Perils of Private Practice: Part 1

Patients have issues dealing with doctor’s and appointments.  However, physicians also have issues with the entire system, including patients as well.  It is 3 pm and Mrs. Jones has been waiting in an MD’s office for 1.5 hours.  She is frustrated with her perception of a cold, distracted and overworked staff, the fact she has been waiting, and the issue that, once she is in for her appointment (and has driven a long distance), she will probably receive about 5-15 minutes with her physician.  She has her own psychological poverty conscious money issues about co-pays and often wonders why a physician practice even needs to get paid the co-pay which stretches her budget when they are already collecting the insurance payment.

And, she has the notion and thinks physicians are wealthy, greedy, and they cook up any and all kinds of schemes to make money at the expense of the patient.  She thinks that they do not listen or care and are only interested in the bottom line.  Mrs. Jones is so frustrated she tells all her friends, neighbors and relatives how terrible her experience was and how her physician is and even goes so far as to trash him or her on the Internet.

Although the above example is an extreme–it does play out and various levels of this kind of thinking and behavior do occur.

However in this blog I am attempting to write about what physicians also go through in dealing with patients and individual and group practices—-it is not all one sided from the patient’s view point.

It is true that service quality varies among clinicians and the various specialties.  It would be ideal to have high quality service as this is hopefully the goal of all offices.  However it is different among various physician offices.  The reasons are many but the scope of this blog is different.

This blog attempt to capture some of what a physician deals with behind the scenes while trying to maintain high quality in clinical practice.

The perception of wealth is often misinterpreted.  Yes, physicians do make higher salaries and are often mocked and criticized in articles and other avenues there is often the comments that how can they be dissatisfied when they are making high dollars?

And so, the media and the public tend to treat or comment that Md’s are basically “spoiled brats not getting their way”– despite their income.

Let us stop right here for a moment.  Highly professional people are paid well in the world and are highly valued–based on their intelligence, experience, education, expertise and what they went through in apprenticeship, training and so on.  They went through many ordeals and all to even render a highly treatment through a professional opinion.  This is not just in Medicine but in all highly technical fields.  Yes, it would be great for all fields to be paid higher and higher and we hope that happens.  However in my opinion, Md’s are often picked on more.  Business people, attorneys and other executive level individuals are often paid much higher and often have high bonuses.

There is a collective archetype in our mass society I feel  that healers including physicians are service related people with the gift of healing and so should be “spiritual”—
— in that they should basically work for the common good and work for little or no pay or with what people volunteer to give.  It is like the monk with a begging bowl or other spiritual people who have to depend on donations.  This old paradigm thinking that is in the collective unconscious has not shifted around the world.

While Medicine in my view should remain deeply spiritual, the paradigm has changed or needs to change and so high dollars are earned with the level of expertise based on Modern societal norms.  High dollars can be coupled with high quality and service–we hope but in our system, that is not always the case.

With that said, physicians are finding that Medicine is not what it once was. Autonomy has certainly eroded.  Physicians are becoming and have become highly technical worker bees at the hands of administrators shifting dollars and doctors all over the map and these effects trickle down to the hiring and firing of physicians and thus their feelings about their own profession.  Many went in for noble and high reasons and thought they would maintain respect and autonomy but that model is far from true today.

Medical knowledge sometimes takes the back burner in many Md’s lives as they have to learn extensively about billing and coding of insurance bills, office management issues, legal issues, malpractice matters, as well as their own personal financial management given high streams of dollars entering their practices; and yet most (not known to many) of the dollars go to expenses, student loans, physician loans and so on.

The system of Medicine is mostly volume driven. With shrinking reimbursements physicians and other health care practitioners have to see and treat higher and higher volumes of patients to keep their offices open and still keep some form of income that matches their high expertise and high amount of work and intensity they invested in their careers.

I have found that graduating residents are knowledgeable but are forced into cookie cutter medicine where they are hypnotized by standards of care (while important) to drive them into prescribing medicines and ordering tests and other treatments based on protocols and community practices rather than on sometimes thinking things through with choices they have the power to make through their own expertise and critical thinking.

And so, back to the office.  This volume driven model along with the complexities mentioned above leaves physicians stressed, dissatisfied, depressed and anxious among many feelings and experiences.  They have to see many people in a very short period of time.  Even in Psychiatry—patients are not seen in the way sometimes patients envision–the classic one to one a half hours.  The primary care specialties including Family Medicine, Internal Medicine, Pediatrics and Psychiatry can be challenging with volume driven practices.

Recent articles have shown that about 47 percent or more Psychiatrists are not taking insurance and have gone to a Self-Pay model; Family Medicine’s percents are also increasing.

In Psychiatry, with an insurance model–patients sometimes are seen in followup for 5 to 15 minutes, sometimes shorter or longer in followup and often about 20 to 40 minutes for an initial evaluation. 

And so, patients leave often with a feeling of dissatisfaction, not feeling heard, feeling rushed and so on.

