Re: HELP FORK IN THE ROAD

[Guest guest]

remind me where you are located???Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all

appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to

use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses

to

let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Dannielle,

We are 65 miles from Chicago west of Naperville Illinois by 20 miles.

To: Sent: Thursday, May 17, 2012 10:47 AMSubject: Re: HELP FORK IN THE ROAD

remind me where you are located???Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all

appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to

use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to

let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Dear .

well you have quite a fork!

I can tell you that the hospitalist position is not good money, I used to make 70 dollars per hour while moonlighting in my 2-3 year of residency.

Would they allow you to form your own corporation? independent contractor? I think is better for taxes, unless you dont mind uncle sam take a lot of your money.

I do not know what to tell you since I do not have a lot of experience.

I would look for another location in your town since you have already patients, I would get a small place ( cheap rent) if I can.

I learned in my small town that everybody reads a small free newspaper that get deliver q week, I got an ad there and 95% of patients saw my add and called.

you have to market yourself and practice like what it is: IMP, special, we care for patients, we listen to them, we dont practice treadmill medicine.

I have a small office that I found by chance driving around town, I asked the Realtors in town and they do not have a clue of IMP or they do not know what small office and cheap means.

I learned that my office is near down town clermont, they are not so many doctors around me. Why because everybody start there because the real state is cheap. I learned that even though I am not in a highway billboard or in a busy mall I can still attract patients via my small newspaper. I think marketing wise is a trail and error thing, local conditions dictate the market like the bacteria sensitivity and resistance.

if you surrender yourself to the hospital group you will sleeping with the enemy, I used to have a hospitalist group taking care of my patients, everything was cool until the Hospital decided to make their own hospital group directly hired by the hospital then guess what? they get rid of the other hospital group, are you ready for that? what are gonna do when that happens? it could happens?

are you ready for the "POLITICS"? are you ready for the commities and meetings to make simple decisions? if you are then go right ahead.

anyway my 1/2 cent. Adolfo

To: Sent: Thursday, May 17, 2012 11:47 AMSubject: Re: HELP FORK IN THE ROAD

remind me where you are located???Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient

from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the

patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to

let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Dear ,

My thoughts and prayers are with you and as you try to make this difficult decision.

 

We were at the same crossroads a few months back.  We could not continue to practice in our current location without Steve continuing to work a second job, which he has done pretty much the entire time he has been in solo practice here (7 years).  We did not want to move, as our son will be a Junior in high school next year, and didn't want to move before he graduated.  We worked with a recruiter to try to find a job within commuting distance of our house.  While there were 2 options, only one offered an interview.  In the meantime, and opportunity came for us to be able to rent a space at 25% less than what we are currently paying in rent.  We considered all of the pros and cons of an employed position vs. self-employment and decided to try to stick it out in the IMP world.  While it does mean that Steve will be working his second job for a while, it does mean that he gets to maintain his autonomy, which he really didn't want to give up.

 

What helped us make our decision most of all was making the list of pros and cons of each job and ranking which of those were most important to us.  While we did (albeit briefly) consider relocating completely out of the area, that was the one most important thing to us - not to move our kids at this time in their lives.  We also decided against owning our own space because we did not want to be saddled with owning expensive real estate when he decides to retire from medicine.

 

There are MANY areas that are looking for physicians.  The hard part is finding an area where you and your family want to live, and where you can work a job that you enjoy.  Steve would rather work anywhere than work as a hospitalist.....

 

Steve is still working for EHR (which is now part of United Healthcare) as a Physician Advisor.  He gets to work from home, and the money (with bonuses) is decent.  Full time employees get full benefits.  While he is not crazy about it, and not what he wants to do long-term, it is enabling us to stay put until our kids get through school.  Some of the PA's really enjoy the work, so it is something you could consider as an alternative to working as a hospitalist.  (It is NOT something that can be done and take care of a baby at home at the same time, however, but it WOULD be an option to be at home if you had someone else there during the same hours to help out with the baby.)

 

You can contact me off-list if you want more details about anything.  Good luck in making your decision.....it is not one that is easy to do!

 

Pratt

 

 

 

Dear IMPS,

 

I need your input and wisdom for help in making a tough change in practice. 

 

and I have been sharing our practice for 8 years in a small 5 room office with three bathrooms total 660 sq-ft.  Plus community hallway linking the rooms in the south hallway of our community hospital.  For this we pay rent $884 per month or $10,000 per year including heat, cooling, electricity, water, cleaning, sharps, and hazardous waste removal.  They maintain the parking lot, grounds, snow removal.

 

This hospital will be building 16 new beds starting 8/2012 to be complete by 9/2013.  At that time they will likely tear down the existing space we rent.  We will have to change office locations.

 

Most of the other physicians in town work for a nearby hospital competitor and a few have signed up with the in town hospital sponsored group.  Our patient population is falling for lack of visibility and group association. 

 

The ER group is offering hospitalist shifts at our hospital for $75 per hour with in house responsibility 7AM- & PM and call coverage 7PM to 7AM.  They are offering no benefits.  They would like me to resign from my own clinic to not scare away hospital business from the other major groups in town. 

 

The medical office building in town is leasing space at $26 per sq-ft increasing 3%per year.  Minimum 1500 sq-ft. or $39,000 per year increasing over 10 years to $51,000 per year 10 years out. 

 

Options:  1.  Wait and see.

2.  Scour the area for cheap office space to re-establish as solo IMP and I become hospitalist. Employ staff to keep from going crazy full time with newborn at home.

3. We close our IMP and we both become hospitalists.

4. Go all in in this small community and buy land and build a building for our IMP practice.  Estimate $3-400,000 clearly about the same as leasing example above or cash flow of $1500 per month for just mortgage, insurance, and taxes. Additional expense unknown for utilities, cleaning, ground keeping, etc.  Would come with a location at stopped intersection, corner lot on city line between two towns. 

5. Move to a bigger town anywhere in the country and start over.

 

Cogitate awhile and let me know your thoughts.  I know may of you have faced this situation of moving locations and/or positions.  I know there are pearls of wisdom and IMP values that will appply.

 

Sincerely,

 

 

 

 

 

 

 

To: Sent: Wednesday, May 16, 2012 4:43 PM

Subject: RE: Would this case be considered abandonment? RE: Great article on medical abandonment issues

 

Excellent points!

 

Dammed if you do, Dammed if you don’t…..the lawyers could argue in both directions…..

 

The problem in this case is that the refills have already been started, setting the precedence…..

 

 

 

From: [mailto: ] On Behalf Of magnetdoctor@...

Sent: Tuesday, May 15, 2012 3:22 PMTo: Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues

 

 

Having just been to a professional boundaries class about another issue, I see red flags all over this.  You should have held your ground and refused to see him, after the first 30d fill.  If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him.  He isn't following your advise anyway.  This is a medical liability as well as a professional one. Cut ties.  We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!.  He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November. 

CCote

To: " IMP Group " <practiceimprovement1 >

Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because " had to do Christmas, no money to go to the doctor " .

His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.

He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?

Thanks a lot.Helen

To: From: bethdo97@...

Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues 

 

Came thru my e-mail from Medscape

 

Dr. Beth Sullivan, DO

 

From: [mailto: ] On Behalf Of Dannielle Harwood

Sent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues

 

 

Beth,

Where did you find this article??

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes ,

Date: Wednesday, May 2, 2012, 3:41 PM

 

Thought some of you might find this article informational.  Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all  formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I.  Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim.  In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still  part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or  to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.

c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with.

This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. 

The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship.  Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers)  it means that I am no longer bound by my duties as a doctor” should be immediately avoided.

- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role.  It is therefore protective of the patient.  This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not  from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise.  It can also  occur if  you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. 

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER.  That is overtly inadequate.

Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided.  In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something  like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients.

(ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up.

You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician.  Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care. 

 

 

-- Pratt

[Guest guest]

,My thoughts with you and also.

Briefly, agree that $75/hr seems like too little for hospitalist.  I'm BCC Annie Skaggs for her perspective, but talking to the hospitalisits in St. , MO, they seem to be doing much better than that.  Ask around if you haven't.

Happy to have you guys move to Southern Cal to be near your parents and help you get established here.    But that's partly selfish.  Nice place for kids though and for your eventual retirement......

Good luck and keep us posted.

SharonSharon McCoy MD

Renaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

 

Dear ,

My thoughts and prayers are with you and as you try to make this difficult decision.

 

We were at the same crossroads a few months back.  We could not continue to practice in our current location without Steve continuing to work a second job, which he has done pretty much the entire time he has been in solo practice here (7 years).  We did not want to move, as our son will be a Junior in high school next year, and didn't want to move before he graduated.  We worked with a recruiter to try to find a job within commuting distance of our house.  While there were 2 options, only one offered an interview.  In the meantime, and opportunity came for us to be able to rent a space at 25% less than what we are currently paying in rent.  We considered all of the pros and cons of an employed position vs. self-employment and decided to try to stick it out in the IMP world.  While it does mean that Steve will be working his second job for a while, it does mean that he gets to maintain his autonomy, which he really didn't want to give up.

 

What helped us make our decision most of all was making the list of pros and cons of each job and ranking which of those were most important to us.  While we did (albeit briefly) consider relocating completely out of the area, that was the one most important thing to us - not to move our kids at this time in their lives.  We also decided against owning our own space because we did not want to be saddled with owning expensive real estate when he decides to retire from medicine.

 

There are MANY areas that are looking for physicians.  The hard part is finding an area where you and your family want to live, and where you can work a job that you enjoy.  Steve would rather work anywhere than work as a hospitalist.....

 

Steve is still working for EHR (which is now part of United Healthcare) as a Physician Advisor.  He gets to work from home, and the money (with bonuses) is decent.  Full time employees get full benefits.  While he is not crazy about it, and not what he wants to do long-term, it is enabling us to stay put until our kids get through school.  Some of the PA's really enjoy the work, so it is something you could consider as an alternative to working as a hospitalist.  (It is NOT something that can be done and take care of a baby at home at the same time, however, but it WOULD be an option to be at home if you had someone else there during the same hours to help out with the baby.)

 

You can contact me off-list if you want more details about anything.  Good luck in making your decision.....it is not one that is easy to do!

