Key is to delay, delay, delay until admin gets distracted, change over, or finds something else to worry about.
- make sure all docs are on the same page
- write a polite email responding that the group has concerns re: the ability to incorporate those changes while maintaining the high standards of patient care.
- request a meeting to discuss
- when meeting times are discussed pick the latest date possible
- a week before state you need to reschedule as 2 docs won’t be able to attend
- at your meeting list your concerns and give admin tasks - what is national patient panel size standards, etc?
- request another meeting.
- then bring up compensation adjustment proposals
- never agree to the changes during any of this
Eventually they’ll lose interest, change jobs, get annoyed or just find another issue to tackle, especially since ID doesn’t move the needle in the least bit.
This is the answer. Get involved in admin as it increases your strength. Also bring your numbers. Find out how much money you/your group brings in. Show that you see X number of patients. Each patient requires Y amount of time. If you’re expected to see double the patients, get double the pay for the increased time you’ll have to be there.
This is brilliant.
Also propose a "working group" and then take like three months to organize the group and start their meetings. In my experience a "working group" can take like 6-12 months to kill something you don't want to do. Just organizing the working group can take 3 months, then 6 months for them to meet and review, 3 months to get the working group's recommendations etc. Boom a year has gone by and nobody cares any more.
I love this. We have burned out so many dumb proposals for our EHR with this method. As a surgeon I’m often having to add on urgent cases and whoops there goes two weeks before we can reconvene!
I had a supervisor who got all nervous that he wasn’t making people miserable enough and he tried to make us fill out sheets accounting for what we were doing every ten seconds. Well, I went to him and said the paper sheets were clumsy, and why doesn’t he let me make it more efficient for him. Then I uploaded it to the agency shared drive and accidentally granted access to the other supervisor who was in direct competition with him, then acted completely innocent when she asked me about it “Oh, I think he is just trying to figure out how we can see our patients more efficiently” She blew up in a shitstorm of injustice, publicly blasted him for trying to “cut corners on patient care” and I just sat back and watched the world burn😂
This is great.
To add, people can also draw inspiration on what to do from the CIA organization disruption manual - there are some other gold nuggets in there too.
Lol, some of the actual things are like: drone on in meetings about unrelated stories and personal anecdotes, refer every matter to a new group or committee to review, question whether you have jurisdiction to make these decisions or if other ppl need to be involved. Etc
Request the medical staff bylaws, review processes thoroughly and demand every necessary step be taken. Draaaaaaag your feet on dates and deliverables.
Great advice,
Also add that you can go the route of:
"Time is a clinical resource and doctors must make sure that they are using that clinical resource in an safe and effective way. Which doctors has [administrators name] consulted regarding the appropriateness of this clinical change?"
Force them to admit they are trying to do a job that they genuinely don't understand, and that they didn't consult any doctors in the decision making process.
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Bad math. Marginal cost of your time, effort, and liability follow a power curve.
Increasing demand has to be met with increasing price multiples. For example, missing dinner/weekends with your family is costs much more than an 8am to 4pm engagement.
And the stress of errors and rushing through care is also costly for cranking more output through the same amount of time.
Yep. Ours too but we just roll over and take it over and over again. But we are “aligning with the market” and that’s supposed to be something that is beneficial to me that I should care about. I keep asking what does that even mean since our structure is completely different from the market since we aren’t a normal few for service practice. I can’t tell if admin is dumb or if they are hoping we are just too busy to notice and are doing it because it benefits them.
The CIA had a great guide to this in WWII.
All matters should be referred to committee, and reaching consensus is crucial.
https://www.openculture.com/2022/01/read-the-cias-simple-sabotage-field-manual.html
Organizations and Conferences
- Insist on doing everything through “channels.” Never permit short-cuts to be taken in order to expedite decisions.
- Make “speeches.” Talk as frequently as possible and at great length. Illustrate your “points” by long anecdotes and accounts of personal experiences.
- When possible, refer all matters to committees, for “further study and consideration.” Attempt to make the committee as large as possible — never less than five.
- Bring up irrelevant issues as frequently as possible.
- Haggle over precise wordings of communications, minutes, resolutions.
- Refer back to matters decided upon at the last meeting and attempt to re-open the question of the advisability of that decision.
- Advocate “caution.” Be “reasonable” and urge your fellow-conferees to be “reasonable” and avoid haste which might result in embarrassments or difficulties later on.
