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Archives : primary care
Is traditional internal medicine dead? – A guest post by Dr. Steven Knope
Introduction by Tannus Quatre PT, MBA
I am pleased to post the following commentary from Dr. Steven Knope, an internal medicine specialist and concierge physician located in Tucson, AZ. I had the pleasure of befriending Dr. Knope a few years ago, and since that time have enjoyed thoroughly Dr. Knope’s perspective on medicine, and vision for the future of healthcare. Dr. Knope’s book, Concierge Medicine: A New System To Get The Best Healthcare, is an excellent read and an important lens through which our country’s current struggles with delivering the best healthcare can (and should) be viewed.
A true healthcare entrepreneur, it’s my privilege to post the following commentary from Dr. Knope titled, “Is Traditional Internal Medicine Dead?”
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Is Traditional Internal Medicine Dead?
by Steven Knope, MD
For the last several years, writers in the New England Journal of Medicine and the Journal of the American Medical Association have authored doomsday editorials about the prognosis of primary care medicine. There has been much discussion about the fact that internists and family practitioners cannot keep pace with rising overheads and falling reimbursement under the traditional third-party payment system. Paraphrasing a recent story published in The New York Times, an internist in Massachusetts who practices under the new RomneyCare program said this: “Every time I see a Medicare patient, it is the equivalent of giving them a ten-dollar bill. I have a six month wait to see a new patient. I run from room-to-room. I can barely make my overhead. I’ve never felt so disrespected in my entire life.”
So is this all just whining and political hyperbole or is internal medicine really dying? The answer to this question was revealed to me by a colleague last weekend while I was at the hospital. I had been called to the ER for one of my patients who was hemorrhaging on the blood thinner, Coumadin. The ER doctor looked at me and said, “You are a dying breed.” I laughed and said, “Yes, I know…but why do you say this?” He responded, “See that list of 9 doctors’ names and phone numbers up there on the wall? You are one of the last of 9 doctors who still admits his own patients to this hospital when they get sick. All of the other internists and family practitioners have abandoned hospital medicine and limit their practice to the office.” I knew that this was a profound statement and it shocked me; but I did not fully digest its implications until I had stabilized my patient and started my drive home.
The hospital where I practice has over 700 doctors on staff. The fact that only 9 of us still take care of our own patients when they are hospitalized answered the question about internal medicine’s future. It is no longer an issue of whether traditional internal medicine can survive; the facts are – at least outside of the concierge model – internal medicine is already dead.
What are the consequences for patients? What happens to the average person in Tucson, Arizona when he or she gets chest pain, develops pneumonia or has a seizure? Can they reach their internist or family practitioner for a medical emergency? Most patients who call their primary care doctor for a medical emergency can’t even reach his staff during normal office hours. Instead, they will hear a recording on an answering machine, directing them to go to “call 911” for any medical emergency.
Once in the ER, the “doctorless” patient will be admitted to a hospital physician, who is unknown to them. This so-called “hospitalist”, who is a salaried shift-worker, will put in his 12 hours, and then go home. He is a doctor who knows nothing about the patient’s medical history. He has never met the patient. There will be no call from the hospital doctor to the primary care doctor in the office to get a thorough medical history. There will be no medical records transferred to the hospitalist. The hospitalist will attempt to get the best medical history he can from the patient, make some quick medical decisions, and then pass the patient off to one of his colleagues when his shift ends. And so it goes. No continuity of care, no understanding of the patient; the sick person now becomes a “case of pneumonia” or “the stroke in bed 3” to a group of unknown, rotating professionals.
As fewer and fewer young doctors go into internal medicine and family practice, and thousands of primary care doctors retire early due to financial pressures, the primary care shortage will only worsen. Not only will there be no primary internists to take care of their own patients in the hospital, there will be fewer internists available to see patients in the office setting. This inevitable vacuum of internists and family practitioners (traditional diagnosticians) will be filled by nurse practitioners and medical assistants; people with far less training and expertise than an M.D.. If you are fortunate enough to have a good nurse practitioner, you will eventually be referred to an appropriate specialist, who will treat one of your medical problems. If you are not so lucky, a nurse or medical assistant may miss an uncommon or rare diagnosis; he or she may misdiagnose the “headache” that is actually an aneurysm, the “flu symptoms” that turn out to be meningitis, or the “gallbladder problem” that turns out to be a heart attack. Bad things will inevitably happen when doctors are replaced by medical assistants. It is simply a matter of statistics. All doctors make mistakes, but those with less training make more.