 

Pratt

 

 

 

Dear IMPS,

 

I need your input and wisdom for help in making a tough change in practice. 

 

and I have been sharing our practice for 8 years in a small 5 room office with three bathrooms total 660 sq-ft.  Plus community hallway linking the rooms in the south hallway of our community hospital.  For this we pay rent $884 per month or $10,000 per year including heat, cooling, electricity, water, cleaning, sharps, and hazardous waste removal.  They maintain the parking lot, grounds, snow removal.

 

This hospital will be building 16 new beds starting 8/2012 to be complete by 9/2013.  At that time they will likely tear down the existing space we rent.  We will have to change office locations.

 

Most of the other physicians in town work for a nearby hospital competitor and a few have signed up with the in town hospital sponsored group.  Our patient population is falling for lack of visibility and group association. 

 

The ER group is offering hospitalist shifts at our hospital for $75 per hour with in house responsibility 7AM- & PM and call coverage 7PM to 7AM.  They are offering no benefits.  They would like me to resign from my own clinic to not scare away hospital business from the other major groups in town. 

 

The medical office building in town is leasing space at $26 per sq-ft increasing 3%per year.  Minimum 1500 sq-ft. or $39,000 per year increasing over 10 years to $51,000 per year 10 years out. 

 

Options:  1.  Wait and see.

2.  Scour the area for cheap office space to re-establish as solo IMP and I become hospitalist. Employ staff to keep from going crazy full time with newborn at home.

3. We close our IMP and we both become hospitalists.

4. Go all in in this small community and buy land and build a building for our IMP practice.  Estimate $3-400,000 clearly about the same as leasing example above or cash flow of $1500 per month for just mortgage, insurance, and taxes. Additional expense unknown for utilities, cleaning, ground keeping, etc.  Would come with a location at stopped intersection, corner lot on city line between two towns. 

5. Move to a bigger town anywhere in the country and start over.

 

Cogitate awhile and let me know your thoughts.  I know may of you have faced this situation of moving locations and/or positions.  I know there are pearls of wisdom and IMP values that will appply.

 

Sincerely,

 

 

 

 

 

 

 

To: Sent: Wednesday, May 16, 2012 4:43 PM

Subject: RE: Would this case be considered abandonment? RE: Great article on medical abandonment issues

 

Excellent points!

 

Dammed if you do, Dammed if you don’t…..the lawyers could argue in both directions…..

 

The problem in this case is that the refills have already been started, setting the precedence…..

 

 

 

From: [mailto: ] On Behalf Of magnetdoctor@...

Sent: Tuesday, May 15, 2012 3:22 PMTo: Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues

 

 

Having just been to a professional boundaries class about another issue, I see red flags all over this.  You should have held your ground and refused to see him, after the first 30d fill.  If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him.  He isn't following your advise anyway.  This is a medical liability as well as a professional one. Cut ties.  We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!.  He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November. 

CCote

To: " IMP Group " <practiceimprovement1 >

Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because " had to do Christmas, no money to go to the doctor " .

His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.

He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?

Thanks a lot.Helen

To: From: bethdo97@...

Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues 

 

Came thru my e-mail from Medscape

 

Dr. Beth Sullivan, DO

 

From: [mailto: ] On Behalf Of Dannielle Harwood

Sent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues

 

 

Beth,

Where did you find this article??

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes ,

Date: Wednesday, May 2, 2012, 3:41 PM

 

Thought some of you might find this article informational.  Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all  formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I.  Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim.  In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still  part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or  to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.

c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with.

This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. 

The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship.  Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers)  it means that I am no longer bound by my duties as a doctor” should be immediately avoided.

- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role.  It is therefore protective of the patient.  This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not  from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise.  It can also  occur if  you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. 

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER.  That is overtly inadequate.

Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided.  In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something  like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients.

(ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up.

You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician.  Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care. 

 

 

-- Pratt

[Guest guest]

Jeezums  medicine  is so bad every where  What do you want to do?  Do not  work in the er for 75/hr that is highway robbery I suspect buying land and building is not a hot ideaI think you can find space Find space( a variant of choice 2 but why be a hospitlaist is that what you want?

ly if you a re up  for moving  we know that some places people do fine. RI is good     WA state.  Oregon? MAny places in this coutnry primary care doctoring just  sucks I am so  sorry  to hear this Known you since the first IMP 1 cohort calls  when I would hang up and cry.and that first Camp when I  found some littleEgly  sobbing outsdie the pool.

 Keep us posted.grr yikkes

 

Dear IMPS,

 

I need your input and wisdom for help in making a tough change in practice. 

 

and I have been sharing our practice for 8 years in a small 5 room office with three bathrooms total 660 sq-ft.  Plus community hallway linking the rooms in the south hallway of our community hospital.  For this we pay rent $884 per month or $10,000 per year including heat, cooling, electricity, water, cleaning, sharps, and hazardous waste removal.  They maintain the parking lot, grounds, snow removal.

 

This hospital will be building 16 new beds starting 8/2012 to be complete by 9/2013.  At that time they will likely tear down the existing space we rent.  We will have to change office locations.

 

Most of the other physicians in town work for a nearby hospital competitor and a few have signed up with the in town hospital sponsored group.  Our patient population is falling for lack of visibility and group association. 

 

The ER group is offering hospitalist shifts at our hospital for $75 per hour with in house responsibility 7AM- & PM and call coverage 7PM to 7AM.  They are offering no benefits.  They would like me to resign from my own clinic to not scare away hospital business from the other major groups in town. 

 

The medical office building in town is leasing space at $26 per sq-ft increasing 3%per year.  Minimum 1500 sq-ft. or $39,000 per year increasing over 10 years to $51,000 per year 10 years out. 

 

Options:  1.  Wait and see.

2.  Scour the area for cheap office space to re-establish as solo IMP and I become hospitalist. Employ staff to keep from going crazy full time with newborn at home.

3. We close our IMP and we both become hospitalists.

4. Go all in in this small community and buy land and build a building for our IMP practice.  Estimate $3-400,000 clearly about the same as leasing example above or cash flow of $1500 per month for just mortgage, insurance, and taxes. Additional expense unknown for utilities, cleaning, ground keeping, etc.  Would come with a location at stopped intersection, corner lot on city line between two towns. 

5. Move to a bigger town anywhere in the country and start over.

 

Cogitate awhile and let me know your thoughts.  I know may of you have faced this situation of moving locations and/or positions.  I know there are pearls of wisdom and IMP values that will appply.

 

Sincerely,

 

 

 

 

 

 

 

To: Sent: Wednesday, May 16, 2012 4:43 PM

Subject: RE: Would this case be considered abandonment? RE: Great article on medical abandonment issues

 

Excellent points!

 

Dammed if you do, Dammed if you don’t…..the lawyers could argue in both directions…..

 

The problem in this case is that the refills have already been started, setting the precedence…..

 

 

 

From: [mailto: ] On Behalf Of magnetdoctor@...

Sent: Tuesday, May 15, 2012 3:22 PMTo: Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues

 

 

Having just been to a professional boundaries class about another issue, I see red flags all over this.  You should have held your ground and refused to see him, after the first 30d fill.  If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him.  He isn't following your advise anyway.  This is a medical liability as well as a professional one. Cut ties.  We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!.  He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since

November. 

CCote

To: " IMP Group " <practiceimprovement1 >

Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because " had to do Christmas, no money to go to the doctor " .

His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.

He lives in his house and paints houses to make income, so he is not poor enough to qualify for

indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?

Thanks a lot.Helen

To: From: bethdo97@...

Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues 

 

Came thru my e-mail from Medscape

 

Dr. Beth Sullivan, DO

 

From: [mailto: ] On Behalf Of Dannielle Harwood

Sent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues

 

 

Beth,

Where did you find this article??

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes ,

Date: Wednesday, May 2, 2012, 3:41 PM

 

Thought some of you might find this article informational.  Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all  formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I.  Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim.  In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still  part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or  to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.

c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with.

This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all

appropriate collection procedures.  The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship.  Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers)  it means that I am no longer bound by my duties as a doctor” should be immediately avoided.

- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role.  It is therefore protective of the patient.  This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to

use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not  from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise.  It can also  occur if  you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. 

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER.  That is overtly inadequate.

Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided.  In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something  like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients.

(ii) Abandonment can also occur at your office level if your staff refuses to

let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up.

You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician.  Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care. 

 

 

--      MD          ph    fax

[Guest guest]

Sandwich IL has an economic development council that is supposed to help attract and retain businesses. You might contact them for some help in finding locations or financing.

Executive DirectorJim Teckenbrock

Sandwich Economic Development Corporation144 E. Railroad St.Sandwich, IL 60548

Phone: Fax:

Also, you might look into buying a small established building. I checked online sites for commercial real estate in Sandwich and there is a building or two from 79,900 on up. You might also convert a house into an office.

You might decide to forego the office altogether. Start a locums practice or do Nursing Home, and home care for Medicare patients. House calls reimburse via medicare at reasonable rates and you could deduct a portion of you vehicle expenses.

If patient numbers are dropping off, take a look at your marketing again. Make sure patients can find you on the web.

If you would consider working a few counties south in Central IL, let me know.

Ben

Visit Your Group

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..

