Why Wait to See Your Regular Doctor?

Why should you wait to see your regular doctor? The benefits of using your regular doctor's office to see your PCP or another provider with access to your child's medical record are many. I previously wrote several tips about how to use an urgent care wisely, but I wanted to spend more time on the benefits of going to your own doctor rather than an independent walk in clinic in more detail, so removed that portion of the post.

Almost as promised, here it is. The almost is that I promised to post this the next week, but a few other topics interrupted the posting schedule. Better late than never!

There is more to this than could be covered in one post, so this is Part 2. It covers the benefits of seeing someone in your regular doctor's office. Part 3 will cover some of the problems with seeing someone in an independent urgent care.

Your primary care office knows you

Humans benefit from relationships in many ways. When you see the same people over and over, familiarity brings comfort. This can be the same face at the reception desk, the same nurses, or the same physician. Even if the faces change from time to time, the overall clinic's familiarity can bring comfort in a time of significant illness or disease. When you have something difficult to talk about, it's easier with someone you've built a trusting relationship.

Consider teens...

Think of tweens and teens who need an adult to ask for advice.

If they do not have a medical home where they feel welcome, they are less likely to talk about their problems.

As much as we'd all like to think that our kids will talk to us, they aren't always comfortable with that. I've had kids ask parents to leave to talk about so many issues. Some of their "confidential questions" may seem silly to not talk about with a parent, such as how to use deodorant or how to shave, but it happens. Some are really troubling things, such as suicidal thoughts or abusive relationships.

These need to be discussed with a responsible adult, not another tween or teen, so I'm happy when they are comfortable talking to me.

If they've come to the same place year after year for illnesses, injuries, and yearly well visits, they will feel more comfortable.

Even different faces in the same practice offers some consistency

Even if you see different physicians, NPs, or PAs from time to time or go to a satellite office, there is still continuity within that practice.

The medical record has your child's immunization history, previous drug reactions, any underlying illnesses or frequency of illnesses, as well as any other pertinent information. As long as you use that clinic for most medical care. The more often you use outside clinics, the less comprehensive the medical record becomes.

Primary Care Providers (PCPs) and their staff also know your family and that alone can help!

Business of medicine

Talking about the business of medicine might seem self-serving, and it is, but think about keeping your favorite physician in business. The reality is many private clinics are selling out (or just joining) larger health systems. This raises healthcare costs, increases administrative burdens, and diminishes the personal touch of healthcare.

I hate thinking about business and insurance issues, but as a business owner, I must.

I have two big regrets from my student days.

The first is that I wish I studied abroad because once work and family life start, it's too hard to take long trips.

The second is that I wish I took business classes to prepare myself for a career in medicine. Most medical students are so eager to learn the massive information about medicine, they forget that one day they might be a business owner.

Unfortunately the number of physicians who own their own practice is falling. I suspect that has a lot to do with physician burnout and the increasing suicide rate of physicians, but that's another topic!

I've learned a lot of business along the way, in large part to SOAPM. Unfortunately not all physicians have learned about business. Life is busy and it's hard to balance everything. We tend to already work long hours, so it's hard to fit one more thing in at the end of the day. I think medicine is in the state it's in now because healthcare has been led by non-clinical business people who might understand business, but have no idea how it impacts the health of people.

Care outside your primary office (Medical Home)

Now that many routine visits are going to outside providers, family physicians and pediatricians are struggling to stay in business.

We still see our patients for illnesses, but they tend to be more chronic issues.

Daily headaches for the past 6 months takes a lot more time in the office than an earache that started this morning. We can't see as many chronic issues as acute illnesses, so the amount of money we bring into the office is down due to less volume.

The costs of rent, insurance, staff salaries, and more doesn't go down, so covering those costs becomes difficult.

Urgent care from a business perspective

Routine sick visits are quick and easy.

They're the bread and butter of primary care offices.

That's why urgent care centers are popping up in pharmacies and on every other corner. They are short visits, but insurance companies pay well for them. Because they're short, many can be done in a standard shift. This brings in easy money to a clinic.

Chronic issues, mental and behavioral health, and other issues not typically seen in urgent cares take more time.

If a patient with symptoms more than what can be handled in an urgent care shows up, they are quickly assessed, offered a token treatment and told to follow up with their doctor. Or they're simply told to go to the ER. Urgent cares don't waste time on big issues.

The impact urgent care use has on a PCP schedule

You wouldn't think at first of all the trickle down effects that going elsewhere for care has on your primary doctor's life.

Remember that if we're not seeing patients, we aren't brining money into the practice. The money doesn't directly line our pockets - it's needed to pay essential bills. We have to fill our day with patients one way or another.

Well visits and short vs long sick visits

Many doctor's offices differentiate sick and well slots in their appointment schedule. This allows us to see a balance of well visits for routine care as well as to save time for sick kids and those with chronic issues. Many of us have short and long visit slots to account for the amount of time typically needed for each visit concern.