Offices sometimes do not have the funding to hire RN or other higher educated staff to take on physician supportive roles to educate, support and handle matters outside of MD short office visits.

Phone calls bombard the office for anything and everything where extra support staff cannot be hired and this leaves patients and physicians frustrated.  Papers need to be filled out, logistics on medications and illness need to be dealt with, prior authorization forms need to be done (which some physicians have stopped due to volume and time consumption)—along with a whole host of issues that the current reimbursement rates do not leave enough margin to increase staff to produce a higher quality of support.  Clients think sometimes all this can be absorbed by the office and should be free.  However, more and more offices have to charge fees for various non-covered services. Holistic medicine support for patients is mostly nil and void due to lack of reimbursement and people’s unwillingness to pay.

All of these above tasks to name a few are not usually  reimbursed by insurance for the most part. Insurance is designed to withhold as much money as possible, delay payments come up with excuses and codes to not pay, deliberately lose paper work, and frankly internally many dollars are withheld to places we will never know where the dollars go.  And yet, we see article after article of CEO’s and other upper management receiving bonuses in the millions of dollars.

When physicians charge fees outside of insurance as non-covered tasks, patients often go ballistic and this affects the healing morale of the office.

Many patients and clients schedule initial evaluations and then do not show up or cancel without a 24 hour notice, not considering the office needs but only their own.  This leave empty holes in scheduling.   If a doctor has scheduled 10 new patients and only three show up–that time is lost and so are dollars.  People want their issues to be done largely by phone when many offices are now asking clients and all to come in, pay a co-pay to be seen for their questions. When a no show fee is asked for this is another source of anger for clients –but yet it is necessary to keep the office going.

Then, if doctors ask for a refundable deposit for new appointments, bombs and explosions occur for staff by phone and in person and that often leaves the office stressed and depressed. 

In my experience there is resentment to pay co-pays and thousands of reasons why people do not come to pay their copay.  Co-pays are vital to keep the office open.  Often people’s money issues, crises, stresses, are shifted to the MD office and MD—their own anger is hurled and projected onto staff.

If someone was purchasing an item at Target would that be as much as an issue?

People sometimes do not want to wake up to realize that Medicine has a business side and that treatments and all have to be paid in order for the service to even exist.  MD’s and all are not volunteers.  And, seemingly high costs —are actually lower than what was being paid in past years.  Most do not realize how much really goes away behind the scenes in overhead and other professional expenses. 

Logistics aside, people do not want to pay extra for quality either, yet demand it without paying.

In my opinion, they want too much and often have unrealistic expectations of what can happen in a 5-15 or 20 to twenty five minute  (if even that) office visit.  A full therapy session cannot happen in that time frame and for the skimpy dollars being paid by insurance for even the short visits.  And if they have a need for more time, they do not want to schedule to sometimes avoid the second co pay.

In Psychiatry for example, medication management is not an exact science.  Medications need to be adjusted, subtracted, and added to create the right recipe for results with the least or no side effects.  It is a tricky area because patients have psychological and social issues along with personality challenges and addictions of all kinds that have to be considered.  Medications in my opinion and studies are revealing are only about 60 percent the solution.  The rest is the complex interplay of human issues that the client themselves has to contend with in their own healing.

In this volume driven model, clients often cannot be seen long enough and in depth enough to deal with these deeper issues.  When a referral to therapy is made, there is often no communication between the MD and the therapist.  Often there are gaps in treatment because the client has trouble finding a therapist on an insurance plan and if they do the continuity of seeing that person on a regular basis I have found is very choppy between client and therapist.

Medications that are changed sometimes need closer followup.  Sometimes patients do come but many times they do not return or delay in order to avoid another copay or for other reasons. 

There is a “demand” often for 90 days of medicines so that patients do not have to come as often and they have rigid criteria on expenses from their insurance company.  However in Psychiatry it can be dangerous to have that much medicine in stock due to the nature of the field where patients are more at risk of suicide.  And so, some patients become angry when an MD has to set a limit on the 90 day medication issue.

Controlled substances are a great challenge in office medicine.  Psychiatry is no exception and often has to weigh risks and benefits to the use of controlled anxiety medications and stimulants for depression and ADDHD. Many offices set a limit that people have to come every 30 days –another resentment and anger piece that arises because people again want more medications for less face to face time and of course for less dollars and inconvenience.

There is often a high turnover of patients, no shows, people who come once or twice and then not at all and so the office is constantly challenged to have new patients come into the system in order to keep the clinical and treatment flow going along with business dollars.

And so, these are some of my thoughts on the perils of practice.  My blogs are casual and are written from inspiration in the moment. 

I will try to write more on this subject —-but more importantly I feel solutions need to evolve on what can be done to increase quality, satisfaction and yet still keep the doors open for an office for both client and MD—

Patients can go to the internet to trash an MD but can we do that with them?  Hardly…..