- Del Meyer, MD - http://delmeyer.net -

A Couple of Ways to Improve Practices

Summer is over and I hope we’ve all had some respite from our usual routines as we get down to the business of what we do best–practice medicine and surgery. Our best offense is to do it well. Otherwise we may be replaced by a Physician Assistant or a computer.

While reading ECGs the other day, I saw a colleague’s comment on an adjacent ECG: “I agree [with the ECG computer].” I was so amazed I asked the ECG tech if she’d seen such a comment before. She said it was common practice. Then she looked in her basket and found 20 of 25 ECGs interpreted that very day in which the doctor’s only comment was “I agree [with the computer].” Remember when the hospitals elected not to reimburse us for interpreting ECGs because Medicare had only one reimbursement figure for the combined technical and professional components? They maintained that doctors provided no additional value. It was a Medicare mechanism to get cardiologists and internists to donate further services to a losing government operation. Although we won the battle temporarily, we know there are other hostile carriers sleuthing around to see if doctors really add any value to patient care. I would guess that if they found any area of practice where a computer could do 80% as well as a real live doctor, they would remove that item from the reimbursement list. Do we provide real value to patient care? I think we do. In the instance of ECG interpretation, the computer cannot compare the present tracing with the previous one, which is very important cardiac data. We must compare each ECG to the previous ECG and, if there isn’t one, record a disclaimer. We must take an extra moment to record the value we add to patient care.

A new federal law went into effect on July 1, 1999 that was supposed to reduce phone bills. Actually it increased the charges by 70%. . . . I think Adam Smith predicted the result of government intervention over a century ago.

A related issue for improving our practices is telephone refills of prescriptions. For at least 30 years practice management workshops have advised against practicing medicine by phone, especially prescription treatment. This allegedly gives one the greatest exposure to liability. In a stable solo practice, this never was a problem. Patients were given prescriptions with enough refills to last until the next scheduled evaluation. If a three-month appointment was recommended, all prescriptions were given with three monthly refills, which in effect allows the patient to change the appointment up to a month later. On a stable patient with yearly appointments, the prescription would be for 12 refills which in effect still gives the patient an extra month’s supply, thus eliminating the need for a pharmacy call or fax in case the appointment is delayed a few weeks.

Along come changes in practice patterns: Patients now switch doctors with less concern than changing hairdressers or barbers. Because new patients are not trained in appropriate liability-reducing care, the rash of phone calls and faxes from pharmacists can paralyze an office for hours. Attempts to retrain patients are resisted by such comments as, “Dr. Previous always called them in and never complained,” or “Dr. Prior even had a phone line for prescription refills.” To staff the latter on a full time basis must have cost $30,000 per year at current certified medical assistant rates of $15 an hour. Even taking up to half or quarter time of an office assistant, the cost would still be $7500 to $15,000 per year. A good suggestion would be for the medical community to implement the concept of giving enough medications to last until the next appointment plus one month. That would save the nearly 3,000 doctors in this community (if they are anything like Dr. Prior) about $21 million a year.

The federal government has released guidelines warning academic institutions not to rely too heavily on Scholastic Testing. . . . Actually I think that fits. They are also worried about too much medical excellence, as can be seen in their moves to reduce the reimbursement codes to board certified specialists–explaining that they require less time to make complicated diagnoses. Anyone try to do six consults an hour?