Melissa Young, MD

“The best laid plans of mice and men often go awry.” And so is true in a medical practice. While careful planning is essential to making things run smoothly in an office, the unexpected happens and things don’t always go as anticipated.

Sometimes, it’s a minor inconvenience. We had a couple of episodes of a backed-up toilet several years ago. It overflowed and, needless to say, it was unpleasant. At least we have another restroom that the patients could use. In both instances, the paper towels had been flushed down the toilet (and we suspect by the same patient). At that point, we eliminated paper towels completely from the room and had an electric hand dryer installed. Hasn’t happened since.

At times, the disruption can really throw a wrench into the works.  Earlier this year, we had trouble with our fax server. Faxes were not being received and they were not being sent. We typically get dozens of lab results, prescription requests and certificates of medical necessity forms, and those forms need to be filled out and sent back in order for patients to get their medications and supplies. Many calls and texts and emails went between us and our IT service provider.  A technician came in more than once before it all got straightened out. But it was a couple of weeks struggling with the issue.

Weather can wreak havoc on a schedule, too. One snow day can cause significant delays in patients being seen for follow up appointments when your schedule is already packed. I don’t know why it took me 10 years to think of this, but I recently told my staff to block one day in January and February as emergency snow days. If we’re lucky and this winter is mild, it is easy enough to fill an empty day with patients on the wait list. Much easier than trying to squeeze 20 patients into a full schedule.

And while one day of bad weather can be hard to deal with, some storms can be truly catastrophic. Granted, we were far enough inland when hurricane Sandy hit New Jersey that we did not sustain physical damage to the building, but we did lose power for several days. And no power means no EHR, no phone, no fax, in addition to no lights. So not only could we not see patients, but I couldn’t even look at patients’ records or send prescriptions. Fortunately, at the time, voicemail was being forwarded to my cell phone (which I charged in my car) so I could call in some prescriptions, but patients with Medicare need to have their prescriptions for testing supplies either sent electronically or by fax, verbal orders are not accepted. I had to go to the hospital and use the fax there to send prescriptions.

So while we do our best each day to lay out plans to keep things efficient, one must be prepared to deal with the unexpected and to accept that some things are beyond our control.

Articles

Running a medical practice means being ready for the unexpected

When your best laid plans don’t work out

 features contributions from members of the medical community. The expressed opinions are that of the writer(s) and do not necessarily reflect the opinions of 

This month, I celebrate the 10-year anniversary of opening my own practice. Wow. Ten years. It hardly seems like it could be true.

Much as I prepared for the transition from being an employed physician to a practice owner, not everything went as planned, and I learned a lot along the way. I was already writing for 

 at the time, and I frequently wrote about the trials and tribulations of starting my own practice. I’m going to devote the next few posts on what I’ve learned over the last decade - and what has changed.

Let me start by telling you what things did, and did not, go according to my business plans. I wrote out a well-thought-out 5-year plan. I computed start-up costs - everything from computers and exam tables to paper towels and hand soap. Seeing this document again for the first time in years, I can’t believe I actually created this.

A glaring difference in my plan versus what happened in reality is my current solo practice situation. The plan had been to start solo, add a nurse practitioner (NP) midway through the first year, then add a second physician and nurse practitioner in year two. In reality, I was solo until I hired a second physician in year two, then we briefly had a nurse practitioner (NP). We never did hire another NP, and the other physician left last year, so I am back to solo practice.

Looking at projected expenses, with just two physicians and no NPs, I had been spending less on payroll than planned, though I did not take into account making contributions to employees’ retirement accounts. Given the busy nature of our practice, I am not spending on marketing at all. Since I use call forwarding after-hours, I do not have to pay an answering service. Medical waste disposal also costs less than anticipated. And because of my busy schedule, I generally don’t travel for medical education. Instead, I try to find conferences nearby or online, minimizing that as an annual expense.

I am, however, paying more than anticipated for telephone, internet and network support. Malpractice insurance costs a lot less for endocrinology than I thought, but medical, dental, workers’ comp and commercial liability insurance all cost more.

One of my objectives on my plan was to have an average of 450-500 patient visits per month within the first six months of operation and more than 700 patients by the beginning of the second year. I just looked at March 2010’s schedule, and I was seeing maybe half my target. That was a result of having a schedule that was still mainly new patients. Now that I am seeing only follow-up patients, I am probably seeing about 400-450 patients a month. That goal of 700 was based on the premise of having a NP and a second physician at the practice.

