Different approaches to the summit

[Guest guest]

All along I've been aiming to demonstrate a model capable of delivering

better care in a vital and sustainable practice. As a primary care

doc I want to show that excellent primary care can help solve some of the

biggest problems facing the U.S. health care system. By delivering

reliably better care, we can help lower the total cost of health

care.

To reach this goal, we need new ways of doing our work. Lowering

overhead has allowed us to get off the hamster wheel and focus on the

care. Simple yet effective measurement strategies tell us how well

our office perform. Patient-centered collaborative care teaches us

new ways of working with all of our patients to achieve better outcomes.

My means to that end was to create a solo practice with no staff to first

test the operations and use of information technology.

Next Judy Zettek RN came on board to help us push the envelope of superb

care/outcomes.

Larry Lindeman demonstrates the model in a two physician practice that is

financially viable with staff in a very cost of living and malpractice

region (Chicago). I've seen his practice and it is very simple,

very nice. Just as others challenged me with " no one else will

be able to do it, " we're going to hear from a growing number

of practices with more than one doc practicing in the IMP mode.

Zero staff and all alone is one means to the goal.

Some staff and partner doc is another.

Because we live in different environments and have different needs, I

know that we need many paths to the goal. Thanks, Larry, for

sharing yours.

Gordon

At 08:12 PM 12/27/2006, you wrote:

While I agree that efficiency is

very important, don't ignore the possibility of hiring a staff

person after things get busy. I have found that with a staff ratio of

slightly over 1:1 (1.5 doctors and 1.8 staff) I am now able to make a

little over the national norm for FP's. It was surprising how much a

difference adding just a few patients a day made to the bottom line. I am

currently seeing about 17 patients on average per day and my partner sees

about 7/ day which is busy but doable with my staff. Last summer I was

very nervous about hiring a 0.8 fte LPN to help especially with our

quality program but she has easily paid for her salary. We do review our

processes very carefully to be able to see this many patients. We spend

at least 1.5 hours per week on staff meetings trying to improve both our

clinical and our business sides of the practice.

Larry Lindeman MD

Lynn,

Thank you for your candid thoughts and perspective. Each time i

think I will hire staff, I need to come back here and talk about

increased efficiency. I will share some insight into my proctice at

the three year mark in June.

Thanks again,

lynn ho wrote:

Two years into the micropractice, my personal office efficiency seems

to

have made significant improvements over the past 3 months with your

ideas,

THANKS to all of you who sent helpful tips and lent moral

support.

I was unable to keep track of where those wasted hours went, the logs

were

just too difficult to keep, but I now no longer have to stay up until

2-3-4AM once a week just to get caught up on the billing. My out of

work-

work hours are now much saner (maybe financial stuff, taxes,

reconciling

accounts, paying bills one weekend a month, some desultory bidding on

eBay

for cheap office and medical stuff, etc.) and I feel much less burned

out.

I think I can manage and enjoy this style of practice for a long time

(some

years, I'm thinking); it appears doable AND sustainable for

me.

Here's a solo - solo list of the things that got changed in the past

3

months, that really seemed to help me LOTS, not really in any ranking

order:

1) NEVER answer the phone, pretty much ALWAYS let the machine take a

message. I was letting the phone interrupt me before- takes some

training

to just let it ring, but the payoff is big. Also, be meaner about

having

patients come in- less phone medicine and more face to face medicine

makes

me feel less put upon.

2) Try to avoid calling any results, TRY to email all the results

possible,

a close second leaving messages on an answering machine, paper the

3rd most

useful method (but takes longer); leaving a message on a machine is

also

fine, but you can't predict when you call if someone is going to be

home or

not! the worst of all is being stuck on the phone for 'by the way'

questions

from a patient.

3) Electronic billing is great! Much faster and easier than paper

(may

save me 2-4 hours per week upfront) but more importantly, on the

downstream

side, doesn't allow those smarmy insurances to get away without

paying

because you didn't catch them before 6 months expires- provides proof

of

submission date. I Almost like billing now. Why didn't I do this

before?

4) Hired a poster/biller to argue with the insurance companies, 5-6

hours

every 1-2 weeks. Thank goodness and worth every penny, for the peace

of mind

alone.

