Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 Honestly I do not know how you guys with no staff are doing this. Today I saw 5 patients and generated 3 referrals and 2 preauths. I still have. 4 other referrals with preauths from earlier in the week. This alone will take me several hours.Connected by DROID on Verizon Wireless HELP FORK IN THE ROAD > > > > > > Dear IMPS, > > > > I need your input and wisdom for help in making a tough change inpractice. > > > > 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 hospitalsponsored > group. Our patient population is falling for lack of visibility and > group association. > > > > The ER group is offering hospitalist shifts at our hospital for $75per > hour with in house responsibility 7AM- & PM and call coverage 7PM to > 7AM. They are offering no benefits. They would like me to resignfrom > 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 RE how to surviveSeveral points --1) Volume and pt load still will dictate the cash total. I vary about 45-55 pts/4 day week, and "moonlight" out of office for the other day. Choice of moonlighting depends on opportunity (I have a parttime as an oc/med doc at a local plant, student clinic doc on retainer during the school year 1 am a week). Nursing home work if you like it (I don't).Most docs ALWAYS moonlight at some level, even if you call rounding on your pts moonlighting at the hospital?2) Rental opportunities -- consider approaching independent specialists. I rent from a podiatrist 2 days a week at a perdiem basis works well, a Gen Surg 3 days a week, all works out. I pay both $60/day. You can get good synergy with a specialist, harder with another primary (tried that didn't work out too well).3) Hospitals really arent the only game in town -- who pays most of your income? My area the BCBS pays 70%+ of my gross. Approach THEM for practice development. They'd probably want more independents than a monopoly.4) Sorry, guys. Hospitalist pay is about $60-75/hour if you are a contractor, thats what the locum tenens tell me, at least when I've had offers (not taken) for Philly.I don't think of solo being "squeezed out" so much as all of us are on the firing line of being "convinced" that our way "doesn't work". Guess what? This is UNTRUE!!! Dr Starfield through Hopkins PROVED it. Don't drink the coolaid but don't try to convince these guys. Pts are my best referral source, phone book (yes, the paper book) is the second. Have advertised in locals, some work, some don't.Regards to all, we are all in the same boat and need to keep sharing.Matt in Western PASolo since 2004; FP since 1988, worked for HMO x 6 years, hospital x 8 years, will NEVER NEVER work for anyone but myself WILLINGLY....Relatively poor (over 6 figs last 2 years) but am happy.matlev@... email me if I can help....To: Sent: Friday, May 18, 2012 12:52:49 PMSubject: 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. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 Let's all move to RI!!Matt in Western PAPS do you have lobster like Jeanne?HahaTo: practiceimprovement1 Sent: Friday, May 18, 2012 1:32:17 PMSubject: RE: HELP FORK IN THE ROADI 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 yearsafter initial startup of 2 - 3 years, 750- 800 patients, 40 patients per week - come to RI? demand is tremendous here for primary caremodel does seem to work here or perhaps this particular carryout of the model and the coastline is beautiful7 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 > > > 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: >] > 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=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 “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 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 RE NJ survival.Did survey here before -- Looks like in Calif, NJ, NY Medicare is BEST payor, and commercials pay 80% or less of THAT. Is that correct Kathy? If it is (I think so) that is why it is so hard for you :-(In Pa, Medicaid only pays $23/visit if they show...I also don't take that (stopped year 4 when I was building up more so got annoyed at these pts.Now in year 9, still holding at 45-50 for 4 days a week, is still a struggle for me to attract enough but am working on a few ideas.Regards,Matt in Western PATo: Sent: Friday, May 18, 2012 2:59:41 PMSubject: RE: HELP FORK IN THE ROAD 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 “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 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 RE numbers.Agree with Larry.Also add that you should see if you can get paid to do preventive care (NOT welcome to Medicare exam, yuk) on same day as urgent or chronic care, esp with Medicare advantage and PPO pts. That pays well and is NOT fraudulent.Matt in Western PATo: Sent: Friday, May 18, 2012 4:42:50 PMSubject: Re: HELP FORK IN THE ROAD 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 “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 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 Don't sleep.I also have staff...it does make management more difficult but survivable.M in Western PAFrom: dharwood100@...To: Sent: Friday, May 18, 2012 9:12:00 PMSubject: Re: HELP FORK IN THE ROAD Honestly I do not know how you guys with no staff are doing this. Today I saw 5 patients and generated 3 