New Employer: is this normal???

[BigSib]

Long story short, entire system went under and everyone was given a contract to continue working from the bigger dog in the area. Everyone was in a vulnerable position and overall was provided reasonable pay in my opinion to remain in their clinics with somewhat similar staff, same patients, etc.

New employer has taken away much of our autonomy. None of the following were in the contract, but could potentially refer to policies listed elsewhere. Are these things normal?

- Basically anyone in the very large system can put a pt on my schedule for any reason at any time.
- 20min apt slots
- Any outside contract like nursing home med director, precepting students, etc they take a 25% cut (wow!)
- Medicare AWV seems impossible to complete as there's like 30min of questions to toggle through for the roomer just to get to the meat of the visit. In asking around it seems many PCPs just don't do them.
- Pts call an outside nursing pool rather than our office. Epic messages are then sent to us. Pts are unable to get ahold of us directly.
- No samples allowed. Not a big deal but I liked to keep anticoag and inhalers on hand for some unique situations.
- Nursing home care has its own division. I am unable to use any of my own standing orders. NPs field all the calls and manage. Seems I'm just there to meet the criteria to visit the patient the way they describe it.

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[VA Hopeful Dr]

There's a similar set up with a hospital system in my area.

Centralized scheduling is a very popular thing these days. I don't much like it, but it does make sure your schedule is always full.

20 min slots are great for patient satisfaction and give plenty of time for quality metrics if that's a big thing. I don't like them because if you have that few appointments per day, your acute patients will have a harder time being seen.

Not making AWV's easy has never made sense to me. That is the easiest money that can be earned for primary care, hospitals should be making that as easy as possible for us.

I don't do any NH stuff so no insight there.

So yes, very normal. Still frustrating though.

 

[Keona]

Long story short, entire system went under and everyone was given a contract to continue working from the bigger dog in the area. Everyone was in a vulnerable position and overall was provided reasonable pay in my opinion to remain in their clinics with somewhat similar staff, same patients, etc.

New employer has taken away much of our autonomy. None of the following were in the contract, but could potentially refer to policies listed elsewhere. Are these things normal?

- Basically anyone in the very large system can put a pt on my schedule for any reason at any time.
- 20min apt slots
- Any outside contract like nursing home med director, precepting students, etc they take a 25% cut (wow!)
- Medicare AWV seems impossible to complete as there's like 30min of questions to toggle through for the roomer just to get to the meat of the visit. In asking around it seems many PCPs just don't do them.
- Pts call an outside nursing pool rather than our office. Epic messages are then sent to us. Pts are unable to get ahold of us directly.
- No samples allowed. Not a big deal but I liked to keep anticoag and inhalers on hand for some unique situations.
- Nursing home care has its own division. I am unable to use any of my own standing orders. NPs field all the calls and manage. Seems I'm just there to meet the criteria to visit the patient the way they describe it.

For the AWV specific question my nurses are able to complete the majority of the visit and I go in the room and verify all the questions quickly and make sure nothing got missed and the patients are on their way. My nurse hates them because they take her so long. I love them because we get all the screenings and immunizations addressed and when I leave that room my note is totally done 99.5% of the time.

20 min model of any appt at any time is what our system is also moving towards.

We are still allowed to do samples thankfully because I’ve got some patients that really need for the doughnut hole each year.

I’ve never heard of doing phone calls where patients couldn’t get through to the office.

My nursing home pay is just included in my overall salary for seeing patients. We do not have a NP who goes to the nursing home.

We don’t get paid for taking students. With the drs we only take md students from local medical schools (no do students nearby).

Are you in the verified physician thread area? May be a better place to ask the questions.

 

[anonperson]

Long story short, entire system went under and everyone was given a contract to continue working from the bigger dog in the area. Everyone was in a vulnerable position and overall was provided reasonable pay in my opinion to remain in their clinics with somewhat similar staff, same patients, etc.

New employer has taken away much of our autonomy. None of the following were in the contract, but could potentially refer to policies listed elsewhere. Are these things normal?