[Guest guest]

,Any chance you can try out your idea of a “health club†in addition to the dollar a day practice. In other words, go retainer fee with extra benefits? Maybe one of you could do the hospitalist thing (as a regular paid gig) and the other can start up the retainer practice?The $300,000-$400,000 seems steep to me for a building, but that may just be the going rate in your area.Tough times for those of us trying to do the right thing. Good luck with all your decisions. From: [mailto: ] On Behalf Of EglySent: Thursday, May 17, 2012 11:13 AMTo: Subject: HELP FORK IN THE ROAD Dear IMPS, I need your input and wisdom for help in making a tough change in practice. and I have been sharing our practice for 8 years in a small 5 room office with three bathrooms total 660 sq-ft. Plus community hallway linking the rooms in the south hallway of our community hospital. For this we pay rent $884 per month or $10,000 per year including heat, cooling, electricity, water, cleaning, sharps, and hazardous waste removal. They maintain the parking lot, grounds, snow removal. This hospital will be building 16 new beds starting 8/2012 to be complete by 9/2013. At that time they will likely tear down the existing space we rent. We will have to change office locations. Most of the other physicians in town work for a nearby hospital competitor and a few have signed up with the in town hospital sponsored group. Our patient population is falling for lack of visibility and group association. The ER group is offering hospitalist shifts at our hospital for $75 per hour with in house responsibility 7AM- & PM and call coverage 7PM to 7AM. They are offering no benefits. They would like me to resign from my own clinic to not scare away hospital business from the other major groups in town. The medical office building in town is leasing space at $26 per sq-ft increasing 3%per year. Minimum 1500 sq-ft. or $39,000 per year increasing over 10 years to $51,000 per year 10 years out. Options: 1. Wait and see.2. Scour the area for cheap office space to re-establish as solo IMP and I become hospitalist. Employ staff to keep from going crazy full time with newborn at home.3. We close our IMP and we both become hospitalists.4. Go all in in this small community and buy land and build a building for our IMP practice. Estimate $3-400,000 clearly about the same as leasing example above or cash flow of $1500 per month for just mortgage, insurance, and taxes. Additional expense unknown for utilities, cleaning, ground keeping, etc. Would come with a location at stopped intersection, corner lot on city line between two towns. 5. Move to a bigger town anywhere in the country and start over. Cogitate awhile and let me know your thoughts. I know may of you have faced this situation of moving locations and/or positions. I know there are pearls of wisdom and IMP values that will appply. Sincerely, To: Sent: Wednesday, May 16, 2012 4:43 PMSubject: RE: Would this case be considered abandonment? RE: Great article on medical abandonment issues Excellent points! Dammed if you do, Dammed if you don’t…..the lawyers could argue in both directions….. The problem in this case is that the refills have already been started, setting the precedence….. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Tuesday, May 15, 2012 3:22 PMTo: Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues Having just been to a professional boundaries class about another issue, I see red flags all over this. You should have held your ground and refused to see him, after the first 30d fill. If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him. He isn't following your advise anyway. This is a medical liability as well as a professional one. Cut ties. We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!. He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November. CCoteTo: " IMP Group " <practiceimprovement1 >Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because " had to do Christmas, no money to go to the doctor " . His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.HelenTo: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues Came thru my e-mail from Medscape Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues Beth,Where did you find this article??DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoingâ€. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

,

A few thoughts from Northern California.....

1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs.

2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas.

3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice.

4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable.

5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see.

6. You are welcome in Northern CA any time!

Blessings!

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate

collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only

clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with

a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

what working doing Urgent care, it may pay good if you look for it carefully. adolfo To: Sent: Friday, May 18, 2012 8:34 AM Subject: RE: HELP FORK IN THE ROAD

,

A few thoughts from Northern California.....

1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs.

2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas.

3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice.

4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable.

5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see.

6. You are welcome in Northern CA any time!

Blessings!

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate

collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only

clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a

patient with

a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

,

A few thoughts from Northern California.....

1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs.

2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas.

3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice.

4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable.

5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see.

6. You are welcome in Northern CA any time!

Blessings!

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate

collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only

clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with

a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Hi

My $0.02. I'm sure you're looking at your own priorities and preferences that

matter most. Do you want to be an employed hospitalist with everything that

entails? How tied are you geographically?

The hospitalist position doesn't sound very appealing. The new building sounds

like a lot of risk in an area where you're not sure about demand.

Scouring for less expensive space could be good. Are you able to differentiate

your practice from the big groups? Or are they doing pretty well in patient

satisfaction?

If all else fails, I have a place at the beach for you with high demand and lots

of office space!

Haresch

www.onefamilydoctor.com

>

> Dear IMPS,

>  

> I need your input and wisdom for help in making a tough change in practice. 

>  

> and I have been sharing our practice for 8 years in a small 5 room

office with three bathrooms total 660 sq-ft.  Plus community hallway linking

the rooms in the south hallway of our community hospital.  For this we pay rent

$884 per month or $10,000 per year including heat, cooling, electricity, water,

cleaning, sharps, and hazardous waste removal.  They maintain the parking lot,

grounds, snow removal.

>  

> This hospital will be building 16 new beds starting 8/2012 to be complete by

9/2013.  At that time they will likely tear down the existing space we rent. 

We will have to change office locations.

>  

> Most of the other physicians in town work for a nearby hospital competitor and

a few have signed up with the in town hospital sponsored group.  Our patient

population is falling for lack of visibility and group association. 

>  

> The ER group is offering hospitalist shifts at our hospital for $75 per hour

with in house responsibility 7AM- & PM and call coverage 7PM to 7AM.  They are

offering no benefits.  They would like me to resign from my own clinic to not

scare away hospital business from the other major groups in town. 

>  

> The medical office building in town is leasing space at $26 per sq-ft

increasing 3%per year.  Minimum 1500 sq-ft. or $39,000 per year increasing over

10 years to $51,000 per year 10 years out. 

>  

> Options:  1.  Wait and see.

> 2.  Scour the area for cheap office space to re-establish as solo IMP

and I become hospitalist. Employ staff to keep from going crazy full time

with newborn at home.

> 3. We close our IMP and we both become hospitalists.

> 4. Go all in in this small community and buy land and build a building for our

IMP practice.  Estimate $3-400,000 clearly about the same as leasing example

above or cash flow of $1500 per month for just mortgage, insurance, and taxes.

Additional expense unknown for utilities, cleaning, ground keeping, etc.  Would

come with a location at stopped intersection, corner lot on city line between

two towns. 

> 5. Move to a bigger town anywhere in the country and start over.

>  

> Cogitate awhile and let me know your thoughts.  I know may of you have faced

this situation of moving locations and/or positions.  I know there are pearls

of wisdom and IMP values that will appply.

>  

> Sincerely,

>  

>

[Guest guest]

le,Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average†FP salary, but it is possible to use this model and still do pretty well. From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD ,A few thoughts from Northern California.....1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs. 2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas. 3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice. 4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable. 5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see. 6. You are welcome in Northern CA any time! Blessings!DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoingâ€. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Sorry ,Not trying to sugar coat anything. Just trying to point out that the model in and of itself does not mean financial ruin. Though I do not make as much as many of my colleagues, I am definitely keeping my head above water and definitely above $100,000/year. I would agree that a lot of IMPs don’t make that much, but I believe that at least in this area, the model is working. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Friday, May 18, 2012 1:21 PMTo: Subject: Re: HELP FORK IN THE ROAD With all due respect , in previous surveys of the group, you are distinctly in the minority on this. Most do make under 90K. That is just a fact of IMP life in most places, many have struggled to make 60K. Let's not sugar coat anything here. CCoteTo: Sent: Friday, May 18, 2012 9:52:49 AMSubject: RE: HELP FORK IN THE ROAD le,Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average†FP salary, but it is possible to use this model and still do pretty well. From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD ,A few thoughts from Northern California.....1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs. 2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas. 3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice. 4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable. 5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see. 6. You are welcome in Northern CA any time! Blessings!DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoingâ€. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

With all due respect , in previous surveys of the group, you are distinctly in the minority on this. Most do make under 90K. That is just a fact of IMP life in most places, many have struggled to make 60K. Let's not sugar coat anything here.

CCote

To: Sent: Friday, May 18, 2012 9:52:49 AMSubject: RE: HELP FORK IN THE ROAD

le,

Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average†FP salary, but it is possible to use this model and still do pretty well.

From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD

,

A few thoughts from Northern California.....

1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs.

2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas.

3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice.

4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable.

5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see.

6. You are welcome in Northern CA any time!

Blessings!

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

I agree, but am going to leave the details vague.Sangeetha

 

le,Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average” FP salary, but it is possible to use this model and still do pretty well.

 

From: [mailto: ] On Behalf Of Dannielle Harwood

Sent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD

  

,A few thoughts from Northern California.....1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs.

 2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas.

 3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice.

 4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable.

 5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see.

 6. You are welcome in Northern CA any time!  

Blessings!Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes ,

Date: Wednesday, May 2, 2012, 3:41 PM  Thought some of you might find this article informational.  Hope it is informative for those on our list.

Dr. BethMedico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all  formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now. I.  Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim.  In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still  part of your practice but is actually not getting needed care. This can happen in several ways:

a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or  to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.

c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with.

This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. 

The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship.  Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers)  it means that I am no longer bound by my duties as a doctor” should be immediately avoided.

- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role.  It is therefore protective of the patient.  This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not  from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise.  It can also  occur if  you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. 

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER.  That is overtly inadequate.

Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided.  In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something  like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients.

(ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up.

You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician.  Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care. 

  

[Guest guest]

I might be the minority also

but no extra fees, insurance model, making $120 - $140 annually ( have made more

when working like a crazy person) for past 4-5 years

after initial startup of 2 - 3 years,

750- 800 patients, 40 patients per week 

- come to RI? demand is tremendous here for primary care

model does seem to work here or perhaps this particular carryout of the model 

and the coastline is beautiful

7 IMP practices have opened in past 5 years here.

Lynn

________________________________

> To:

> From: sangeethamurthy@...

> Date: Fri, 18 May 2012 10:23:19 -0700

> Subject: Re: HELP FORK IN THE ROAD

>

>

>

> I agree, but am going to leave the details vague.

>

> Sangeetha

>

>

> On Fri, May 18, 2012 at 9:52 AM, Dr. Brady

>

<drbrady@...<mailto:drbrady@...\

l.com>>

> wrote:

>

>

> le,

>

> Regarding point #3. Though my practice has been around a while (9

> years) and is big for an IMP (1.25 FTE and see around 70 people/week),

> I easily make over $100,000. Last year, with the help of the MU funds,

> I broke the $150,000 level. I don’t charge any fees. I don’t do any

> second jobs. I know I have still not hit the “average” FP salary, but

> it is possible to use this model and still do pretty well.

>

>

>

>

>

> From:

>

<mailto: \

>

>

[mailto: <mailto:@yahoogr\

oups.com>]

> On Behalf Of Dannielle Harwood

> Sent: Friday, May 18, 2012 8:35 AM

> To:

>

<mailto: \

>

>

> Subject: RE: HELP FORK IN THE ROAD

>

>

>

>

>

> ,

>

> A few thoughts from Northern California.....