referrals and 2 preauths. I still have. 4 other referrals with preauths from earlier in the week. This alone will take me several hours.Connected by DROID on Verizon Wireless 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 Matt, it’s worse. I just ran a report. Aetna pays 44-66% Medicare. Amerihealth 77%. BCBS 65%. Cigna 54%. Empire BCBS 61-65%. United 53%. These are just on the 99214 code but that is my most common code. How do you drop your worse payor in this situation? Horizon/BCBS is the largest insurer in the state and I guess the best commercial payor but it’s pretty poor. I guess I could drop United/Oxford and Cigna, it’s not that many patients so it won’t affect much change. And quite frankly, we are getting calls from people with United and Cigna that their doctors have dropped the insurance and they need a new doctor. Not accepting. I do accept Medicaid. It’s capitated for the most part. I don’t have many, but it actually had been working out OK. Haven’t analyzed it lately. The dual covered (Medicare/Medicaid) are also on capitated plans. But as you can see, no one else even pays 80% Medicare so if I don’t get that 20% it’s still better than commercial plans. I did figure that if I could see 60 patients a week without increasing staffing at all, I would make a “decent living” which is in the 50-60k range. No where close to what Lynn or others are making, but you can see why by what I get paid. Kathy 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 I've got to agree also that this model is no more a set-up for financial ruin than any other primary care practice. I've been open < 3yrs, had a baby in the interim, and cleared $150,000 each year (planning on earning a bit less than that this year as I've hired a nurse in an effort to work a little less and be home with my kids more -- good success on that front so far -- but still anticipate > $130,00), though that does not include health insurance, which my family receives through my husband's job. Earning just about median FP salary for my region and infinitely happier than I would be in a hamster wheel primary care practice. Rochester, NY is another friendly place for IMP practices. Keep on keeping on!- Queenan, MDQueenan Family Medicine and Maternity Care " Mindful Medicine for whole body, mind, and spirit " **As of 3/1/11, we have moved from our prior location on East Ave to 1580 Elmwood Ave**1580 Elmwood Ave, Ste FRochester, NY 14620 (phone and fax) queenan@...www.queenanfamilymedicine.comThis email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legalinformation. The information is intended only for the use of the individualor entity named above. If you are not the intended recipient of this material, you may not use,publish, discuss, disseminate or otherwise distribute it. If you are not theintended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy theinformation that email in error Re: HELP FORK IN THE ROAD Posted by: " Lynn Ho " lynnhri@... lynnhri Fri May 18, 2012 10:32 am (PDT) 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 yearsafter initial startup of 2 - 3 years, 750- 800 patients, 40 patients per week - come to RI? demand is tremendous here for primary caremodel 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 > > > 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. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 Kathy, that's TERRIBLE! It seems like NJ should be ripe for a physician revolution. Doctors NEED to be dropping these companies so that patients and employers scream and make them pay better. Do you have enough Medicare to go cash-only plus Medicare? ---Sharlene > > > > From: Beth Sullivan > > > <bethdo97@... <mailto:bethdo97%40windstream.net> > <http://us.mc1803.mail.yahoo.com/mc/compose?to=b > ethdo97%40windstream.net>> > > Subject: Great article on medical abandonment > issues > > To: > > > ericacodes <mailto:ericacodes%40yahoogroups.com> > <http://us.mc1803.mail.yahoo.com/mc/compose?to > =ericacodes%40yahoogroups.com>, > > > > <mailto:%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. > > > > > > > > > > > > > > > > > > > > > ------------------------------------ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 I'm with you, le. I'm solo with just my husband helping out with nonclinical stuff, and I can't even comfortably keep up with the work generated by 30 patients per week. I'm trying to work on becoming more efficient, but have not had much success so far. If I could comfortably see 40 patients per week, I would be on Cloud 9!!!---Sharlene > > > > 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 cost > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 Thanks for the words of encouragement, .I was getting a little nervous with some of the pessimism!Frederick Elliott MDBuffalo, NYFuture IMP in 2013 I've got to agree also that this model is no more a set-up for financial ruin than any other primary care practice. I've been open < 3yrs, had a baby in the interim, and cleared $150,000 each year (planning on earning a bit less than that this year as I've hired a nurse in an effort to work a little less and be home with my kids more -- good success on that front so far -- but still anticipate > $130,00), though that does not include health insurance, which my family receives through my husband's job. Earning just about median FP salary for my region and infinitely happier than I would be in a hamster wheel primary care practice. Rochester, NY is another friendly place for IMP practices. Keep on keeping on!