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Of course practice is hard; the system is insane.

Fam Pract Manag. 2004;11(6):17

Some of the absurdity of practicing today is captured nicely in this issue by the chance juxtaposition of two articles – “Understanding When to Use 99211,” page 32, and “Getting the Most From Language Interpreters,” page 37. Not that the articles are absurd in themselves. In the first, Emily Hill, PA-C, gives succinct advice on how to make sure you don’t lose income through disuse or misuse of 99211, and in the second, Emily Herndon, MD, and Linda Joyce offer useful tips for improving the care of patients whose language you don’t speak. Each article is important in its own way; each can help you improve your practice.

No, the absurdity lies in this: It takes Hill three pages to explain how to make reasonably sure you can get paid a rather small amount for a minor service, and even if you do everything she says, you may not be able to collect from every payer. But it takes Herndon and Joyce two sentences to explain why you may need to pay for the relatively expensive services of a translator: Basically, the law says that, under certain circumstances, you have to pay. Period. There you have it: To collect income you’ve earned, you need to jump through hoops, but a simple unfunded mandate is enough to squeeze that income out of you. And depending on the number of LEP patients in your practice, you may use the income from a lot of 99211s in paying for, say, $3-a-minute phone translation.

Four roads out

Of course, this is hardly the root of the problem or even a very important part of it; this is nothing but one more example of the absurdity you can see whichever way you look – an absurdity born of fragmented policies, political pressures, conflicting incentives, an unsystematic health care “system,” fierce competition and any number of social trends. This is just a snapshot of our neighborhood. Absurdity is where you practice.

How one should behave in such a neighborhood is of practical importance. It seems to me there are four avenues of action (or inaction) open:

Go with the flow; don’t fight the absurd, just complain about it. That way, though, seems to lead to cynicism, depression, steadily falling practice revenues and early retirement.

Move out of the neighborhood. This is the path followed by the growing number of family physicians who are opening cash-only practices, membership practices and the like and, I suppose, by a portion of those who choose to go to part-time practice (see our cover story, “Part-Time Practice: Making It Work,” page 45).

Get really good at jumping through hoops. This is the route followed by many prosperous, reasonably happy family physicians across the country. They’re the ones who have figured out how to make sure they don’t miss the 99211s; they work continually on building efficiency and improving systems to make sure they can provide good care and generate decent revenue despite the chaos.

Fight against the absurd. This is largely a political fight carried out within the house of medicine, in legislatures and in the voting booth. For family medicine, it’s also the Future of Family Medicine project. (If you haven’t read the project report yet, you may want to; it will govern a lot of the efforts of the AAFP and other major family medicine organizations for some time to come. You’ll find it online at Success in this arena is rare, but it brings enormous benefits.

If you look at the content of Family Practice Management with these four roads in mind, you’ll see that we devote some space to each – although relatively little to the first. (We figure that you don’t need our help to get cynical and depressed.) For family medicine to survive and flourish, I think, we can’t neglect any of the other three roads. Nontraditional practices may contain the seeds of the future. Skill at getting through hoops held out by payers and governments is the secret to survival in the short term. And, hard though it may be, fighting the craziness of the system is incumbent upon the family physician who cares for his or her patients, future, colleagues and country.

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