you have is to do the work then drop in in the am for a>> minute or two and bill for the visit)>> finally --call dr Oncology it is entirelyp ossible he has no idea the>> nurses do not know his phone numbers or maybe he does not know how>> incompetent his service is.>> >> And finanlly rememebr the nurses-they --can call the m nusing home medical>> director who assumes that responsibility>> >> Next.patietn calls after seeing dr Heart about geting theirmeds "sure i can>> hellp you with that . when can you come in?">> I fear for you Annie . you give it away all the time and then compalian>> You may be enabling.>> I understand that the medical situation in your neck of the woods is tougher>> than here but you have more than twice as many patients as me and only see>> the same number I do There is room .Respect yourself and patietns and>> docotrs will respect you>> >> I really am worried.>> >> >> >> >> >>

[Guest guest]

RE Specialty care ongoing.

IF a pt has been seeing a Cardiologist for his/her CAD, and says to me, in midst of caring for DM, other issues, the Cardiologist needs to do their OWN refills, ie, I didn't see them for that issue, so I'm not refilling their meds for them.

Esp if pt wants mailorder refills which the cardiologist doesn't want to bother with? If pt wants (and I offer, most of the time, unless unstable) to see ME for their HTN, then, fine. But if Cardiology is seeing for ischemic cardiomyopathy, they're deciding which med to give them, Cardiology needs to refill the meds for THAT condition. Not just use me as their refill "scut puppy" as we used to say in med school/internship. He who sees the pt for that problem NEEDS to follow the labs, AND the meds.

As far as hypothyroidism, DM, depression, most HTN, sure, I follow most of these pts. If cardiology does care and refers them back to me, with follow up if needed, sure, I do that. But many of pts see Cardiology every 6 months, but pt tries to get me to refill med when they're relatively unstable. So specialist should follow up with refills, just like labs, etc.

ABSOLUTELY if a pt sees an Endocrinologist once, twice a year for hypothyroidism, WHY would I REFILL that medicine for them????? What is the Endocrinologist seeing them for if not for monitoring their med? (Most hypothyroid pts in my area are stable, and followed by primary care, as Endocrinology has its hands full with insulin pumps and brittle diabetics).

Dr Matt Levin

Pittsburgh, PA

re why provviding SNF care for specialists>> >> >> >> sorry about earlier Sometiimes I type a whole note and it willnot send.>> and i do not know how in teh em ail set up i have to save...>> >> I think the trouble here is with Annie who has a heart of gold but needs a>> script to avoid being a doormat.>> >> Nurses are the first ones to protect their licenses Believe me they>> understand>> If the snf unit called me i would say oh my that is terrible the patietn>> is in pain? Needs a commode? I can't legally do that since i am not the>> admitting doc... Did you call teh hospital operatro/ Dr Oncology's service?>> Call me back if that does not help>> (Another choice you have is to do the work then drop in in the am for a>> minute or two and bill for the visit)>> finally --call dr Oncology it is entirelyp ossible he has no idea the>> nurses do not know his phone numbers or maybe he does not know how>> incompetent his service is.>> >> And finanlly rememebr the nurses-they --can call the m nusing home medical>> director who assumes that responsibility>> >> Next.patietn calls after seeing dr Heart about geting theirmeds "sure i can>> hellp you with that . when can you come in?">> I fear for you Annie . you give it away all the time and then compalian>> You may be enabling.>> I understand that the medical situation in your neck of the woods is tougher>> than here but you have more than twice as many patients as me and only see>> the same number I do There is room .Respect yourself and patietns and>> docotrs will respect you>> >> I really am worried.>> >> >> >> >> >>

[Guest guest]

Yes, that sounds pretty much the same as what I do. As I'm sure you know,

certain specialists just do not like to do medical management(ie, surgeons,

other " procedurists " ) & I guess that is why they chose the field they did rather

than primary care.

>

>

> Date: 2006/03/12 Sun PM 04:51:24 EST

> To: < >

> Subject: Re: Re: re why provviding SNF care for

specialists

>

> RE Specialty care ongoing.

>

> IF a pt has been seeing a Cardiologist for his/her CAD, and says to me, in

midst of caring for DM, other issues, the Cardiologist needs to do their OWN

refills, ie, I didn't see them for that issue, so I'm not refilling their meds

for them.

>

> Esp if pt wants mailorder refills which the cardiologist doesn't want to

bother with? If pt wants (and I offer, most of the time, unless unstable) to

see ME for their HTN, then, fine. But if Cardiology is seeing for ischemic

cardiomyopathy, they're deciding which med to give them, Cardiology needs to

refill the meds for THAT condition. Not just use me as their refill " scut

puppy " as we used to say in med school/internship. He who sees the pt for that

problem NEEDS to follow the labs, AND the meds.

>

> As far as hypothyroidism, DM, depression, most HTN, sure, I follow most of

these pts. If cardiology does care and refers them back to me, with follow up

if needed, sure, I do that. But many of pts see Cardiology every 6 months, but

pt tries to get me to refill med when they're relatively unstable. So

specialist should follow up with refills, just like labs, etc.

>

> ABSOLUTELY if a pt sees an Endocrinologist once, twice a year for

hypothyroidism, WHY would I REFILL that medicine for them????? What is the

Endocrinologist seeing them for if not for monitoring their med? (Most

hypothyroid pts in my area are stable, and followed by primary care, as

Endocrinology has its hands full with insulin pumps and brittle diabetics).

>

> Dr Matt Levin

> Pittsburgh, PA

>

> re why provviding SNF care for

specialists

> >>

> >>

> >>

> >> sorry about earlier Sometiimes I type a whole note and it willnot send.

> >> and i do not know how in teh em ail set up i have to save...

> >>

> >> I think the trouble here is with Annie who has a heart of gold but

needs a

> >> script to avoid being a doormat.

> >>

> >> Nurses are the first ones to protect their licenses Believe me they

> >> understand

> >> If the snf unit called me i would say oh my that is terrible the

patietn

> >> is in pain? Needs a commode? I can't legally do that since i am not the

> >> admitting doc... Did you call teh hospital operatro/ Dr Oncology's

service?

> >> Call me back if that does not help

> >> (Another choice you have is to do the work then drop in in the am for a

> >> minute or two and bill for the visit)

> >> finally --call dr Oncology it is entirelyp ossible he has no idea the

> >> nurses do not know his phone numbers or maybe he does not know how

> >> incompetent his service is.

> >>

> >> And finanlly rememebr the nurses-they --can call the m nusing home

medical

> >> director who assumes that responsibility

> >>

> >> Next.patietn calls after seeing dr Heart about geting theirmeds " sure i

can

> >> hellp you with that . when can you come in? "

> >> I fear for you Annie . you give it away all the time and then compalian

> >> You may be enabling.

> >> I understand that the medical situation in your neck of the woods is

tougher

> >> than here but you have more than twice as many patients as me and only

see

> >> the same number I do There is room .Respect yourself and patietns and

> >> docotrs will respect you

> >>

> >> I really am worried.

> >>

> >>

> >>

> >>

> >>

> >>