- Queenan, MDQueenan Family Medicine and Maternity Care"Mindful Medicine for whole body, mind, and spirit" **As of 3/1/11, we have moved from our prior location on East Ave to 1580 Elmwood Ave**1580 Elmwood Ave, Ste FRochester, NY 14620 (phone and fax) queenan@...www.queenanfamilymedicine.comThis email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legalinformation. The information is intended only for the use of the individualor entity named above. If you are not the intended recipient of this material, you may not use,publish, discuss, disseminate or otherwise distribute it. If you are not theintended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy theinformation that email in error Re: HELP FORK IN THE ROAD Posted by: "Lynn Ho" lynnhri@... lynnhri Fri May 18, 2012 10:32 am (PDT) 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 yearsafter initial startup of 2 - 3 years, 750- 800 patients, 40 patients per week - come to RI? demand is tremendous here for primary caremodel 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 > > > 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. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 19, 2012 Report Share Posted May 19, 2012 For and others contemplating IMP practices:I also think it is worth thinking about a niche practice. I know a headache and mood disorder internist who has carved out a nice niche; lots of options: fertility and hormone specialist; new mom and baby specialist; there are people who want to pay for good health care Membership or extra fee practices are the viable way in some areas. To some degree, depends how service oriented you are and how bad most of the other practices are (waiting weeks or months for short appointments where the doctor doesn't even have time to listen and you see them that day with a helpful visit....many people want to pay for access to that). Two soap box moments: Agree that some of the insurance reimbursement rates in some parts of the country are crazy. And it is worth considering if you are helping that system limp along by participating. We are professionals. People respect us just by nature of the MD (or whatever you have) and will PAY to see us. Don't forget, you have CHOICES. Lots. You may have a job funded by grants or govt. or whatever that allows you to do charity work in your job, or you can run a business and do charity work in and/or outside of your business (or not at all, but please do a little ), but don't be a victim. I'm sorry that the primary care system is a mess now, but you do have choices. (May not be easy at first, but they are there.)OK, back to our regularly scheduled program. SharonSharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617 PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com On Sat, May 19, 2012 at 12:10 PM, Frederick Elliott wrote: Thanks for the words of encouragement, .I was getting a little nervous with some of the pessimism!Frederick Elliott MDBuffalo, NY Future IMP in 2013 I've got to agree also that this model is no more a set-up for financial ruin than any other primary care practice. I've been open < 3yrs, had a baby in the interim, and cleared $150,000 each year (planning on earning a bit less than that this year as I've hired a nurse in an effort to work a little less and be home with my kids more -- good success on that front so far -- but still anticipate > $130,00), though that does not include health insurance, which my family receives through my husband's job. Earning just about median FP salary for my region and infinitely happier than I would be in a hamster wheel primary care practice. Rochester, NY is another friendly place for IMP practices. Keep on keeping on!- Queenan, MDQueenan Family Medicine and Maternity Care " Mindful Medicine for whole body, mind, and spirit " **As of 3/1/11, we have moved from our prior location on East Ave to 1580 Elmwood Ave**1580 Elmwood Ave, Ste FRochester, NY 14620 (phone and fax) queenan@...www.queenanfamilymedicine.com This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legalinformation. The information is intended only for the use of the individualor entity named above. If you are not the intended recipient of this material, you may not use,publish, discuss, disseminate or otherwise distribute it. If you are not theintended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy theinformation that email in error Re: HELP FORK IN THE ROAD Posted by: " Lynn Ho " lynnhri@... lynnhri Fri May 18, 2012 10:32 am (PDT) 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 yearsafter initial startup of 2 - 3 years, 750- 800 patients, 40 patients per week - come to RI? demand is tremendous here for primary caremodel 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 > > > 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. