In a pilot study at Massachusetts General Hospital, 30 patients who had come to see their primary care physician for routine follow-up or acute care agreed to first have a visit via a computer equipped with a Web camera. Their physician sat in another room to conduct the visit. After patients and the doctor completed questionnaires about the virtual visit, they met face to face and went through a second visit with a hands-on physical examination. While the
patients liked the face-to-face doctors' appointments better, the videoconference visits were almost as popular.
A study published in the British Journal of General Practice found that increasing the number of same-day appointments by 10% actually lowered the number of satisfied patients. Due to the findings, researchers from the University of Bristol said practices should be wary when increasing the number of same-day appointments to meet access targets.
Phone calls to a medical practice are usually numerous and labor-intensive. New staff members are often hired to help handle the call volume, many times with limited formal training on practice policies and procedures. The results of these fast hires can be disastrous to a practice.
Start by reviewing procedures and tracking the number and type of phone calls that come into the practice. Listen to your staff members conducting the call to determine how to restructure this function.
Since phone calls are an integral part of a patient's satisfaction with the practice, management should develop a telephone training program for new employees. This program can also be used as a refresher course for experienced staff members.
The following are topics to include in your manual:
How to appropriately answer a telephone call. For example, refer to a script that includes answering with the practice's name, introducing yourself, and asking, "How can I help you today?"
How to deal with angry patients. Create a script that reassures patients that you will be able to answer their questions and refer them to the appropriate resource to resolve their issue.
How to handle patients' individual requests, such as leaving a message with a provider or asking for guidance with a medical emergency. Staff members should have a list of nearby medical centers, hospitals, pharmacies, and other resources for which to refer a patient.
Practice managers should conduct staff training before or after office hours. This gives staff members a better chance to focus on the materials presented and to more quickly learn and perform the functions.
Training programs should be designed with a positive spin to improve and update efficiencies within the practice, rather than a forum that tells staff members they are doing the job incorrectly.
Have a planned agenda, along with supporting documentation and handouts. Start the session on time and factor in a short or long break depending on the length of the session. Allow enough time at the end of the program for staff members to ask questions and share their concerns.
This article was adapted from one that originally ran in the August 2008 issue ofThe Doctor's Office, a HealthLeaders Media publication.
Robert Tennant, senior policy advisor with MGMA, discusses the CMS proposed timeline for implementing the ICD-10 code set and explains the administrative burden it could place on medical practices.
There has long been an institutional bias in medical education against primary care. Many doctors we have spoken with have recounted how they were steered away from primary care by preceptors in medical school. The general sentiment conveyed to medical students long has been that surgical and diagnostic specialties are for the most accomplished students and that primary care is for the less accomplished.
This bias has been combined in recent years with a growing disparity in income between primary care physicians and specialists. The result is an acute shortage of primary care doctors, and a particularly severe shortage of general internists.
Less than 30% of medical students selecting internal medicine residencies now plan to practice primary care, according to an Association of American Medical Colleges survey. The majority are opting to become hospitalists or internal medicine sub-specialists.
The recruitment challenge
Internal medicine therefore is the most challenging specialty to recruit today. Finding a traditional general internist —one who rounds on patients in the morning, maintains an office practice, then rounds again in the evening—is the recruiting equivalent of scaling Mount Everest.
While an internist practicing as a hospitalist might work 40 hours a week and, with a rotation of seven days on and seven off, enjoy 20 weeks of vacation a year, a traditional internist typically will work 60 hours a week and have four weeks of vacation. On top of this, a hospitalist is likely to earn several thousand dollars more a year than a traditional internist.
The traditional internal medicine model is close to moribund, since very few candidates are interested in this practice style. This obliges hospitals to establish hospitalist programs so that they can offer internists outpatient-only settings, which are usually more attractive than traditional internal medicine settings.