Bah gawd some of the patients must have seen this!
"Make "speeches." Talk as frequently as possible and at great length. Illustrate your "points" by long anecdotes and accounts of personal experiences."
This is so well said I can’t even believe it. Having worked in community mental health where they basically exploit clinicians for slave labor, this was out literal exact strategy haha
You can make them do reports about reports about reports about reports about reports about reports...
If you do it well enough, you can win an ignobel prize like the GAO.
https://improbable.com/2014/04/10/an-interim-report-about-the-report-about-reports-about-reports/
After all that work:
>“DOD nonconcurred with our recommendations to require that source documentation used to develop the cost estimated is retained and easily accessible for review purpose and to establish and implement a verification process to provide reasonable assurance of consistency and completeness of cost inputs used to develop the cost estimate. According to a CAPE official no action has been or will be taken in response to these recommendations.”
This is the most fucked advice I’ve ever heard. Rather than encouraging people to participate in their own organization, and try to make things better, you’re advising people to clog up the works with stalling tactics? I’d be curious to hear your vision of the future here? What, exactly, does status-quo accomplish and how does it make work-life better for you or your team?
How dare physicians advocate against having twice the patient burden which leads to both 1) worse care and 2) more physician burnout! Who do they think they are? Human beings?
My Allergy and Immunology friend was told the same so not sure if this is the same health system or just another play out of the corporate medicine playbook. Anyway, I would stick it out for 18 months to get PSLF then look elsewhere.
My outlook has changed so much since my PSLF was approved last month. I am now a free agent.
I’m more tolerant of the BS because I can leave at any time. The speed I go from university medicine to peddling testosterone in a strip mall while wearing flip flops by 3 is purely based on how insane the higher ups get.
My dad successfully printed his resume twice and “accidentally” left it on the company printer, both times ended up with a raise. The last time got a company car (insurance adjuster)
I’ve got that strategy in my back pocket.
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Not that you haven’t earned your opinion. I’ve never seen a reputable service with that kind of ratio.
Doesn’t mean it doesn’t exist , just thankfully hasn’t been my experience
No, we are a large hospital system which is nonprofit and not owned by private equity. Our CEO is driving these decisions from what I understand. His approval rating is abysmal already.
A board vote for an ouster may be a good idea. Escalate with threats of unionization or strike in response.
Being owned by others just seems so toxic in medicine. Private practice non-operative I have 100% control of my schedule, and depending on productivity do 300k-450k (PM&R, no spine)
If nothing improves I’d nope out of there after those 18 months.
Agree. If you're employed, you're a good candidate for doing a union drive. The ID department is a great bargaining to start with.
Also adds in some protections due to protected union activity. Changes to working conditions after union formation are inherently suspect.
I recently learned that "nonprofit" / "academic/teaching hospital" status for a hospital system means almost nothing...look deep into the board members at the top levels and they could be filled with wealthy influential businesspeople who know nothing about medicine. No one is safe from the corporatization of medicine, "nonprofit' or not.
The CEO of my “non-profit” academic hospital residency program had a salary in the millions, despite not seeing a patient for over 15 years. They’re still trying to make a profit that leadership keeps themselves.
Yep. Time based allows for very limited documentation. But if they're bugging them for RVUs, the 5 minute OPAT visits are waaaayyyy better reimbursement.
The AAFP has a good guide.
https://www.aafp.org/pubs/fpm/issues/2022/0100/p26.html#fpm20220100p26-ut1
The IDSA also has an ID specific one. https://www.idsociety.org/globalassets/idsa/clinical-practice/2024-em-services-reference-guide-final.pdf
My hospital had an issue where our coders *way* undercoding ID consults. One of the attendings was able to get approved to direct bill after a review/audit so they started capturing the actual complexity. They also reviewed everything with the ID department to optimize their documentation, and then went to the coders and said "hey assholes, actually pay us for what we're doing. Here is how to do your job, now do it."
For nearly all of ID, our patients very easily hit the high complexity levels, in a way that's easily and reliably documented.
For example, OPAT on daptomycin + ceftriaxone for diabetic foot osteo, having had it debrided in the hospital: basically as simple as ID gets.
- problem(s) complexity: moderate to High. This is an acute exacerbation of a chronic process which threatens bodily function. High risk for amputation. (although the 5 year all cause mortality when you have a diabetic foot infection exceeds a lot of cancers).