Next month, I’ll talk about what has changed over the last 10 years. One thing that hasn’t is the mission statement I wrote in 2009. It reads: 

“The Mission of (the practice) is to provide comprehensive diabetes and endocrine healthcare to our patients that meets or exceeds national standards. (The practice) is committed to providing services that result in high patient satisfaction, a professionally fulfilled staff and a consequently successful and profitable business.”

It is still my intent to provide quality care and a friendly work environment while trying to remain financially successful. While not everything has gone according to plan, I believe the practice has been successful, and I have learned that success comes in many different forms.

, MD, FACE, FACP, is sole owner and solo practitioner at 

Mid Atlantic Diabetes and Endocrinology Associates, LLC

. As such, she is both actively involved in patient care and practice management while also raising two kids and a dog in suburban New Jersey.

One physician reflects on her decision to leave her employer, start her own practice and how she followed (and deviated) from her startup plans.

A decade of lessons learned from private practice 

’s blog features contributions from members of the medical community. The expressed opinions are that of the writers and do not necessarily reflect the opinions of 

Since opening my own practice almost 10 years ago, I have had few changes in staffing. I have had employees leave on their own accord, and I have had to let a couple go. Some had jobs lined up before they left, and I believe they have all gone on to other workplaces.

Now, I have been told that I must be careful about what I say about former employees when potential new employers call for a reference. I have heard that there is a risk of litigation if an employer says something negative, which then causes someone to be rejected.

I suppose the easy way out would be to just say positive things, such as “She did her job well,” “He was punctual,” “Everybody loved her,” or “She is missed.” But unless those things are true, isn’t it wrong for me to lie to the new employer? If someone was inept, late or obnoxious doesn’t the potential employer deserve to know? After all, that’s why they contacted me in the first place.

Perhaps I should be noncommittal.  I could say things like, “He performed his duties satisfactorily,” “There were no negative reviews,” or “There is nothing of concern in her work history.”

Or I could get a little creative and let the potential employer read between the lines. I could say “When she showed up for work, she accomplished the tasks that were given to her,” meaning “She was absent a lot.” Or, “He was very open to constructive criticism,” which could mean, “He was constantly making mistakes, and we had to keep correcting him.” Or, “When a task was important to him, he did it very well,” meaning “He picked and chose what work he would do.”

In our very litigious society, we walk on eggshells every day. We do our best not to offend. This is unfortunate, because sometimes the truth is unpleasant. And in a service-oriented business such as medicine, proper staffing is essential both for patient and physician satisfaction. It would be nice to know the truth about a prospective employee without the prior boss having to worry about getting sued.

One solo practicioner mulls over what she should or shouldn’t say when sought for a reference check.

What to say when asked about former employees

Much like online review sites, where only the unhappiest of customers take the time to write a comment, I often find myself writing about my latest frustration with the practice of medicine.

 and how patients would rather believe the latest issue of the 

 than their physicians. That isn’t what I signed up for when I became a physician.

But two very different recent patient encounters, oddly enough only tangentially related to my specialty of endocrinology, reminded me once again of the beauty and art that is the practice of medicine.

The other day, I saw a patient who I had inherited from another endocrinologist. His reputation of being a very anxious person preceded him. He doesn’t even allow us to check his blood pressure because he gets so worked up at doctors’ offices that his BP is often sky high.

In truth, he has very little need to see an endocrinologist. His thyroid issue resolved itself years ago, but he wants to keep an eye on it, so he still comes every few months. We reviewed his labs and were finished fairly quickly. I asked him if there was anything else he needed to discuss. He said, “I know this isn’t your area, but maybe you can help me. I hate flying, but my wife booked us a vacation in the Caribbean. I don’t even like the beach. I’m afraid I’m going to get on the plane and freak out.”

Well, he is correct. As a physician, this is not my area of expertise, but I am a frequent traveler. I am also someone with an irrational fear of heights. I told him that while my phobia is different than his, I understand what it’s like to intellectually know something is safe and yet still be deathly afraid of it.

We talked a little about the safety of flying and some coping mechanisms. He said his primary care physician had offered him a prescription for Xanax to ease his anxiety but that after talking to me, he already felt better about the whole thing.

On a sadder note, hours before I wrote this, I sat by the hospital bed of a patient who was recently diagnosed with pancreatic cancer.

He was a little cranky when I first walked in, probably because I woke him. He was annoyed that his glucose had gone too low the night before. He complained of the side effects of his chemotherapy.