Even the outpatient-only model, however, may not be as attractive to internists as working as a hospitalist. Hospitalists typically see 15 or fewer patients per day, while internists often see 25 or more. In addition, hospitalists are employed by a hospital or a group, while many internal medicine settings feature independent practices where physicians must contend with reimbursement and other practice management issues.
Many physicians prefer the security of employment today to the uncertainty of private practice and we advise clients to employ internists where possible (some states prohibit hospitals from employing physicians, however.)
Focusing on patients
The attraction of internal medicine—whether traditional or outpatient only—is patient rapport. Hospitalists see acute patients who have "interesting" cases, but such cases can be draining when they are all the doctor sees. Hospitalists also tend to get barraged on weekends when hospital staff is reduced and they must manage heavy patient loads. In addition, hospitalists enjoy no patient continuity. Once discharged from the hospital, patients go back to their general internists.
An internist, by contrast, will see well patients and can follow patients over time. The emotional rewards of general internal medicine still trump the "shift work" of hospital practice for some physicians. While the emotional appeal of internal medicine will attract some candidates, today’s market requires that incentives be competitive.
A competitive internal medicine opportunity will feature balance—a reasonably high salary ($160,000-$170,000 for outpatient only, $180,000 - $200,000 for traditional), combined with 4-5 weeks of vacation/CME, a turn-key setting that does not require a long ramp-up time, minimal night and weekend call, employment, and, where appropriate, educational loan forgiveness.
As long as reimbursement is weighted toward procedures and away from consultative practice, and as long as medical school bias exists, the supply of primary care physicians, internists in particular, will be constrained. This challenge can be met by aggressive finding candidates who are attracted to the emotional rewards of internal medicine—and emphasizing those aspects during the recruitment process—and by offering incentives packages that are balanced and competitive.
Allen Dye is Vice President of Marketing and Troy Fowler is Vice President of Recruiting for Merritt, Hawkins & Associates, a national physician search and consulting firm. They can be reached at adye@mhagroup.com and tfowler@mhagroup.com.This column originally ran in the September 2008 issue ofPhysician Compensation & Recruitment, a HealthLeaders Media publication.
As costs continue to rise and overall profit margins shrink for physician practices, many groups are forming partnerships and looking to other forms of consolidation and collaboration to bring in additional revenue, expand market share, and generally make it easier to navigate the healthcare minefield.
However, these financial arrangements are under a lot of scrutiny, and setting them up can be a major headache. A physician can barely sneeze these days without implicating the Stark self-referral law, the anti-kickback statute, or a host of other federal regulations. I'm being a little hyperbolic, but if other physicians are in the room during the sneeze, it might be a good idea to document their reactions.
Just this week, for instance, the OIG took another hard stance against certain joint ventures between physicians. The advisory opinion related to a contractual joint venture between two practices—one providing cancer treatment services in a free-standing facility and the other a urology group.
The cancer center offers intensity-modulated radiation therapy (IMRT) to treat prostate cancer, and the urologists who refer patients for IMRT wanted to bring the service in-house through a series of written agreements allowing the urologists to lease the space, equipment, and personnel services necessary to perform the procedure.
It would have been a mutually beneficial arrangement: The urologists would get access to the equipment they need, and the cancer center would bring in some additional revenue from the equipment rent and reimbursement for other administrative expenses.
But the OIG argued that the arrangement could potentially violate the anti-kickback statute. As healthcare lawyer David Harlow points out, this isn't a drastically new direction for the OIG; it has issued three other advisory opinions taking a similarly tough stance against this type of contractual joint venture. This case is a reminder, however, that you must carefully plan these partnerships and never assume that an arrangement is permissible unless you have solid evidence to back it up. Federal and state governments certainly aren't afraid to prosecute for fraud or improper self-referral.
That doesn't necessarily mean the partnerships aren't worthwhile. But the legal and administrative costs can be a burden, particularly for small practices. That's part of the reason we're seeing a lot of mergers and growth in group size—bigger organizations more often have the business and legal experts to deal with requirements like assessing fair market value and scrutinizing contracts.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.
