Comments on: The way we practice primary care doesn’t make sense http://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html Tue, 14 Feb 2012 17:18:00 +0000 hourly 1 By: richhttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-140626 rich Sun, 22 Aug 2010 14:49:04 +0000 http://www.kevinmd.com/blog/?p=44997#comment-140626 nguem: I think the answer is- go work or the VA. The pay differential is not that much between private and va docs and benefits are good. nguem: I think the answer is- go work or the VA. The pay differential is not that much between private and va docs and benefits are good.

]]> By: Kristie Shttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139530 Kristie S Tue, 03 Aug 2010 23:59:53 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139530 I have been a patient at Mayo Clinic Primary Care in Jacksonville for about 8 years. I have only on very, very rare occasions had to wait for my physician. The majority of the time he is in my room within minutes after I undress and is apologetic if I have to wait five minutes for him.I will say however, that it is made known to you that you are expected to arrive on time for your appointment and if you are late, your appointment will be cancelled. C'est la vie. It happened to me once, I got stuck in traffic, was late, and that was life, I rescheduled. They were very nice about it, but it's my responsibility to be on time an appointment time is not a suggestion. I have been a patient at Mayo Clinic Primary Care in Jacksonville for about 8 years. I have only on very, very rare occasions had to wait for my physician. The majority of the time he is in my room within minutes after I undress and is apologetic if I have to wait five minutes for him.

I will say however, that it is made known to you that you are expected to arrive on time for your appointment and if you are late, your appointment will be cancelled. C’est la vie. It happened to me once, I got stuck in traffic, was late, and that was life, I rescheduled. They were very nice about it, but it’s my responsibility to be on time an appointment time is not a suggestion.

]]> By: Sandrahttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139419 Sandra Mon, 02 Aug 2010 18:06:44 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139419 I'm an internist, in the process of leaving my clinic practice at Kaiser for a more doable job in long-term care. I have been running my IM practice at Kaiser very differently than the norm as described by Dr Lim above, for the past 3 years. I have based my practice on the medical home and what I perceive health care to be like in Sweden. I start with my day's schedule (and upcoming days and weeks' schedules) and scrutinize each appt and what i know about each patient, and determine if an MD-level appt is truly needed or not, in my opinion. For those that are not needed in my view (approx half), I have a skilled triage RN with a flair for this type of work, call those folks and say that I asked her to call to get more info. I outline some options for the RN to offer (RN & MD advice with MD appt in few days if no imorovement), direct-access PT, redirect to the specialist they've already seen for same issue, etc). Thus about half or more of my appts are handled this way. I see about 6-8 pts per day and spend the rest if my worktime doing emails with pts (20-30 per day) and discussing test results with pts either via written comments or email. I have 1400 pts, 80% of whom are avid emailers. i have shifted all the non-MD work, including appts that don't need to happen, to other team members. My quality scores are among the top 10% in Kaiser nationally, and my patient satisfaction scores are 89% delighted or more. It has all been working brilliantly. Problem is, the folks who run the insurance side of Kaiser are not supportive of doing things this radically, and I have to beg for the level of RN support needed for doing things this way; there is no system-wide cultural support for me, I'm considered "ahead of my time" and there is resentment amongst team members for my shifting work to them. There is no actual time carved out of my day for me to do emails with 80% of my patients, the expectation is that i will get it done on my own time in the evenings. Doing tjings this way works great if I am on top of things 24/7, but if I take any time off, it all becomes nightmarish and not doable once again, like for all my colleagues all the time. I’m an internist, in the process of leaving my clinic practice at Kaiser for a more doable job in long-term care. I have been running my IM practice at Kaiser very differently than the norm as described by Dr Lim above, for the past 3 years. I have based my practice on the medical home and what I perceive health care to be like in Sweden. I start with my day’s schedule (and upcoming days and weeks’ schedules) and scrutinize each appt and what i know about each patient, and determine if an MD-level appt is truly needed or not, in my opinion. For those that are not needed in my view (approx half), I have a skilled triage RN with a flair for this type of work, call those folks and say that I asked her to call to get more info. I outline some options for the RN to offer (RN & MD advice with MD appt in few days if no imorovement), direct-access PT, redirect to the specialist they’ve already
seen for same issue, etc). Thus about half or more of my appts are handled this way. I see about 6-8 pts per day and spend the rest if my worktime doing emails with pts (20-30 per day) and discussing test results with pts either via written comments or email. I have 1400 pts, 80% of whom are avid emailers. i have shifted all the non-MD work, including appts that don’t need to happen, to other team members. My quality scores are among the top 10% in Kaiser nationally, and my patient satisfaction scores are 89% delighted or more. It has all been working brilliantly. Problem is, the folks who run the insurance side of Kaiser are not supportive of doing things this radically, and I have to beg for the level of RN support needed for doing things this way; there is no system-wide cultural support for me, I’m considered “ahead of my time” and there is resentment amongst team members for my shifting work to them. There is no actual time carved out of
my day for me to do emails with 80% of my patients, the
expectation is that i will get it done on my own time in the evenings. Doing tjings this way works great if I am on top of things 24/7, but if I take any time off, it all becomes nightmarish and not doable once again, like for all my colleagues all the time.

