My clinic and the state of medicine

January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.

Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….

Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.

So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.

A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.

I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.

Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.

If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.

If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.

Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65

We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.

And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.

https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/

This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..

I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….

Fraud in medicine: medicare application

Medicare quit paying my clinic at the end of July, on the 31st.

I was still half time in clinic, we were interviewing a new receptionist as my receptionist of five years wanted to retire by August first. We got some sort of notification from medicare, but their letters are very cryptic.

My new receptionist was needing orientation and help and I was really tired after July. I redid the medicare application and sent it in. We continued to see medicare patients and turn in the bills.

Our medicare contractor is noridian. They sent us a cryptic letter saying that something was wrong with the application. This was, mind you, a renewal. I had been seeing medicare patients for five years in my clinic.

I call them. I am given a name and a number to identify the call. I have two Ptan numbers, one for me as a physician and a second for the clinic. The first call said that my personal Ptan application was correct but the clinic one wasn’t.

I did it again and mailed it. Second day air. He said that our payments should be released in 10-14 days.

Ten days. Nothing. Fourteen. Nothing. I am pulling from savings to run the clinic. I call a second time. Again I am given a name and a number. She said I had to CALL to get paid once the application was received. I said the first guy didn’t say that. She said another 10-14 days.

We wait. After ten days I call. A third number and person. Once again I have a cryptic email. I ask about the PTan number on the email, which is not my clinic’s Ptan number. Oh, says the man, that is what is wrong with your application. He says to do form (numbernumbernumber B) not form (numbernumbernumber A). And it will be 10-14 days after they receive it.

I do it AGAIN. I do notice that all of the old copies of the form in our file have the PTan numbers wrong. Weird. They have been paying me for five years.

Ten days. I call a fourth time. She says that it will be 30 days not 10 to 14 until medicare lets me know if my application is correct. Or they might pay me after 10-14 days. They aren’t, so I argue that something must still be wrong. What is it? She can’t tell me. I want a supervisor. She says that I can talk to a supervisor in 10-14 days. We figure out that the Ptan number on the application is correct. I say, “I am writing my congresswoman.” and hang up.

So I do. I find my Senator’s email and I write to her. I have been a rural family practice doctor for 25 years and I saw a 98 year old yesterday and a 91 year old today and I LIKE my elderly patients, but I have HAD it with medicare, at least with the contractor noridian that is running medicare for my state. I list the phone call dates and names and identifying numbers and I say FIX IT because otherwise I am for the first time in 25 years seriously considering quitting medicare.

Two days later noridian sends an email saying they are releasing my payments.

The next day we get a direct deposit for $9000.00. That is a START.

One week later we get a call from noridian explaining what is wrong with our application. Not just one thing. Noridian doesn’t seem to have a copy of our business license from five years ago. We have to put the personal Ptan on page xgyb-14. They want details about the nursing home. Do I do home visits?

The noridian person explains that our application has actually been wrong for five years, but now they are getting audited so they have to get everything cleaned up.

So THEY have KNOWN it was wrong for five years, but held my payments since July, while they try to get their act together and tell me what the hell is wrong with it?

I want to be paid INTEREST for all the time I have spent on the phone and redoing the cryptic application.

And many thanks to my congresswoman, for keeping my clinic open.

I took the picture at the Kinetic Sculpture Festival here in September. The outfits make more sense than dealing with noridian, that’s for sure….

first posted on everything2.com on 11/30/15