Have you seen the report that says "illiterate" healthcare consumers cost the United States more than $100 billion each year? It's a frightening number, and even scarier when you consider this figure doesn't include the costs of poor outcomes resulting from a patient's lack of a basic understanding of their health and treatment options.
So I guess it shouldn't surprise me to hear the industry talking about the need to increase the health literacy rate of consumers. Patients have to be "trained" to talk to their clinicians, some say. They must educate themselves about common medical terms and think ahead about the questions they want to ask about their diagnosis and treatment options. A "literate" patient will go a long way to solving the quality issues that plague our healthcare system, they say.
But I've got to ask: Why is it my responsibility as a patient to educate myself on something that my doctor already knows? Why can't my doctor—who is already well educated in the subject—take the time to explain my condition to me in a way that I will understand?
Don't get me wrong. I'm not saying patients should sit back and let the doctor make all of their healthcare decisions. I'm all for patients being involved in their care. In fact, I like to think that I'm one of these engaged patients. When I or someone in my family receives a diagnosis, I'm immediately online looking for information that will help me understand it. But I don't believe my 30 minutes of Internet research will make me an expert. I use what I find online as a guide to help me ask the right questions. When there's a healthcare decision to be made, I want an educated, experienced healthcare professional to help me make the right choice.
Physicians have years of classroom and on-the-job training. They're put through the rigors of residencies and fellowships and have worked in various parts of the hospital to gain a complete understanding of the conditions that I and other patients may present. In my mind, this experience has made them experts in their field. So the idea of "training" patients to talk to their physicians seems a bit absurd. Why does making the right decision in healthcare fall strictly on the shoulders of the patient? Don't doctors already have the knowledge needed to help patients make the right decision?
The problem isn't just that patients lack an understanding of basic medical terms. It goes deeper than that. Our healthcare system isn't designed to give physicians the time to sit down, educate, and counsel patients about their illnesses and treatment options. Patients often complain that their doctor spoke a lot of "medicalese" and left the room before they had a chance to digest the given information. This situation is all too common, and one that, when repeated time and time again, does little to help patients become more interested and involved in their own care.
Improving patient engagement and understanding isn't just a job for the patient—but one for the entire healthcare industry. Physicians need to be encouraged to spend time with patients and translate these medical terms that members of the general public just don't understand. In short, doctors need to speak the language of the patient. Doing so will eliminate the fear and intimidation that many patients face during an office visit and encourage them to get more involved in their own care.
The secret to giving patients a higher quality healthcare experience doesn't fall on just the patient. Quality healthcare requires a partnership between patients and providers. All of us—patients and providers—have some work to do.
Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at mlarkin@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media QualityLeaders, a free weekly e-newsletter that reports on the top quality issues facing healthcare leaders.
Recent research from the New England Healthcare Institute found that approximately 25% of all emergency-room visits were for non-urgent issues, and another 25% could have been addressed by a visit to a doctor's office. In a blog posting, Harvard Pilgrim Health Care chief executive Charles Baker studies the research and suggests the healthcare system should do more to keep those patients out of the ER.
Hospital bugs like MRSA and C Diff may always be with us, a top consultant microbiologist with Ireland's Health Protection Surveillance Centre has warned. The priority in hospitals around the world is to minimize the incidence of Healthcare-Associated Infections as much as possible, and Fidelma Fitzpatrick, MD, believes hospitals have procedures in place to prevent them. But eventually eliminating MRSA, C Diff, and other infections in hospitals or the community is problematic because "as long as there is healthcare, there will be HCAIs," she added.
The chief legislative advocate for the New Jersey office of the AARP wrote a guest commentary this week in the Bergen Record urging state lawmakers to pass legislation to give patients the information they need to choose the right facility for their healthcare needs. Marilyn Askin says in the commentary that hospital-specific medical error information is still hidden from the New Jersey public, which has the right to know which medical facilities have the highest and lowest major medical error rates.
