My friend Charlie has an aversion to undergoing a stress test. Although he needs one, he cannot put up with the paperwork he knows will ensue from walking the treadmill. Instead of receiving just one bill, he anticipates with dread forming a billing relationship with everyone in the hospital who was in any way involved with his care. “They all think they’re independent contractors,” he complained to me recently. “I get billed, billed again as they reconcile with my insurance company and rebilled. I really think this system discourages utilization.”
Charlie is a business type, having gone to business school, and I always like his take on things. He loves prying into the economics of being a physician and has learned that we are a troubled lot, distressed about rising costs and limited revenues. That concerns Charlie because he is uncomfortable with physicians who are uncomfortable with the viability of their practices. This, he believes, may influence the care they provide. His solution: “Let’s give all doctors an extra $50,000 a year so they can stop worrying about themselves and afford to worry about their patients.”
Charlie’s last experience in a hospital chastened him. He was sent in by his doctor for a barium enema because he was experiencing some lower abdominal pain. In the middle of the procedure, just as they finished pumping him full of contrast, the power in the X-ray room went dead. “Hold on, we’re calling the electrician!” That, Charlie conceded, was dire but not nearly as bad as the billing complexity that followed. “It’s as if everyone —doctors and patients alike — is trapped in this miserable web.” His resolution: “I’m not getting any more sophisticated tests. Regardless of the outcome, you will get bludgeoned by the system for months thereafter. That’s more stressful than having heart disease.”
Nancy, a local ob/gyn, unexpectedly appeared in my office at the noon hour today wanting to speak with me. Generally, I don’t get visited by specialists, so I was a bit perplexed. Nancy quickly cleared up my confusion.
“I’m afraid I made a boo-boo. I admitted one of your patients and forgot to ask if she had a primary care doctor,” she said. She then explained that Karen Wilson had had a spontaneous abortion several days ago and had presented to Nancy’s office with a fever of 104°F. Suspecting an endometritis, Nancy had hospitalized her with what turned out to be pneumonia. Then, a chest X-ray suggested a pulmonary embolism. “We confirmed it with an axial CT, and by then I was in over my head,” she said, “so I asked for a medical consult. Adam’s been taking care of her, but this morning I found out that you were her PMD. I should have asked and I’m real sorry. Adam said you could take over her care and he’d stay on as the consult.”
I was speechless. “Nancy,” I said, “you’re the first doctor in a long time to apologize for not notifying me about my patient’s hospital admission. I really appreciate you doing that, and it’s quite all right. Adam’s a good doc and it sounds like he’s doing the right things for her. I don’t need to get involved, but I will visit her today. Thanks so much for coming by.”
As she was leaving, I thought of how far a little consideration goes in improving doctor-doctor relations!
Urgent care without walls
I love new ideas. Many times they’re fleeting, but sometimes I file them away for future reference, hoping to resurrect them when circumstances permit. I rebirthed one just the other day. Resting between racquetball games with my FP friend Jeff, I discovered that his office was hiring a family nurse practitioner and he was concerned about whether he would be busy enough to pay her and still cover his expenses. “There are days when I have openings, and it’s going to be hard to share patients when my own schedule isn’t full,” he said.
“Here’s the solution,” I said. “Let’s get some partners and form Fort Bragg Urgent Care. All we need is a telephone with call forwarding and an answering machine.”
The concept, I explained, was not to build a new urgent care center but to use our own offices more efficiently. “What if,” I began, “a group of us were to agree to form a loose association and see patients on an urgent basis as our schedules allowed? We would rotate the telephone triage among our office FNPs on a weekly basis and refer those patients to our colleagues who had openings. If there were no available slots that day, we could apologetically refer them to the emergency department. No one would be under any obligation to see patients, but when practical we could be providing a valuable community service by shortening the wait time and expense for people who would otherwise have to use the ED.”
“Boy, that’s a great idea,” Jeff said. “Count me in. By the way, when did you think of it?”“About two years ago,” I said. “Care to see the logo?”