- Basically anyone in the very large system can put a pt on my schedule for any reason at any time.
- 20min apt slots
- Any outside contract like nursing home med director, precepting students, etc they take a 25% cut (wow!)
- Medicare AWV seems impossible to complete as there's like 30min of questions to toggle through for the roomer just to get to the meat of the visit. In asking around it seems many PCPs just don't do them.
- Pts call an outside nursing pool rather than our office. Epic messages are then sent to us. Pts are unable to get ahold of us directly.
- No samples allowed. Not a big deal but I liked to keep anticoag and inhalers on hand for some unique situations.
- Nursing home care has its own division. I am unable to use any of my own standing orders. NPs field all the calls and manage. Seems I'm just there to meet the criteria to visit the patient the way they describe it.

20 min slots is what Kaiser does and I'm sure this type of scheduling template is spreading based on their influence. The FQHC I work at adopted this scheduling as well.

Similarly, if there are any open slots, they want to be able to fill them. The thought is, empty slots is lost revenue.. This is true to an extent but can be annoying. There should be a daily cap on how many patients can be in your schedule. For example, in my set up, they max out at 24 patients scheduled. Cannot book more without the physicians permission. If it's less than that, anyone can schedule though.

Patients not having direct access is similar as well.. Some patients complain but this is a systems issue. I don't care one way or the other.

 

[Lee Ik-jun MD]

20 minutes is far better than the 15 minutes I used to have. but everything you mentioned looks "normal" except for the " Any outside contract like nursing home med director, precepting students, etc they take a 25% cut (wow!")"

 

[FrustratedFamDoc]

Long story short, entire system went under and everyone was given a contract to continue working from the bigger dog in the area. Everyone was in a vulnerable position and overall was provided reasonable pay in my opinion to remain in their clinics with somewhat similar staff, same patients, etc.

New employer has taken away much of our autonomy. None of the following were in the contract, but could potentially refer to policies listed elsewhere. Are these things normal?

- Basically anyone in the very large system can put a pt on my schedule for any reason at any time.
- 20min apt slots
- Any outside contract like nursing home med director, precepting students, etc they take a 25% cut (wow!)
- Medicare AWV seems impossible to complete as there's like 30min of questions to toggle through for the roomer just to get to the meat of the visit. In asking around it seems many PCPs just don't do them.
- Pts call an outside nursing pool rather than our office. Epic messages are then sent to us. Pts are unable to get ahold of us directly.
- No samples allowed. Not a big deal but I liked to keep anticoag and inhalers on hand for some unique situations.
- Nursing home care has its own division. I am unable to use any of my own standing orders. NPs field all the calls and manage. Seems I'm just there to meet the criteria to visit the patient the way they describe it.

You have hit point for point my work life to a T.

The scheduling thing is brutal. Random new patients plugged in, with no care for how it will flow.

New older pt to establish - 4 mo complicated pt f/u - hospital f/u - new pt to establish is not an unusual start to my afternoon. Trying to find records of medical history, meds, etc is a complete …. Show, so frequently I go in the room to see a new patient praying they know their history and that it’s not too complicated, because my next room is a hospital f/u 1 week stay new onset a fib and lung mass.

How your day will go is always in the what and where they are plugged in, not the how many you see.

You can see 15 in a day and feel whooped, or 25 and feel great.

2 wellness exams back to back will put my nurse behind at least 10-15 minutes. Then you add in a new patient and complicated hospital Follow up that still has some unresolved issues and the pharm won’t cover a med and they’re not quite sure they picked up everything at the pharmacy, or they just haven’t picked it up yet and their systolic is 175… oh, and room 3 needs a neb treatment, a shot of steroids and I’ll recheck in 15 minutes. It’s a wrap. That is sadly, at least 1 afternoon a week for me. Have fun on the charting.

You’re now at least 40 minutes behind and flustered. There’s only so much pre-charting you can do to mitigate that.

Now imagine an afternoon of 14 pleasant, active and compliant patients under 60 who can actually remember their issues. A couple ortho complaints, few bp adjustments and tweaking depression meds, some dietary counseling, etc. Then you get a pt with 3 days worsening LLQ pain, fever and peritoneal signs. … you’ll still probably leave work on time.