>

> 1. Many NP's/PA's here in town make more than $75 per hour. The ones

> working in the ER most certainly do. I think that price is too low

> unless it is also including a major benefit package?? Call a locums

> company and see what you would make per hour taking Illinois locums

> jobs.

>

>

>

> 2. If you have ever considered moving to another part of the country

> this is a great time to look at that option. I have moved 2x in my

> career. Once from Baltimore to Denver and then from Denver to CA. We

> finally figured out that being closer to family was a big deal to us

> and then looked at cost of living vs salaries etc.Lucky for us most

> places need doctors. That said it is much easier to create niche

> practices in larger metropolitan areas.

>

>

>

> 3. I do not think the numbers add up for a single doctor to be in an

> IMP style practice unless a very low salery is acceptable. Yes, I know

> I am an IMP. I think.....and I am totally open for the group to point

> out how wrong I am here......that for the most part the IMP doctors are

> either content with less than 90k year or they work a second job or

> they are a retainer or cash only practice.

>

>

>

> 4. I think the system is trying to squeeze solo doctors out...new

> regualtions are popping up all the time that are very difficult to

> comply with based on our size. Again, if doing a niche practice, cash

> etc in a larger area this may be survivable.

>

>

>

> 5. I also know that hospitals that are building new projects tend to

> run behind so you may have a little time to wait and see.

>

>

>

> 6. You are welcome in Northern CA any time!

>

>

>

> Blessings!

>

> Dannielle

>

>

>

> From: Beth Sullivan

>

<bethdo97@...<http://us.mc1803.mail.yahoo.com/mc/compose?to=bethdo97%\

40windstream.net>>

> Subject: Great article on medical abandonment issues

> To:

>

ericacodes <http://us.mc1803.mail.yahoo.com/mc/compose?to=ericaco\

des%40yahoogroups.com>,

>

<http://us.mc1803.mail.yahoo.com/mc/compose?\

to=%40yahoogroups.com>

> Date: Wednesday, May 2, 2012, 3:41 PM

>

>

>

> Thought some of you might find this article informational. Hope it is

> informative for those on our list.

>

> Dr. Beth

>

> Medico-legal: Unintentional and accidental abandonment

>

> Last week we looked at how to avoid a claim of abandonment of a patient

> when you are terminating that patient from your practice.

>

> However, it is still possible to be the subject of an actionable

> abandonment claim by patients you specifically had no ongoing

> physician-patient relationship with and patients you discharged in full

> technical compliance with all formal requirements and even by patients

> you consider to be fully active in your practice.

>

> Let's look at those situations now.

>

> I. Failure to carry through on an accrued duty

>

> Last week, the necessity to engage in limited-scope work like physicals

> and screenings only under a disclaimer that no ongoing

> physician-patient relationship is thereby established was discussed.

>

> However, the critical word there is “ongoing”.

>

> Even within the scope of the limited care that you are providing, you

> still have the duties of a physician relative to what that examination

> reveals, even if it exceeds the intended purpose of the examination and

> is not part of your specialty.

>

> The law assumes that the examinee would expect to be told of any

> medically important issues the physician finds and that this imposes a

> duty of reasonable care on the physician to reveal any such to the

> examinee.

>

> Therefore, for example, if you notice a suspicious mole on the back of

> a patient you are performing a disability physical on, you are

> obligated to not just document it in the record with a recommendation

> for follow-up but to inform the patient that it is something they need

> to have attended to by their own physician.

>

> Similarly, if you are doing an initial evaluation to decide if you will

> even accept the patient into your practice, as, for example, many

> plastic surgeons do, and you identify significant hypertension that was

> previously unknown, yo! u are obligated to both inform the patient and

> to offer to send the results to their primary care physician.

>

> You do not, however, have to order a biopsy or prescribe an

> anti-hypertensive or even make sure that the patient followed-up as you

> suggested. That would all be care associated with an ongoing

> relationship with the patient and it exceeds your duty.

>

> In other words, your duty was limited to dealing appropriately with

> what might accrue during the examination that you performed and that

> limited duty was fulfilled in full when you alerted the patient and

> activated an appropriate follow-up system. More is not required, but

> less is abandonment.

>

> II. Constructive abandonment

>

> (i) This can occur when the termination process looks perfect on paper

> but, in the real world, the patient is actually left high and dry.

>

> Whether the patient can get another physician, either within the time

> frame you specified or at all, must be realistic or you will be deemed

> to have constrictively abandoned the patient.

>

> For example, if you have specialized skills not otherwise available in

> your area, or you practice ! in an isolated rural town where traveling

> to another physician is impossible for your patient, or even if you are

> the only practitioner in your area who accepts Medicaid or Medicare and

> your patient is otherwise completely unable to pay for treatment, then

> your responsibilities as the discharging physician are higher than

> usual in terms of making sure that your patient can actually get

> alternative treatment, beginning with allotting more than the usual

> time for the patient to get a new physician.

>

> However, if no matter how ample the transition period you offer is

> there simply are no practical alternatives to you, you may not be able

> to terminate the patient without facing an abandonment claim. In that

> case, you should contact your state medical board for instructions on

> how to proceed.

>

> (ii) Constructive abandonment can also occur when the patient is still

> part of your practice but is actually not getting needed care.

>

> This can happen in several ways:

>

> a. Failure to initiate treatment that was warranted

>

> This is more of a technical aspect of pleading in a medical malpractice case.

>

> The premise is that the patient is internally abandoned within the

> active doctor-patient relationship because the ! care that was needed

> never began, leaving them as though they actually had no access to the

> treatment at all.

>

> Abandonment is alleged separately from medical negligence, but from

> your point of view in terms of defending the two issues are

> inextricable on a practical basis.

>

> b. Refusal to assist the patient in accessing appropriate support

>

> Physicians who refuse to fill out forms for such matters as legitimate

> disability claims or to get the patient an appropriate medical device

> or to keep a patient’s medically-required utilities on, or who will do

> so only for a significant fee that the patient cannot pay, can be held

> to have abandoned their patients.

>

> Of course, a physician is not expected to be a kowtowing hand-puppet to

> an overly demanding patient or to an outright scammer to avoid being

> charged with abandonment. Constructive abandonment would only apply

> when the treatment or the assistance really were warranted but were

> unilaterally denied by the physician without good cause.

>

> c. Refusal to see the patient.

>

> This most commonly occurs when the patient has a very large outstanding

> bill that they are refusing to address and the doctor tells them that

> they will not be scheduled for further appointments until that is dealt

> with.

>

> This acts as constructive abandonment because the patient thereby loses

> substantive access to the doctor while the bill remains unpaid.

>

> Such a situation should instead be dealt with by the! formal discharge

> of the patient from the practice, followed by all appropriate

> collection procedures.

>

> The potential for falling into constructive abandonment in such “self

> help” situations is an important reminder of two points:

>

> - There is no such thing as de facto termination by conduct. Even if

> the patient actually sues the doctor, that does not, in and of itself,

> end the physician-patient relationship. Therefore, any approach to a

> troublesome patient that begins with the idea that “Well, since the

> patient did (fill in thing that drives you bonkers) it means that I am

> no longer bound by my duties as a doctor” should be immediately

> avoided.

>

> - The law views the physician-patient relationship as one in which the

> patient, as the one needing expert services for their health, is in the

> dependent role. It is therefore protective of the patient. This means

> that any doctor who finds themselves in opposition to a troublesome

> patient should make sure to use only clearly sanctioned methods, such

> as formal discharge, that actually afford the doctor considerable

> protection.

>

> d. Another situation in which constructive abandonment can come into

> play is with regard to coverage.

>

> Because you are responsible for providing an adequate alternative to

> your patients when you are unavailable for an extended period, if you

> do not do so, thereby leaving the patient functionally uncovered, it

> can give rise to an abandonment claim.

>

> This could occur if you use a covering doctor who is not reasonably

> equivalent to you & nb! sp;(e.g.; not from the same specialty or a

> closely allied one, such as internal medicine and cardiology covering

> for each other, or is barely out of training when you are very

> experienced) and so cannot provide a comparable level of expertise. It

> can also occur if you continue to use an answering service even after

> it habitually proves unreliable at getting messages from the patient to

> the covering doctor accurately and promptly.

>

> Since in both of those situations the patient really has no meaningful

> access to appropriate care through the coverage system their doctor has

> put in place, there is a predicate for an abandonment claim.

>

> III. Inadvertent abandonment

>

> (i) Coverage can be an issue in this regard as well when it is completely

> absent.

>

> This is not the situation where the doctor deliberately puts no

> coverage in place and simply leaves a voice message telling patients to

> call 911 or to go to ER. That is overtly inadequate.

>

> Instead, this occurs when there is a proper call schedule in place but

> the covering doctor becomes unavailable and no replacement is

> provided. In that situation, to the extent that the doctor needing

> coverage could have reasonably - that would be something like taking

> the call yourself instead of going to a planned party, not coming back

> from your vacation in China - prevented the problem, they can be deemed

> to have abandoned their patients.

>

> (ii) Abandonment can also occur at your office level if your staff

> refuses to let a patient with a real problem talk to you or schedules a

> necessary appointment too far in the future or i! f your staff merely

> files away the chart of a patient who actually needs to do some

> important follow-up.

>

> You need to have set office policies in place - preferably in writing,

> since you may have to prove them - to avert these problems.

>

> In summary: The laws governing medical abandonment are predicated on

> the more dependent status of the patient in the relationship with the

> physician. Therefore, when terminating a patient or when dealing with

> a patient actively, it is essential to fulfill your duty to make sure

> that your patient will not be left without appropriate care.

>

>

>

>

>

>

>

>

>

[Guest guest]

I was going to say it's not the model so much as how many patients you

see. So 70 patients a week is 15 patients a day. I wonder how many

patients a day the lower income practices see.

I see more like Lynn but make enough to qualify for Medicaid I think if

I were the sole provider for the family. Might be because insurance

pays so much lower than Medicare or might be due to costs (overhead) and

I am not a MicroPractice (not the same thing as an IMP anymore).

