From: "L

From: "L. Gordon Moore" <gmoore@idealhealthnetwork.com>
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Date: Wed, 18 Jan 2006 09:33:13 -0500
Subject: [Practiceimprovement1] Closing to new patients in primary care
Reply-To: Practiceimprovement1@yahoogroups.com

I'm horrified to read that Annie is forced to accept new patients from all plans based on their contract terms. Staying always open to new patients forever is a logical and practical impossibility. At some point the practice is full (with allowance for attrition).   New patients joining a practice that is full creates an unsustainable imbalance that results in too much work poorly performed, medical error, poor satisfaction, and eventually burnout for both the patients and the clinician.

While we see examples all around us of unhappy patients & clinicians, burnout and medical error, we also see examples of practices that seem to remain open to new patients ad infinitum. How is this possible? It is possible if the rate of new patient acquisition matches the rate of attrition. This is a practice that has achieved equilibrium.

Remember that the ultimate goal of open access scheduling is to match supply and demand. Recognize that in an open access scheduling system we have eliminated the delay and the distinction between "urgent" and "routine" and that this is very attractive to new patients.    A practice with open access scheduling must turn away new patient demand that exceeds their supply. The only other way to maintain the supply/demand match and open access scheduling is to continually grow to meet the demand.

Continual growth is a SYSTEM property, not the property of an individual clinician or clinical team. Systems can grow by adding clinicians/teams. At some point, an individual team will reach saturation and MUST deflect demand that exceeds their supply. The system helps by creating other supply.

So how does a practice with waits and delays achieve equilibrium?

In a typical practice, the delay for "routine" appointments stretches out into the future to the point where established patients are no longer tolerant and leave the practice at a rate that matches the influx of new. The length of the delay is the natural "break" point at which the attrition matches the influx of new patients.

We know that this passive approach does not come free. It creates immense work for the practice of copying charts for patients transferring out, the extra work of establishing a relationship with a new patient, and the endless, ultimately pointless and uncompensated work of triage where we sort demand based on "urgency."

The lack of continuity over time for patients transferring practices creates the increased probability of poor preventive and chronic disease care (part of the reason behind the dismal 56% achievement rate in the McGlynn study (The Quality of Health Care Delivered to Adults in the United States. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. New England Journal of Medicine, June 26, 2003.)).

Each clinician has a choice: actively or passively manage demand. The passive choice drives up the cost of health care for all and erodes satisfaction as well as outcomes.

The active choice is awkward, especially for physicians. We see ourselves as healers. Our ranks are rich with conflict-avoiders who just want to make people happy. When we continue to accept new patients beyond our capacity, we create the platform of harm for all we serve.

My bias is obvious. I choose to deliver superb care to the number of patients I can serve and no more. I have the luxury in Rochester NY of not being forced to continually accept new patients beyond my capacity. If presented such a contract, I would not sign. Annie doesn't have that choice.

Why would an insurance company do this bad thing? I suspect the motivation is based on the desire to maintain access for members and to have broad panels of providers when the insurer goes to market with employers. The problem with this motivation is that it is an illusion that results in harm. Once aware of the illusion and harm, insurers must stop this behavior or risk the accusation that greed for contracts supercedes good health care.

So what can Annie do when the contracts stipulate behavior that is counter to the best interest of her patients? The insurance companies force bad behavior and bad patient care, but knowing Annie and the care that she delivers, I trust her to do the right thing.    We as a group can help her argue for the right thing and can help raise the awareness of these insurance rules that seem to help but ultimately harm our patients.
Gordon
At 11:50 AM 1/17/2006, you wrote:

All my major contracts include provisions that I am not allowed to close to new members. If I want to “officially” close, they require that I terminate the contract. Apparently that is the standard around here, but all the plans ignore it if you close to all new patients, unless someone fusses. I have had to take a few REALLY insistent new patients who called their carriers to complain that I wouldn’t take them. Then I get a call from the ins co where they point out that I am in violation of my contract by closing to new patients, but “we understand that you are closed across the board, so we’ll ignore it if you will go ahead and take Mr. SoAndSo as he is making such a stink.”….yada yada yada Great way to start out on a good therapeutic relationship with a new doc, huh?

From: "John Brady, MD" <drbrady@thevillagedoctor.hrcoxmail.com>
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Date: Mon, 8 May 2006 20:55:26 -0400
Subject: RE: [Practiceimprovement1] controlling growth
Reply-To: Practiceimprovement1@yahoogroups.com

Getting too big will kill your ability to provide quality care and have a life. However, when I shut down to new patients last year my practice slowed too much as I had a lot of military and they moved on. What I have done since is just limit my new patients to the insurances that pay the best and Medicare (as I am a sucker for elderly patients). Since then, I believe the influx and the outflow have remained relatively constant. A few cautions, however. First keep a pulse on the community. One of the internists in the area recently left outpatient to do a hospitalist only practice (ironically because he was being forced to see too many patients a day by his hospital owned practice) and left 900 Medicare patients to fend for themselves. I accepted probably 15 of these and we have closed down to new Medicare until this wave slows down (later in summer). Secondly, don’t get too heavy on one insurance. Although it makes sense to take the best payers, if they change the rules (ex. blending of payments) you have to have the ability to threaten to walk. Finally, a lot may depend on the insurance contracts you have. Some may require you to accept a minimum of 250-500 patients before shutting down (usually the HMOs). Obviously shutting down prematurely in one of these can lead to bad things.