The more patients go to urgent cares for quick visits, the fewer same day short sick visit slots are needed in PCP schedules. This means we must adjust our schedules to have more well visit and longer chronic issue slots so we're not sitting around doing nothing.

Schedules of today look and feel different

Since we have less need for short acute visits, we fill those with longer chronic issue visits and well visits. Both of these tend to fill in advance, unlike short acute visits that tend to be needed on the same day.

Some days that means my patients who want to see me are told I have no availability. They can still be seen in my office's walk in clinic, but they can't schedule with me.  I'd like to be able to see my patients when they want to be seen, but supply and demand ring true.

Unfortunately, these longer visits are relative money losers and they can be more emotionally draining for the physician due to the chronic nature of the conditions seen. Some days I wish to be able to see a straight forward earache or sore throat....

How much is a visit worth?

We use a billing system that identifies an office visit by complexity and time. This is set by regulations, not your doctor's office -unless they're a concierge cash based practice.

A typical sick visit that lasts about 10- 15 minutes is considered a 99213, which is valued at about $74. So two sick visits is therefore worth about $148.

If a visit is over 25 minutes or complex, it is considered a 99214, which is valued at $109. We therefore lose nearly $40 for every prolonged visit because we spend more time. If we saw two different patients in that same time, we'd bring more money into the practice.

Once in awhile this isn't a big deal, but as more people go to urgent cares for routine illnesses, PCPs are left with mostly complex visits. This hurts the bottom line and is emotionally more draining for the physician. It's hard to deal with serious issues all day long.

This isn't about being greedy.

If I was in it for the money, I wouldn't have picked pediatrics after medical school.

Pediatricians are consistently some of the lowest paid physicians.

I chose pediatrics because I love it. But I still have to pay the bills at the end of the day. We have to pay office rent (or mortgage), malpractice insurance, insurance on our vaccine supply and other inventory, salaries for all staff, health insurance for staff, IT equipment and management, etc.

Just like any business, it takes money coming in to stay in business.

Changes to the value of a visit?

There's a proposal to change the way office visits are paid by insurance companies.

This is a proposal to have insurance companies set the relative value for each visit at the same payment rate. This means if you're seen for 5 minutes the doctor gets paid the same as if they spend 45 minutes with you.

I see this being very detrimental for pediatric care because it will encourage many quick visits instead of a comprehensive visit. But if we spend too long with a patient, we can't earn enough money to pay the bills at the end of the month, so it will be necessary to make visits short to be able to see enough patients at the end of the day to cover costs.

I worry that people will gloss over issues that need more time. Abdominal pain is commonly constipation, but can be many things. We just won't have time to talk it all through in one short visit.

This is a proposal that will benefit the independent walk in clinics that tend to see many earaches, coughs, rashes, and other quick issues. It will not be good for those of us who manage a lot of mental and behavioral health.

Or our patients.

Free advice is bad for business

It gets worse. Pediatricians give away advice for free all the time.

People call us to ask how to manage symptoms and conditions throughout the day and night. Most of these calls are done for free, yet we pay for staff to take them.

Often parents call and we give advice on how to manage symptoms before following up in the office during business hours. It isn't uncommon to learn that parents took their child to a late night urgent care instead of waiting.

Parents often call asking if the care given elsewhere is appropriate or if we can we write a school excuse or refill medications when we never even saw the child for the issue.

We can't manage what we didn't see.

If you bring your business elsewhere, only go where you trust that the provider has experience with children and can handle your child's symptoms. When you have questions about their treatment plan, ask them. If you need a school or work excuse, ask them for it.

You'd never buy a Kia and then ask Toyota for parts or free repairs. You return to the original dealer, right? (I chose these brands because they're the two in my garage now. I have nothing against either, but they're different.)

Urgent cares don't give away anything for free.

Stand alone urgent cares don't cover questions 24/7.

Primary care offices are required to offer 24/7 phone availability. Either they staff it themselves or they pay someone else to do it.

This is just one more way that urgent cares have the business advantage. They don't have this monetary cost or quality of life issue.

All these calls hurt a medical home's bottom line because we're paying our staff to talk to families - often back and forth calls. It's a considerable amount of time. Time for a service that brings in no money, but we still must pay staff to do it.

Physician burnout

You might wonder what physician burnout has to do with a person choosing to go to an outside urgent care or their physician's office.

A lot really.

There's of course a financial loss when people go elsewhere, but it's more than that.

As mentioned above, the more urgent cares are utilized, the more a PCP must handle more difficult chronic problems, which tend to be more emotionally draining.

PCPs now have to spend extensive time documenting review of outside provider notes. Insurance companies are setting many rules and protocols to reconcile charts and update the primary care record whenever our patients see other providers. In the paper chart days, I could quickly skim consultant notes, but now it takes a couple of hours per day of unpaid time to review them all.

Seriously. Hours. Every day.

I struggle to keep up. And I'm not alone.

New reports come in every day - even when we're off.