It’s brutal. It sucks. There’s no care as to how it’s going to go when they do that to me. I’m told they’re blocking my schedule, but then some random nurse from the call center 2 states away ignores it and puts them in anyway.

I could really go on more of a rant about how awful it is but I’m trying to be more positive.

 

[Egg122]

If it's not in your contract how can they take a 25% cut for you to be a medical director in a nursing home? Are you having the nursing home call your office and utilizing office staff for this position? If so, then the employer taking a cut for providing administrative support is reasonable.

 

[Lee Ik-jun MD]

@FrustratedFamDoc , why don't you try a variety of work , maybe something to think about when contract negotiation is up
. what works for me 2 days of primary care and 2 days of something else in a 4 day work up. the 2 days of something else is either urgent care or ER shifts. and that has been very helpful for my stress level and mental heath.

I'll take an urgent care/ ER patient with 1-2 problem and tell them to see their PCP after I " fix" what's going on now versus a " new patient" with 15 different issues, refill on his Norco, sign his DMV disabled placard , assess and sign his Disability form LOL!

 

[FrustratedFamDoc]

I’m already heading in that direction and am in talk with a system in town that will give me full control over my schedule. I’ll have a noncompete period, commute about an hour then when it has expired, I’ll be back in town and my old patients will see me again, and I won’t have to see 15 new patients a week… that take spots that my 10 year established patients could of had.

I’ve worked along side a fantastic NP for 7 years who may be interested in a change of scenery.

Working 3 10s, 4 days off with her doing the same and we share patients.

Before this new org blew everything up, I had a small shared office and a superstar staff. “Of course they can come in” was always the answer. I have a very busy practice but everyone was taken care of and my office morale was great. I actually see fewer patients now, work 3x as hard and have to fade at least 3 “we tried to call yous” a day.

Do not sign with an org that gives you no control of your schedule.

 

[VenusinFurs]

This seems normal for big orgs except: I have never gotten paid for nursing home rounds or taking students.

The Medicare annual really can not be done just by the physician in 20 minutes. They need to have nurses completing most of the work for you (the mini mental, fall scale, depression screening, review of imms and preventative measures) so you can just review their answers and make plans for any identified issues (physical therapy for fallers, make a follow up for depression or abnormal mini mental etc)

 

[VA Hopeful Dr]

This seems normal for big orgs except: I have never gotten paid for nursing home rounds or taking students.

The Medicare annual really can not be done just by the physician in 20 minutes. They need to have nurses completing most of the work for you (the mini mental, fall scale, depression screening, review of imms and preventative measures) so you can just review their answers and make plans for any identified issues (physical therapy for fallers, make a follow up for depression or abnormal mini mental etc)

If you're having nurses do the questions, a medicare Wellness visit should take you less than 5 minutes.

 

[Ironheme]

If you're having nurses do the questions, a medicare Wellness visit should take you less than 5 minutes.

Is your staff also putting in pre-orders? I need to get on your level if you're able to do them in five minutes.

I find myself always double checking everything. Imms are usually never correct (what is due, what has been done, etc).

 

[VA Hopeful Dr]

Is your staff also putting in pre-orders? I need to get on your level if you're able to do them in five minutes.

I find myself always double checking everything. Imms are usually never correct (what is due, what has been done, etc).

5 minutes is the slow ones. If they are up to date on everything preventative then it's more like 60 seconds

My nurses don't put in orders, but Epic has a great Express Lane for it. Some of my partners do have their nurses put in the orders.

 

[Ironheme]

5 minutes is the slow ones. If they are up to date on everything preventative then it's more like 60 seconds

My nurses don't put in orders, but Epic has a great Express Lane for it. Some of my partners do have their nurses put in the orders.

Thanks for the explanation.

I checked and currently our version of Epic doesn't have an express lane that I can find for it. I'll check again later, but it's possible it's in a rarely used section since I hadn't realized there was one. I don't have very many patients that are UTD on all preventatives. I work in an area where the majority believe doctors are only for when you are sick.

 

[VA Hopeful Dr]

Thanks for the explanation.

I checked and currently our version of Epic doesn't have an express lane that I can find for it. I'll check again later, but it's possible it's in a rarely used section since I hadn't realized there was one. I don't have very many patients that are UTD on all preventatives. I work in an area where the majority believe doctors are only for when you are sick.