As a concierge physician, people often ask me how this move toward a government-run healthcare system will affect me professionally. Speaking honestly, I tell them that it will help my practice, but I do not think this is good news for the country. As an independent concierge doctor, I am not subject to the rules or fees set by Medicare or Medicaid, nor do I deal with third-party insurance carriers or HMOs. I work for my patients, not a third-party with a conflicting financial agenda. As someone who practices full-service internal medicine, the demand for my services will continue to increase. However, this outlook about my own practice does not make me happy. I have small children. I am concerned about their future. I am concerned about what the changes in primary care will do the future of American medicine; what will happen if the art of internal medicine is completely lost. I am worried about what it will mean to the efficiency of medicine as a whole, to have no diagnosticians and clinicians to treat the majority of problems that do not need a specialist.
I have found a unique niche in medicine, which allows me to truly practice what I was trained to do. For most of my colleagues, however, this is no longer the case. They too were trained to care for patients from the office, to the hospital, to the ICU. Now, they no can longer afford to take care for their patients when they develop life-threatening illnesses. They are now “clinic doctors.” Their hospital skills have atrophied. They will never practice comprehensive medicine again. For them, the game is already over. For them, internal medicine is already dead. For their patients, and the society as a whole, this is a great loss.
Medical practice management 101: Scalability
In this new series on The Healthcare Entrepreneur Blog, we’ll be taking a look at a number of medical practice management concepts that medical practice managers, administrators, and clinic owners should consider as part of their planning and day-to-day management. The principles we’ll be outlining as part of the Medical Practice 101 series are applicable to all types of medical practices including general medicine, the surgical specialties, and rehabilitation services such as physical and occupational therapy.
Here, we’ll discuss the concept of scalability as relevant to medical practice management. Scalability is the ability for a medical practice to expand its current systems, infrastructure, operations, and staff alongside the growth of the practice over a number of months or years. Scalability is an area of medical practice management that is not always fully considered when planning for the implementation of electronic medical records and business systems used to run and administer the medical practice, and can end up costing a medical practice severely in terms of time and money in order to meet the changing demands of a practice over time.
When planning for the use of electronic medical records (EMR) and practice management software (PMS), one of the scalable solutions that we like around here is the the use of web-based software or software-as-a-service (SAAS). The use of web-based or SAAS solutions allows a practice to operate one medical facility just as easily as operating two or more sites because the infrastructure used to link each user with the medical practice database exists via the internet. The need for a robust hardware infrastructure, including servers and virtual private networks (VPN’s) is minimized, and with it – the upfront cost of implementation.
Web-based software is typically provided on a per-user license basis, meaning that as additional providers or staff join the practice, additional licenses (or ’seats’) are purchased which allow the medical practice to easily grow, or ’scale’ their investment alongside the growth of the medical practice. Web-based software is a very scalable solution when it comes to medical practice management, which is why our medical practice consultants often recommend web-based solutions to our clients when determining solutions that will allow them to continue with their medical practice management infrastructure over the long haul.
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Tannus Quatre is a private practice consultant and principal with Vantage Clinical Solutions, Inc., a nationwide healthcare consulting and management firm located in Bend, OR and Denver, CO. Tannus specializes in the areas of healthcare marketing, strategy, and finance, and can be reached through the Vantage Clinical Solutions website.
Physician office sends patient data to wrong fax number…for 3 years
A Tennessee physician practice apparently sent out hundreds of faxes to a wrong fax number, breaching the privacy of likely hundreds of patients over the course of 3 years. Lots of questions about this one, like the obvious one: why wasn’t this remedied after the first error?
This is a huge HIPAA violation, and should serve as a reminder to make sure procedures are in place to verify and cross-check fax numbers and all other addressed material for all patient-related communications.
“This is a total breach of privacy,” Keith said. “This is supposed to be confidential, and it just so happens we have some scruples here and wouldn’t do anything with that information. We’ve shredded them, but you can have a file an inch thick in no time.”
via Doctors mistakenly fax patients’ data to Indiana company | The Tennessean.
Blogging in healthcare: The power of instant communication
Blogging can (and should) be considered a powerful strategy used for marketing, publicity, and even damage control for an organization who’s stakeholders exist online. For small private practices and large healthcare organizations alike, the power of blogging to reach an audience is often underestimated. The article below from Health Leaders Media does a great job of outlining the benefits of a blogging strategy for healthcare providers, as well as some tips on who and how blogging should be performed.
