Let’s talk numbers and visit frequency

[djmatte, ADN, MSN, RN, NP]

I’m hitting a point in my job where I’m heavily considering an employer change. They hired me almost two years ago with the expectation I would be in an 18 to 22 patients per day situation. As of now, my typical patient load is about 15 ppd. I’m considering moving on because I’m concerned with the books and new pushes to get More production out of providers despite no real changes in our population. We work with a heavy Medicaid population who have a propensity to no shoe for which we can’t financially penalize them. Our clinics have expanded where they Built a brand new facility. But no new patients have been really acquired and many are just transferring to the new place From the less desirable location.

In an average day, I might have 18-22 scheduled, but often come in to find well under the expected number. Factor in 1/3 of my patients who no show and I’m dumbfounded on how to affect change. I discussed this with my boss who turned it back to ask what I’m doing to ensure that patient comes back. (Mildly insulting as there’s a significant population I think have latched onto my practice) They have pushed for all no show patients to be called and rescheduled that day. They have pushed for providers to do their own scheduling in the room (despite a scheduling department and front office). we accept patients who blow passed their appointment times despite our scheduled load. They are desperately trying to establish protocols for seeing patients more often with a finite load. at the same time, they are trying to meet quality measures as the company as a whole doesn’t perform well in these (An area of revenue generation if they took the time to actually educate their providers).

Their latest idea which leaves the worst taste in my mouth is their plan to incentivize numbers. Specifically over a quarter, if you hit x patients, YOU get a thousand dollars. After that quarter, failure to hit x may result in an evaluation of your salary and possible reductions. That latter part has me most concerned as I feel there are a ton of parts I can neither control or influence systemically. I have a suspicion they are trying to milk this population for every cent by overscheduling patients repeatedly just to hit those numbers. Charting and quality be dammed. To be fair, I sit right in the middle of a pack of 20 providers. But have a feeling the company is stretching themselves too thin trying to be a regional household name.

[djmatte, ADN, MSN, RN, NP]

8 hours ago, djmatte said:

I’m hitting a point in my job where I’m heavily considering an employer change. They hired me almost two years ago with the expectation I would be in an 18 to 22 patients per day situation. As of now, my typical patient load is about 15 ppd. I’m considering moving on because I’m concerned with the books and new pushes to get More production out of providers despite no real changes in our population. We work with a heavy Medicaid population who have a propensity to no shoe for which we can’t financially penalize them. Our clinics have expanded where they Built a brand new facility. But no new patients have been really acquired and many are just transferring to the new place From the less desirable location.

In an average day, I might have 18-22 scheduled, but often come in to find well under the expected number. Factor in 1/3 of my patients who no show and I’m dumbfounded on how to affect change. I discussed this with my boss who turned it back to ask what I’m doing to ensure that patient comes back. (Mildly insulting as there’s a significant population I think have latched onto my practice) They have pushed for all no show patients to be called and rescheduled that day. They have pushed for providers to do their own scheduling in the room (despite a scheduling department and front office). we accept patients who blow passed their appointment times despite our scheduled load. They are desperately trying to establish protocols for seeing patients more often with a finite load. at the same time, they are trying to meet quality measures as the company as a whole doesn’t perform well in these (An area of revenue generation if they took the time to actually educate their providers).

Their latest idea which leaves the worst taste in my mouth is their plan to incentivize numbers. Specifically over a quarter, if you hit x patients, YOU get a thousand dollars. After that quarter, failure to hit x may result in an evaluation of your salary and possible reductions. That latter part has me most concerned as I feel there are a ton of parts I can neither control or influence systemically. I have a suspicion they are trying to milk this population for every cent by overscheduling patients repeatedly just to hit those numbers. Charting and quality be dammed. To be fair, I sit right in the middle of a pack of 20 providers. But have a feeling the company is stretching themselves too thin trying to be a regional household name.

Please ignore spelling errors as this was posted from my phone. ?

[ToFNPandBeyond]

Ah...working in primary care can feel like taking you're taking two steps forward, one step back. Or putting out fires with a garden hose...Somehow, it just never seems like you're doing enough.

It's why I left it almost entirely. But I've read your past posts and I see you are passionate about primary care, so what do you do?

I think the new policy at your job regarding possibly reducing ones pay when there are factors that are out of your control, like no shows, etc is B.S.

Particularly when serving Medicaid populations or those with no insurance, often times their life circumstances make it difficult for them to make it to care. You shouldn't be punished for this.

What type of population do you want to serve? I'm all for serving those with limited means, but understand the beaurocracy will be great. When the government is heavily involved (as is the case in FQHCs), obtaining money will be more difficult for these healthcare clinics, and healthcare facilities will make it glaringly obvious (IMHO) that they will prioritize the might dollar over patient care.

If you serve the upper class, you may have a cushier job; however this may have their own set of problems (cash pay will likely dictate, and with the backing of upper management who can pocket the money without having to claim it all, how you diagnose and treat them). You may not feel as fulfilled as you desire for helping make change like you mention.

So, decisions, decisions. Seems like, however, that you aren't happy with the change in your employers policy. And I don't blame you. If there isn't a way for them to negotiate something that is to your liking, then you know what you have to do.

[KatieMI, BSN, MSN, RN]

Welcome to reality, my friend ?

the fact is, most of private practices work this way. Different populations but same problem.

a few measures to assure return visits apart from being oh-so-nice to everyone:

- best: be more flexible with controlled substances. I know how it sounds but it does the job wonderfully. Not necessary to go for narks. Collecting (sorry: aggressively screening) for insomnia is very good too as even Belsomra is Schedulle IV. These folks will vvome back as by clockwork

- get someone sertified for Suboxone.

- all other chronic conditions with reasonable frequent lab control. Edpecially DM and NALD.