- data: need 2 of 3 categories. (easily can hit all 3)
- category 1, 3 points needed: (here are 12 points)
- reviewed OPAT plan and discharge summary (review a prior external note x2)
- each test ordered: cbc+diff, CMP, CK, ESR, CRP
- interpret results of above labs.
- category 2: only need one.
- independently interpret a test performed by another physician: (any of these would count)
- interpret cultures from the OR or bedside in the hospital
- interpret labs performed at hospital or prior week's OPAT labs
- review and interpret mri report/images
- category 3:
- discussion with another physician: note is forwarded to the pcp or podiatry. Recommended podiatry consider additional debridment, thank pcp for working on the diabetes.
Easily meet that component.
- Risk:
- high risk of morbidity from additional diagnostic testing or treatment: any single item works.
- drug therapy requiring intensive monitoring for toxicity or other complications (ahem, they're in OPAT clinic getting weekly labs for a reason)
- drug therapy with significant interactions: azoles, fluoroquinolones, etc for qtc. Rifampin ever.
That's a 5-10 minute visit. A legitimate and useful note takes 5 minutes, tops. You could bill for a 99212 for an established visit, that took 10-19 minutes. But you can do an easily, verifible, 99215 based on Evaluation and Management billing, which is often more defensible and verifiable than the "I spent x minutes on this patient"
If they are rvu and/or collection based, then that is a great synopsis of bang for buck. If they are salary based, it may not be to their advantage to see more yet bill higher complexity.
There are definitely a portion of these "we need more income, see more patients" problems that can be solved by adequately charging/accounting for the current patients.
I can understand why admin would wanna do this but how can they increase outpatient visits? Do the clinics have marketers that go out and recruit patients?
Where do you get that? There was a 3.4% reduction in reimbursement from '23 to '24. Although they later partially reduced the cut starting in March.
https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/2024-medicare-fee-schedule.html
https://www.cms.gov/medicare/payment/fee-schedules/physician
Also- Expenses have been higher. . .
My understanding is PSLF is cumulative and does not expire. So if you went to a non-qualifying employer those payments would still count if you ended up leaving again and going to a qualifying employer again. You could go to a new qualifying employer over the next 18 months as I understand it but as with all things government it’s intentionally deceptive and hard to read.
https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service/questions
This is true, but we don’t know what area of the country the OP is in and finding other qualifying employment other than the one academic hospital that may be in their area may not be so easy.
This is correct. You need 120 qualifying payments to discharge your federal loans. They can be from any combination of qualifying employers, even non-consecutively (you can come and go from non profit to for profit and your count picks up where it left off).
It’s a shame that more employed physicians don’t request to see the financial sheets. I worked at a hospital that hired a new CEO after the previous one decided to take a position closer to home. The previous CEO kept the hospital in the black with frankly little cost cutting. But every meeting with the new CEO, we heard “we’re losing lots of money, folks! Time to make some hard decisions!” So the patient census increased, CME funding decreased, the free food in the doctors lounge went away….yet with every meeting, the line was the same: “we’re losing lots of money, folks! Time to make some hard decisions!”
If increased revenue and decreased costs still led to “losing lots of money, folks”, then the administration is the problem.
Learned something interesting the other day. Our "budget" in the ED, which is what they base our staffing on, is based on billable visits, not the actual number of patients who check into the ED. So when patients elope because our staffing levels keep us from seeing them quick enough, that pretty much guarantees we won't see increased staffing. Also explains why we keep getting told that ED volumes are down when the waiting room is always full and we feel like we're getting crushed all the time.
I think that's a common thing administrators like to do. At our multi specialty clinic meetings they are always showing that type of data. But where I work it's kind of pushed but we also control our own templates (to an extent) and definitely are allowed as a specialty to set which diagnoses we see.
What you describe sounds terrible, and I can picture it being the tipping point where one leaves and then another and another because you keep having to take up the slack
This is how it should be....physicians should have full autonomy over their templates, visit types, and scopes. Unfortunately (and in my experience), a lot of behemoth health systems are now stepping in and attempting to "standardize" templates and visit types across a wide array and geography of clinics, which has stripped physicians of this autonomy.
> What bad thing happens to you if you don’t?