I'm guilty of logging in even when I'm on vacation. This is not healthy for me mentally. I know that. It's bad for what should be my personal and family time. It's just easier to me though to spend this time logging in so I can "do a few charts" to keep me from being overwhelmed when I'm back to work. There's no time to catch up when I have to see patients all day and continue to get new charts to review each day.

Our physicians try to help others out when we're on vacation, but many charts really should be seen by the PCP, not the partner.

Every day I go to work before seeing patients and stay a couple hours after I'm finished seeing patients. I review charts as I eat lunch unless I have a meeting so I can get home to my family a little earlier each day.

Charting does not bring satisfaction.

One of the benefits of working in healthcare is the satisfaction of knowing that we help others. All the years in training. The sleepless nights. Missed kids activities. All of this is worth it when we feel like we make a difference in someone's life.

Reviewing charts does not help me feel like I am taking good care of patients. It does update me on what's going on with them, but it isn't fulfilling like when I see a patient and help them.

There are so many clicks to review one chart and update it as expected - reconciling mediation lists, updating hospitalizations or the injury list, and more. It's difficult to keep up.

If most care is done in the medical home, the chart is updated at the time of the visit and these chart reviews would be less. Sometimes it is not advisable to stay within the medical home. There are true emergencies and times that specialists should get involved. These are unavoidable and necessary.

Most urgent care trips are not really urgent. They break the medical home concept for convenience.

No wonder there's so much physician burnout these days.

Not only do we need to see more difficult or chronically sick patients because the quick acute care illnesses go elsewhere, but we also must review their notes and incorporate them into the patient chart for zero reimbursement.

That's asking for burnout!

Use the Medical Home

What can you do to help your physician avoid burnout and stay in business?

Be seen by them whenever possible. Let them see the volume of patients they need to see to cover costs. Use them for quick sick visits as well as routine physicals and following up of chronic issues. Avoid going elsewhere unless it's really needed.

The reality is that many private practice physicians are selling out to (or simply joining) big corporations because they can't make ends meet.

I've heard their patients complain about the loss of personalized service and added costs.

Please consider the long term effects when you use outside services.

What keeps patients in the medical home?

There are many things that have been tried to allow people to be seen in their medical home. Not all work.

Sometimes people just think another location is more convenient. I know this because I get reports from urgent cares that saw a patient of mine when we were open. Instead of calling for an appointment or coming to my office's walk in, which is available all hours that we're open, they go elsewhere.

Extended hours

I've heard time and time again from patients, other physicians, and medical administration types that extending hours is important to private practice.

Even this can be a problem.

We see patients use outside urgent cares when we have regular business hours. Maybe a 5 minute shorter drive makes a difference?

My office even tried extending hours beyond our already generous regular hours. We were already open longer than standard business hours and our regular hours include walk in for patients all day every weekday and half days on Saturdays, but we stayed open even later for awhile.

Staying open later increased our expenses in staff salaries, but we found that people still went to other urgent care centers. We lost money at that time of day. People had asked for later hours, but then didn't use them.

Walk in

One of the most complimented aspects of my office is the availability of our walk in clinic. Our patients can be seen in our office by one of our staff any time we're open by simply walking in.

This has many of the benefits of being seen in the medical home while offering the flexibility of other urgent cares.

It still has the downside of not being able to see your PCP. You will see whoever is staffing the walk in clinic at that time, and of course this person can always consult with your PCP if needed.

It also has lead to the schedule changes noted above, since most people prefer this convenience. We now have relatively few short sick visit slots in the schedule. This can lead to less availability when there are a number of parents who prefer a scheduled appointment on the same day.

Phone calls

As mentioned above, PCPs must be available 24/7 by phone.

A phone call can be used by parents to keep their kids out of urgent cares and ERs. We can offer advice to get through the night (or until the office opens).

Follow the advice, and if your child needs to be seen, try to do it in the medical home. Of course if your child is in uncontrollable pain, is struggling to breathe, is dehydrated, or has other significant issues, he should be seen immediately.

Many offices, my own included, offer a ton of free advice on our websites. This has been debated from a business standpoint since it's free advice. From a quality of life standpoint, the clinicians in my office like having things easily accessible for parents. When we give advice on the phone or during an office visit, much is forgotten. Having it easily accessible for parents to review is a great resource for them and helps to decrease the number of return calls for clarification. This also helps the physician's quality of life.

Telehealth

There is a general push toward providing virtual visits through secure video conferencing. Even my insurance company keeps pushing me to register so that I can easily be "seen" when I'm sick. (I haven't.)

I think this is a very dangerous slippery slope. Many sick people need to be examined to be able to properly diagnose things that require prescription treatments. Yet I know they are happy to call and get a prescription, so if it's available they will use it.

Again, getting what you want is not always what you need.

I do see great potential for telehealth in the medical home and to improve access to specialists. It can be used to follow up on many issues in an appropriate way.

I worry that people will use it to get poor care for common acute sick issues. When your baby's fussy or has a fever, you just want help, right? Just because you can doesn't mean you should use it.

I strongly believe that we need guidelines to use this as a way to bring care to people when they could benefit from it. But telehealth should be restricted to only appropriate uses.