Tuesday, September 25, 2007

A check-list to the rescue!

I recently hired a medical assistant. She came to me fresh out of school. Actually, she is still in school, technically, because she is doing her externship in my office. I am training her.

I like her. She is eager and honest, and for me, nothing else matters more. Otherwise, she is blank slate and knows NOTHING! That is how I wanted it.

However, blank slates don't know how to properly clean exam rooms, sterilize instruments, set-up for procedures, forward phone-calls, dip urines, or anything that is required and basic to medical practice. Despite my repeated efforts to train her, she just could not quite seem to "get it" and was messing up left and right.

Now I had 3 options.

  1. Fire her

  2. Promote her

  3. Study her

I decided that the substrate was there and that I would need to figure out why she was failing me, or actually, why I was failing her. After a brief period of observation I learned that she was simply overwhelmed by the volume and was unable to remember her duties and to prioritize them.

The solution: a check-list.

I spent approximately 20 minutes brainstorming her duties and compiling them into a check-list format, which I then printed out and reviewed with her. I was afraid to insult her, so I told her that I used check-lists in college and medical school, and found them to be indispensable. All of which was true. She took the list in the vain that I had offered it and something amazing happened.

Her performance has taken a 180 degree turn immediately. Tasks are being completed on-time, without prompting, and I am free to pursue my duties. She is less stressed and happier, and so am I.

A check-list! Give it a try.


The IU.

Friday, September 21, 2007

The Free Market and Medicine

I often overhear in the physician lounges, or read on the internet, about many doctors' views on the free market. Typically, the doctors argue that "standard free market principles" do not apply to medical practice. Their arguments go something like this:
  • I charge $180 for an new patient consult, but only get paid $90, and therefore, free market principles do not apply.
  • I charge $5000 for a total knee, but only get $1200, and therefore, free market principles do not apply.
  • A radical prostatectomy is worth $4000, yet I only get $900 and therefore, free market principles do not apply.

Over the past 7 years, I have heard this line of reasoning hundreds of times.

I don't think they understand the free market. Let's use another industry to elucidate and clarify the problem. Let's use the toy industry.

Mattel designs, markets, and sells toys, but they don't make them. Since Mattel is a corporation, it's fiduciary responsibility is to maximize profits. One way to do this is by minimizing costs. A great way to minimize production costs is to outsource manufacturing to countries that can do it more cheaply. Mattel outsources toy manufacturing to Chinese factories.

Mattel, like United Health Care, has lots of money and thus leverage over the manufacturers. Mattel uses this leverage to negotiate production costs for its toys. The Chinese factories can either take it or leave it. Since the factories can not remain viable without a contract from Mattel, they choose to accept the terms of the contract, and then attempt to maximize their own profits by cutting production costs and increasing production rates. The Chinese factory does this by paying workers extremely low wages, using cheap materials, and, as we have now learned, using inexpensive lead based paints on the toys.

Mattel pays the factories cut-throat rates, which forces the factories to cut corners to make a profit, which, unfortunately, can ultimately impact the consumer negatively. On the other hand, however, the consumers in the USA and Europe, don't want to pay a lot for their toys, so the cycle continues.

Sounds familiar, right.

United Health Care does not produce health care, it only pays for it. As a corporation, its fiduciary responsibility is to maximize profits. One way it can do this is by minimizing production costs. United Health uses it's leverage, much like Mattel and the Chinese factories, to negotiate cut-throat production rates to the factories, which in this case are the providers. Unable to remain viable without the contract, we chose to take it, rather than leave it.

Now, to maximize our own profits, we attempt to cut our costs and increase production. We do this by outsourcing services, downsizing office (factory) sizes, and hiring low wage personnel and then we see more and more patients. The downside of this is that ultimately the consumer--the patient--can get hurt because in our efforts to cut-corners and increase production, we may make mistakes and hurt people. As a society, we accept this because, like toy purchasers, consumers of health care don't want to pay a lot for the product and the cycle continues.

See, our health care model is the epitome of the free market, and anyone who suggests otherwise is wrong.

Thanks for listening,

The IU.

Another Blogging Success Story

I got a new patient today. . .from India. He has been a devotee of Dr Schoor's Urology Blog, and is town on business. He has liked what he has read, and is coming to see me as a patient.

Cost to me: $0.00

Not Bad.