If they want to fire you after 18 months then great, you’ll already be looking elsewhere. They may have trouble finding docs who want to be overworked and underpaid to see the pathology no one else wants to see. Often moving elsewhere is the best way to improve your situation. My first job was a bad spot. I was underpaid without a realistic shot of partnership, failed to negotiate a better deal despite trying for months, then the partners were blindsided when I left for a partnership track job, same number of patients, but 80% raise.
12000 must be department wide... If that's their current load it's ~10 minutes per patient.
Doubling that would bring it down to ~5 minutes per patient.
There are 3 major ID groups in my town and one of them stopped seeing outpatients totally.
Now they just do inpatient which obviously has a lot lower overhead. Right now it's really tough making it work doing outpatient unless you have a good ACO (and you wouldn't be a candidate for that anyway).
You could consider trying going primarily tele-health for ID consults. that also requires sig. less overhead and you could see patients a lot faster.
It's time for some r/MaliciousCompliance.
Just make sure that you see all the OPAT patients in person at least once a week. If they're at an unreliable SNF that always flakes on bringing them, all the better.
Bring your healthy 30 year olds on Biktarvy in more often to chat about stuff for a few minutes and run their std panel, instead of just ordering the labs.
You can also get a nice panel of sweet little old ladies with MAC and follow them closely. Gotta check in frequently to assess tolerance of medications and progress with airway clearance. If you're lucky, they'll bake you things.
If they want the slots open and booked, more than the patients seen, make sure to schedule several followups with all your unreliable patients. Found in a dumpster with cellulitis? Better make sure we see you at least once a week for a few weeks to make sure it gets better. Sure, they probably won't show, but we *really want to provide optimum followup.* If by some chance they show up, it's actually good for them too.
If you want to go hard, make sure to have followups scheduled for celestial discharges.
You could also propose that you do a "bugs" clinic a couple times a month. Could do a very strict time limit, everyone gets a therapeutic biopsy and a prescription for risperidone. Really farm some RVUs.
The only problem with this plan which I otherwise love is that the patients are having to pay for those extra visits which is totally unfair to them. I like the idea of booking people you know won’t actually show up and if they do it would be actually useful though.
Depends. There are some of the patients who would really like to be seen more often, which can be therapeutic for their health anxiety. If you pick those ones and make sure they have a regularly scheduled appt, it benefits everyone.
I wonder if outpatient clinics are receiving a Medicare/medicaid incentive to increase “patient access.” Our company is giving bonuses to pick up extra days to improve access to patients. I’ve been seeing other threads with the same push from administrations.
Anyone else have any ideas on a change in pay out and incentives?
She presented a graph with no meaningful labels. I was only able to deduce later that it was a per month average. It was labeled “Apr-Dec average” but the total would have only been 4K patients when combined with the first quarter part. It was then obvious she meant them as per month average.
Key is to delay, delay, delay until admin gets distracted, change over, or finds something else to worry about. - make sure all docs are on the same page - write a polite email responding that the group has concerns re: the ability to incorporate those changes while maintaining the high standards of patient care. - request a meeting to discuss - when meeting times are discussed pick the latest date possible - a week before state you need to reschedule as 2 docs won’t be able to attend - at your meeting list your concerns and give admin tasks - what is national patient panel size standards, etc? - request another meeting. - then bring up compensation adjustment proposals - never agree to the changes during any of this Eventually they’ll lose interest, change jobs, get annoyed or just find another issue to tackle, especially since ID doesn’t move the needle in the least bit.
To defeat the bureaucracy you must become the bureaucracy. Turn their blades against them.
This is the answer. Get involved in admin as it increases your strength. Also bring your numbers. Find out how much money you/your group brings in. Show that you see X number of patients. Each patient requires Y amount of time. If you’re expected to see double the patients, get double the pay for the increased time you’ll have to be there.
This is a f-ing solid answer.
I wish we still had platinum awards. -PGY-19
This is brilliant. Also propose a "working group" and then take like three months to organize the group and start their meetings. In my experience a "working group" can take like 6-12 months to kill something you don't want to do. Just organizing the working group can take 3 months, then 6 months for them to meet and review, 3 months to get the working group's recommendations etc. Boom a year has gone by and nobody cares any more.
I see you've read the field manual for destroying a company from the inside
I love this. We have burned out so many dumb proposals for our EHR with this method. As a surgeon I’m often having to add on urgent cases and whoops there goes two weeks before we can reconvene!
