Category: Physicians

My kind of doc

published date
February 23rd, 2007 by

Last day of vacation and no real time to blog, but two people sent me a link to today’s WSJ article: Faltering Family M.D.s Get Technology Lifeline; Doctors Think Small To Revive Solo Role For Primary Care.

They rightly concluded that I would applaud the efforts by some primary care physicians to offer a high-service model to a regular sized panel of patients by relying on technology and intelligent operations. It’s a much better solution than the concierge model.

[I]n early 2001, Dr. Moore took a risky step. He borrowed about $15,000 to start a solo medical practice in a tiny space with no nurse, receptionist or waiting room. He bought computer software to help him track patients’ appointments, illnesses and medications, and to process insurance claims.

Patients at his “micropractice” can call or email to get appointments the same day. Visits last 30 minutes. Dr. Moore can be reached day or night on his cellphone. To refill a prescription, he walks “zero feet,” he says, and taps a few keys on his laptop. “I was able to build a Norman Rockwell practice with a 21st-century information-technology backbone,” he says.

More later…

The role of retail

published date
February 21st, 2007 by

MinuteClinic and its rivals in the in-store quick clinic market have generated a lot of interest on the part of traditional providers. Some providers are quick to poke holes in the clinics’ quality. From the Washington Post (Is ‘Quick” Enough?)

“Convenience is not enough,” the AMA lamented in a recent editorial. Comparing the mini-clinic phenomenon to kudzu –the tree-strangling vine rampant in the South– the AMA complined these new services are spreading too far, too fast. In a policy statement this fall, the [American Academy of Pediatrics] “opposes retail-based clinics as an appropriate source of medical care for children, and adolescents and strongly discourages their use.”

There may be something to this skepticism, but it’s a little bit funny to read the complaints, which include:

  • Staffing by nurse practitioners rather than doctors. (That’s funny because it’s a strategy popularized  by physician offices.)
  • Lack of continuity of care as the various practitioners who see a patient over time may not communicate with one another. (Now isn’t that the pot calling the kettle black?)

I’m not rushing to seek care at retail, but I’m glad these clinics are keeping traditional providers on their toes and getting them to find ways to increase convenience and availability. A new article in NEJM by Richard Bohmer, MD evaluates the impact of the clinics and compliments them for developing a strong value proposition for patients with low complexity conditions. He also notes that patients manage to do a good job of segmenting themselves according to complexity;as a result only about 10% of patients have to be turned away from the clinics for presenting with something the clinic can’t handle.

One change I expect to see as a consequence of the rise of in-store clinics is physician offices becoming more willing to try open access scheduling, which often lets patients be seen on the same day. A HelthLeaders article, Nothing to Fear: The Myths of Same-Day Scheduling, shows providers they shouldn’t worry about “insatiable demand,” “fewer encounters,” or “lower revenues.” The article doesn’t mention, but should, that not providing easy access could lead to an erosion of patients as more seek convenient, in-store visits.

Another HealthLeaders article If You Can’t Beat ‘Em in the same edition, inadvertently demonstrated why the type of competition retail clinics offer is necessary.

“We were the first to open in New Jersey, so you could say it was a defensive measure to create a competitive barrier,” says Donald Parker, president of AtlanticCare… “We have about a 65 percent market share in our region, so that presents a unique challenge for an outside provider who has no reputation in the market…”

I don’t know AtlanticCare, but that attitude is typical of a monopolistic integrated delivery system that exists to exert power over health plans and employers rather than to ensure operational efficiency and high service levels. I actually think it should be relatively easy for a chain of quick clinics to establish a foothold in such an environment.

The sad case of Rebecca Riley

published date
February 15th, 2007 by

The tragic death of 4-year old Rebecca Riley, who died after an overdose of psychiatric medications, has sparked a lot of discussion and finger pointing. An article in today’s Boston Globe (Bipolar labels for children stir concern) suggests that part of the problem is the overuse of bipolar disorder as a diagnosis.

Riley… was exceptionally young when she was diagnosed, just 2 1/2. But among somewhat older children, the bipolar label has proliferated to the point that some psychiatrists now suspect the diagnosis may be sometimes misused, placing some children at unnecessary risk from the serious medications that usually follow.

I asked Mickey Segal, MD, PhD, CEO of decision support company SimulConsult, for his thoughts. Here’s what he said:

The case is odd because the parents are charged with murder using prescribed drugs, yet the doctor is being investigated by the Board of Registration in Medicine for prescribing the drugs. What scenario is being suggested?

The article also suggests that diagnosis of bipolar disorder is colored by reimbursements:

[Dr. Jennifer Harris , a clinical instructor at Harvard University and supervisor at Cambridge Health Alliance] and others point out that a diagnosis of bipolar disorder is considered more serious than attention deficit hyperactivity disorder or post traumatic stress disorder. A child diagnosed as bipolar thus tends to have much easier access to a range of help, from a spot in a therapeutic school to insurance coverage for hospitalization.

But it is a serious matter to suggest that “up-coding” influences treatment decisions.
Part of the problem is that there is no way to make a definitive diagnosis of either bipolar disorder or attention deficit disorder, since we don’t have genes for either disease yet. Since drugs for both disorders have dangers, we need a deeper understanding of these diseases, hopefully resulting in therapies that are more benign or more effective. Until then, doctors and patients will try different things and there will be some tragedies.

The cost of co-pays

published date
February 14th, 2007 by

A friend told me about her really good pediatrician whose practice is really badly run. Appointments get mixed up, requests for referral authorizations go unanswered and so on. She recently received bills for her three kids going back two years. The bills were small, ranging from $7 to $30 per kid for unpaid co-pays.

A cover letter explained that the office had hired an auditor to go through the records and find problems; it asked that co-pays be paid at the time of visit in order to reduce administrative costs from sending small bills. I told the mom it was a good idea to pay the co-pays when she visits, so the poor ped doesn’t have to struggle even harder to make ends meet. I feel badly for the guy, even if he’s brought a lot of this on himself.
She told me this experience actually made her less inclined to pay the co-pay at the time of appointment. After all the office has demonstrated its inability to track what it’s billed and collected. Although she paid what was requested on the new bill, for all she knows she had already made payment at the time of appointment. She’d rather wait to receive the bills and pay them as they come in.

On the other hand, she could also make sure to pay at the window every time. That way she could be confident that if a co-pay bill came it had already been paid. She could save the little cash receipts they hand out, too, though that is a bit of a burden on a mom whose already juggling 3!

What you don’t know can’t hurt you

published date
February 8th, 2007 by

As a doctor friend said, “If someone thinks they’re completely healthy it just means they haven’t had a full workup.” What I think he meant is that if you go looking with the latest tools and diagnostics you’ll find something, even if it’s not really there.

That sentiment was reinforced for me today by an AuntMinnie article on overdiagnosis of lung cancer.

Overdiagnosis is common in computed tomography (CT) lung cancer screening, according to a report in the February issue of Radiology.

“Screening high-risk patients with chest CT may result in lung cancer overdiagnosis, especially in women,” Dr. Rebecca M. Lindell from the Mayo Clinic, Rochester, MN, told Reuters Health…

“Overdiagnosis, especially in women, may be a substantial concern in lung cancer screening,” the authors conclude.

At a minimum, such overdiagnosis exacts a high emotional toll on patients and their families. It can be physically and financially damaging, too when unpleasant and sometimes dangerous treatments ensue for those who don’t need it.