He said, “They haven’t made any great strides in treating pancreatic cancer. I know I am going to die. Why are they making me take 15 pills? My family gets upset that I don’t want to take the pills because they make me sick. They say, ‘If you don’t take them, you’ll die.’ Well, I’m going to die, anyway.”

I got him some tissues, and I held his hand while he cried. It took all my strength not to cry with him.

After a time, I explained to him about palliative care and asked for permission to recommend a consult. I told him that giving him quality of life is most important right now.

And he’s right: Some things don’t matter. His glucose doesn’t need to be perfect. It’s OK for it to be a little high. He can eat what he’d like because he needs his strength.

He looked at me and told me I was the only one who came to visit every day. I was the only one who understood, and he appreciates that.

Physicians are often painted as pill pushers or smart but with no heart. There are times that our current healthcare system forces some physicians to behave that way.

I know darn well that taking the time to ease someone’s anxieties, whether it be about a plane ride or one’s mortality, doesn’t pay the big bucks. But you know what? This is exactly what I signed up for and why I still practice medicine.

Physician Melissa Young shares two patient encounters that remind her of her primary role: to care for and comfort others.

Why I still practice medicine

 Physicians Practice’s blog features contributions from members of the medical community. The opinions expressed are that of the writers and do not necessarily reflect the opinions of P

When medical school applicants ask me for pre-interview advice, I tell them, “When they ask you why you want to go into medicine, don’t say ‘I want to help people.’ That’s what everyone says.” And everyone says it because we want to care for others.

Sure, we love science and the human anatomy (and aren’t phased by bodily functions or fluids). Practicing medicine has a pretty good guarantee of a comfortable, albeit not luxurious, lifestyle. But unless you really want to help people, there are much less stressful and more lucrative career paths.

We spend several years and thousands of dollars learning how to practice medicine because we want to do good. We want to make the diagnosis and manage the disease process. We want to educate and improve people’s well-being. Doing all that can be physically and emotionally exhausting, but it can also be exhilarating and deeply satisfying.

And yet, in today’s healthcare system, we cannot perform the most basic task of caring for our patients. When I started practice a little less than 20 years ago, I didn’t have to get prior authorizations (PAs) for drugs. At least, not very often.

Now, there are all these nonmedical people dictating what tests or drugs are and are not available. Now, I’m forced to deliver the bad news to my patients after mumbling to myself “I hate insurance companies” for the nth time that day that. Now, I must submit three or four PAs a day - and that doesn’t count the prescriptions I change because I am certain the PA will get denied.

I’ve reached a point where I feel like there’s no point in even trying. Once the insurance company says, “Brand X is not preferred. Formulary alternatives are Y and Z,” I know the PA questions will include “Has the patient tried and failed Y and Z?” and “Does the patient have a contraindication to Y and Z?” If you answer no, Brand X is denied. It doesn’t matter that the patient has been on Brand X for a decade and Y and Z didn’t exist then. If he hasn’t previously tried them with no benefit, he has to switch.

I wouldn’t mind so much if the insurance company’s reason was based on clinical studies showing Brands Y and Z are superior, but it usually isn’t. Sometimes, data that suggests certain drugs are superior are the formulary exclusions. In some drug classes, the preferred drugs are changed annually, back and forth and back and forth, among the members of the class.

Physicians battle with insurance companies daily to get the medications their patients need. We also have to wrangle with insurance companies for tests to be performed. For example, I have a patient with an adrenal mass. The American Association of Clinical Endocrinologists (AACE) guidelines say to reimage after three to six months. My patient was a little lax in scheduling, so it was eight months later when she called to say she needed a precertification. It was rejected.

Her insurance company’s policy is to reimage after 12 months. I even did a peer-to-peer review. My “peer,” a non-endocrinologist, told me the insurance company would not cover the test any earlier because it follows different guidelines from the AACE.

My patient had to anxiously wait for the next four months before her insurance company would cover her test. Her anxiety translated into multiple phone calls to my office staff and me. I understand, of course, but I am also frustrated that I can’t care for her. My hands are tied by insurance companies.

pharmacies have started interfering as well

There are many things that contribute to what is being called physician burnout: the increasing cost of doing business, decreases in reimbursement, increasing regulations, changes in patient expectations of physicians and physician practices, and online reviews.

In my opinion, the biggest obstacle we face every day, and the one most likely to result in burnout, is payers and pharmacies interfering with our medical expertise. Their desire to save a buck is antithetical to delivering what we believe is the best care for our patients. The healthcare system needs to put patients back at the forefront and let physicians practice medicine. Maybe then we can start improving patients’ lives.