Same here, that's why 90+% of my AWVs are done at the time of other appointments. The preventative talks are easy.

"You're due for a/several vaccine(s) today. Would you like to discuss those or are you not really a vaccine person?".

"You've due for colon cancer screening. <insert 1 minute talk about colonoscopy v. Cologuard>, which one of those sounds least bad to you?"

"Its time for your mammogram, I'm going to get that ordered and scheduled before you leave today."

"You're due for your prostate cancer screening blood test. I'll just add that to the other labs we're getting today."

 

[Eysteve228]

Same here, that's why 90+% of my AWVs are done at the time of other appointments. The preventative talks are easy.

"You're due for a/several vaccine(s) today. Would you like to discuss those or are you not really a vaccine person?".

"You've due for colon cancer screening. <insert 1 minute talk about colonoscopy v. Cologuard>, which one of those sounds least bad to you?"

"Its time for your mammogram, I'm going to get that ordered and scheduled before you leave today."

"You're due for your prostate cancer screening blood test. I'll just add that to the other labs we're getting today."

Exactly this in my practice (productivity based hospital employed outpatient, however do have fair amount of autonomy working with my practice manager on our processes and how we run as well as full schedule control). Medicare AWVs are often added as - 25 modifiers on days I am seeing these patients for problem focused visits, I just let them know they are due for it and our LPN takes care of it. Bonus points that she takes care of the preventative questions above and I just review and sign off on the visit, literally takes 10 seconds at most and rvu equivalent is higher than a 99214. Extra bonus for those who she advises on and completes advanced care planning, that compensates almost as highly as the AWV and is billed that day as well.

 

[Sardonix]

Same here, that's why 90+% of my AWVs are done at the time of other appointments. The preventative talks are easy.

"You're due for a/several vaccine(s) today. Would you like to discuss those or are you not really a vaccine person?".

"You've due for colon cancer screening. <insert 1 minute talk about colonoscopy v. Cologuard>, which one of those sounds least bad to you?"

"Its time for your mammogram, I'm going to get that ordered and scheduled before you leave today."

"You're due for your prostate cancer screening blood test. I'll just add that to the other labs we're getting today."

Do you also do chronic medical management during these visits? I find NO patients seem to understand what is involved in an AWV and that there is additional billing involved if we do anything other than the screening issues.

 

[VA Hopeful Dr]

Do you also do chronic medical management during these visits? I find NO patients seem to understand what is involved in an AWV and that there is additional billing involved if we do anything other than the screening issues.

I do. They way our system works is that patients have a chronic disease appointment scheduled. 1-2 days before the appointment, a nurse calls and asks all the questions and does a depression/dementia screening.

Since it's the AWV added to a regular visit instead of the other way around, the billing issue rarely comes up.

 

[Sardonix]

I do. They way our system works is that patients have a chronic disease appointment scheduled. 1-2 days before the appointment, a nurse calls and asks all the questions and does a depression/dementia screening.

Since it's the AWV added to a regular visit instead of the other way around, the billing issue rarely comes up.

Damn. That's pretty slick. Therefore my shop will probably never make it happen.

 

[BigSib]

If it's not in your contract how can they take a 25% cut for you to be a medical director in a nursing home? Are you having the nursing home call your office and utilizing office staff for this position? If so, then the employer taking a cut for providing administrative support is reasonable.

Good question! The answer I got was 'that is what we've always done.' lol I dunno

No nothing in my contract about the 25% cut. And no they literally don't help in any way. I take the calls for 40 patients or the NP I supervise there does. I sign all the papers. I do all the meetings.

And FYI I took the contract and just didn't let them know because it makes zero sense to me otherwise.

 

[Keona]

Good question! The answer I got was 'that is what we've always done.' lol I dunno

No nothing in my contract about the 25% cut. And no they literally don't help in any way. I take the calls for 40 patients or the NP I supervise there does. I sign all the papers. I do all the meetings.

And FYI I took the contract and just didn't let them know because it makes zero sense to me otherwise.

Who does the billing? Are they helping with that at least? How’s it going since you started with new contract?