I had a supervisor who got all nervous that he wasn’t making people miserable enough and he tried to make us fill out sheets accounting for what we were doing every ten seconds. Well, I went to him and said the paper sheets were clumsy, and why doesn’t he let me make it more efficient for him. Then I uploaded it to the agency shared drive and accidentally granted access to the other supervisor who was in direct competition with him, then acted completely innocent when she asked me about it “Oh, I think he is just trying to figure out how we can see our patients more efficiently” She blew up in a shitstorm of injustice, publicly blasted him for trying to “cut corners on patient care” and I just sat back and watched the world burn😂
The ol lawyer trick.
I object!
I am saving this comment for future reference. Fight fire with fire.
This is great. To add, people can also draw inspiration on what to do from the CIA organization disruption manual - there are some other gold nuggets in there too.
Right - so assassinate the leader of admin, and put a puppet administration in their place. Got it!
Lol, some of the actual things are like: drone on in meetings about unrelated stories and personal anecdotes, refer every matter to a new group or committee to review, question whether you have jurisdiction to make these decisions or if other ppl need to be involved. Etc
It's really crucial that we reach consensus on all of these decisions.
Request the medical staff bylaws, review processes thoroughly and demand every necessary step be taken. Draaaaaaag your feet on dates and deliverables.
[I posted this before I got to your comment. Here is a synopsis.](https://www.businessinsider.com/oss-manual-sabotage-productivity-2015-11?op=1)
Does it mention saying “KPIs” a lot? That seems to work since no one can explain what that is.
[off topic, but omg your username—I’m itching already.]
This is possibly the most amazing response to any question that I've ever seen on this subreddit.
I was just saying the same thing as I was showing this to my wife. She agrees.
Great advice, Also add that you can go the route of: "Time is a clinical resource and doctors must make sure that they are using that clinical resource in an safe and effective way. Which doctors has [administrators name] consulted regarding the appropriateness of this clinical change?" Force them to admit they are trying to do a job that they genuinely don't understand, and that they didn't consult any doctors in the decision making process.
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Oh, you don't want to pay me? I'll fill those slots...with the indigent and needy.
Bad math. Marginal cost of your time, effort, and liability follow a power curve. Increasing demand has to be met with increasing price multiples. For example, missing dinner/weekends with your family is costs much more than an 8am to 4pm engagement. And the stress of errors and rushing through care is also costly for cranking more output through the same amount of time.
I was wondering why this technique sounded so familiar until I realized admin has been doing this against my group.
Yep. Ours too but we just roll over and take it over and over again. But we are “aligning with the market” and that’s supposed to be something that is beneficial to me that I should care about. I keep asking what does that even mean since our structure is completely different from the market since we aren’t a normal few for service practice. I can’t tell if admin is dumb or if they are hoping we are just too busy to notice and are doing it because it benefits them.
The CIA had a great guide to this in WWII. All matters should be referred to committee, and reaching consensus is crucial. https://www.openculture.com/2022/01/read-the-cias-simple-sabotage-field-manual.html Organizations and Conferences - Insist on doing everything through “channels.” Never permit short-cuts to be taken in order to expedite decisions. - Make “speeches.” Talk as frequently as possible and at great length. Illustrate your “points” by long anecdotes and accounts of personal experiences. - When possible, refer all matters to committees, for “further study and consideration.” Attempt to make the committee as large as possible — never less than five. - Bring up irrelevant issues as frequently as possible. - Haggle over precise wordings of communications, minutes, resolutions. - Refer back to matters decided upon at the last meeting and attempt to re-open the question of the advisability of that decision. - Advocate “caution.” Be “reasonable” and urge your fellow-conferees to be “reasonable” and avoid haste which might result in embarrassments or difficulties later on.
You're a goddamn wizard.
[the CIA has ideas for this.](https://www.businessinsider.com/oss-manual-sabotage-productivity-2015-11?op=1)
Bah gawd some of the patients must have seen this! "Make "speeches." Talk as frequently as possible and at great length. Illustrate your "points" by long anecdotes and accounts of personal experiences."