]]> By: Chris Keller, MSN, RNhttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139394 Chris Keller, MSN, RN Mon, 02 Aug 2010 12:52:10 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139394 What if docs had posters on their waiting room walls: 1) "The real cost of treating diabetes for a year is $___," with a rough breakdown of that cost. Likewise for other chronic conditions. 2) There are more basic ways of taking care of your health than taking medications. There is prevention and there are lifestyle changes. The real cost of medical care for a person taking care of their health in a personally responsible way is $___- ___(this is a range). (Rough breakdown includes a yearly visit to your doc, the cost of vitamin supplements, the cost of a good pair of walking shoes and weekly healthy grocery costs for a family of 3. Or whatever else the individual doc would like to see on this list, such as gym membership. 3) The "basics" are these things: _________. For a child: _________. For my older patients: ________(Patient education.) 4) These cultural practices can undermine your health: _____. (Individual doc fills in the blank with such things as "fast food," "x-amount of alcohol," "sitting in front of a screen--TV or computer--for x-number of hours/day," "recreational drugs," etc.) 5) Insurance costs and reimbursements are NOT in line with real costs. Negotiate with your insurance company, altering your plan for your individual health needs and means, and consider direct payments for basic care (concierge plans) with catastrophic coverage from insurance companies. 6) As a primary care physician, I am altering my relationship with insurance companies and hospitals in these ways: ________________ (i.e., use of hospitalists, relationship with Medicare/Medicaid, # of minutes per visit, communication via phone/email v face-to-face visits, health coaches/triage nurses will contact you, "medical home" practice, etc.). 7) Don't count on either insurance nor government plans to safeguard your health and address your needs. Take personal responsibility for your health. 8) This should probably be #1--a statement of my philosophies about healthcare availability, such as "I believe everyone deserves BASIC healthcare." And/or "I have care plans suited to those with chronic conditions, to adults who are generally in good health and to those who have an acute episode, such as an accident or injury, and children ages birth through 18. Ask at the front desk for details. You will receive a written care plan from my triage nurse or nurse practitioner. Be assured, however, that I am always ready to individualize your care". What if docs had posters on their waiting room walls: 1) “The real cost of treating diabetes for a year is $___,” with a rough breakdown of that cost. Likewise for other chronic conditions.
2) There are more basic ways of taking care of your health than taking medications. There is prevention and there are lifestyle changes. The real cost of medical care for a person taking care of their health in a personally responsible way is $___- ___(this is a range). (Rough breakdown includes a yearly visit to your doc, the cost of vitamin supplements, the cost of a good pair of walking shoes and weekly healthy grocery costs for a family of 3. Or whatever else the individual doc would like to see on this list, such as gym membership.
3) The “basics” are these things: _________. For a child: _________. For my older patients: ________(Patient education.)
4) These cultural practices can undermine your health: _____. (Individual doc fills in the blank with such things as “fast food,” “x-amount of alcohol,” “sitting in front of a screen–TV or computer–for x-number of hours/day,” “recreational drugs,” etc.)
5) Insurance costs and reimbursements are NOT in line with real costs. Negotiate with your insurance company, altering your plan for your individual health needs and means, and consider direct payments for basic care (concierge plans) with catastrophic coverage from insurance companies.
6) As a primary care physician, I am altering my relationship with insurance companies and hospitals in these ways:
________________ (i.e., use of hospitalists, relationship with Medicare/Medicaid, # of minutes per visit, communication via phone/email v face-to-face visits, health coaches/triage nurses will contact you, “medical home” practice, etc.).
7) Don’t count on either insurance nor government plans to safeguard your health and address your needs. Take personal responsibility for your health.
8) This should probably be #1–a statement of my philosophies about healthcare availability, such as “I believe everyone deserves BASIC healthcare.” And/or “I have care plans suited to those with chronic conditions, to adults who are generally in good health and to those who have an acute episode, such as an accident or injury, and children ages birth through 18. Ask at the front desk for details. You will receive a written care plan from my triage nurse or nurse practitioner. Be assured, however, that I am always ready to individualize your care”.