There are many variables.

Kathy Saradarian, MD

From Primary Care Unfriendly NJ

Great article on medical abandonment

issues

> To:

>

ericacodes <http://us.mc1803.mail.yahoo.com/mc/compose?to

=ericacodes%40yahoogroups.com>,

>

<http://us.mc1803.mail.yahoo.com/mc/

compose?to=%40yahoogroups.com>

> Date: Wednesday, May 2, 2012, 3:41 PM

>

>

>

> Thought some of you might find this article informational. Hope it is

> informative for those on our list.

>

> Dr. Beth

>

> Medico-legal: Unintentional and accidental abandonment

>

> Last week we looked at how to avoid a claim of abandonment of a

patient

> when you are terminating that patient from your practice.

>

> However, it is still possible to be the subject of an actionable

> abandonment claim by patients you specifically had no ongoing

> physician-patient relationship with and patients you discharged in

full

> technical compliance with all formal requirements and even by

patients

> you consider to be fully active in your practice.

>

> Let's look at those situations now.

>

> I. Failure to carry through on an accrued duty

>

> Last week, the necessity to engage in limited-scope work like

physicals

> and screenings only under a disclaimer that no ongoing

> physician-patient relationship is thereby established was discussed.

>

> However, the critical word there is “ongoing”.

>

> Even within the scope of the limited care that you are providing, you

> still have the duties of a physician relative to what that examination

> reveals, even if it exceeds the intended purpose of the examination

and

> is not part of your specialty.

>

> The law assumes that the examinee would expect to be told of any

> medically important issues the physician finds and that this imposes a

> duty of reasonable care on the physician to reveal any such to the

> examinee.

>

> Therefore, for example, if you notice a suspicious mole on the back of

> a patient you are performing a disability physical on, you are

> obligated to not just document it in the record with a recommendation

> for follow-up but to inform the patient that it is something they need

> to have attended to by their own physician.

>

> Similarly, if you are doing an initial evaluation to decide if you

will

> even accept the patient into your practice, as, for example, many

> plastic surgeons do, and you identify significant hypertension that

was

> previously unknown, yo! u are obligated to both inform the patient and

> to offer to send the results to their primary care physician.

>

> You do not, however, have to order a biopsy or prescribe an

> anti-hypertensive or even make sure that the patient followed-up as

you

> suggested. That would all be care associated with an ongoing

> relationship with the patient and it exceeds your duty.

>

> In other words, your duty was limited to dealing appropriately with

> what might accrue during the examination that you performed and that

> limited duty was fulfilled in full when you alerted the patient and

> activated an appropriate follow-up system. More is not required, but

> less is abandonment.

>

> II. Constructive abandonment

>

> (i) This can occur when the termination process looks perfect on paper

> but, in the real world, the patient is actually left high and dry.

>

> Whether the patient can get another physician, either within the time

> frame you specified or at all, must be realistic or you will be deemed

> to have constrictively abandoned the patient.

>

> For example, if you have specialized skills not otherwise available in

> your area, or you practice ! in an isolated rural town where traveling

> to another physician is impossible for your patient, or even if you

are

> the only practitioner in your area who accepts Medicaid or Medicare

and

> your patient is otherwise completely unable to pay for treatment, then

> your responsibilities as the discharging physician are higher than

> usual in terms of making sure that your patient can actually get

> alternative treatment, beginning with allotting more than the usual

> time for the patient to get a new physician.

>

> However, if no matter how ample the transition period you offer is

> there simply are no practical alternatives to you, you may not be able

> to terminate the patient without facing an abandonment claim. In that

> case, you should contact your state medical board for instructions on

> how to proceed.

>

> (ii) Constructive abandonment can also occur when the patient is still

> part of your practice but is actually not getting needed care.

>

> This can happen in several ways:

>

> a. Failure to initiate treatment that was warranted

>

> This is more of a technical aspect of pleading in a medical

malpractice case.

>

> The premise is that the patient is internally abandoned within the

> active doctor-patient relationship because the ! care that was needed

> never began, leaving them as though they actually had no access to the

> treatment at all.

>

> Abandonment is alleged separately from medical negligence, but from

> your point of view in terms of defending the two issues are

> inextricable on a practical basis.

>

> b. Refusal to assist the patient in accessing appropriate support

>

> Physicians who refuse to fill out forms for such matters as legitimate

> disability claims or to get the patient an appropriate medical device

> or to keep a patient’s medically-required utilities on, or who will do

> so only for a significant fee that the patient cannot pay, can be held

> to have abandoned their patients.

>

> Of course, a physician is not expected to be a kowtowing hand-puppet

to

> an overly demanding patient or to an outright scammer to avoid being

> charged with abandonment. Constructive abandonment would only apply

> when the treatment or the assistance really were warranted but were

> unilaterally denied by the physician without good cause.

>

> c. Refusal to see the patient.

>

> This most commonly occurs when the patient has a very large

outstanding

> bill that they are refusing to address and the doctor tells them that

> they will not be scheduled for further appointments until that is

dealt

> with.

>

> This acts as constructive abandonment because the patient thereby

loses

> substantive access to the doctor while the bill remains unpaid.

>

> Such a situation should instead be dealt with by the! formal discharge

> of the patient from the practice, followed by all appropriate

> collection procedures.

>

> The potential for falling into constructive abandonment in such “self

> help” situations is an important reminder of two points:

>

> - There is no such thing as de facto termination by conduct. Even if

> the patient actually sues the doctor, that does not, in and of itself,

> end the physician-patient relationship. Therefore, any approach to a

> troublesome patient that begins with the idea that “Well, since the

> patient did (fill in thing that drives you bonkers) it means that I

am

> no longer bound by my duties as a doctor” should be immediately

> avoided.

>

> - The law views the physician-patient relationship as one in which the

> patient, as the one needing expert services for their health, is in

the

> dependent role. It is therefore protective of the patient. This

means

> that any doctor who finds themselves in opposition to a troublesome

> patient should make sure to use only clearly sanctioned methods, such

> as formal discharge, that actually afford the doctor considerable

> protection.

>

> d. Another situation in which constructive abandonment can come into

> play is with regard to coverage.

>

> Because you are responsible for providing an adequate alternative to

> your patients when you are unavailable for an extended period, if you

> do not do so, thereby leaving the patient functionally uncovered, it

> can give rise to an abandonment claim.

>

> This could occur if you use a covering doctor who is not reasonably

> equivalent to you & nb! sp;(e.g.; not from the same specialty or a

> closely allied one, such as internal medicine and cardiology covering

> for each other, or is barely out of training when you are very

> experienced) and so cannot provide a comparable level of expertise.

It

> can also occur if you continue to use an answering service even

after

> it habitually proves unreliable at getting messages from the patient

to

> the covering doctor accurately and promptly.

>

> Since in both of those situations the patient really has no meaningful

> access to appropriate care through the coverage system their doctor

has

> put in place, there is a predicate for an abandonment claim.

>

> III. Inadvertent abandonment

>

> (i) Coverage can be an issue in this regard as well when it is

completely

> absent.

>

> This is not the situation where the doctor deliberately puts no

> coverage in place and simply leaves a voice message telling patients

to

> call 911 or to go to ER. That is overtly inadequate.

>

> Instead, this occurs when there is a proper call schedule in place but

> the covering doctor becomes unavailable and no replacement is

> provided. In that situation, to the extent that the doctor needing

> coverage could have reasonably - that would be something like taking

> the call yourself instead of going to a planned party, not coming back

> from your vacation in China - prevented the problem, they can be

deemed

> to have abandoned their patients.

>

> (ii) Abandonment can also occur at your office level if your staff

> refuses to let a patient with a real problem talk to you or schedules

a

> necessary appointment too far in the future or i! f your staff merely

> files away the chart of a patient who actually needs to do some

> important follow-up.

>

> You need to have set office policies in place - preferably in writing,

> since you may have to prove them - to avert these problems.

>

> In summary: The laws governing medical abandonment are predicated on

> the more dependent status of the patient in the relationship with the

> physician. Therefore, when terminating a patient or when dealing with

> a patient actively, it is essential to fulfill your duty to make sure

> that your patient will not be left without appropriate care.

>

>

>

>

>

>

>

>

>

------------------------------------

[Guest guest]

I would be very careful before investing a lot of money into an new office when your patient volume and collections are decreasing. I would take a very close look as to why your visits are decreasing. Usually after you have been in business a few years no marketing is needed. I would take a very close look at your how's your health numbers. Personally, I think having staff who can answer the phone call on the first or second ring can significantly increase your volume. Make sure you see everyone the same day they call even if they are new patients. I would also take a very close look at your coding and collections per visit. I agree that seeing 10 -12 patients per day if you are solo solo or 12-15 patients per day if you have minimal staff is essential. I have not heard much success with the added fee model in Illinois although there are a few exceptions. I dropped my short trial of a membership fee after 6 months after a very hostile reception from patients and the neighborhood. The high malpractice costs in Illinois make the very low overhead model in Illinois almost impossible. Adding a staff member almost always will increase income but only if there is enough to demand to increase your patient visits as you expand capacity.I'd be happy to drive out there and talk about your practice if you would like.

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

I was going to say it's not the model so much as how many patients you

see. So 70 patients a week is 15 patients a day. I wonder how many

patients a day the lower income practices see.

I see more like Lynn but make enough to qualify for Medicaid I think if

I were the sole provider for the family. Might be because insurance

pays so much lower than Medicare or might be due to costs (overhead) and

I am not a MicroPractice (not the same thing as an IMP anymore).

There are many variables.

Kathy Saradarian, MD

From Primary Care Unfriendly NJ

Great article on medical abandonment

issues

> To:

>

ericacodes <http://us.mc1803.mail.yahoo.com/mc/compose?to

=ericacodes%40yahoogroups.com>,

>

<http://us.mc1803.mail.yahoo.com/mc/

compose?to=%40yahoogroups.com>

> Date: Wednesday, May 2, 2012, 3:41 PM

>

>

>

> Thought some of you might find this article informational. Hope it is

> informative for those on our list.