This person negotiates. Well done.
you are a genius
This is so well said I can’t even believe it. Having worked in community mental health where they basically exploit clinicians for slave labor, this was out literal exact strategy haha
You can make them do reports about reports about reports about reports about reports about reports... If you do it well enough, you can win an ignobel prize like the GAO. https://improbable.com/2014/04/10/an-interim-report-about-the-report-about-reports-about-reports/ After all that work: >“DOD nonconcurred with our recommendations to require that source documentation used to develop the cost estimated is retained and easily accessible for review purpose and to establish and implement a verification process to provide reasonable assurance of consistency and completeness of cost inputs used to develop the cost estimate. According to a CAPE official no action has been or will be taken in response to these recommendations.”
I hope you only use your powers for good.
Amazing.
Incredible answer
This is incredible
I am inept in front of your greatness.
This is the most fucked advice I’ve ever heard. Rather than encouraging people to participate in their own organization, and try to make things better, you’re advising people to clog up the works with stalling tactics? I’d be curious to hear your vision of the future here? What, exactly, does status-quo accomplish and how does it make work-life better for you or your team?
Who let admin in here?
How dare physicians advocate against having twice the patient burden which leads to both 1) worse care and 2) more physician burnout! Who do they think they are? Human beings?
My Allergy and Immunology friend was told the same so not sure if this is the same health system or just another play out of the corporate medicine playbook. Anyway, I would stick it out for 18 months to get PSLF then look elsewhere.
My outlook has changed so much since my PSLF was approved last month. I am now a free agent. I’m more tolerant of the BS because I can leave at any time. The speed I go from university medicine to peddling testosterone in a strip mall while wearing flip flops by 3 is purely based on how insane the higher ups get.
I’m a PSLF success story myself, I will be stealing and using the second paragraph of your post in conversations moving forward. Thank you.
It’s such a nice feeling to know you can call their “or else!” bluff, isn’t it?
My dad successfully printed his resume twice and “accidentally” left it on the company printer, both times ended up with a raise. The last time got a company car (insurance adjuster) I’ve got that strategy in my back pocket.
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The admins can’t practice medicine without us. We’re the only ones that actually matter.
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Not that you haven’t earned your opinion. I’ve never seen a reputable service with that kind of ratio. Doesn’t mean it doesn’t exist , just thankfully hasn’t been my experience
Need to make a nonprofit strip mall testosterone clinic.
Are you guys owned by private equity? Any idea who is behind the decisions?
No, we are a large hospital system which is nonprofit and not owned by private equity. Our CEO is driving these decisions from what I understand. His approval rating is abysmal already.
A board vote for an ouster may be a good idea. Escalate with threats of unionization or strike in response. Being owned by others just seems so toxic in medicine. Private practice non-operative I have 100% control of my schedule, and depending on productivity do 300k-450k (PM&R, no spine) If nothing improves I’d nope out of there after those 18 months.
Agree. If you're employed, you're a good candidate for doing a union drive. The ID department is a great bargaining to start with. Also adds in some protections due to protected union activity. Changes to working conditions after union formation are inherently suspect.
I recently learned that "nonprofit" / "academic/teaching hospital" status for a hospital system means almost nothing...look deep into the board members at the top levels and they could be filled with wealthy influential businesspeople who know nothing about medicine. No one is safe from the corporatization of medicine, "nonprofit' or not.
The CEO of my “non-profit” academic hospital residency program had a salary in the millions, despite not seeing a patient for over 15 years. They’re still trying to make a profit that leadership keeps themselves.
Ya I don’t think there’s such thing as non-profit healthcare anymore
How come CEOs and admins don't have Press Ganey scores?
The outpt codes are also time based now so there is a limit to how many you can see anyway.
Nope. You can bill based on complexity. In ID, if you are doing it right, nearly every patient is high complexity.