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 20, 2012 Report Share Posted May 20, 2012 Uggggghhh.....I don't know what to say, except I'm so sorry....To: Sent: Saturday, May 19, 2012 10:49:58 AMSubject: RE: HELP FORK IN THE ROAD Matt, it’s worse. I just ran a report. Aetna pays 44-66% Medicare. Amerihealth 77%. BCBS 65%. Cigna 54%. Empire BCBS 61-65%. United 53%. These are just on the 99214 code but that is my most common code. How do you drop your worse payor in this situation? Horizon/BCBS is the largest insurer in the state and I guess the best commercial payor but it’s pretty poor. I guess I could drop United/Oxford and Cigna, it’s not that many patients so it won’t affect much change. And quite frankly, we are getting calls from people with United and Cigna that their doctors have dropped the insurance and they need a new doctor. Not accepting. I do accept Medicaid. It’s capitated for the most part. I don’t have many, but it actually had been working out OK. Haven’t analyzed it lately. The dual covered (Medicare/Medicaid) are also on capitated plans. But as you can see, no one else even pays 80% Medicare so if I don’t get that 20% it’s still better than commercial plans. I did figure that if I could see 60 patients a week without increasing staffing at all, I would make a “decent living†which is in the 50-60k range. No where close to what Lynn or others are making, but you can see why by what I get paid. Kathy 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 “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 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 20, 2012 Report Share Posted May 20, 2012 Think most docs in NJ work for hospitals for salary???To: Sent: Saturday, May 19, 2012 2:51:55 PMSubject: Re: HELP FORK IN THE ROAD Kathy, that's TERRIBLE! It seems like NJ should be ripe for a physician revolution. Doctors NEED to be dropping these companies so that patients and employers scream and make them pay better. Do you have enough Medicare to go cash-only plus Medicare? ---Sharlene > > > > From: Beth Sullivan > > > <bethdo97@... <mailto:bethdo97%40windstream.net> > <http://us.mc1803.mail.yahoo.com/mc/compose?to=b > ethdo97%40windstream.net>> > > Subject: Great article on medical abandonment > issues > > To: > > > ericacodes <mailto:ericacodes%40yahoogroups.com> > <http://us.mc1803.mail.yahoo.com/mc/compose?to > =ericacodes%40yahoogroups.com>, > > > > <mailto:%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. > > > > > > > > > > > > > > > > > > > > > ------------------------------------ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 20, 2012 Report Share Posted May 20, 2012 If the need is great enough in your area, you may have to consider an independent subscription practice to survive, but not sure NJ will allow it, or if you can coordinate this. There is an outfit that has had some success in the Wash DC area called Privia Health whom I have a family member paying about $30/month for "additional services/access" to her PCP. I talked with them, they want you to imply to your pt base that all services will ultimately be that way.I don't see that happening, and of course there would continue to be the challenge of your insurers letting you stay on panel. But it is worth a look; you would end up with a much smaller practice but you might survive much better.See the numbers would be that if you had 600 pts, paying $30 each per month for "access," = $18,000 per month as base.I don't think the need is that great yet in my area; if I had 1000 "good" pts/month, I'd consider it but the insurers in my are pay me more than Medicare mostly, and Medicaid is increasing and pushing the employed docs into the hampster wheel so I've been getting some of those. Still many others go to the newer "urgicare" market around my way.Good luck.Matt in Western PATo: Sent: Saturday, May 19, 2012 10:49:58 AMSubject: RE: HELP FORK IN THE ROAD Matt, it’s worse. I just ran a report. Aetna pays 44-66% Medicare. Amerihealth 77%. BCBS 65%. Cigna 54%. Empire BCBS 61-65%. United 53%. These are just on the 99214 code but that is my most common code. How do you drop your worse payor in this situation? Horizon/BCBS is the largest insurer in the state and I guess the best commercial payor but it’s pretty poor. I guess I could drop United/Oxford and Cigna, it’s not that many patients so it won’t affect much change. And quite frankly, we are getting calls from people with United and Cigna that their doctors have dropped the insurance and they need a new doctor. Not accepting. I do accept Medicaid. It’s capitated for the most part. I don’t have many, but it actually had been working out OK. Haven’t analyzed it lately. The dual covered (Medicare/Medicaid) are also on capitated plans. But as you can see, no one else even pays 80% Medicare so if I don’t get that 20% it’s still better than commercial plans. I did figure that if I could see 60 patients a week without increasing staffing at all, I would make a “decent living†which is in the 50-60k range. No where close to what Lynn or others are making, but you can see why by what I get paid. Kathy 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 “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 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 21, 2012 Report Share Posted May 21, 2012 Our computer generates referrals directly from a note, and we can do the billing from the computer in about 5 minutes a day. Takes about 2 hours a month for AR handling. Would take me longer to have someone. Most prior auths (for radiology) are done by the radiology firms. Meds are infrequent, since I use mostly generics and can be done quickly on the web. Never leave after 