Friday, October 11, 2013

Private Practice: The End of an Era or a Value Added Proposition?

-Kameron Gifford, CPC  10/11/13

The practice of medicine in America is changing rapidly under new regulations, greater enforcement and tightening reimbursement policies. We are seeing more and more physicians opting to sell their practices rather than the time honored tradition of “modify and adapt”.
This month marks a significant point in our journey down the road of “Healthcare Reform” for the entire industry, but to me, it means more than the opening of healthcare exchanges and the final countdown to ICD-10; it signifies the potential end of an era. 
Just as any other small business owner, my father has worked countless hours building his business from the ground up. Over the last 35 years, he has kept his patients healthy, managed employees, handled payroll and navigated numerous changes in insurance and healthcare reform. He has supervised residents, moonlighted in the Emergency Room, held medical directorships and worked hand in hand with managed care companies to improve their outcomes. 
On October 2nd, at 70 years old, he sold his private practice to a “corporate medical group.” This sell was bitter sweet for me as I have come to know and care for each and every one of our patients.  As a child, I spent many summer days reading medical text books in his office and accompanying him on hospital rounds. As an adult, I was honored to work side by side with him as his office manager.
Today, I ponder the future experiences of my patients and the overall effect on outcomes. Who will “lead” their plight for wellness now? What does the commercialization of primary care mean for consumers? What is the ultimate number of dollars saved versus the experience of the care delivered? And how will corporate medicine ultimately affect future access?
Policies and procedures are a necessary evil in terms of practice management. For example, we did not accept walk-ins, but I never turned a patient away from my window. Would you shut the door on a friend in need? Of course not, even when it is inconvenient . When Mr. Hernandez’s grandson was visiting from New York, and was stung by a jelly fish, we worked him in, even though he was 17, and we did not see anyone under 18. This flexibility on the front line increases patient satisfaction and improves the overall experience of care. 
When you called the office, there was a 1 in 3 chance that I (the office manager) would answer the phone. Why, because during clinic, I sat up front and checked out every patient. Because this is the last step in the process, and ultimately your last opportunity to ensure that your “customer” leaves with a smile, or at least a clear understanding of what to do next. My “instructions” came in many different vehicles, but the over arching theme was “please call with questions, I am here to help and I care”.
Same day appointments were always available and “no show” patients didn’t exist. When employers changed plans and Mr. Jones forgot his insurance card, we still checked his blood pressure, and when Mrs. Allen accidentally enrolled in a plan we were not participating with, we continued her treating her all year without a charge. Why? Because after 15 years of care it was the right thing to do. Mrs. Allen only came in twice that year, but 5 years later she is still with us. When new members were added to our managed care rosters, we reached out to them, instead of waiting for them to contact us. All this was standard procedure, years before the ACA or quality incentives. 
My father ran his practice with strict protocols. He took the history of all new patients, personally. Our collection of new patient forms did not include the standard lists of boxes to check. His “standard” set of questions had been refined again and again through out the years to ensure a “yes” or “no” answer would be difficult. Instead of “do you drink?” it might be “what did you drink with dinner last night?” or "how much do you drink?" Antibiotics were never given out over the phone, and sinus infections were confirmed by a sinus x-ray before writing the prescription. All appointments for tests and specialists were made by us, without exception. Why? Because this ensured we always received the report, and would be able to remind them when and where they were to go. Diabetics and pre-diabetics were seen every 3 months fasting, and we tracked and monitored all LDL’s internally on a quarterly basis. Every  patient had a comprehensive physical exam, even before Medicare Wellness Exams were reimbursed. And when you came to our office for our physical, you met with doctor in his office, after getting dressed to discus the results. All of this, long before primary care came into the spotlight, and quality was ever mentioned in terms of payment.
So, what value has this acquisition ultimately added to the experience of care for my patients? Will the shiny new furniture and upgraded computers really have an impact on their health? And what about the "standards" of corporate medicine? Will the new spirometery machine really improve the overall health of the population, or will it's purpose be closer tied to revenue?
I can’t help but wonder what will be lost in translation from private practice to corporate medicine? If Mrs. Jackson calls without her hearing aids in, will a live person be there to assist her? Or will she be forced to fumble through an automated phone system? And if she gets a voicemail instead of a person, how will that ultimately influence her decision to seek or not to seek care?
Now consider for a moment the potential financial impact of 1 coronary event, or the prevention of 1 coronary event.  That phone call might have been our single opportunity to reduce the probability of a negative outcome.  
I am willing to bet that the magical point of sustainability in our healthcare system lies within both our past experiences and future capabilities. Perhaps the answer we are all searching so desperately to find is not black and white, but instead a mix of "old" and "new." As an industry, I believe that we need to embrace the collective experiences of those who have been on the front lines, and work together to create innovative solutions instead of closing the door on an era and such a wealth of intelligence.  There is no one that knows what your members need or want more than the person that answers the phone at your PCP’s office. I believe the most innovative solutions are yet to come.  What could this collective intelligence add to your current value proposition?

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