Thursday, April 12, 2007

15-minute Med Checks

I noted in today's Northern Star that Dr. Diana Kraft, Northern Illinois University's psychiatrist for 15 years, has retired after being told she must cut back on the amount of time she spends evaluating patients. The side bar in the paper indicates:
"On March 8, Kraft was notified by her supervisor that the time allotted for her to see patients would be reduced from 60 minutes for a new patient to 45 minutes, and 20 minutes for a return patient down to 15 minutes. Incorporating paperwork and dictation, Kraft would only be allotted 30 minutes of face time for a new patient and 10 minutes for a return patient, she said."
I hate it when administrators see patient care as an assembly line which can get speeded up when demand or profits require more efficient widget production. People are not widgets.


NeoNurseChic said...

Aww that's sad. In psychiatry, it is sadder than it is in other fields, IMHO. At my neurologist's office, I get to see him for about 10-15 minutes I think? I don't time it. But they time people for the same slot even...and I think they book every 15 minutes.

The nurse practitioner sees patients once a half hour. The one I see refuses to be double-booked. However, she did tell me to double book once because I was just going to get nerve blocks, and she said she could squeeze nerve blocks between patients. She is always on time, and for her, I feel absolutely horrendous being late. (My psychiatry appts are so much longer (well, an hour is set aside and he used to stop after 40 minutes but now stretches to like 45-50 and sometimes he'll go for the full hour if I show up 10 minutes late....) and he has a more flexible schedule, and I see him more often which is why I don't feel as bad about being late - I used to, but it's unfortunately something that happens to me a lot...) The NP spends a lot of time with me - she is very thorough, and we usually spend some time talking about unrelated things - whether it's me telling her about things on the cluster headache websites or sharing my own insights related to headache or discussing work, school, or music stuff. Usually we spend a few minutes talking about those things. And the last time I saw her, I mentioned that my best friend at work was having bad headaches and is pregnant. I didn't say it with the intention of getting advice. I really was using it as an example of yet one more person at work who gets bad headaches. Well, she actually asked me a few questions about my friend, and she told me that I could let my friend know that for one, based on gestation, the headaches should be improving some soon, and also that sometimes pregnant migraine patients are given demerol injections to use at home no more than 2x/week, and also that compazine is safe to take even daily during pregnancy, and that should help the headaches and the resulting nausea both from the migraine and pregnancy... I just finally passed the info onto my friend today, because I hadn't seen her recently - and her headaches HAVE improved over the past few weeks. She said "if they had stayed as bad as they were, I thought I was going to lose my mind." I said, "I know what you mean....." She saw a small glimpse of my daily world. She was working with the headaches but she wasn't doing dishes or cooking. Her husband actually even got mad at her for not washing his dishes once - and they've been married just since August but he is really nice! When she told me that, I said I was going to kill him. She's pregnant and suffering from terrible headaches, and he is yelling at her for not washing his dirty dishes. She said she normally would on days she's off from work, but the headaches made her not able to do that kind of stuff. That is my sink is full of dishes. It's just that for me, this has been going on for over 6 years now, and probably will go on for the rest of my life (I'm interested to see how mine are during pregnancy - for some, they get better), whereas for her, hopefully this was just for a few weeks.

So my NP had time for talking about my friend as well as addressing my own headache issues and giving me nerve blocks. I don't know how she gets paid - like if she is on salary from the center. For that matter, I do'nt know if the docs are also on salary from the center or if they get paid based on each individual patient they see. Now I sort of want to know... I don't know if insurance reimburses one better than the other. Her fee is smaller...$100 for the appt versus $180 for his. Well, I just pulled out the receipt... if we're talking coding, it is $100 for OV, Expnd, Prob Foc, L3 (99213) - this is under Established patient... It is $130 for OV, Detled, Mod Cmpl, L4 (99214), and $180 for OV, Cmprh, High Cmpl, L5 (99215).

Now - I have 3 receipts in front of me. 2 are from seeing an NP on 2 days of infusion...the 1st day is the L4 one....and the other 2 days of infusion are the L3 ones. My neuro's from yesterday is L5. I just pulled out one from January which was a regular appt with the NP, and it was L3. I don't feel like digging through my file to see if the last one with my neuro was an L5 also. Guess that's why the NP fee is $100 and his is more. It's based on the Levels. I thought I read on someone else's blog once that some company was making L4 and L5 difference between the 2...or what I mean is, not getting paid differently for L5 over L4. Wonder if that was one of those BC newer plans that get complained about. Huh.. This is a world unknown to me.

I get paid by the hour - my paycheck comes out of money budgeted to our unit. I am in the unit's budget. Along with the price of formula. And a box of gloves. If I go the extra mile and reorganize my baby's bedside, change their linens a bunch, really do a few extra (but not required) things during my shift, then I am not paid any differently than someone who might do the bare minimum. (On our unit, I'd say the majority are the former, not the latter...) I'm also not paid differently if I have 2 babies that are relatively healthy versus 2 babies that are intubated, critical, or whatever - however the billing is different for the hospital/doctors depending on those things. The only way to differentiate for nursing is how much of a raise on the bell curve my boss gives...

Someday, I will have to worry about this, however....just not as a bedside, hospital nurse.

Wonder how much more broken the system is going to have to be before it gets fixed. Almost like it has to completely crash and reach armageddon before it can be wiped away and started over - sort of like Noah and the flood..... LOL......

Take care,
Carrie :)

Catherine said...

I had an psych appt today and even walking in there with a list of questions and concerns I knew it would take longer than 10-12 min (usually it only takes me 5). As much as I regretted pushing over into someone else's time, it had to be done.