Melissa Young, MD, FACE, FACP, is sole owner and solo practitioner at 

The ongoing battle to get patients the treatments they need is a major contributor to physician burnout.

The fight against prior authorizations

 blog features contributions from members of the medical community. The opinions expressed are that of the writers and do not necessarily reflect the opinions of 

Self-monitoring of blood glucose is an essential part of managing diabetes. It is both a necessary practice for those who adjust their insulin based on their glucose levels and an educational tool for patients who want to know what happens if/when they eat three slices of pizza instead of a salad for dinner.

Monitoring glucose is also a kind of safety precaution. Patients with diabetes who feel weak or dizzy are instructed to check their glucose to make sure it’s not too low. Glucose monitoring is so important for diabetes management that Medicare will pay for one test strip per day for patients who have diabetes and are only taking oral agents. Medicare will pay for three test strips per day for those on insulin. Beyond that, Medicare will cover more if there is a documented need, such as episodes of hypoglycemia or for medication adjustment.

However, I learned from several local CVS pharmacies and endocrinologists in other states that CVS as a company has decided it will not dispense more than Medicare’s basic allowance, one if on pills and three if on insulin. I was told that is all they will dispense regardless of what a physician prescribes or any circumstances that may justify more frequent testing.

I believe this is tantamount to practicing medicine without a license. I could not believe that a pharmacy would take it upon itself to decide what is appropriate testing for patients.

 reached out to CVS for comment (see below). CVS confirmed it has decided to restrict patients to the number of strips covered under Medicare’s “standard utilization guidelines.” For those who have been prescribed more than the ‘standard,’ CVS is asking for new prescriptions that meet such guidelines. The company makes no mention of accommodations for patients with legitimate reasons to check more often nor does the company mention that Medicare makes exceptions for patients with documented reasons for more frequent testing.

I was so incredulous at this new development and so upset on behalf on my patients that I wrote two my state representatives and state senator. My state senator’s chief of staff reached out to me, and he is also going to contact CVS. I’m waiting for his reply. I also wrote to our local paper. The deafening silence has me even more perturbed. To me, this is an emergency. What are patients who need these supplies supposed to do?

To make sure this wasn’t a change in Medicare’s policy I was unaware of, I also called a local Walgreens to find out if they have similar protocol. I was told no-it’s business as usual. However, Walgreens sends physicians a form asking for a diagnosis code and for a reason for more frequent testing, if applicable.

Some colleagues have tried to talk me off the edge. They tell me patients can get their supplies cheaper on Amazon. While some patients can go to different pharmacies, some payer plans require them to go to specific pharmacies. And yes, patients can also use a durable medical equipment supplier.

But I don’t think patients should have to seek care elsewhere or potentially pay out of pocket because their pharmacy refused to fill a prescription that a physician wrote and the payer authorized.

It’s bad enough that decisions are made by non-medical people at payers or insurance companies, which are more concerned about profit than patients. This is unacceptable, and we must draw a line.

If we allow CVS to make this decision on behalf of physicians and our patients, then where does this end? What else can pharmacies restrict? Will pharmacies now dictate what our patients can and cannot have?

If so, the healthcare system is even more broken than I thought.

. As such, she is both actively involved in patient care and practice management while also raising two kids and a dog in suburban New Jersey

Editor’s Note: Physicians Practice reached out to CVS Pharmacy for comment. The company shared the following statement:

“CVS Pharmacy is committed to supporting the health needs of patients who have diabetes while also complying with applicable requirements and guidelines. Effective January 29, 2019, CVS Pharmacy limits quantities of diabetic testing supplies (DTS) covered under Medicare Part B to Medicare’s standard utilization guidelines in order to meet Medicare’s medical necessity requirements. 

“Under these guidelines, CVS will dispense DTS - including diabetic test strips and lancets - to non-insulin dependent Medicare Part B patients for testing no more than once per day; and to insulin dependent Medicare Part B patients for testing no more than three times per day.

“In the lead up to the January 29 effective date, we contacted our diabetic Medicare Part B patients, and their prescribers, who have previously filled a DTS prescription at CVS Pharmacy to inform them of our adherence to Medicare’s standard utilization guidelines. Medicare Part B patients with current DTS prescriptions that exceed the guidelines will require a new prescription that meets Medicare’s standard utilization.”

Monitoring glucose levels is important for managing diabetes. CVS Pharmacy now limits quantities of diabetic testing supplies to meet Medicare Part B’s medical necessity requirements, superseding doctor’s orders.