Author Archives: Brent Long

Brent Long

About Brent Long

A physician assistant currently practicing in a physician owned multispecialty group as a family practice physician assistant. With over 20 years experience he is dedicated and motivated to see primary care survive as a profession and source of healing and comfort to those that we serve.

Carrot on a stick.

BaitAre you chasing the carrot? Have you gotten a nibble yet? Pay for performance continues to grow as a policy, with little evidence supporting that it works. Many of my colleagues feel frustrated over the current methodology of pay for performance (P4P) programs. Each insurance company seems to have its own P4P program. Difficulty incorporating EHR systems into compliant reports causes time consuming hand written or hand entered report generation and increased expense for added ancillary staff. Add to this that the rules change frequently and the carrot never gets any closer is leading me to wonder if it is worth the effort.
There have also been several studies that I have read over the past several weeks that show that it is becoming common practice for some physicians to discharge patients from their practice for noncompliance in receiving recommended cancer screening tests or if they have complex medical conditions that make it difficult to get their vital signs or labs to meet guidelines (so called gaming the system). With more than 30 million more Americans expected to have health insurance in the future, how much more gaming of the system will occur. Is this good for patient care?
If after several attempts at compliance with preventive services fail, I grovel, letting my patients know that my reimbursement from their insurance is adversely effected. In effect, if they are not going to do it for themselves or their families, would they do it for me? I have not studied the response to this or how often I have done this but anecdotally it works. This is certainly a shift in my norm of practicing preventive care for the past 20 plus years.
One quality factor that is especially low in some primary care offices is the child and adolescent annual physicals. Some practices now offer incentives this group of patients. “Get your physical and have a chance to win a gift card for downloading music to your MP3 player.” Now were dangling a carrot in front of our patients so we can get a bigger carrot.
It is also apparent that primary care providers are affected much more by P4P programs then other specialties. When our office provides primary care services to a diabetic patient who follows with endocrinology there is no way to remove them from the panel that we are responsible for. If their hemoglobin A1C is not to goal, our fault. If they see a cardiologist who feels that a BP of 140/90 is ok for a diabetic and stops there medicine, our fault. If their cardiologist or endocrinologist is happy with an LDL of 150 and decreases their statin, our fault. So how long will we chase the carrot.

The Fish Bowl

bigstock-Gold-fishes-in-aquarium-17062952 - CopyMy mother possessed an aquarium filled with tropical fish. I recall she obtained her fish from a small store in the lazy town I grew up in. My twin brother and I accompanied her on one of excursions. After paying for the fish I insisted on carrying the plastic bag out of the store. She reluctantly complied with this request. What I can’t remember is what happened next. I either dropped the bag or became enraged at something my brother did and slammed the bag down. You can guess what happened. By the time my mother exited the store there was a bag full of fish belly up, dead. “Do not Tap On The Glass” signs are posted on fish tanks for a reason. The stress affects the health of the fish. Shock waves can even kill these small fish.
Working in primary care I often feel like a fish trapped in an aquarium. Everyone can see me. Insurance companies, government agencies, medical boards, and patients have full access to my charts, prescriptions statistics and even how many samples a drug company supplied to me. Someone is constantly tapping on the glass. The stress is sometimes unbearable and makes the job of providing compassionate care difficult.
I whole heartedly agree that transparency in medical care is necessary. However, when it takes me 30 minutes on the phone to get an MRI of the brain approved for someone with unusual headaches, or I have to fill a prior authorization form out because the insurance company has a preferred generic ace inhibitor I feel like a small fish beating up against the side of an aquarium. When will insurance companies and government run agencies have the same transparency?

Tootsie Pops

250px-Tootsie_Pops_1At the ripe old age of four I recall visiting our family practitioner, a gentle, and kind man advanced in years. I don’t remember if I cried when I got the shots. I don’t remember if I was scared. I don’t remember much past the smell of the disinfectant. What I do remember is the Tootsie Pops. An office visit always produced that reward. Either he or his wife (who also doubled as his nurse, cleaning lady, office manager, secretary and biller) would open the cabinet at the bottom of the exam table and miraculously the bottomless box of Tootsie Pops appeared. Grabbing my favorite color purple, I ravenously removed the wrapper and walked out proudly working on another cavity to help buy my dentist’s new car.
Today we hear much about patient satisfaction. Large companies, practice consultants and speakers thrive on this. We often try to take a problem and make it complex. The consulting firms and those specializing in patient satisfaction position themselves knowing that there are those willing to throw money at the problem to solve it.
Like that simple treat mentioned above, little things can mean a lot. Eye contact, a smile, a warm greeting, kind facial expressions and sometimes just listening is what our patients want and need.
I plan on discussing some simple, inexpensive things we can do to keep patients satisfied with care , with office staff, and with primary care in general.

The Knife

Should Have Used A Pry Bar.

Should Have Used A Pry Bar.

Some 15-20 years ago while working on the siding of the mobile home I lived in at the time I needed some leverage to remove some heavy staples that were holding up cables.  Rather than go expend the energy  of rummaging through my “well organized” tool box I pulled my hunting knife from my back pocket.   I recall spending over 80 dollars on this precision instrument of carbon steel, brass and wood.  I also recall that I owned it less than one month when I broke it. Fortunately I only broke the first 1/2 inch of the blade. Grinding it down, I created a rounded tip and salvaged it.  I still have this knife.  Every time I Use it I am reminded to USE THE RIGHT TOOL FOR THE JOB. As primary care providers we face many challenges.  The Affordable Care Act and the uncertainty of payments. The need to meet every increasing demands of time and create and foster a patient centered environment. HIPPA, CMS, PPOs, HMOs, ACOs, Pay for Performance, Patient Satisfaction, Prior Authorizations, Gate Keeping, Capitation, Evidence Based and Copay: How many of the anacroyms or phrases even entered primary care providers minds 20 years ago?  I look back and wish I had used the pry bar instead of my knife.  It still works, but it has never been the same.  More vitial today, we need to use the right tools for our job of proving appropriate compassionate care to our clients today.  If you have a specific need or question that you have not found the answer to or have a tested practice that works for you in dealing with our challenges let us know.