>

> Dr. Beth

>

> Medico-legal: Unintentional and accidental abandonment

>

> Last week we looked at how to avoid a claim of abandonment of a

patient

> when you are terminating that patient from your practice.

>

> However, it is still possible to be the subject of an actionable

> abandonment claim by patients you specifically had no ongoing

> physician-patient relationship with and patients you discharged in

full

> technical compliance with all formal requirements and even by

patients

> you consider to be fully active in your practice.

>

> Let's look at those situations now.

>

> I. Failure to carry through on an accrued duty

>

> Last week, the necessity to engage in limited-scope work like

physicals

> and screenings only under a disclaimer that no ongoing

> physician-patient relationship is thereby established was discussed.

>

> However, the critical word there is “ongoing”.

>

> Even within the scope of the limited care that you are providing, you

> still have the duties of a physician relative to what that examination

> reveals, even if it exceeds the intended purpose of the examination

and

> is not part of your specialty.

>

> The law assumes that the examinee would expect to be told of any

> medically important issues the physician finds and that this imposes a

> duty of reasonable care on the physician to reveal any such to the

> examinee.

>

> Therefore, for example, if you notice a suspicious mole on the back of

> a patient you are performing a disability physical on, you are

> obligated to not just document it in the record with a recommendation

> for follow-up but to inform the patient that it is something they need

> to have attended to by their own physician.

>

> Similarly, if you are doing an initial evaluation to decide if you

will

> even accept the patient into your practice, as, for example, many

> plastic surgeons do, and you identify significant hypertension that

was

> previously unknown, yo! u are obligated to both inform the patient and

> to offer to send the results to their primary care physician.

>

> You do not, however, have to order a biopsy or prescribe an

> anti-hypertensive or even make sure that the patient followed-up as

you

> suggested. That would all be care associated with an ongoing

> relationship with the patient and it exceeds your duty.

>

> In other words, your duty was limited to dealing appropriately with

> what might accrue during the examination that you performed and that

> limited duty was fulfilled in full when you alerted the patient and

> activated an appropriate follow-up system. More is not required, but

> less is abandonment.

>

> II. Constructive abandonment

>

> (i) This can occur when the termination process looks perfect on paper

> but, in the real world, the patient is actually left high and dry.

>

> Whether the patient can get another physician, either within the time

> frame you specified or at all, must be realistic or you will be deemed

> to have constrictively abandoned the patient.

>

> For example, if you have specialized skills not otherwise available in

> your area, or you practice ! in an isolated rural town where traveling

> to another physician is impossible for your patient, or even if you

are

> the only practitioner in your area who accepts Medicaid or Medicare

and

> your patient is otherwise completely unable to pay for treatment, then

> your responsibilities as the discharging physician are higher than

> usual in terms of making sure that your patient can actually get

> alternative treatment, beginning with allotting more than the usual

> time for the patient to get a new physician.

>

> However, if no matter how ample the transition period you offer is

> there simply are no practical alternatives to you, you may not be able

> to terminate the patient without facing an abandonment claim. In that

> case, you should contact your state medical board for instructions on

> how to proceed.

>

> (ii) Constructive abandonment can also occur when the patient is still

> part of your practice but is actually not getting needed care.

>

> This can happen in several ways:

>

> a. Failure to initiate treatment that was warranted

>

> This is more of a technical aspect of pleading in a medical

malpractice case.

>

> The premise is that the patient is internally abandoned within the

> active doctor-patient relationship because the ! care that was needed

> never began, leaving them as though they actually had no access to the

> treatment at all.

>

> Abandonment is alleged separately from medical negligence, but from

> your point of view in terms of defending the two issues are

> inextricable on a practical basis.

>

> b. Refusal to assist the patient in accessing appropriate support

>

> Physicians who refuse to fill out forms for such matters as legitimate

> disability claims or to get the patient an appropriate medical device

> or to keep a patient’s medically-required utilities on, or who will do

> so only for a significant fee that the patient cannot pay, can be held

> to have abandoned their patients.

>

> Of course, a physician is not expected to be a kowtowing hand-puppet

to

> an overly demanding patient or to an outright scammer to avoid being

> charged with abandonment. Constructive abandonment would only apply

> when the treatment or the assistance really were warranted but were

> unilaterally denied by the physician without good cause.

>

> c. Refusal to see the patient.

>

> This most commonly occurs when the patient has a very large

outstanding

> bill that they are refusing to address and the doctor tells them that

> they will not be scheduled for further appointments until that is

dealt

> with.

>

> This acts as constructive abandonment because the patient thereby

loses

> substantive access to the doctor while the bill remains unpaid.

>

> Such a situation should instead be dealt with by the! formal discharge

> of the patient from the practice, followed by all appropriate

> collection procedures.

>

> The potential for falling into constructive abandonment in such “self

> help” situations is an important reminder of two points:

>

> - There is no such thing as de facto termination by conduct. Even if

> the patient actually sues the doctor, that does not, in and of itself,

> end the physician-patient relationship. Therefore, any approach to a

> troublesome patient that begins with the idea that “Well, since the

> patient did (fill in thing that drives you bonkers) it means that I

am

> no longer bound by my duties as a doctor” should be immediately

> avoided.

>

> - The law views the physician-patient relationship as one in which the

> patient, as the one needing expert services for their health, is in

the

> dependent role. It is therefore protective of the patient. This

means

> that any doctor who finds themselves in opposition to a troublesome

> patient should make sure to use only clearly sanctioned methods, such

> as formal discharge, that actually afford the doctor considerable

> protection.

>

> d. Another situation in which constructive abandonment can come into

> play is with regard to coverage.

>

> Because you are responsible for providing an adequate alternative to

> your patients when you are unavailable for an extended period, if you

> do not do so, thereby leaving the patient functionally uncovered, it

> can give rise to an abandonment claim.

>

> This could occur if you use a covering doctor who is not reasonably

> equivalent to you & nb! sp;(e.g.; not from the same specialty or a

> closely allied one, such as internal medicine and cardiology covering

> for each other, or is barely out of training when you are very

> experienced) and so cannot provide a comparable level of expertise.

It

> can also occur if you continue to use an answering service even

after

> it habitually proves unreliable at getting messages from the patient

to

> the covering doctor accurately and promptly.

>

> Since in both of those situations the patient really has no meaningful

> access to appropriate care through the coverage system their doctor

has

> put in place, there is a predicate for an abandonment claim.

>

> III. Inadvertent abandonment

>

> (i) Coverage can be an issue in this regard as well when it is

completely

> absent.

>

> This is not the situation where the doctor deliberately puts no

> coverage in place and simply leaves a voice message telling patients

to

> call 911 or to go to ER. That is overtly inadequate.

>

> Instead, this occurs when there is a proper call schedule in place but

> the covering doctor becomes unavailable and no replacement is

> provided. In that situation, to the extent that the doctor needing

> coverage could have reasonably - that would be something like taking

> the call yourself instead of going to a planned party, not coming back

> from your vacation in China - prevented the problem, they can be

deemed

> to have abandoned their patients.

>

> (ii) Abandonment can also occur at your office level if your staff

> refuses to let a patient with a real problem talk to you or schedules

a

> necessary appointment too far in the future or i! f your staff merely

> files away the chart of a patient who actually needs to do some

> important follow-up.

>

> You need to have set office policies in place - preferably in writing,

> since you may have to prove them - to avert these problems.

>

> In summary: The laws governing medical abandonment are predicated on

> the more dependent status of the patient in the relationship with the

> physician. Therefore, when terminating a patient or when dealing with

> a patient actively, it is essential to fulfill your duty to make sure

> that your patient will not be left without appropriate care.

>

>

>

>

>

>

>

>

>

------------------------------------

[Guest guest]

As far as the model working or not working, I believe that it is almost impossible to make a reasonable income without having staff unless you have added fees. There is definitely a sweet spot is having enough staff and too much staff. I also think that you need to see enough patients. I average about 60 patients a week and make above the national average for FP's.

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

Sorry ,Not trying to sugar coat anything. Just trying to point out that the model in and of itself does not mean financial ruin. Though I do not make as much as many of my colleagues, I am definitely keeping my head above water and definitely above $100,000/year. I would agree that a lot of IMPs don’t make that much, but I believe that at least in this area, the model is working. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Friday, May 18, 2012 1:21 PMTo: Subject: Re: HELP FORK IN THE ROAD With all due respect , in previous surveys of the group, you are distinctly in the minority on this. Most do make under 90K. That is just a fact of IMP life in most places, many have struggled to make 60K. Let's not sugar coat anything here. CCoteTo: Sent: Friday, May 18, 2012 9:52:49 AMSubject: RE: HELP FORK IN THE ROAD le,Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average” FP salary, but it is possible to use this model and still do pretty well. From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD ,A few thoughts from Northern California.....1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs. 2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas. 3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice. 4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable. 5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see. 6. You are welcome in Northern CA any time! Blessings!DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoing”. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Dear Larry.We will go on and on about what model work or not. I think the simple math here: less expenses more profit, I think that is very relative and it depends how much do your rice and beans on the table cost?if you are happy with 80,90,100,120,140,150...... K a year it is completely up to you and your family. I believe the money is very important at the end of the day we have business and if we are in red numbers we can not survive.do you want to make a lot of money and unhappy/miserable at the same time? I think there should be an equilibrium. anyway I like my steak well done. adolfo To: Sent: Friday, May 18, 2012 4:51 PM Subject: Re: HELP FORK IN THE ROAD

As far as the model working or not working, I believe that it is almost impossible to make a reasonable income without having staff unless you have added fees. There is definitely a sweet spot is having enough staff and too much staff. I also think that you need to see enough patients. I average about 60 patients a week and make above the national average for FP's.