Monday, September 17, 2007

A View From My Window

I have a corner office, 2nd floor, that has a commanding view of my parking lot and road that leads up to it. I often use the window onto the lot as a sort of extension of my physical examination. Here are some things about patients that I have seen and learned from my window view.
  • Angry: On several occasions I have seen patients of mine honk, yell, or gesture angrily at other drivers in the lot. These people are uniformly lambs in my office, but this tells me that they are not very nice people at their cores.
  • Unethical: Once in a while, people park in the handicapped spots, yet are not physically handicapped. I know this because I take their histories. What they don't know is that I witnessed them committing these acts. Again, these people are always nice to me, but dishonesty is dishonesty, and their actions point towards their ethics.
  • Aggressive: Long Island has no shortage of aggressive drivers. So does my parking lot. Aggressive drivers cause many problems for society in general and basically these people think that they own the roads.
  • Selfish: Taking up 2 spots: People do this for 2 reasons: they have a nice car or they don't care about others. Either way, I think it suggests that they are either selfish or vain.
  • Inattentive: I can tell this when I see patients leave my office, go to their cars, then pull out of their space without looking, while simultaneously smoking a cigarette on the cell phone. Multitasking has it's place, but not while driving. It also suggests to me that I may want to have another informed consent discussion with the patients.

Maybe I'm overreaching, but I think that private behaviors go towards personality types in general. I just feel like I know these people better by witnessing an admittedly small sample of their driving.

Hope you enjoyed the post.

The IU.

Thursday, September 13, 2007

Four Sure-Fire Methods to Go out of Network

Every physicians' dream is to go out of network and really "stick it" to the insurers. Just follow these 4 steps, and you too can do it.
  1. Become a regional, national, or better yet, international name in your specialty. Have patients travel from far and wide to see you. It'll help if you write a book that becomes an international best-seller and in the process, you become Oprah's friend and confidante. Alternatively, you can invent a truly life saving or life- improving medical device. Either way, this'll get you there.
  2. Change to a specialty that sees predominantly emergencies and relocate your practice to a hospital that sees only well insured, non-medicare patients, then gouge the hell out of the patient's insurance policies. Also, hope that state legislators continue to turn a blind eye to this consumer-unfriendly practice.
  3. Become an out-of-network anesthesiologist and price gouge off the backs of your hard working in-network surgeons and hospitals.
  4. Join a top-tiered academic medical center, then rise through the ranks of your department until you are a huge national or international name. Also, see method #1.

See, it's easy.

The IU.

Wednesday, September 12, 2007

Cost Containment: Here's some tricks

With declining reimbursements, the only way to to remain viable is through revenue generation coupled with cost containment. I'd like to talk a bit about costs, and some obvious--and not-so-obvious-ways to minimize them.

Fixed Costs: These are items like rent and insurance. While you probably have little negotiating power in this area, with regard to rent you can keep costs down the following ways:

  • Maximize productive use of space. I pay $26 per square foot, and use all of it productively. An EMR helps here, because I don't need to dedicate several hundred square feet to chart storage. Also, mobile units, such as portable sonogram machines, client computers, and portable lab equipment, also helps. And of course, I have VPN, because it essentially converts my house or Starbucks, or anywhere with an internet connection into an extension of the office.
  • Maximize revenue generation areas of the office. These areas include exam rooms, your office, and the lab. Back office functions, such as insurance claims submissions and billing work, can be virtual, via your VPN, yet remain "in-house" as opposed to being outsourced. With a well networked office, exam rooms can serve as exit offices while you go to the patient in the adjacent room.
  • On-demand Supply Ordering and Smart Storage: Closets = Square footage = $$. With some thought and planning, shelving, exam tables, cabinets, and closet space can be used for maximal storage at minimal square foot usage. In addition, I order supplies as needed, since my vendor, PSS Worldwide Medical, always delivers next day.

Variable costs: These include costs for items such as medical supplies, payroll, utilities, stamps, etc, and can be determined by examining the profit-loss statements prepared by the accountant. here are some ways to keep variable costs down.

  • On-demand supply ordering. DELL Computers uses this concept. I do as well, just make sure you don't run out of Foley drainage bags after you've already placed the Foley.
  • Part-time employees: Simple. They cost less than full time employees, plus no overtime.
  • On-demand staffing: I staff heaviest on the busiest days. Plus, since I am capable and willing to pick-up slack on days that we are inadvertently short staffed, this method works out well. Busy days or light days, open or closed, phones are always!!! staffed.
  • Amortization of utility payouts. Most utility companies will estimate a fixed monthly cost for you to pay based on a prior years consumption. I like it for cash-flow management.
  • Have your phones (VOIP), cellphones, & internet on fixed plans, so that costs do not soar with usage. Get the maximum minutes for cell phones, since the incremental costs of the plan are much less than overage payments. VOIP is cheap, plus never varies with usage. On the balance, I've been happy with it, yes, even for the "mission critical" functions. I'm talking to you, Sunrise.
  • Fax. Why snail mail when you can fax the referral letter. Not only is it faster, more efficient, and trackable, it is cheaper. I love my fax. Yeh, yeh, yeh, I know, HIPAA. But it can be done and still be in compliance

Direct costs: These are costs that are directly involved in patient care. Here's how to minimize these costs.