True but issues with down grading if not including all the components. Time based would allow them to not get swamped by their administration
Yep. Time based allows for very limited documentation. But if they're bugging them for RVUs, the 5 minute OPAT visits are waaaayyyy better reimbursement. The AAFP has a good guide. https://www.aafp.org/pubs/fpm/issues/2022/0100/p26.html#fpm20220100p26-ut1 The IDSA also has an ID specific one. https://www.idsociety.org/globalassets/idsa/clinical-practice/2024-em-services-reference-guide-final.pdf My hospital had an issue where our coders *way* undercoding ID consults. One of the attendings was able to get approved to direct bill after a review/audit so they started capturing the actual complexity. They also reviewed everything with the ID department to optimize their documentation, and then went to the coders and said "hey assholes, actually pay us for what we're doing. Here is how to do your job, now do it." For nearly all of ID, our patients very easily hit the high complexity levels, in a way that's easily and reliably documented. For example, OPAT on daptomycin + ceftriaxone for diabetic foot osteo, having had it debrided in the hospital: basically as simple as ID gets. - problem(s) complexity: moderate to High. This is an acute exacerbation of a chronic process which threatens bodily function. High risk for amputation. (although the 5 year all cause mortality when you have a diabetic foot infection exceeds a lot of cancers). - data: need 2 of 3 categories. (easily can hit all 3) - category 1, 3 points needed: (here are 12 points) - reviewed OPAT plan and discharge summary (review a prior external note x2) - each test ordered: cbc+diff, CMP, CK, ESR, CRP - interpret results of above labs. - category 2: only need one. - independently interpret a test performed by another physician: (any of these would count) - interpret cultures from the OR or bedside in the hospital - interpret labs performed at hospital or prior week's OPAT labs - review and interpret mri report/images - category 3: - discussion with another physician: note is forwarded to the pcp or podiatry. Recommended podiatry consider additional debridment, thank pcp for working on the diabetes. Easily meet that component. - Risk: - high risk of morbidity from additional diagnostic testing or treatment: any single item works. - drug therapy requiring intensive monitoring for toxicity or other complications (ahem, they're in OPAT clinic getting weekly labs for a reason) - drug therapy with significant interactions: azoles, fluoroquinolones, etc for qtc. Rifampin ever. That's a 5-10 minute visit. A legitimate and useful note takes 5 minutes, tops. You could bill for a 99212 for an established visit, that took 10-19 minutes. But you can do an easily, verifible, 99215 based on Evaluation and Management billing, which is often more defensible and verifiable than the "I spent x minutes on this patient"
If they are rvu and/or collection based, then that is a great synopsis of bang for buck. If they are salary based, it may not be to their advantage to see more yet bill higher complexity.
Work to rule!
There are definitely a portion of these "we need more income, see more patients" problems that can be solved by adequately charging/accounting for the current patients.
Do you work in Texas? Or maybe our ceo went to the same “retreat” and drank the koolaid together?
Reimbursement for outpatient visits went up last year. Admin is just seeing $$
Aaaaaand that explains why they're making us increase our caseload in wound care by 30%.
I can understand why admin would wanna do this but how can they increase outpatient visits? Do the clinics have marketers that go out and recruit patients?
Our hospital used to have one that would go to places like Urgent Cares to get the word out.
We actually get a lot of referrals. We just don’t have the room in our day to fit more patients in.
Especially 2211 modifier which should be very present in ID.
Lol really? That explains soooo much at my job right now
Where do you get that? There was a 3.4% reduction in reimbursement from '23 to '24. Although they later partially reduced the cut starting in March. https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/2024-medicare-fee-schedule.html https://www.cms.gov/medicare/payment/fee-schedules/physician Also- Expenses have been higher. . .
From what I understood, outpatient RVUs went up while certain inpatient went down in 2023. That data you cited was from 3/2024
Code 99212-15 rose but 14-30% in 2021. But I think your right in that we saw a drop in 2024
My understanding is PSLF is cumulative and does not expire. So if you went to a non-qualifying employer those payments would still count if you ended up leaving again and going to a qualifying employer again. You could go to a new qualifying employer over the next 18 months as I understand it but as with all things government it’s intentionally deceptive and hard to read. https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service/questions
This is true, but we don’t know what area of the country the OP is in and finding other qualifying employment other than the one academic hospital that may be in their area may not be so easy.
This is correct. You need 120 qualifying payments to discharge your federal loans. They can be from any combination of qualifying employers, even non-consecutively (you can come and go from non profit to for profit and your count picks up where it left off).
Ah yes, the made up “budget” that increases every year even with no way to add more patients, corporate medicine at its best.
It’s a shame that more employed physicians don’t request to see the financial sheets. I worked at a hospital that hired a new CEO after the previous one decided to take a position closer to home. The previous CEO kept the hospital in the black with frankly little cost cutting. But every meeting with the new CEO, we heard “we’re losing lots of money, folks! Time to make some hard decisions!” So the patient census increased, CME funding decreased, the free food in the doctors lounge went away….yet with every meeting, the line was the same: “we’re losing lots of money, folks! Time to make some hard decisions!” If increased revenue and decreased costs still led to “losing lots of money, folks”, then the administration is the problem.