6. From: [ ] On Behalf Of dharwood100@... [dharwood100@...] Sent: Friday, May 18, 2012 7:12 PM To: Subject: Re: HELP FORK IN THE ROAD Honestly I do not know how you guys with no staff are doing this. Today I saw 5 patients and generated 3 referrals and 2 preauths. I still have. 4 other referrals with preauths from earlier in the week. This alone will take me several hours. Connected by DROID on Verizon Wireless 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 21, 2012 Report Share Posted May 21, 2012 What EMR and tech tools are you using Jim?Thanks,Ben To: " " < > Sent: Monday, May 21, 2012 1:23 PM Subject: RE: HELP FORK IN THE ROAD Our computer generates referrals directly from a note, and we can do the billing from the computer in about 5 minutes a day. Takes about 2 hours a month for AR handling. Would take me longer to have someone. Most prior auths (for radiology) are done by the radiology firms. Meds are infrequent, since I use mostly generics and can be done quickly on the web. Never leave after 6. From: [ ] On Behalf Of dharwood100@... [dharwood100@...] Sent: Friday, May 18, 2012 7:12 PM To: Subject: Re: HELP FORK IN THE ROAD Honestly I do not know how you guys with no staff are doing this. Today I saw 5 patients and generated 3 referrals and 2 preauths. I still have. 4 other referrals with preauths from earlier in the week. This alone will take me several hours. Connected by DROID on Verizon Wireless 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 21, 2012 Report Share Posted May 21, 2012 so most of the doctors that we refer to "require" that we use their particular referral form. Very irritating and prevents direct faxing from my note and computer.I am doing my own billing now...this is taking me more time than it should but not too bad.The main issue is that I have only received about 21K for approx 400 patient visits...not enough to keep the office afloat....actually I take that back. It is enough to keep the office afloat but not enough to pay me too!!Dannielle > > From: Dr. Brady > <drbrady@...<mailto:drbradythevillagedoctor (DOT) hrcoxmail.com>> > Subject: RE: HELP FORK IN THE ROAD > To: > <mailto:@yahoogr oups.com> > Date: Friday, May 18, 2012, 10:45 AM > > > > , > > 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:@yahoogr oups.com> > [mailto: ] On Behalf Of Egly > Sent: Thursday, May 17, 2012 11:13 AM > To: > <mailto:@yahoogr oups.com> > 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 unknow Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 21, 2012 Report Share Posted May 21, 2012 leI get asked all the time " we will send you/do you have " our referral form and I say sorry we are required to work out of our computer and our computer does not have your form. I will send all the information needed but I cannot do your form. I am very firm That's it.These people are nuts to ask you. The specilaists who do that are trying to drive better info flow from PCPs who are not gonna send it no matter what form anyone constructs. It punishes the rest of us. I have few specialists here ,they are not hungry they are overwhelmed and they put up barriers but I never get push back. on that one. I have a template for consults in the emr and of course it can be some work to do up a consult but mostly the emr has the template with the labs pushed in and I just have to free text the problem and then ugh gather up anything like old consults or other labs- that is the work part. The template has everything needed and the demographics etc my npi etc I would posit that anyone in primary care needs to be saying sorry, no.Our job is to prepare the patietn fo r that visit and corodiante their care and we need to make the appointment while the patietn is here. I need to do this now. I cannot fill out forms and wait to get the date set up later then notify the patietn or have the specialist do it- and then the patietn will not capture it and will no show etc etc, a cycle of poor results. I f an office cannot do that I tell them i will not use their services . IMO primary care needs to say this every day Sorry no, in primary care we need ....xyz.I say all the time I end up with a problem sometimes due to scarcity of say rheum( who GRADED my consults and returned them t o me ,until I called and got a sorta tough response but worked it out -after I sat through the speech of what is wrong with us PCPs) but over the years I have cultivated relationships with these offices and if I get a receptionist who wants me to do her form that answer is no, we are required use the computer your form is not in our computer we are obligated to use our form I will get you what you need. It feels tough but it isMY dinner time and workload. I meet my obligation to the patient. You know at the VA where there was a COMMON record the urologists still wanted primary care to fill out their form!! And I agree with JIm practice like no pA for meds a re needed if at all possible.The imaging is payer and area dependent -I got XRay to do the last one for me I mean they want to get paid. good luckJean so most of the doctors that we refer to " require " that we use their particular referral form. Very irritating and prevents direct faxing from my note and computer. I am doing my own billing now...this is taking me more time than it should but not too bad.The main issue is that I have only received about 21K for approx 400 patient visits...not enough to keep the office afloat....actually I take that back. It is enough to keep the office afloat but not enough to pay me too!! Dannielle > > From: Dr. Brady > <drbrady@...