  • Everyone does everything. MA's do data entry, answer phones, clean rooms etc. The docs answer phones (if they are not seeing patients) when needed, clean rooms, order supplies, schedule patients, e-file labs. Again, an EMR and a VPN helps here as well.
  • Part time employees and on-demand staffing: see above.
  • Creative patient scheduling: Figure out which works best for you; clinic, open access, proportional, or wave scheduling, and then determine minimal staff requirements for your office hours.
  • Ergonomic room design. I have rigged my rooms so that I can do a many procedures without an assistant present. I learned these skills as a surgery resident in central line clinic. In fact, I can prep with my left hand, place the scope with my right hand, and simultameously do a UA with my toes (kidding!). If you have 2 hands, a brain, and a Mayo Stand, you can make it work as well, and in the mean time, you'll free up staff to answer phones and book new patients or enter claims.
  • Training and process management: Training employees well and developing efficient processes of doing business will allow you and your employees to work smarter and with less mistakes and to get the job done right the first time. This simply saves money.

Indirect costs: These costs cover non-patient care activities, such as back-office staff and billers. Here's how to minimize these costs.

  • See direct costs.
  • VPN
  • EMR
  • Embrace technology
  • Multi-task
  • See training and process management

Hope you enjoyed the post and thanks for listening. And Seaspray, thanks for the baby card. Unexpected and appreciated.

The IU.

Tuesday, September 11, 2007

Why I recommend a VPN

I have exactly 5 seconds to publish to the blog, so I am going to be brief. VPN's--virtual privacy networks--are among the best features of the modern computing age. Here are some reasons why you may wish to invest in one for your office.
  • Ability to check labs and study reports from home or away
  • Ability to catch up on charting from home or away
  • Ability to access schedule from home or away
  • Ability to put drug-seekers in their proper place
  • Ability to access charts when not in the office
  • Ability to always seem omniscient
  • Ability to grow faster by "booking" patients that call during "off" hours
  • Ability to submit claims remotely
  • Ability to have multiple offices with one central chart storage system
  • Ability to stay connected yet have a life at the same time

And others. At the risk of stealing from MasterCard's add campaign:

  • 8 port VPN router $200
  • Computer guy to set you up with VPN ~ $500
  • Checking labs while giving your newborn a midnight bottle Priceless!

Get a VPN. You'll like it!

Thanks for listening,

The IU.

Friday, September 07, 2007

A little known side of urine analysis

Urine analysis by dip stick is a CLIA waived lab test. What this means is that as long as you follow the manufacturers directions, exactly, you will be in compliance with CLIA'88 regulations and will not need not anything other than a CLIA Waived Certificate to legally do the tests and bill for them. But here is the rub. You must follow the manufacturers directions exactly, because veering from the package insert directions automatically converts your waived lab into a high complexity lab, and you don't want to go there. Below is a description of the QC (quality control) requirements for urine analysis.

  • The package insert from the test strips recommend that QC (quality control) be performed on every new package of test strips.

  • QC, according to the package insert, involves 2 sets of negative controls, and 2 sets of positive controls

  • If you use an automated test strip reader, the manufacturer recommends that, at the very least, QC be performed daily, as above, on all testing days.

  • Each test costs 33 cents (PSS brand) or 50 cents (Bayer Brand), thus daily QC just for UAs costs netween $1.20 and $2.00, or between $370 and $624 per year.

If you don't, then in essence you are converting a waived test to a high complexity CLIA test. Good luck.

Dr Schoor


Thursday, September 06, 2007

Forms the Easy Way

Scheduling surgeries at the hospital has become somewhat painful due to none other than hand writing issues. I have decent handwriting, and I print so as to make it that much more legible. Still, every 3rd or 4th OR scheduling form ultimately bounces back to us for clarification or re-do based, no doubt, on legibility. I suggested that the hospital make the booking forms available on-line, and they said "great idea", but nothing happened. Here's how I do it now:
  • OmniPage 5.1 ($89.00, Staples)
  • Forms are scanned in and then converted to digitally amendable forms on my computer
  • We configured the forms so that my information is stored and automatically entered into the form without the need for duplication of data entry.
  • My staff enters the patient demographic data and insurance information
  • I enter the diagnosis and code (if I know the code off hand) and the procedures and CPT codes (if I know them off hand).
  • The form is saved in the "OR scheduling directory" and the patients chart
  • We then "print to efax" and the form is faxed directly from desktop to OR scheduling office

We just began doing it and the increase in efficiency is readily apparent. Plus, I enjoy home grown solutions, though hat tip to Sunrise Urology for the OmniPage tip.