Congrats on getting to this point. I think one of the biggest challenges with this model is knowing when to say when as the difference between having too many patients and not enough patients is one office visit a day. But beware of pushing too hard today in order to get all the loans paid off as you might find you’re burning out in another 5 years. Good luck. John

From: "Michelle Eads" <michelle.eads@worldnet.att.net>
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Date: Thu, 19 Oct 2006 09:22:24 -0600
Subject: [Practiceimprovement1] When to close to new pts?
Reply-To: Practiceimprovement1@yahoogroups.com

I agree – the size of your patient panel is determined after you have become ‘full’. I have been adjusting my panel size downward since I opened 3 years ago – I Initially ‘calculated’ (based on typical 2-3 visits/pt/yr model, and anticipating 30 minute appts) that I should have ~700 pts. But in my practice, more often the appts are 45-60 minutes long, and, as I engage in the IMP stuff (time consuming) to further improve my practice/pt care, I have gradually pared down to 400 pts.

I followed Gordon’s advice, and was glad I did. To help you determine when you should close, I recommend monitoring your schedule, and when you are nearly full, start closing the gate. This depends on your rate of growth. If you are growing like mad, then start closing when your schedule is 70-80% full for a couple of weeks. If your growth rate is slower, then start closing when you are 90% full. You can always let people in, but it’s hard to shed them quickly if you are in meltdown mode. Even after you close, you will have people trickle in (‘Could you see my husband, too, pleeeez? You’re the only doctor he trusts…’, etc).

Michelle A. Eads, M.D.

From: "Kathy Saradarian" <qualityfp@hughes.net>
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Date: Thu, 19 Oct 2006 17:40:56 -0400
Subject: RE: [Practiceimprovement1] When to close to new pts?
Reply-To: Practiceimprovement1@yahoogroups.com
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A lot of us find the thought of “closing” our practices scary. That’s because most docs have the mindset of “got to grow, got to grow, grow bigger, keep growing” as a sign of success.

I have “officially” closed my practice about 6 months ago. If anyone calls, they are told that the practice is closed to new patients, but my receptionist will take down the info. I am not closed on any insurance panels yet mostly because of their restrictions and a little out of my laziness. Horizon Blue Cross Blue Shield says I can’t close until my panel has 250 patients or more. Horizon NJ Health (NJ Medicaid HMO) won’t let me “close” until I have 50 patients on my panel. We are waiting, hovering 47-51 so missed the close opportunity. What I plan to do is being listed as "closed to new patients". Existing patients can stay in the practice if they switch insurance and then I can always “let people in” one at a time if I want.

I think it actually makes the practice more desirable for patients to have to be “accepted” or wait to get in. I am accepting certain age range. I have a lot of older, sicker patients and few young and healthy. So the young and healthy are being accepted one at a time. What patients are being told is that we are closed “for now” but they can always check back in 6 months. If I start to see too many openings in the schedule when I look ahead then I will reopen.

I don’t know how many official “active” patients I have but there are > 1800 in the system, and based on my PPRNet Practice Report there are almost 790 active patients (seen in the last 12 months). It’s probably more as young, healthy patients may go a year without being seen.

Kathy Saradarian, MD

Branchville, NJ

Solo low-staff practice since 4/03

In practice since 9/90

Practice Partner User since 5/03

On Oct 19, 2006, at 1:56 PM, Jessica Ellsworth wrote:

Why is the thought of closing so scary? I know I need to . I have over 1200 pt, avg 6-10 new pt requests daily. I see Avg 16-20 pts a day, and I’m maxed out. But does one close temporarily?, for a few months? I guess the fear (probably irrational) is suddenly the pt count drops. It seems premature to close a panel, when I’ve only been opened at my permanent site for 8 months….

Jessica T. Ellsworth, MD

9377 E. Bell Road, Suite 175

Scottsdale, Az 85260

From: Nancy Guinn <NGuinn555@comcast.net>
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Date: Thu, 19 Oct 2006 18:46:30 -0600
Subject: Re: [Practiceimprovement1] When to close to new pts?
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I have "closed" several times - first to the insurance companies, so that they can't randomly assign patients to me. When I felt overwhelmed, I would also close to word of mouth patients, then reopen when things got slow. I usually have kept open to family members of people I'm seeing, but I've even stopped that, as I got about 5 % too busy in the last 6 months.

Nancy