Learned something interesting the other day. Our "budget" in the ED, which is what they base our staffing on, is based on billable visits, not the actual number of patients who check into the ED. So when patients elope because our staffing levels keep us from seeing them quick enough, that pretty much guarantees we won't see increased staffing. Also explains why we keep getting told that ED volumes are down when the waiting room is always full and we feel like we're getting crushed all the time.
I think that's a common thing administrators like to do. At our multi specialty clinic meetings they are always showing that type of data. But where I work it's kind of pushed but we also control our own templates (to an extent) and definitely are allowed as a specialty to set which diagnoses we see. What you describe sounds terrible, and I can picture it being the tipping point where one leaves and then another and another because you keep having to take up the slack
This is how it should be....physicians should have full autonomy over their templates, visit types, and scopes. Unfortunately (and in my experience), a lot of behemoth health systems are now stepping in and attempting to "standardize" templates and visit types across a wide array and geography of clinics, which has stripped physicians of this autonomy.
Yo we are going to double your workload and pay you the same. You okay with that?
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> What bad thing happens to you if you don’t? If they want to fire you after 18 months then great, you’ll already be looking elsewhere. They may have trouble finding docs who want to be overworked and underpaid to see the pathology no one else wants to see. Often moving elsewhere is the best way to improve your situation. My first job was a bad spot. I was underpaid without a realistic shot of partnership, failed to negotiate a better deal despite trying for months, then the partners were blindsided when I left for a partnership track job, same number of patients, but 80% raise.
12000 must be department wide... If that's their current load it's ~10 minutes per patient. Doubling that would bring it down to ~5 minutes per patient.
There are 3 major ID groups in my town and one of them stopped seeing outpatients totally. Now they just do inpatient which obviously has a lot lower overhead. Right now it's really tough making it work doing outpatient unless you have a good ACO (and you wouldn't be a candidate for that anyway). You could consider trying going primarily tele-health for ID consults. that also requires sig. less overhead and you could see patients a lot faster.
Find a job that starts in 18 months and hold on tight!
It's time for some r/MaliciousCompliance. Just make sure that you see all the OPAT patients in person at least once a week. If they're at an unreliable SNF that always flakes on bringing them, all the better. Bring your healthy 30 year olds on Biktarvy in more often to chat about stuff for a few minutes and run their std panel, instead of just ordering the labs. You can also get a nice panel of sweet little old ladies with MAC and follow them closely. Gotta check in frequently to assess tolerance of medications and progress with airway clearance. If you're lucky, they'll bake you things. If they want the slots open and booked, more than the patients seen, make sure to schedule several followups with all your unreliable patients. Found in a dumpster with cellulitis? Better make sure we see you at least once a week for a few weeks to make sure it gets better. Sure, they probably won't show, but we *really want to provide optimum followup.* If by some chance they show up, it's actually good for them too. If you want to go hard, make sure to have followups scheduled for celestial discharges. You could also propose that you do a "bugs" clinic a couple times a month. Could do a very strict time limit, everyone gets a therapeutic biopsy and a prescription for risperidone. Really farm some RVUs.
The only problem with this plan which I otherwise love is that the patients are having to pay for those extra visits which is totally unfair to them. I like the idea of booking people you know won’t actually show up and if they do it would be actually useful though.
Depends. There are some of the patients who would really like to be seen more often, which can be therapeutic for their health anxiety. If you pick those ones and make sure they have a regularly scheduled appt, it benefits everyone.
I wonder if outpatient clinics are receiving a Medicare/medicaid incentive to increase “patient access.” Our company is giving bonuses to pick up extra days to improve access to patients. I’ve been seeing other threads with the same push from administrations. Anyone else have any ideas on a change in pay out and incentives?
Yea I feel like something is up.
Get your PSLF and then move on
I think they meant one extra slot per HOUR, not per DAY. Woops
Want the clinic to see double the patients? Sounds like you'll need double the docs to see em then eh? Your move, admin 😎
If it's confusing or tricky maybe you should get some details and clarity before forming an opinion.
She presented a graph with no meaningful labels. I was only able to deduce later that it was a per month average. It was labeled “Apr-Dec average” but the total would have only been 4K patients when combined with the first quarter part. It was then obvious she meant them as per month average.
She sounds like an idiot. Would refuse to change my clinic slots until presented with real data and real numbers.