The IU.

Monday, September 03, 2007

Cold Busted!

Technology has made it very difficult for drug seekers to fool us physicians. In the past, though, this was not the case. Prior to advent of the CT scan, drug seekers had somewhat of a golden age. During this gilded age, these addicts could go into any ER, or call any urologist on-call, give the doctor a history suggestive of kidney stones and renal colic, state that they were allergic to IV contrast, and that their stones were uric acid, so not visible on regular x-rays, and then they would receive their fix. The more ERs they went to, and the more doctors they called, the more drugs they would receive, and perhaps even sell on the street to other narcotic addicts. I came out of medical school and became an intern on the urology service in 1994, just prior to the era of the ubiquitous ER CT scan, and I learned fast how to differentiate drug seekers from true renal colic patients. I still use those skills today.

Now, life has become difficult for drug seekers because technology is readily available that allows us doctors to catch the drug seekers in their own lies. Yesterday, I achieved what I would characterize as a pinnacle moment in my on-going game of out-wit-the-drug-seeker. A person claiming to be my patient called me Sunday ~9AM, and stated that I saw him 2 weeks previously both at the hospital and in my office and that he was still in pain from a kidney stone that he had not yet passed. I did not recognize his name. This would be somewhat usual for a kidney stone patient in my practice, because I have few of them. Red flag number one, but still possible. He when on to say that he was taking oral toradol--a medication that I have never prescribed because it is ineffective for pain--and that the toradol was not helping him. Red flag number 2, but still possible. I then asked him if he would like me to call in something stronger, and then I asked him what has helped in the past, an old urologist trick to smoke-out the seekers, since they always have their preferred drug and will often tell you not only the name of the drug, but their desired dose, potency, and quantity. He stated he wanted hydrocodone 7.5mg. Boom, red flag number 3. I then asked him for his pharmacy, and he stated that it was closed for the holiday, but that I could try this "24 hour" pharmacy. OK, red flag 4, but still I was giving him the benefit of the doubt. I asked him for his phone number and for him to spell his name out for me, and then I said that I would call in the prescription. And here is where the fun began.

I have an EMR and can access my entire office network, both EMR and PM software, from my house. I logged into my network and searched through the patient names in my PM software, looked through the charts, and even looked for a copy of his drivers license, which we always scan into our system on the patient's first visit. Low and behold, he was not a patient in my practice. I even typed in a variety of permutations for possible spellings of his name, and still, no patient by his name, or anything even close to it. As I was trying to find any evidence that he was in fact my patient, he called back, 5 minutes later, to find out why I had not yet called his pharmacy. I told him that I was having difficulty verifying that he was my patient, at which point he seemed to become annoyed. He swore that I had seen him in my "Smithtown office" 2 weeks ago, and that he had received a letter from my office in the past few days, only that his name was severely misspelled on the letter and "was not even close to my name." I asked him how we spelled it on the letter, and he stated that he forgot and that he "lost" the letter and could not remember what it said. At this point he was really irate and was trying to put me on the defensive--how could I not remember my patients! This is a good technique used my many drug-seekers and often they threaten to "tell" your senior partner, or attending, or boss, or "the medical board" and to have you fired, or worse. Now that I am the boss, this just pissed me off, and I decided to end the conversation. I told him that if his pain was severe, he could go to the ER, but that I would be unable to prescribe the narcotic for him without verifying that he was an established patient of mine, then I hung up on him. This is the first time I so competely, efficiently, and undeniably caught a drug seeker as they tried to defraud me. Un-@#$%-believable!

Drug seekers are really a bain in our collective exhistences. They will lie and cheat--even steal--to get what they need, the drugs, and we the doctors, are the victims. Their behavior puts us doctors in a precarious position, for if we deny them the drugs, we risk negative word of mouth and damage to our reputations and practices. Yet if we acquiesce, we risk providing poor medical care at the least, and being accused of malpractice and possibly criminal offense--diversion--at the worst. Many drug seekers have successfully sued the very physicians to whom they lied when the doctors yielded, gave them their candy, and then damages ensued.

Attempting to obtain a narcotic prescription under false pretenses is a crime, and if the physician facilitates it, then he/she may be committing a crime as well. I always give my patients the benefit of the doubt and err on the side of trying to alleviate their suffering. But when I diagnose them as a drug seeker, I cut them off mercilessly, and if I can prove they lied to me, I'll contact the authorities and report the crime. I did so on this patient.

If you are a drug addict and are reading this blog entry, be forwarned. There is a new sheriff in town. And his name is The Independent Urologist.


The IU.