February 2000 Table of Contents
Letters
On insurance companies
To the Editor:
Insurance companies now have another way to shirk payments on lab tests. Since our practice, like others, has many insurance companies to deal with, the companies know that a mistake will eventually be made when we confuse which of the four or five laboratories we should send a patient's labs to. If a mistake does occur, the insurance company doesn't have to pay! The labs make the patient responsible, who in turn makes the doctor's office responsible for the bill, according to the contract.
This business strategy is as insane as if a store clerk were held responsible for customers' bills. That company wouldn't stay in business long.
Obviously, I feel that insurance companies should pay for their clients' bills, but that makes too much sense in today's business of medicine. Today is the day of insurance companies exploiting doctors. They are eroding the patient-physician relationship -- the greatest joy of medicine. I pray for the day doctors and patients regain control and push insurance companies into the role for which they were created.
Thank you for "your ear" for the family physicians of America.
John Saxer, MD
Overland Park, Kan.
Seeking mediocrity?
To the Editor:
Few articles, if any, have caused me more anguish than "Improving Chronic Disease Care in the Real World: A Step-by-Step Approach" [October 1999, page 38].
The real positives of this article are contained in the last two pages, where "how-to" recommendations are made for instituting changes in the practice habits of physicians. The real negatives of the article are contained in "Step 3: Aim for something."
In this step, the quality improvement team of Family Care Network defines its measures and goals for diabetes care: 60 percent of patient charts should have a documented self-management plan, 80 percent of charts should have a diabetic flowchart system, 90 percent of patients should have two or more HbA1c measures within a year, etc.
Very few, if any, professional organizations would accept goals with percentages like these. Why should physicians? Can you imagine pilots setting their goals for improvement at the end of the year at 60, 70, 80 or 90 percent? Is it no wonder that managed care and other organizations looking over the shoulders of physicians are complaining?
In my opinion, setting physicians' goals so low is not acceptable in a profession that was once regarded so highly. When one seeks mediocrity one will probably succeed; only when one seeks perfection can excellence be obtained.
James W. Hall, MD
Kansas City, Mo.
Response:
Dr. Hall's question regarding health care goals is an important one. It emphasizes the distinction between idealistic goals (e.g., 100 percent of patients meet targets) and realistic, attainable goals. Most studies demonstrate that, in the United States, the care of patients with diabetes meets the American Diabetes Association's recommended goals less than 35 percent of the time. To improve these outcomes significantly, the entire system of care must be redesigned. The current system is designed to achieve the results it produces. "Trying harder" will not produce better results.
The goals mentioned in the article are not arbitrary. They are set by the Institute for Healthcare Improvement and cannot be accomplished without a significant breakthrough in care redesign. If Family Care Network, or any other medical group, can meet these goals, it will be on the leading edge of diabetes care.
Berdi Safford, MD
Family Care Network
Ferndale,
Wash.
Too many managers
To the Editor:
The article about the collapse of medical management groups was excellent ["Disintegration: How Employed Doctors Are Landing on Their Feet," November/December 1999, page 36]. But it didn't mention one of the major problems our practice met in dissolution with MedPartners.
MedPartners' management framework left our five-physician, one-nurse-practitioner practice with a MedPartners manager (who left when the company did), a general office manager and five supervisors. After the MedPartners affiliation ended, with no financial history to work from, we needed months of observation and financial monitoring to determine that we were extremely top-heavy in management. We increased the number of physicians to seven and were still able to pare our management staff down to a general manager, one accounts-payable manager, one nursing supervisor and one staff supervisor. The change in management saved our practice nearly 10 percent of our operating costs.
My advice to any physician resuming management of his or her own practice is this: Analyze your management needs early on and adjust them quickly to avoid unnecessary expenses.
Marjorie Uhalde, PhD, MD
Reno, Nev.
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