<mailto:drbradythevillagedoctor (DOT) hrcoxmail.com>> > Subject: RE: HELP FORK IN THE ROAD > To: > <mailto:@yahoogr oups.com> > Date: Friday, May 18, 2012, 10:45 AM > > > > , > > 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:@yahoogr oups.com> > [mailto: ] On Behalf Of Egly > Sent: Thursday, May 17, 2012 11:13 AM > To: > <mailto:@yahoogr oups.com> > 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 unknow -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 22, 2012 Report Share Posted May 22, 2012 Emds create a referral letter from my progress Note. I can fax it from the emr as long as I haveThe doctor info with the fax .It is 1,2,3 . If they give me problems because I'm not usingTheir forms I look for another one.Adolfo E. Teran, MD leI get asked all the time " we will send you/do you have" our referral form and I say sorry we are required to work out of our computer and our computer does not have your form. I will send all the information needed but I cannot do your form. I am very firm That's it.These people are nuts to ask you. The specilaists who do that are trying to drive better info flow from PCPs who are not gonna send it no matter what form anyone constructs. It punishes the rest of us. I have few specialists here ,they are not hungry they are overwhelmed and they put up barriers but I never get push back. on that one. I have a template for consults in the emr and of course it can be some work to do up a consult but mostly the emr has the template with the labs pushed in and I just have to free text the problem and then ugh gather up anything like old consults or other labs- that is the work part. The template has everything needed and the demographics etc my npi etc I would posit that anyone in primary care needs to be saying sorry, no.Our job is to prepare the patietn fo r that visit and corodiante their care and we need to make the appointment while the patietn is here. I need to do this now. I cannot fill out forms and wait to get the date set up later then notify the patietn or have the specialist do it- and then the patietn will not capture it and will no show etc etc, a cycle of poor results. I f an office cannot do that I tell them i will not use their services . IMO primary care needs to say this every day Sorry no, in primary care we need ....xyz.I say all the time I end up with a problem sometimes due to scarcity of say rheum( who GRADED my consults and returned them t o me ,until I called and got a sorta tough response but worked it out -after I sat through the speech of what is wrong with us PCPs) but over the years I have cultivated relationships with these offices and if I get a receptionist who wants me to do her form that answer is no, we are required use the computer your form is not in our computer we are obligated to use our form I will get you what you need. It feels tough but it isMY dinner time and workload. I meet my obligation to the patient. You know at the VA where there was a COMMON record the urologists still wanted primary care to fill out their form!! And I agree with JIm practice like no pA for meds a re needed if at all possible.The imaging is payer and area dependent -I got XRay to do the last one for me I mean they want to get paid. good luckJean so most of the doctors that we refer to "require" that we use their particular referral form. Very irritating and prevents direct faxing from my note and computer. I am doing my own billing now...this is taking me more time than it should but not too bad.The main issue is that I have only received about 21K for approx 400 patient visits...not enough to keep the office afloat....actually I take that back. It is enough to keep the office afloat but not enough to pay me too!! Dannielle > > From: Dr. Brady > <drbrady@...<mailto:drbradythevillagedoctor (DOT) hrcoxmail.com>> > Subject: RE: HELP FORK IN THE ROAD > To: > <mailto:@yahoogr oups.com> > Date: Friday, May 18, 2012, 10:45 AM > > > > , > > 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:@yahoogr oups.com> > [mailto: ] On Behalf Of Egly > Sent: Thursday, May 17, 2012 11:13 AM > To: > <mailto:@yahoogr oups.com> > 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 unknow -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 22, 2012 Report Share Posted May 22, 2012 What's your EMR, if I may ask. I'm considering either Amazing Charts or Practice Fusion.Frederick Elliott MDBuffalo, NYFuture IMP in 2013 leI get asked all the time " we will send you/do you have" our referral form and I say sorry we are required to work out of our computer and our computer does not have your form. I will send all the information needed but I cannot do your form. I am very firm That's it.These people are nuts to ask you. The specilaists who do that are trying to drive better info flow from PCPs who are not gonna send it no matter what form anyone constructs. It punishes the rest of us. I have few specialists here ,they are not hungry they are overwhelmed and they put up barriers but I never get push back. on that one. I have a template for consults in the emr and of course it can be some work to do