]]> By: jsmithhttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139324 jsmith Sat, 31 Jul 2010 16:32:34 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139324 One word, HJ: concierge. One word, HJ: concierge.

]]> By: imdochttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139274 imdoc Fri, 30 Jul 2010 03:05:41 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139274 Some years after the whole delivery model implodes, some ivy league school will do a 'study' and begin promoting the novel idea of a well-trained generalist physician.... Some years after the whole delivery model implodes, some ivy league school will do a ‘study’ and begin promoting the novel idea of a well-trained generalist physician….

]]> By: ninguemhttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139197 ninguem Thu, 29 Jul 2010 05:38:49 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139197 "......Only integrated health systems such as Washington State’s Group Health Cooperative have been able to thus far afford the changes necessary to transform their old-style practices into what is being called the patient-centered medical home. And though Group Health has already seen their efforts result in improved patient satisfaction and cost savings, for many docs, adapting to the changes hasn’t been easy....."Does Group Health's data actually support this statement? At least with regard to cost savings?http://www.kevinmd.com/blog/2010/06/medical-home-save-primary-care-money.html “……Only integrated health systems such as Washington State’s Group Health Cooperative have been able to thus far afford the changes necessary to transform their old-style practices into what is being called the patient-centered medical home. And though Group Health has already seen their efforts result in improved patient satisfaction and cost savings, for many docs, adapting to the changes hasn’t been easy…..”

Does Group Health’s data actually support this statement? At least with regard to cost savings?

http://www.kevinmd.com/blog/2010/06/medical-home-save-primary-care-money.html

]]> By: med studenthttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139192 med student Thu, 29 Jul 2010 01:40:21 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139192 I don't understand # 6 on Dr. Lin's article: "6) when face-to-face visits are necessary to build trust."Aren't many visits required to build the "necessary trust"? Doesn't transfering care to another person like an NP damage and somewhat negate the need for that trust in the physician, and create a need to trust the mid-level practitioner? Lastly, if #6 were carried out appropriately, would it truly free up any time from the physician? I don’t understand # 6 on Dr. Lin’s article: “6) when face-to-face visits are necessary to build trust.”

Aren’t many visits required to build the “necessary trust”? Doesn’t transfering care to another person like an NP damage and somewhat negate the need for that trust in the physician, and create a need to trust the mid-level practitioner? Lastly, if #6 were carried out appropriately, would it truly free up any time from the physician?

]]> By: HJhttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139185 HJ Wed, 28 Jul 2010 23:17:24 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139185 At this point, my PCP is more of a referral service. I haven't ever had a PCP that helped me live the good life-OK in my twenties I had a great GYN. There aren't any good ol' days for me to be nostalgic about. At this point, my PCP is more of a referral service. I haven’t ever had a PCP that helped me live the good life-OK in my twenties I had a great GYN. There aren’t any good ol’ days for me to be nostalgic about.

]]> By: jsmithhttp://www.kevinmd.com/blog/2010/07/practice-primary-care-sense.html#comment-139180 jsmith Wed, 28 Jul 2010 22:17:03 +0000 http://www.kevinmd.com/blog/?p=44997#comment-139180 Very well said ninguem. People will pay for haircuts and smokes but think your time and effort should be free to them. The future is clear to see. We ain't seen nothin' yet as regards "inconvenience." The PCP shortage is starting to bite big time. Five or ten years from now it will be much worse, and pts will be incensed by the cost and ineffectiveness specialty care. They'll look back at this decade as the good ole days. The new PCPs and a few well heeled pts will be livin' the good life in the world of concierge, and it'll be the cattle call for the rest. We told you so, America. Very well said ninguem. People will pay for haircuts and smokes but think your time and effort should be free to them.
The future is clear to see. We ain’t seen nothin’ yet as regards “inconvenience.” The PCP shortage is starting to bite big time. Five or ten years from now it will be much worse, and pts will be incensed by the cost and ineffectiveness specialty care. They’ll look back at this decade as the good ole days. The new PCPs and a few well heeled pts will be livin’ the good life in the world of concierge, and it’ll be the cattle call for the rest.
We told you so, America.

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