- availability of mental health, nutrition services, lab and Xrsy on premices

and, yes, playing with your salary like this - indication for updating your CV

Good luck!

[egg122 NP, MSN, APRN]

This sounds like a FQHC in CT that I know of... They need to be scheduling you with more patients than 18-22 to make up for the known no show rate. Agree to take any walk ins, even if they have an urgent care section of your clinic. Tends to be a quick visit that can bring you up to your full patient load and may bring more people onto your panel.

In addition, many FQHC have nursing visits for BP checks, ECG, shots, etc- if you see the patient and write a quick note it can be put under your name to bill and will increase your daily case load (it elevates from a 99211 to a 99212). Just tell the nurse to let you know about these so you can see the patient's between regular visits.

Please avoid controlled substances unless absolutely indicated or unless you have a specific interest in creating a pain management panel.

[djmatte, ADN, MSN, RN, NP]

Appreciate the responses all. Simply put imo the biggest problem starts at the scheduling level. While it’s the holidays, today I’m walking into a ten patient day. Odds are we are too thin across the population as there are only 2-4 providers even at goal. And it certainly isn’t for lack of effort.

While I appreciate the suggestions on controlled substances, I’m not sure this is sound practice. The thought of bringing a patient back monthly for refills on addictive substances moves into pill mill territory imo. And that’s certainly abundant in our area.

I have shown value to the clinic outside my primary duties and maybe that will be enough to argue against changes. Particularly with committee involvement, helping setup training protocols, and establishing methods within our charting system to make others charting more efficient. They might argue at the end of the day there’s still a bottom line, but that will either leave me uninvolved in anything outside my duties or just reinforce a job change.

either way I appreciate the insight.

[FullGlass, BSN, MSN, NP]

I just changed jobs to another FQHC and the primary care providers have high turnover and low morale. There is a very high no show rate (30%), so the clinic double books PCPs. That puts them under a lot of stress and on the days when all the patients show up, it's ridiculous.

My previous job was in a rural FQHC and we had a low no show rate, because the next closest clinic is 20 miles and 50 miles to the nearest town, where the wait is 3 months to see a PCP. The clinic also "fired" patients with a lot of no-shows.

I agree with suggestions to obtain an x-waiver for suboxone. Developing a "specialty" in an area could help to increase your patient load. I had an x-waiver and was also known as the "go to" person for psych. In addition, I was the only female provider, so got a lot of women's health appointments. Before changing jobs, I was in the process of obtaining the DMV physical exam credential for examining commercial truck drivers. Perhaps you can create a niche for yourself.

[missladyFNP]

Hi djmatte,

Sorry for your frustration and hang in there! I am a new FNP and work for an FQHC so I am aware of what you mean. I worked for the government for 7 years before this job so I knew coming in what the expectation was. I have been in my position shy of 60 days (I should add that I did clinicals at this location for a year) and Im up to seeing 12 patients + some walk-ins per day where as there are NPs that have been there longer than me only seeing 5 patients. The expectation is for us to see 18-24.

For me personally, I like having control over my schedule and seeing patients that I am familiar with, thats why I chose primary care. I don't like walk-ins, they always tend to be a train wreck. I am working aggressively to reach my 18-24 scheduled patient per day.

I see primarily medicaid patients as well. These patients tend to fall out of the sky with an avalanche of complaints. Visits at my clinic are only 20 minutes for ALL patients. I always have them address the most pertinent complaint and then bring them back for subsequent visits. This ensures that I address their issues and a 20 minute visit isn't turning into 1 hour and putting the clinic behind. Some complaints can have the patient coming back every week for a month before you even get to a physical exam. 90% of the patients I see haven't had a physical or PAP in years. I schedule both before for they leave. At my clinic the MAs can schedule the appointments, maybe this is a task you can delegate to them. I also schedule the patients a follow-up appointment in 1 week to review their labs if I ordered anything, this return visit is a good time to do immunizations if needed and education with the patient. I only give 30 days of medication for many patients if they have not had a physical and are uncontrolled. I meet the patient where they are. If a patient has a job and is stable, I am more flexible with seeing them further out but they are required to update me via the online portal.

I also like making sure I see patients that I am familiar with before lunch and at the last slot of the day. If I dont have one of my scheduled patients in there it always turns into a walk-in and takes much longer than the allotted 20 minutes.

We have absolutely NO control over no- shows or cancellations. I don't prescribe any controlled substances, they are automatically referred to the pain clinic. In all honesty I only see myself in this population 1-2 years. The population is exhausting and the lack of support from administration makes the burnout more intense. Im contemplating not even staying for the HRSA loan forgiveness. It may just be time for a change. With your experience Im sure you could specialize or do urgent care with no problem. I hope this helps and Best Wishes?

[djmatte, ADN, MSN, RN, NP]

Appreciate the responses all and you are giving me lots of good perspective.

There is a bit of a thickening plot here. One area of concerns for me was the billing side where my percentages of 213 and 214 visits were WAY off the national average. 20% of my charts billed were a 214 while 70ish % were 213 patients. There are a lot of factors for this and there's a possibility it's a reflection of the area. But I was concerned enough to dig deeper. There are a number of providers who are seeing the same thing and they have taken to printing off their schedule daily and making their own spreadsheets to track what they personally bill.

We were told that occasionally there is a need to downgrade billing (either from the insurance company or if billing catches something themselves). It was always suggested this practice is not the norm. We were told about a tool that allows us to check percentages of adjusted chart billing. I had someone run an audit for 4 days from my charts to check this and 100% of my 214 patients were changed to something else (unable to determine exactly what but likely downgraded to a 213). I need a bigger sample size to get a better idea of what is happening, but either I am the WORST coder and note writer in history (not the case) or someone is hamstringing us on the back side.