"To resolve denial of a claim, you need a chart and a physician—both of which aren't in physical proximity of the billing office," Korneluk adds. "Centralization causes duplication and frustration. It will work in 10 years when electronic clinical records are tied to billing records."
Parshall says if properly executed, centralization can be very efficient.
Central switchboards in group practice is a mistake. "Every doctor should have his own team phone number so that receptionists answer the phone with the doctor's name," Korneluk says. "I believe patients who call their doctors should get a warm, friendly voice who knows them. Have you ever called a machine and gotten a warm, smiling voice? Physicians don't usually call in on their main numbers because they can't get through. They call in on the back line. Doctors should call on heir main lines to do a Quality check to see if their phones are answered appropriately. Doctors also come into their offices through a back door so they don't see what patients see." Centralized records do not improve efficiency. "In fact, it provides dis-economy of scale," Korneluk says. "The frequency of losing a chart goes up. Efficiency and productivity go way down and group costs go way up. Charts should be closest to the person who needs them, namely the nurse."
Demand management is a failure. "In recent years, many insurers installed demand management hotlines for patients to call for triage. Patients don't use them. When you get sick, you're going to call Consuelo or Dr. Welby because those are the people with whom you have a relationship," Korneluk says. Parshall says anyone's help is appreciated in the middle of the night when you don't feel like disturbing the doctor. "We're big on telephone triage."
There is no oversupply of physicians. "The oversupply will not materialize," Korneluk says. "The demand for services is growing faster than supply, even in the subspecialties. Boomer parents are aging and now boomers are getting up there. In some areas of the country, you can't get an appointment with an OB/GYN for three months. The average physician-to-patient ratio is about 430-1, depending on whose numbers you believe. Go to Portland where the ration is about 150-1. Those physicians still do well. Then go to Peoria where it's approximately 900-1 and those doctors are still worried about managed care and going out of business.
"We've studied managed care situations where doctors say managed care killed me. Sure, they have to hustle, but they're busy. If there was projected to be an oversupply, it's correcting, because the number of graduating sub-specialists is declining."
There is little or no correlation between the time the physician spends with the patient and the quality of the visit. ""physicians who spend eight minutes versus 30 minutes get the same scores on patient satisfaction studies. The quality versus quantity issue is 7 true in medicine. Does the patient have your full attention or are you running out of the room to answer phone calls?" asks Korneluk.
As you cut expenses, your overhead goes up. "in the short range, the practice saves money," Korneluk says. "But as you cut overhead and infrastructure, you also cut productivity. Now you have a highly paid doctor or nurse handling administrative chores."
Pay staff well. "Pay staff peanuts and you get monkeys," he advises. He also finds that the "greenest" employee is often the one who is asked to answer the phones-the last place that person should be.
Doctors who work faster do not get more done. "What we found is that in order to speed up, doctors need to slow down," Hess says. "If you watch a doctor who has great interpersonal impact, he walks and speaks slowly. The more he hurries, the more frustrated he gets, the more he screws up and the more stress. Just take the wasted time out of the system."
Patients are not directed to doctors by insurers alone. "One of the things we've really seen this last year is that physicians have bought into this whole idea that third-party entities will be turning patients on or off to a practice really at whim," Korneluk says. "The reality is that patients are always going to get sick and they're always going to go to a doctor. Patient choice will always be part of the system, no matter what managed care program is in place. Patients are going to say 'I love my doctor and I'm going to refer my doctor to my friends.'"
A week after the Korneluk Deerfield Beach seminar, one participant is enthusiastically making changes. Hector Delgado, MD, a Miami family practitioner, returned and old his partner they can improve their efficiency.
"Mr. Korneluk made me much more aware of the time I spend in wasted activities," Dr. Delgado said. "We are now clustering our exam rooms. Instead of both of us running between two halls, we are grouping four exam rooms for each doctor together in the same hall to save time going between rooms. And, we're considering removing the doorknobs."
Maureen Glabman is a Miami-based health care reporter.
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