A blog can be a powerful way to get a hospital’s message out to the public, says Mark Whitman, vice president of digital marketing at Ohio-based brand consulting firm Northlich. “A big advantage of blogs is that information can be shared quickly among all stakeholders,” he says. “Quick response and sharing of information can help stop misinformation and rumors that can be very damaging during times of crisis.”
via Hospital Blogs Can Help During Times of Controversy | www.healthleadersmedia.com
Interstate competition for primary care doctors
Competition for a shrinking pool of qualified primary care doctors is hurting states that have a hard time recruiting against higher paying markets. For Vermont, the lure of a high quality of life isn’t quite enough it seems.
The reasons for the doctor shortage, which has been gradually worsening over the years, are well documented. Much of the problem boils down to money. Medical students who opt to specialize rather than enter primary care practices stand to make significantly more because specific procedures earn higher reimbursements than generalized care and diagnoses. For medical students leaving school with debt loads often topping $150,000, the decision to enter primary care practice often means a degree of financial hardship, according to survey-based research conducted in Vermont and nationwide.
Exerpted from: Doctor shortage proves painful to state: Times Argus Online.
A Doctor by Choice, a Businessman by Necessity
A good essay in the NYTimes.com which speaks to the rising commercialism of healthcare.
I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”
via Essay – A Doctor by Choice, a Businessman by Necessity.
Specialization in health care means more cost to the system
It’s the unfortunate reality that while increased specialization of labor in health care can result in better care, it most certainly results in more expensive care. This is going to be an issue until we find a way to pay more for “brain time” or “cognitive medicine.”
From, the NY Times: Let Doctors Bid for Medicare Business
Researchers have observed that having one additional specialist (per 100,000 people) in a region leads to about $13 more in health care spending per Medicare patient. New York City, for instance, has 186 specialists for every 100,000 residents, which is twice as many as Albany’s 93. Accordingly, Medicare spends $12,114 a year treating each patient in New York City, but only $5,950 in Albany.
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Tannus Quatre PT, MBA is a private practice consultant and principal with Vantage Clinical Solutions, Inc., a nationwide healthcare consulting and management firm located in Bend, OR and Denver, CO. Tannus specializes in the areas of healthcare marketing, strategy, and finance, and can be reached through the Vantage Clinical Solutions website.
Choosing a new primary care doctor: What the media is saying
Here’s a great clip from ABC News that discusses a framework for choosing a primary care physician. Knowing what the media is telling patients about how to find providers is an important step toward setting up marketing messages and systems that will help attract and retain a loyal following.
- Ask family and friends who they trust
- Find out where your doctor is affiliated
- Check the doctor’s credentials
- Find out the doctor’s accessibility
- Find out what your doctor will cost
Click here for the ABC News video
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Tannus Quatre PT, MBA is a private practice consultant and principal with Vantage Clinical Solutions, Inc., a nationwide healthcare consulting and management firm located in Bend, OR and Denver, CO. Tannus specializes in the areas of healthcare marketing, strategy, and finance, and can be reached through the Vantage Clinical Solutions website.
If doctors want more time with their patients, they better be creative
It is possible after all, to spend more time with a patient. It just can’t be done using outdated paradigms. This article below from the New York Times tells the story of Dr. Battle, a primary care physician from New York that is leveraging technology and an innovative business model in his successful primary care practice. The result…more time with patients and exceedingly better care than the status quo.
To make personalized care possible in an era when compensation is often tied to the number of patients they see, doctors use technology to streamline processes and reduce administrative costs. Dr. Batlle, for example, uses online appointment scheduling and manages his medical records electronically. He prescribes medications from his computer and offers virtual visits by phone and e-mail.
If All Doctors Had More Time to Listen – NYTimes.com
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Tannus Quatre PT, MBA is a private practice consultant and principal with Vantage Clinical Solutions, Inc., a nationwide healthcare consulting and management firm located in Bend, OR and Denver, CO. Tannus specializes in the areas of healthcare marketing, strategy, and finance, and can be reached through the Vantage Clinical Solutions website.
The business of referrals in medicine
In any industry, new business is required for growth, but it’s naturally much harder to come by. This has an impact on health care.
The New York Times published an essay titled, “Referral System Turns Patients Into Commodities” recently, and it provides stellar insight into the behind-the-scenes business relationships that are driving supply and demand of both patients and specialty care.
Logic says that a referral should depend only on a patient’s needs and the reputation and skill of the physician to which the patient is referred. But medicine is a business too, so that isn’t how it always works in practice.
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Tannus Quatre PT, MBA is a private practice consultant and principal with Vantage Clinical Solutions, Inc., a nationwide healthcare consulting and management firm located in Bend, OR and Denver, CO. Tannus specializes in the areas of healthcare marketing, strategy, and finance, and can be reached through the Vantage Clinical Solutions website.
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