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

Sorry ,Not trying to sugar coat anything. Just trying to point out that the model in and of itself does not mean financial ruin. Though I do not make as much as many of my colleagues, I am definitely keeping my head above water and definitely above $100,000/year. I would agree that a lot of IMPs don’t make that much, but I believe that at least in this area, the model is working. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Friday, May 18, 2012 1:21 PMTo: Subject: Re: HELP FORK IN THE ROAD With all due respect , in previous surveys

of the group, you are distinctly in the minority on this. Most do make under 90K. That is just a fact of IMP life in most places, many have struggled to make 60K. Let's not sugar coat anything here. CCoteTo: Sent: Friday, May 18, 2012

9:52:49 AMSubject: RE: HELP FORK IN THE ROAD le,Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average†FP salary, but it is possible to use this model and still do pretty well. From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD ,A few thoughts from Northern California.....1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also

including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs. 2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas. 3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am

totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice. 4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable. 5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see. 6. You are welcome in Northern CA any time!

Blessings!DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now.

I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoingâ€. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would

expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their

primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination

process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with

allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an

appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient

thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing

expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a

covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be

an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away

the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

What about imps sharing staff? Remotely answering the phone to get patients in etc.

 

I would be very careful before investing a lot of money into an new office when your patient volume and collections are decreasing. I would take a very close look as to why your visits are decreasing. Usually after you have  been in business a few years no marketing is needed. I would take a very close look at your how's your health numbers. Personally, I think having staff who can answer the phone call on the first or second ring can significantly increase  your volume. Make sure you see everyone the same day they call even if they are new patients.  I would also take a very close look at your coding and collections per visit. I agree that seeing 10 -12 patients per day if you are solo solo or 12-15 patients per day if you have minimal staff is essential.

 I have not heard much success with the added fee model in Illinois although there are a few exceptions. I dropped my short trial of a membership fee after 6 months after a very hostile reception from patients and the neighborhood. 

The high malpractice costs in Illinois make the very low overhead model in Illinois almost impossible. Adding a staff member almost always will increase income but only if there is enough to demand to increase your patient visits as you expand capacity.

I'd be happy to drive out there and talk about your practice if you would like. 

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

 

I was going to say it's not the model so much as how many patients you

see. So 70 patients a week is 15 patients a day. I wonder how many

patients a day the lower income practices see.

I see more like Lynn but make enough to qualify for Medicaid I think if

I were the sole provider for the family. Might be because insurance

pays so much lower than Medicare or might be due to costs (overhead) and

I am not a MicroPractice (not the same thing as an IMP anymore).

There are many variables.

Kathy Saradarian, MD

From Primary Care Unfriendly NJ

Great article on medical abandonment

issues

> To:

>

ericacodes <http://us.mc1803.mail.yahoo.com/mc/compose?to

=ericacodes%40yahoogroups.com>,

>

<http://us.mc1803.mail.yahoo.com/mc/

compose?to=%40yahoogroups.com>

> Date: Wednesday, May 2, 2012, 3:41 PM

>

>

>

> Thought some of you might find this article informational. Hope it is

> informative for those on our list.

>

> Dr. Beth

>

> Medico-legal: Unintentional and accidental abandonment

>

> Last week we looked at how to avoid a claim of abandonment of a

patient

> when you are terminating that patient from your practice.

>

> However, it is still possible to be the subject of an actionable

> abandonment claim by patients you specifically had no ongoing

> physician-patient relationship with and patients you discharged in

full

> technical compliance with all formal requirements and even by

patients

> you consider to be fully active in your practice.

>

> Let's look at those situations now.

>

> I. Failure to carry through on an accrued duty

>

> Last week, the necessity to engage in limited-scope work like

physicals

> and screenings only under a disclaimer that no ongoing

> physician-patient relationship is thereby established was discussed.

>

> However, the critical word there is “ongoing”.

>

> Even within the scope of the limited care that you are providing, you

> still have the duties of a physician relative to what that examination

> reveals, even if it exceeds the intended purpose of the examination

and

> is not part of your specialty.

>

> The law assumes that the examinee would expect to be told of any

> medically important issues the physician finds and that this imposes a

> duty of reasonable care on the physician to reveal any such to the

> examinee.

>

> Therefore, for example, if you notice a suspicious mole on the back of

> a patient you are performing a disability physical on, you are

> obligated to not just document it in the record with a recommendation

> for follow-up but to inform the patient that it is something they need

> to have attended to by their own physician.

>

> Similarly, if you are doing an initial evaluation to decide if you

will

> even accept the patient into your practice, as, for example, many

> plastic surgeons do, and you identify significant hypertension that

was

> previously unknown, yo! u are obligated to both inform the patient and

> to offer to send the results to their primary care physician.

>

> You do not, however, have to order a biopsy or prescribe an

> anti-hypertensive or even make sure that the patient followed-up as

you

> suggested. That would all be care associated with an ongoing

> relationship with the patient and it exceeds your duty.

>

> In other words, your duty was limited to dealing appropriately with

> what might accrue during the examination that you performed and that

> limited duty was fulfilled in full when you alerted the patient and

> activated an appropriate follow-up system. More is not required, but

> less is abandonment.

>

> II. Constructive abandonment

>

> (i) This can occur when the termination process looks perfect on paper

> but, in the real world, the patient is actually left high and dry.

>

> Whether the patient can get another physician, either within the time

> frame you specified or at all, must be realistic or you will be deemed

> to have constrictively abandoned the patient.

>

> For example, if you have specialized skills not otherwise available in

> your area, or you practice ! in an isolated rural town where traveling

> to another physician is impossible for your patient, or even if you

are

> the only practitioner in your area who accepts Medicaid or Medicare

and

> your patient is otherwise completely unable to pay for treatment, then

> your responsibilities as the discharging physician are higher than

> usual in terms of making sure that your patient can actually get

> alternative treatment, beginning with allotting more than the usual

> time for the patient to get a new physician.

>

> However, if no matter how ample the transition period you offer is

> there simply are no practical alternatives to you, you may not be able

> to terminate the patient without facing an abandonment claim. In that

> case, you should contact your state medical board for instructions on

> how to proceed.

>

> (ii) Constructive abandonment can also occur when the patient is still

> part of your practice but is actually not getting needed care.

>

> This can happen in several ways:

>

> a. Failure to initiate treatment that was warranted

>

> This is more of a technical aspect of pleading in a medical

malpractice case.

>

> The premise is that the patient is internally abandoned within the

> active doctor-patient relationship because the ! care that was needed

> never began, leaving them as though they actually had no access to the

> treatment at all.

>

> Abandonment is alleged separately from medical negligence, but from

> your point of view in terms of defending the two issues are

> inextricable on a practical basis.

>

> b. Refusal to assist the patient in accessing appropriate support

>

> Physicians who refuse to fill out forms for such matters as legitimate

> disability claims or to get the patient an appropriate medical device

> or to keep a patient’s medically-required utilities on, or who will do

> so only for a significant fee that the patient cannot pay, can be held

> to have abandoned their patients.

>

> Of course, a physician is not expected to be a kowtowing hand-puppet

to

> an overly demanding patient or to an outright scammer to avoid being

> charged with abandonment. Constructive abandonment would only apply

> when the treatment or the assistance really were warranted but were

> unilaterally denied by the physician without good cause.

>

> c. Refusal to see the patient.

>

> This most commonly occurs when the patient has a very large

outstanding

> bill that they are refusing to address and the doctor tells them that

> they will not be scheduled for further appointments until that is

dealt

> with.

>

> This acts as constructive abandonment because the patient thereby

loses

> substantive access to the doctor while the bill remains unpaid.

>

> Such a situation should instead be dealt with by the! formal discharge

> of the patient from the practice, followed by all appropriate

> collection procedures.

>

> The potential for falling into constructive abandonment in such “self

> help” situations is an important reminder of two points:

>

> - There is no such thing as de facto termination by conduct. Even if

> the patient actually sues the doctor, that does not, in and of itself,

> end the physician-patient relationship. Therefore, any approach to a

> troublesome patient that begins with the idea that “Well, since the

> patient did (fill in thing that drives you bonkers) it means that I

am

> no longer bound by my duties as a doctor” should be immediately

> avoided.

>

> - The law views the physician-patient relationship as one in which the

> patient, as the one needing expert services for their health, is in

the

> dependent role. It is therefore protective of the patient. This

means

> that any doctor who finds themselves in opposition to a troublesome

> patient should make sure to use only clearly sanctioned methods, such

> as formal discharge, that actually afford the doctor considerable

> protection.

>

> d. Another situation in which constructive abandonment can come into

> play is with regard to coverage.

>

> Because you are responsible for providing an adequate alternative to

> your patients when you are unavailable for an extended period, if you

> do not do so, thereby leaving the patient functionally uncovered, it

> can give rise to an abandonment claim.

>

> This could occur if you use a covering doctor who is not reasonably

> equivalent to you & nb! sp;(e.g.; not from the same specialty or a

> closely allied one, such as internal medicine and cardiology covering

> for each other, or is barely out of training when you are very

> experienced) and so cannot provide a comparable level of expertise.

It

> can also occur if you continue to use an answering service even

after

> it habitually proves unreliable at getting messages from the patient

to

> the covering doctor accurately and promptly.

>

> Since in both of those situations the patient really has no meaningful

> access to appropriate care through the coverage system their doctor

has

> put in place, there is a predicate for an abandonment claim.

>

> III. Inadvertent abandonment

>

> (i) Coverage can be an issue in this regard as well when it is

completely

> absent.

>

> This is not the situation where the doctor deliberately puts no

> coverage in place and simply leaves a voice message telling patients

to

> call 911 or to go to ER. That is overtly inadequate.

>

> Instead, this occurs when there is a proper call schedule in place but

> the covering doctor becomes unavailable and no replacement is

> provided. In that situation, to the extent that the doctor needing

> coverage could have reasonably - that would be something like taking

> the call yourself instead of going to a planned party, not coming back

> from your vacation in China - prevented the problem, they can be

deemed

> to have abandoned their patients.

>

> (ii) Abandonment can also occur at your office level if your staff

> refuses to let a patient with a real problem talk to you or schedules

a

> necessary appointment too far in the future or i! f your staff merely

> files away the chart of a patient who actually needs to do some

> important follow-up.

>

> You need to have set office policies in place - preferably in writing,

> since you may have to prove them - to avert these problems.

>

> In summary: The laws governing medical abandonment are predicated on

> the more dependent status of the patient in the relationship with the

> physician. Therefore, when terminating a patient or when dealing with

> a patient actively, it is essential to fulfill your duty to make sure

> that your patient will not be left without appropriate care.