up a consult but mostly the emr has the template with the labs pushed in and I just have to free text the problem and then ugh gather up anything like old consults or other labs- that is the work part. The template has everything needed and the demographics etc my npi etc I would posit that anyone in primary care needs to be saying sorry, no.Our job is to prepare the patietn fo r that visit and corodiante their care and we need to make the appointment while the patietn is here. I need to do this now. I cannot fill out forms and wait to get the date set up later then notify the patietn or have the specialist do it- and then the patietn will not capture it and will no show etc etc, a cycle of poor results. I f an office cannot do that I tell them i will not use their services . IMO primary care needs to say this every day Sorry no, in primary care we need ....xyz.I say all the time I end up with a problem sometimes due to scarcity of say rheum( who GRADED my consults and returned them t o me ,until I called and got a sorta tough response but worked it out -after I sat through the speech of what is wrong with us PCPs) but over the years I have cultivated relationships with these offices and if I get a receptionist who wants me to do her form that answer is no, we are required use the computer your form is not in our computer we are obligated to use our form I will get you what you need. It feels tough but it isMY dinner time and workload. I meet my obligation to the patient. You know at the VA where there was a COMMON record the urologists still wanted primary care to fill out their form!! And I agree with JIm practice like no pA for meds a re needed if at all possible.The imaging is payer and area dependent -I got XRay to do the last one for me I mean they want to get paid. good luckJean so most of the doctors that we refer to "require" that we use their particular referral form. Very irritating and prevents direct faxing from my note and computer. I am doing my own billing now...this is taking me more time than it should but not too bad.The main issue is that I have only received about 21K for approx 400 patient visits...not enough to keep the office afloat....actually I take that back. It is enough to keep the office afloat but not enough to pay me too!! Dannielle > > From: Dr. Brady > <drbrady@...<mailto:drbradythevillagedoctor (DOT) hrcoxmail.com>> > Subject: RE: HELP FORK IN THE ROAD > To: > <mailto:@yahoogr oups.com> > Date: Friday, May 18, 2012, 10:45 AM > > > > , > > 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:@yahoogr oups.com> > [mailto: ] On Behalf Of Egly > Sent: Thursday, May 17, 2012 11:13 AM > To: > <mailto:@yahoogr oups.com> > 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 unknow -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 22, 2012 Report Share Posted May 22, 2012 Welford chart notesSent from my iPod What's your EMR, if I may ask. I'm considering either Amazing Charts or Practice Fusion.Frederick Elliott MDBuffalo, NYFuture IMP in 2013 leI get asked all the time " we will send you/do you have" our referral form and I say sorry we are required to work out of our computer and our computer does not have your form. I will send all the information needed but I cannot do your form. I am very firm That's it.These people are nuts to ask you. The specilaists who do that are trying to drive better info flow from PCPs who are not gonna send it no matter what form anyone constructs. It punishes the rest of us. I have few specialists here ,they are not hungry they are overwhelmed and they put up barriers but I never get push back. on that one. I have a template for consults in the emr and of course it can be some work to do up a consult but mostly the emr has the template with the labs pushed in and I just have to free text the problem and then ugh gather up anything like old consults or other labs- that is the work part. The template has everything needed and the demographics etc my npi etc I would posit that anyone in primary care needs to be saying sorry, no.Our job is to prepare the patietn fo r that visit and corodiante their care and we need to make the appointment while the patietn is here. I need to do this now. I cannot fill out forms and wait to get the date set up later then notify the patietn or have the specialist do it- and then the patietn will not capture it and will no show etc etc, a cycle of poor results. I f an office cannot do that I tell them i will not use their services . IMO primary care needs to say this every day Sorry no, in primary care we need ....xyz.I say all the time I end up with a problem sometimes due to scarcity of say rheum( who GRADED my consults and returned them t o me ,until I called and got a sorta tough response but worked it out -after I sat through the speech of what is wrong with us PCPs) but over the years I have cultivated relationships with these offices and if I get a receptionist who wants me to do her form that answer is no, we are required use the computer your form is not in our computer we are obligated to use our form I will get you what you need. It feels tough but it isMY dinner time and workload. I meet my obligation to the patient. You know at the VA where there was a COMMON record the urologists still wanted primary care to fill out their form!! And I agree with JIm practice like no pA for meds a re needed if at all possible.The imaging is payer and area dependent -I got XRay to do the last one for me I mean they want to get paid. good luckJean so most of the doctors that we refer to "require" that we use their particular referral form. Very irritating and prevents direct faxing from my note and computer. I am doing my own billing now...this is taking me more time than it should but not too bad.The main issue is that I have only received about 21K for approx 400 patient visits...not enough to keep the office afloat....actually I take that back. It is enough to keep the office afloat but not enough to pay me too!! Dannielle > > From: Dr. Brady > <drbrady@...