5) Instant Medical History- really a time saver, documents and does

it

well, often more completely than I would have done, patient does the

work,

made all my paper rating scales obsolete. I REALLY appreciate it by

the

ends of the days when I sometimes would get way overwhelmed and feel

late,

even though I wasn't, and essentially not document anything in a

complicated

note, then (groan) have a complicated note to finish after the visit.

(this

is NOT happening any more!) Gives me a great start on the note,

reminds me

of details/problems that I did ask about but forgot completely about

and

would never have documented in my past methods, doesn't get tired by

the end

of the day like I do. Now without even a guilty start, I am easily

billing

just about all 99214s. Audit me! For $50 a month, much cheaper than a

medical assistant and has one hell of a medical background. I'd

highly

recommend it.

6) Other helpful things- 1) more patients are using appointment quest

and

making their appointments online, it's a matter of training but means

lots

less time on the phone for me; 2) new patient volume is tightly

controlled

and ratcheted down, less abstracting of old records has to happen,

also the

'more mature' patient population is requiring less training and

effort; 3)

my technology has stopped jerking me around, for the moment- haven't

had a

major issue in almost 3 months, just have to keep my fingers crossed,

really

don't want to add any more technology pieces now or ever (but I

suppose I'll

have to as time goes on); 4) paperless office and workflow it

generates

really contribute to efficiency in general.

What is great about the ultrasolo IMP style is that I can just decree

to

myself to change the above processes, and it happens. If they don't

work,

they get improved on or chucked out. The results are immediate,

dramatic

and telling, and there is no chain of command. I really like

that!

The other side of 'sustainable' for me is income, and for some reason

that

seems to be improving too. Now paying myself $6000/month (I think you

could

count it as $7000, if you look at retirement contributions) and it

seems as

if that is still increasing. That would be for about 40 booked

appointments

a week, mostly 99214s and some preventive care, in a state with about

average reimbursement but where preventive+e/m code visits are

bundled, and

where the major insurers will not pay extended visit codes.

I think my malpractice rates will fall for 2 reasons: I am changing

to a

cheaper carrier and I may qualify (I hope) for part time malpractice

rates,

from about $12000 to about $8000. (I used your letter, ,

-thanks!-

about considering my practice as a part time practice despite the

greater

than part-time hours, and preliminarily, it seems that they are going

to

bite.)

I did knock down my rent/utilities payments to $1050 per month from

$1700,

goaded into this move to cheaper/smaller space by looking at the

overhead

breakdown for IMPs in general and realizing mine was way out of

whack.

Lastly, I think my accounts receivables will improve by a lot over

the next

6 months due to electronic billing- I'm sure I've missed a pile of $$

but

I'm not going to go back and try to mine them- too frustrating and it

will

make me too angry. Forward is the way to go at this point.

I think my income will settle somewhere in the 8-9K range a month

including

retirement benefits, at about the 40 visits a week/ 25 booked patient

hours, which for me will be fine. It's more than I've ever made

before, but

certainly not at the FP 'average', but then I am not working in a

patient

mill, I am also not doing hospital work and my schedule is not

crammed and

AAHHH -at this acceptable-for-me income level, the satisfaction of

the way

the practice runs trumps all.

Future things I will probably work on- take more (at least some)

vacation

and find more compatible coverage; proselytize for an IMP partner?;

get a

more complex patient registry going and some population management;

?group

visits - I will have to gear up to fight about reimbursement, RI is

so

backwards!; learn and practice motivational interviewing techniques,

to move

people a little bit further along; RELAX a little mentally, as things

actually appear to be working out.

So things are looking up! Thank you all for being the crowd that you

are,

and for just being out there. Could not have done this without you

all, and

the inspiration and experience that you - provide/share. (Solo-solo

would

have killed me off by now, probably about 6 months ago.)

Here's hoping for the coming year, if you are a new IMP, that you

begin to

settle as reasonably as I have done over the past few months, or if

you have

already established and attained a sustainable spot, that you can

maintain

it despite predicted stormy health care weather. Happy New

Year!

Lynn Ho

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