Monday, October 17, 2005

Is the solo primary care practitioner a dying breed?

At least in the last decade, it seems that while specialists continued to profit, the primary care physician suffered from paycuts and a devaluation of their work by today's redefined insurance environment. Procedures are rewarded with money (i.e. high insurance reimbursements) but time spent face-to-face, counseling patients through the troubled waters of their overall health, is paid poorly. Every few months Medical Economics magazine has a new article about the bleak future of primary care. I peruse the magazine to stay on top of the business issues of running a practice, but often find it a bit morose and depressing. Frankly, I've learned more about the business of medicine by being in it, than by reading it in a magazine. If I had paid attention to everything they say, I probably wouldn't be in solo practice; in fact, I might be swayed to find another profession with a sunnier future. About 20-25% of family practitioners believe they will retire in the next 1-3 years. It's not just falling reimbursements, it's the continual battle to get paid. See Crazy Billing Analogies on the 10/16/2005 post at Medpundit. I couldn't have put it better myself. Apparently, our work has less value when it's bundled together on the same day. Whereas if it's done on separate days, it is fully reimbursable!?! When I get around to writing about billing, I'll show you possible ways around this. Yes, we have to use creative billing, or the insurance companies would gladly strip the value off of anything we do. Remember, they don't make money when they pay you!

Now the future may not be so great after all for specialists. Look at the Sept. 16 issue of Medical Economics with a story titled, Exclusive Survey: The earnings freeze - now it's everybody's problem. Median incomes are now failing to keep up with inflation across the board, because payers are increasing reimbursements by stingy numbers: in 2004, 1.5% for Medicare, 2.2% on average for other insurers. In contrast, consumer prices, a reflection of inflation and the power of your dollar, rose 3.3%. According to the Centers for Medicare and Medicaid Services, practice expenses, on the other hand, rose 4% in 2004. You do the math.

SO HOW DO WE MAKE UP FOR THE DIFFERENCE?

1) VOLUME! VOLUME! VOLUME! See more patients every day! See them till you drop! Multiply your daily visits by your current number [squared]. Yes, become a robot. Spend only 5 minutes with each patient. Sore throat? O.k. - Z-pack. Good-bye! Next. But honestly, how many patients can you see in a day before you start pulling your hair out (or losing it, for that matter), feeling dehumanized and compromising your quality of life, your philosophy of patient care and your availability to your loved ones? If you're like me, a balance is warranted.

2) Drop carriers that pay you little, and cost you and your office staff a lot of money. [Low reimbursement + Slow payments]/(Time on the phone chasing claims)= Lost money.

3) Acquire training in services that reimburse at higher rates than regular office visits, then offer these to your patients. Disclosure: I by no way endorse any of these programs or have any financial relationship to them, but I'm always getting brochures of this kind in the mail. One example is Empire Medical Training. There are dozens out there. To stay in business nowadays you have to be creative; you have to be able to market yourself.

4) Join an IPA (Independent Practice Association) - usually sponsored by a Hospital for its network of physicians. In exchange for a yearly membership fee, an IPA negotiates reimbursement rates as a whole for its physicians, thus having the pull of numbers to obtain higher reimbursements per CPT code than a solo physician could signing up individually with the plan. There is power in numbers! Being solo does not mean: be isolated.

5) If you're busy enough, perform tests in your office that you would normally send out (i.e. echo's, PFT's, Bone-densitometry, X-ray's, etc...). There are services now that assist you in doing this, and provide the skilled physicians to interpret the tests. It can be done, and it does not have to violate any of the Stark II regulations. If you're confused about this, consult your lawyer. If you don't have one, now's a good time. It's always good to have a lawyer friend or friendly lawyer on hand.

6) Have your mom or wife come work with you at the front desk. First, it's a salary that is actually coming back home, and second, it's a business expense to reduce your net income. Besides, doesn't mom bake the best chocolate chip cookies?

7) Outsource your billing to India. Hey, it's cheap! And they also have a pleasant accent! You could hire a team to badger the insurance companies so much, that they will want to pay you on time, just so that you will leave them alone! [In fact, just forget the rest. Let's just all band together and create a huge outsourced billing team in India!]

Call me stubborn, but I refuse to believe that the solo primary care physician is a dynasaur, waiting to become extinct. If you take away the mom and pop primary care office, you're basically stripping doctors of the right to free-enterprise that is continuously being challenged by today's rising and merging corporate powers. The same way that the president is supposedly working to protect small businesses, he (and hopefully she in the future) should recognize the need to protect solo physician offices from being destroyed by macro-economic forces. The same way that people have a right to medical care, so do doctors have the right to practice medicine the way they enjoy it, within the confines of accepted medical practice standards and ethics. So, don't be silent. Become active in your local and national medical societies. Write your congresspersons. Tell them that you will not tolerate cuts in pay, nor feeble raises in reimbursements that fail to match the prime economic indicator of the cost of living -- inflation. If they continue to do this, students will be dissuaded from pursuing a very rewarding [that is, in spite of the insurance conundrum] career in medicine. And secondly, doctors will never experience the most rewarding aspect of becoming a practicing physician in solo practice -- BEING YOUR OWN BOSS!

4 Comments:

Blogger D.P. said...

It is good to be your own boss--just remember who you are there for . . . ;o) Welcome to the blogosphere.

1:04 AM EDT  
Blogger Medicine Man said...

I welcome and appreciate all feedback. The purpose of this blog is to discuss the business side of medicine. It goes without say that the focus of this business is and will always be serving the patient. The same way that a website has the visual display we see and the underlying html code that guides how that display is organized; so too does a doctor's office have the business of seeing and caring for its patients and the back-office for dealing with billing issues and insurance precertification, etc.... You cannot have one without the other.

8:28 AM EDT  
Blogger Dr. Charles said...

great review.

12:54 PM EDT  
Blogger Medicine Man said...

Thank you. :-)

3:36 PM EDT  

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