Like neonursechic, I also see a neurologist and with her it is the same way. They book her for a quick in and quick out, but if I have concerns and I know that it will be sometimes many months before I see her again, I make sure that I don't let her leave until she has addressed all of them.

Call me selfish, but I want to go to a doctor's office knowing that I am receiving the best care possible.

Anonymous said...

I actually AM a widget.
What's a widget?

pemdas said...

I see my psychiatrist at the local behemoth university hospital research center high up on the hill. My friendly employer-funded HMO picks up the tab. You would expect the authorized visits to be just long enough to check the expression on my face and refill my 'script. Maybe I shouldn't jinx it by saying anything about it.

I have a separate therapist so the visits with my psychiatrist are technically med management -- but it's also a bit of therapy. We talk for 50 minutes most appointments. I say most appointments because if I run out of things to talk about we'll end the appointment early. Treating time this casually is a nice feeling. I know that some day things will change -- probably when the HMO puts the hammer down. Until then I will continue to enjoy the unpressured time I get with my psychiatrist.

Rach said...

Time really is a key element of therapy. Talk can't be rushed, the therapist and the patient both must pace how they say what they want to say to ensure that adequate time is left to deal with the issues, and responses that may come from discussion about said issues.

My shrink clearly has a problem with time. Most importantly, he doesn't respect it. My time really is just as valuable as his. I do my best to be flexible in terms of my schedule because I realise that he lacks that same flexibility. What irritates me is that in his particular case, there's a lack of regard for time. Double booking, running late because the phone is ringing, answering the phone in the middle of the session - all examples of how time, when mis-managed can wreak havoc on a patient, and on a practise as a whole.

I often wonder whether time management and time hygiene is discussed in medical school. People who work in private practise (as sole practioners) are as much business people as they are medical people. But they are also human. So really, why is there not a consideration for the patient's time?

Psychiatry in my opinion is as much (if not more) an art, than a science. While boundaries and limitations are necessary, one needs time flexibility to engage in art (in this case talk therapy). Even medication management involves discussion of life style, sleep habits, relationships and other factors that are taken for granted in everyday life.

I certainly hope that psychiatry in North America isn't going the way of robots treating widgets. But more and more, isn't that exactly how it feels?

Midwife with a Knife said...

Widgets are thingamajiggers

NeoNurseChic said...

And now we know why most psychiatrists don't do psychotherapy...unless they have a practice where they do not take insurance up front, or, like my psychiatrist, take a patient on that doesn't have insurance coverage and can't really pay, but helps her by taking what she can pay.

I think those are the only two ways a psychiatrist can do psychotherapy in this world of micromanaged care....

Anonymous said...

I hate it, too. Do you think they are trying to see just how far they can push it? Where do you guys, personally, draw the line? What is the minimum time you need per patient? What will you do if the administration tries to make you go even below that threshold?

DrivingMissMolly said...

Wednesday, I was in a car accident. A man ran a stop sign and I crashed into him.

I felt fine, but while waiting quite a while for the police officer to enter all of our information into his computer, I felt myself stiffening up and experienced some pain in my right breast.

When we were finished at the scene, I went to the nearby ER. I expected to wait since I wasn't in critical condition, but after I got into the room, I waited and waited. I heard someone say across the hall that they were short one doc. The young man that had led me to my room told me that there were four people ahead of me so I knew it would be quite a wait. I cannot tell you how long I waited since I did not look at a clock or ask the time because I knew it would just stress me out, but I was about ready to get re-dressed and take off.

About this time a doc ruched in saying he had just arrived. He looked at my chart and apologized for the wait. He commented that I had been waiting "quite awhile."

He barely touched my shoulder (stiff he said) and my back, then ordered x-rays which he said he was going to expedite because of my anxiety issues. He scurried away. I got my x-rays then he came back in, told me I had a sprained neck and shoulder, said he was going to write me a couple of prescriptions and give me an ice pack. He said for me to wait for the nurse.

I have never seen a doc *scurry* like that. It seemed so undignified.

When I was still waiting for him, I got restless and wandered the ER area in bare feet, gown and pants. I noticed a cork board filled with graphs and statistics regarding "satisfaction," "wait time," and other variables. Really, that is something I'd expect to see in the back area of a fast-food joint or as a motivator at a fund-raiser. How pathetic. I feel sorry for the docs.

Before I went to the ER I thought of my options because I knew the ER would be the worst choice in terms of wait time, but the best because of equipment available and expertise. I thought, I could go to my doc, but I'd have to call, leave a message, wait for them to call back and maybe be able to see me. I though about an "urgent care" place, but what if thet sent me to the ER anyway?

The whole healthcare situation is really getting to be much too much. Something's got to give!


Anonymous said...

At the clinic, I have one patient I can see in the hallway. He answers every question as "wonderful," never has any questions for me or anything he wants to talk about. Occassionally, I call his day program or care provider to check on how he's doing in those settings, but this is Med Management at it's med management-est. In the clinic, I allow half an hour per patient, sometimes I'll squeeze in a third if I know the they're not talkers and that it's just a routine visit. Time depends on the patient, so anywhere from 5-25 minutes in that setting.

Private practice: 2 hours for the initial evaluation, 50 minutes for a therapy session, I often run a few minutes over. I don't do just med management, I don't deal with insurance companies. If someone's not a talker and it gets hard to fill the time, I suggest we meet for half an hour (25 minutes, actually), mainly because it's hard for me to sit with someone who doesn't fill the time.

Lily: feel better.

Gerbil said...

It's either true or a quaint little urban legend that the 50-minute hour owes its existence to claim forms...

Anonymous said...

The requirements are no different than those legislated/demanded in this field. She is lucky she got 45 minutes for new persons. So, stop kveching!Psychaitrist MD in Chicago