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Innovation (survival) in primary care-telehealth/DPC

  • 1.  Innovation (survival) in primary care-telehealth/DPC

    Posted 05-16-2018 07:19
    HI all
    I'm primary care doc in a 3 provider/ 3 admin staff LGBTQ practice in Seattle. We have high overhead (in downtown Seattle,) are very busy/practice is closed to new patients, and have limited Medicare/Medicaid panels.  The issues we're having is similar to what many of you are facing--very long days with increasingly high admin burden for less money and increasing expenses.  Also increasingly, our patients with commercial insurance are limited to networks where they can only be seen within large medical institutions. I'm worried this is the trend and if this gets worse we will lose a large number of patients.  We can't survive on Medicare/Medicaid alone due to our high overhead.

    I'm starting to think we need to make some changes and wondering about offering telemedicine visits and/or trying a DPC hybrid where we we continue to bill insurance but can offer a DPC option for our patients who can no longer see us due to insurance limited networks.  I see a lot of transgender patients and it is very distressing for them to lose their doc and have to find a new provider in a large system.  It would be great to find a way where they can continue to see me.

    I've read previous IMP threads on this but otherwise just getting started. I'm wondering if anyone has any advice in terms of good resources on telehealth or DPC?  Also wondering if anyone out there is doing a DPC and insurance hybrid (or if this by nature is a violation of insurance contracts.)
    Jessica Rongitsch

    Jessica Rongitsch, MD, FACP
    Capitol Hill Medical
    Seattle, WA

  • 2.  RE: Innovation (survival) in primary care-telehealth/DPC

    Posted 05-17-2018 11:51

    HI Dr. Rongitsch,


    Happy to help answer any questions about DPC.  I started my dpc practice in 2010 and we've helped over 450 docs convert to dpc (free) in the last few years.


    We have all of our information for doctors free online (curriculum, starter packet, checklist) and so do a lot of other dpc docs that are passionate about the movement


    Feel free to contact me directly anytime either by email or cell. and C 316.734.8096




  • 3.  RE: Innovation (survival) in primary care-telehealth/DPC

    Posted 05-18-2018 08:39
    I've just started up a cash based practice which allows me to work around the insurance issue. I don't participate with any insurance companies and I'm enrolled with medicare/medicaid only as a prescribing/referring/ordering provider. For my patients who do have insurance, as long as it's not medicare or medicaid, I simply complete the health insurance claim form 1500 and give it to the patient. They then submit this to their insurance for reimbursement of what they paid me.

    Elizabeth Weeks
    Apple Tree Medicine, PLLC
    Williamsburg VA

  • 4.  RE: Innovation (survival) in primary care-telehealth/DPC

    Posted 05-31-2018 11:03
    You're asking how you can improve your profitability in a FFS environment, yes?

    You either need to work more hours or increase your hourly net.  Working more hours is a mug's game.You can increase your hourly net by being paid more per visit, as in more $ for a 99214(negotiation- good luck! or being more selective w insurance --does it make sense for you to see Medicaid pts when the FQHC down the street gets paid $160/visit for Medicaid? ), or coding higher visits (usually more accurate anyway).  Those all have limited effect.

    The best way to improve your profitability in a FFS environment is to improve your operational efficiency by eliminating waste. You don't do this by having someone stand in the hallway shouting, "Faster! Faster!"
    That doesn't work.

    Physician time is probably the most expensive piece of your operations.  Are you wasting MD time? Almost certainly.  You're a very expensive typist. Recent studies have shown MDs spend less than half their time doing what only they can do.  The rest of the time, they're doing things that could be done by other staff (less expensively and more efficiently.)

    The most obvious and best studied example is scribes. Using a scribe usually produces an increase in provider productivity of 50-100%.  If you pay a scribe $20/hr ($15 plus 30% benefits) for a 10 hour day, that's $200/day.  If you go from 2 to 3 visits an hour by not wasting your time typing, that's 8-10 more visits in the day, without cutting down the quality of time you spend with your patients.  At $80/visit, that's $640-$800/day, or $440-$600/day increase.
    Typically, scribes are people looking to move to a higher-skilled job, like pre-PA or premed students, so they're only there for a year or two, but they also get enormous clinical experience from being scribes, so they're willing to accept a lower salary than they might get elsewhere.

    There are other ways to improve operational efficiency.  It's a truism with HR gurus that paying more than median salaries gets better employees. The rule of thumb is that a good employee is 3x more effective than an average employee, and a great employee is 3x as effective as the good employee.  It shows up in fewer errors, better customer service, being a more effective team member in improving processes, spotting problems, and generally going beyond the minimum requirements of the position.

    There are people who specialize in improving processes.  They're gold, and often underemployed, because the biggest barrier to continuous improvement is problems at the top.  The people who WANT to get into management positions are narcissists and psychopaths (so they have power over others); of course those are the LAST people you want in those positions.
    The descriptions for CI, operations improvement, etc., are 'LEAN' and "Toyota Management System".  I'd go talk with someone doing a LEAN initiative, ask them for people leads, and subscribe to newsletters about LEAN.

    You can search on 'seattle' here to find people:

    Good luck!

    More possibilities:

    Here's a search at on 'seattle':
    This came from one of the articles-

    Virginia Mason Medical Center in Seattle, WA, is yet another example of lean in healthcare producing amazing results. Leaders at VMMC created the Virginia Mason Production System, a management method that seeks to continually improve how work is done so there are zero defects in the final product. Staff across the organization use this method to identify and eliminate waste and inefficiency in the processes that are part of the healthcare experience. Results at Virginia Mason are undeniable:

    • Saved $11 million in planned capital investment by using space more efficiently and freed an estimated 25,000 square feet of space using better space designs.
    • Reduced the time it takes to report lab test results to the patient by more than 85 percent.
    • Reduced inventory costs by $2 million through supply chain expense reduction and standardization efforts.
    • Reduced staff walking distance by 60 miles per day.
    • Reduced labor expense in overtime and temporary labor by $500,000 in just one year.
    • Increased productivity by ~93 percent in a few targeted areas by moving the most common supplies to point of use and creating kits containing frequently needed supplies.
    • Reduced premiums for professional liability insurance by 56 percent.

    Peter Liepmann MD FAAFP MBA
    My mission is to fix US health care
    Glendale CA

  • 5.  RE: Innovation (survival) in primary care-telehealth/DPC

    Posted 06-13-2018 15:32
    Somehow I missed this response. Thanks for your thoughtful response!  I will take a look at these resources.  Thank you!

    Jessica Rongitsch, MD, FACP
    Capitol Hill Medical
    Seattle, WA

  • 6.  RE: Innovation (survival) in primary care-telehealth/DPC

    Posted 09-18-2018 11:25
    Here's an interesting article that I just came across recently. Telemedicine is probably one of the solutions.
    5 Ways to Drive Disruptive Innovation in Healthcare remove preview
    5 Ways to Drive Disruptive Innovation in Healthcare
    When it comes to transforming healthcare, one thing is clear: it's a hot topic. Most people see healthcare disruption as coming from two sources: government taking a legislative role that reshapes the big picture business model, and grassroots startupsusing technology to challenge the status quo. We've seen government's recent struggles to help reinvent the system.
    View this on >

    Jerry Benson
    St Paul MN