>

>

>

>

>

>

>

>

>

------------------------------------

[Guest guest]

I strongly disagree with the statement less expenses equals more profit. The people on this list serve who are making more money in general have slightly higher expenses. I agree there is equilibrium. I also know that everyone has their own priorities. My goal is to make enough money, really enjoy my practice and give great care. For people who need to make a certain level of income it is nice to know what you have to do to get there. I stand by my statement that you will not make over $130,000 unless you have at least 1 staff unless you charge extra fees.

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

Dear Larry.We will go on and on about what model work or not. I think the simple math here: less expenses more profit, I think that is very relative and it depends how much do your rice and beans on the table cost?if you are happy with 80,90,100,120,140,150...... K a year it is completely up to you and your family. I believe the money is very important at the end of the day we have business and if we are in red numbers we can not survive.do you want to make a lot of money and unhappy/miserable at the same time? I think there should be an equilibrium. anyway I like my steak well done. adolfo To: Sent: Friday, May 18, 2012 4:51 PM Subject: Re: HELP FORK IN THE ROAD

As far as the model working or not working, I believe that it is almost impossible to make a reasonable income without having staff unless you have added fees. There is definitely a sweet spot is having enough staff and too much staff. I also think that you need to see enough patients. I average about 60 patients a week and make above the national average for FP's.

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

Sorry ,Not trying to sugar coat anything. Just trying to point out that the model in and of itself does not mean financial ruin. Though I do not make as much as many of my colleagues, I am definitely keeping my head above water and definitely above $100,000/year. I would agree that a lot of IMPs don’t make that much, but I believe that at least in this area, the model is working. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Friday, May 18, 2012 1:21 PMTo: Subject: Re: HELP FORK IN THE ROAD With all due respect , in previous surveys

of the group, you are distinctly in the minority on this. Most do make under 90K. That is just a fact of IMP life in most places, many have struggled to make 60K. Let's not sugar coat anything here. CCoteTo: Sent: Friday, May 18, 2012

9:52:49 AMSubject: RE: HELP FORK IN THE ROAD le,Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average” FP salary, but it is possible to use this model and still do pretty well. From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 18, 2012 8:35 AMTo: Subject: RE: HELP FORK IN THE ROAD ,A few thoughts from Northern California.....1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also

including a major benefit package?? Call a locums company and see what you would make per hour taking Illinois locums jobs. 2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas. 3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am

totally open for the group to point out how wrong I am here......that for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice. 4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be survivable. 5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see. 6. You are welcome in Northern CA any time!

Blessings!DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now.

I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoing”. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would

expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their

primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination

process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with

allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an

appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient

thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing

expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a

covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be

an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away

the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Agree with . Before my daughter joined me, I was making way over 150,000 a year, working 4 day weeks with no employees. Since she joined in 07 and the economy tanked have been more around the 100,000 level. I know what Larry is says, but more cost

does equal less take home, unless you get to the point of inefficiency. I believe that is what Larry meant. Together we are makig over 100,000 each with no employees still. With the MU money this year we will be fine, and we are hopeful to get into the CPPCP

or whatever it is, the demonstration Medicare project will be active in Colo. We also do not charge extra fees, as access costs.

From: [ ] On Behalf Of Dr. Brady [drbrady@...]

Sent: Friday, May 18, 2012 11:20 AM

To:

Subject: RE: HELP FORK IN THE ROAD

Sorry ,

Not trying to sugar coat anything. Just trying to point out that the model in and of itself does not mean financial ruin. Though I do not make as much as many of my colleagues, I am definitely

keeping my head above water and definitely above $100,000/year. I would agree that a lot of IMPs don’t make that much, but I believe that at least in this area, the model is working.

From: [mailto: ]

On Behalf Of magnetdoctor@...

Sent: Friday, May 18, 2012 1:21 PM

To:

Subject: Re: HELP FORK IN THE ROAD

With all due respect , in previous surveys of the group, you are distinctly in the minority on this. Most do make under 90K. That is just a fact of IMP life in most places, many have struggled to make 60K. Let's not sugar coat

anything here.

CCote

To:

Sent: Friday, May 18, 2012 9:52:49 AM

Subject: RE: HELP FORK IN THE ROAD

le,

Regarding point #3. Though my practice has been around a while (9 years) and is big for an IMP (1.25 FTE and see around 70 people/week), I easily make over $100,000. Last year, with the help

of the MU funds, I broke the $150,000 level. I don’t charge any fees. I don’t do any second jobs. I know I have still not hit the “average” FP salary, but it is possible to use this model and still do pretty well.

From:

[mailto: ]

On Behalf Of Dannielle Harwood

Sent: Friday, May 18, 2012 8:35 AM

To:

Subject: RE: HELP FORK IN THE ROAD

,

A few thoughts from Northern California.....

1. Many NP's/PA's here in town make more than $75 per hour. The ones working in the ER most certainly do. I think that price is too low unless it is also including a major benefit package?? Call a locums company and see what you would make

per hour taking Illinois locums jobs.

2. If you have ever considered moving to another part of the country this is a great time to look at that option. I have moved 2x in my career. Once from Baltimore to Denver and then from Denver to CA. We finally figured out that being

closer to family was a big deal to us and then looked at cost of living vs salaries etc.Lucky for us most places need doctors. That said it is much easier to create niche practices in larger metropolitan areas.

3. I do not think the numbers add up for a single doctor to be in an IMP style practice unless a very low salery is acceptable. Yes, I know I am an IMP. I think.....and I am totally open for the group to point out how wrong I am here......that

for the most part the IMP doctors are either content with less than 90k year or they work a second job or they are a retainer or cash only practice.

4. I think the system is trying to squeeze solo doctors out...new regualtions are popping up all the time that are very difficult to comply with based on our size. Again, if doing a niche practice, cash etc in a larger area this may be

survivable.

5. I also know that hospitals that are building new projects tend to run behind so you may have a little time to wait and see.

6. You are welcome in Northern CA any time!

Blessings!

Dannielle

Subject: Great article on medical abandonment issues

To:

ericacodes ,

Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical

compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination

and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for

follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was

previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with

the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated

an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you

are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient

can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that

case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the

treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will

do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply

when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.

c. Refusal to see the patient.

This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with.

This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.

Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures.

The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:

- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the

idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.

- The law views the physician-patient relationship as one in which the

patient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly

sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it

can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for

each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from

the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment

(i) Coverage can be an issue in this regard as well when it is completely

absent.

This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.

Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something

like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients.

(ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to

do some important follow-up.

You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.

In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill

your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

All very good advice.I think an IMP model can thrive in the Western NY area (solo-solo 120-140k) and am looking forward to jumping in next year. Mike Elliott MDBuffalo NY

What about imps sharing staff? Remotely answering the phone to get patients in etc.

I would be very careful before investing a lot of money into an new office when your patient volume and collections are decreasing. I would take a very close look as to why your visits are decreasing. Usually after you have been in business a few years no marketing is needed. I would take a very close look at your how's your health numbers. Personally, I think having staff who can answer the phone call on the first or second ring can significantly increase your volume. Make sure you see everyone the same day they call even if they are new patients. I would also take a very close look at your coding and collections per visit. I agree that seeing 10 -12 patients per day if you are solo solo or 12-15 patients per day if you have minimal staff is essential.

I have not heard much success with the added fee model in Illinois although there are a few exceptions. I dropped my short trial of a membership fee after 6 months after a very hostile reception from patients and the neighborhood.

The high malpractice costs in Illinois make the very low overhead model in Illinois almost impossible. Adding a staff member almost always will increase income but only if there is enough to demand to increase your patient visits as you expand capacity.

I'd be happy to drive out there and talk about your practice if you would like.

Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618www.roscoevillagefamilymedicine.com

I was going to say it's not the model so much as how many patients you

see. So 70 patients a week is 15 patients a day. I wonder how many

patients a day the lower income practices see.

I see more like Lynn but make enough to qualify for Medicaid I think if

I were the sole provider for the family. Might be because insurance

pays so much lower than Medicare or might be due to costs (overhead) and

I am not a MicroPractice (not the same thing as an IMP anymore).

There are many variables.

Kathy Saradarian, MD

From Primary Care Unfriendly NJ

HELP FORK IN THE ROAD

>

>

>

>

>

> Dear IMPS,

>

>

>

> I need your input and wisdom for help in making a tough change in

practice.

>

>

>

> and I have been sharing our practice for 8 years in a small 5

> room office with three bathrooms total 660 sq-ft. Plus community

> hallway linking the rooms in the south hallway of our community

> hospital. For this we pay rent $884 per month or $10,000 per year

> including heat, cooling, electricity, water, cleaning, sharps, and

> hazardous waste removal. They maintain the parking lot, grounds, snow

> removal.

>

>

>

> This hospital will be building 16 new beds starting 8/2012 to be

> complete by 9/2013. At that time they will likely tear down the

> existing space we rent. We will have to change office locations.

>

>

>

> Most of the other physicians in town work for a nearby hospital

> competitor and a few have signed up with the in town hospital

sponsored

> group. Our patient population is falling for lack of visibility and

> group association.

>

>

>

> The ER group is offering hospitalist shifts at our hospital for $75

per

> hour with in house responsibility 7AM- & PM and call coverage 7PM to

> 7AM. They are offering no benefits. They would like me to resign

from

> my own clinic to not scare away hospital business from the other major

> groups in town.

>

>

>

> The medical office building in town is leasing space at $26 per sq-ft

> increasing 3%per year. Minimum 1500 sq-ft. or $39,000 per year

> increasing over 10 years to $51,000 per year 10 years out.

>

>

>

> Options: 1. Wait and see.

>

> 2. Scour the area for cheap office space to re-establish as

> solo IMP and I become hospitalist. Employ staff to keep from

> going crazy full time with newborn at home.

>

> 3. We close our IMP and we both become hospitalists.

>

> 4. Go all in in this small community and buy land and build a building

> for our IMP practice. Estimate $3-400,000 clearly about the same as

> leasing example above or cash flow of $1500 per month for just

> mortgage, insurance, and taxes. Additional expense unknow