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When Diagnosing, Doctors Often Ignore Patients’ Social Factors

A recent study from the Annals of Internal Medicine found that doctors often discounted a patient’s social situation when making a medical diagnosis.

Lead researcher Saul Weiner “arranged to send actors playing patients into physicians’ offices and discovered that errors occurred in 78 percent of cases when socioeconomic concerns were a significant factor.”

Evan Falchuk, commenting on the results, provides some context:

It’s hard to expect even the most gifted clinician, trying to make it through yet another week of a hundred or more patient encounters, to get these difficult decisions right. Too much of the context of a patient’s care gets lost in the endless churn of patient visits that the health care system imposes on doctors.I suspect this is enormously frustrating for doctors, although it’s worse for patients. What the researchers call a failure to “individualize care,” a patient might call “not being paid attention to.” It’s a dynamic that anyone who’s been ill has probably seen firsthand.

These findings are entirely unsurprising. Read more »

*This blog post was originally published at*

Medical Students, Specialty Practice, And More Money

With medical students graduating, on average, with almost $160,000 of debt, it’s a major reason why they’re choosing more lucrative specialty practice, which can offer salaries multiple times more than those of primary care fields.

In this clip from The Vanishing Oath, medical economist Amitabh Chandra, Professor of Public Policy at the Harvard Kennedy School of Government, discusses that influence, which contributes to a drastic decline of primary care residency slots being filled by American medical graduates.

Of course, it’s not only money. Primary care practice has a litany of obstacles that can contribute to rapid physician burnout, compounded by the fact that good primary care role models are largely absent from academic settings.

But there’s no denying that the salary disparity is an influential factor, and for many students, often a deciding one.

A video excerpt from The Vanishing Oath, a film directed by Ryan Flesher, M.D.:

*This blog post was originally published at*

Does Group Health’s “Medical Home” Leave The Poor Behind?

Group Health has published two papers recently, one in Health Affairs and the other in JAMA, both extolling the virtues of its Medical Home. These follow their brief report last fall in the NEJM and the lengthy description of their model in the American Journal of Managed Care. Their model has been promoted by the Commonwealth Fund, and it is cited in the currrent issue of Lancet.

The big news is that costs were a full 2% lower than conventional care, hardly a great success –- it wasn’t even statistically significant. But was even this small difference due to the Medical Home, or was it because the Medical Home patients were less likely to consume care? Read more »

*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*

Sneaky Things That Doctors Do To Survive Financially, Part 2

Dr. Val’s note: this post is Dr. Dappen’s continuation of “Sneaky Things That Doctors Do To Survive Financially.”


The Funnel

By Alan Dappen, M.D.

Back to the gridiron we go. Two powerful teams square off. It’s Team Doctors vs Team Insurance. You, the patient, the object of our affection, have bought entry to this game through two payments. The first serves as your season ticket, and is the $800/month fee (coverage for a family of four) that goes to Team Insurance. You gain admittance to today’s game through your $20 dollar co-pay, which is collected by Team Doctor.

The $20 co-pay is really a ruse to distract attention away from Team Insurance and the plays the Doctors are about to pull. In reality, $20 co-pay doesn’t come close to covering the cost of an office visit (more about this on a future posting). Team Insurance is supposed to make up the difference of these costs for Team Doctors. To stay in the game, Team Doctors must hit Team Insurance just right to cough up enough money to cover their bills. On the other hand, Team Insurance hits back, denying and delaying payment of claims from Team Doctors, pocketing plenty of money to keep their fans (share holders) screaming “We’re Number One.”  The focus of this game is on money, with the patient distracted by the $20 co-pay, believing it is fair payment and the middle man (insurance) works in their best interest.

Now let’s look at “The Funnel,” the number one play Team Doctors use to recoup their money. Let’s say you have a typical medical problem and contact your primary care provider for help. You inadvertently have stepped into the playing arena. To get you the help you need, Team Doctors will run you through “The Funnel.”  This formation is the most effective play used to sustain doctors financially. Keeping The Funnel packed to the brim with patients is critical to the success of a medical office, with this success hinging on seeing at least 25 patients a day and keeping the simple problems coming back to ensure the cash follows.

Here’s how The Funnel works:

1.    Overloading: Also known as seeing patients for anything. Insurance companies will only pay primary care providers for a face-to-face visit, and not a phone call or email consultation. Ironically, 70% of typical day-to-day primary care problems can be solved by a phone or email conversation only.  Doctors need payment from insurance providers to stay in business so only conduct office visits, no matter what the problem.  Think back on some of your medical needs and how they were handled: Need a prescription refill? Need to ask a simple question? Need an antibiotic? Need to set-up or discuss a lab test? Need a follow up? Make an appointment to be seen.  Welcome to the funnel!

2.    Get the patient through as fast as possible: Keeping the flow rate constant through the funnel means limiting opportunities where patients can slow their transition through the neck of the funnel, possibly plugging it up, and thus slowing the doctors’ chance for cash.  Four major strategies keep the pay/time ratio flowing properly for Team Doctors:
a.    Ration the long visits, like a physical, by making patients wait 6-12 weeks to come in for them.
b.    Divide and conquer the 20 minute visit. Invite the patient to stick to one problem per visit and then invite her to return to the top of funnel on another day for any additional problems.
c.    Find ways to “increase value” of visits by requesting additional tests or services, like “How about we do an EKG?”
d.    Turfing the “complicated (time consuming)” issues to other practices. Ever been sent to a specialist that your doc couldn’t solve your problem 10 minutes? This is why.

3.    Get the patient to come back, as often as possible. Also know as a refilling The Funnel.  Continuous, fast-paced repeat business is the most important measure of a financially solvent office. Imagine this: Medical partners who get to know their patients and consequently care for their well-being create liabilities if that caring takes longer than 10 minutes on average per patient.

I invite readers to write in their examples of being part of the funnel. Did the funnel compromise your care or inconvenience you?  Why would the doctors run you through the funnel?

Lastly is the question: What can you do about The Funnel? Better understand the system, why the funnel exists and why it’s important that you, the patient, take control of not only your care, but how it’s paid.

Until next week, I remain yours in primary care,

Alan Dappen, M.D.

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