<mailto:drbradythevillagedoctor (DOT) hrcoxmail.com>> > Subject: RE: HELP FORK IN THE ROAD > To: > <mailto:@yahoogr oups.com> > Date: Friday, May 18, 2012, 10:45 AM > > > > , > > 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:@yahoogr oups.com> > [mailto: ] On Behalf Of Egly > Sent: Thursday, May 17, 2012 11:13 AM > To: > <mailto:@yahoogr oups.com> > 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 unknow -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 22, 2012 Report Share Posted May 22, 2012 Oh my, Kathy! Those rates are terrible! Where are you located? Eads, MD Pinnacle Family Medicine Colorado Springs, CO www.PinnacleFamilyMedicine.com From: [mailto: ] On Behalf Of Kathleen Saradarian Sent: Saturday, May 19, 2012 8:50 AM To: Subject: RE: HELP FORK IN THE ROAD Matt, it’s worse. I just ran a report. Aetna pays 44-66% Medicare. Amerihealth 77%. BCBS 65%. Cigna 54%. Empire BCBS 61-65%. United 53%. These are just on the 99214 code but that is my most common code. How do you drop your worse payor in this situation? Horizon/BCBS is the largest insurer in the state and I guess the best commercial payor but it’s pretty poor. I guess I could drop United/Oxford and Cigna, it’s not that many patients so it won’t affect much change. And quite frankly, we are getting calls from people with United and Cigna that their doctors have dropped the insurance and they need a new doctor. Not accepting. I do accept Medicaid. It’s capitated for the most part. I don’t have many, but it actually had been working out OK. Haven’t analyzed it lately. The dual covered (Medicare/Medicaid) are also on capitated plans. But as you can see, no one else even pays 80% Medicare so if I don’t get that 20% it’s still better than commercial plans. I did figure that if I could see 60 patients a week without increasing staffing at all, I would make a “decent living” which is in the 50-60k range. No where close to what Lynn or others are making, but you can see why by what I get paid. Kathy -----Original Message----- From: [mailto: ] On Behalf Of dr_levin@... Sent: Saturday, May 19, 2012 8:44 AM To: Subject: Re: HELP FORK IN THE ROAD RE NJ survival. Did survey here before -- Looks like in Calif, NJ, NY Medicare is BEST payor, and commercials pay 80% or less of THAT. Is that correct Kathy? If it is (I think so) that is why it is so hard for you :-( In Pa, Medicaid only pays $23/visit if they show...I also don't take that (stopped year 4 when I was building up more so got annoyed at these pts. Now in year 9, still holding at 45-50 for 4 days a week, is still a struggle for me to attract enough but am working on a few ideas. Regards, Matt in Western PA From: " Kathleen Saradarian " To: Sent: Friday, May 18, 2012 2:59:41 PM Subject: RE: HELP FORK IN THE ROAD 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 22, 2012 Report Share Posted May 22, 2012 This is NJ. Kathy 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 22, 2012 Report Share Posted May 22, 2012 Kathy what does medicare pay in your region ?can you just move to medicare patients?wow, how do they get away with that, and NYC rates right over the river?Lynn From: [mailto: ] On Behalf Of Kathleen Saradarian Sent: Saturday, May 19, 2012 8:50 AM To: Subject: RE: HELP FORK IN THE ROAD Matt, it’s worse. I just ran a report. Aetna pays 44-66% Medicare. Amerihealth 77%. BCBS 65%. Cigna 54%. Empire BCBS 61-65%. United 53%. These are just on the 99214 code but that is my most common code. How do you drop your worse payor in this situation? Horizon/BCBS is the largest insurer in the state and I guess the best commercial payor but it’s pretty poor. I guess I could drop United/Oxford and Cigna, it’s not that many patients so it won’t affect much change. And quite frankly, we are getting calls from people with United and Cigna that their doctors have dropped the insurance and they need a new doctor. Not accepting. I do accept Medicaid. It’s capitated for the most part. I don’t have many, but it actually had been working out OK. Haven’t analyzed it lately. The dual covered (Medicare/Medicaid) are also on capitated plans. But as you can see, no one else even pays 80% Medicare so if I don’t get that 20% it’s still better than commercial plans. I did figure that if I could see 60 patients a week without increasing staffing at all, I would make a “decent living” which is in the 50-60k range. No where close to what Lynn or others are making, but you can see why by what I get paid. Kathy 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. > > > > > > > > > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
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