In a recent Forbes editorial, conservative commentator John Goodman argues that the Texas Medical Board is sending the state back to “the middle ages” because they are trying to limit the practice of medicine in the absence of a face-to-face, doctor-patient relationship. He believes that telemedicine should have an unfettered role in healthcare – diagnosis and treatment should be available to anyone who wishes to share their medical record with a physician via phone. This improves access, saves money, and is the way of the future, he argues.
He is right that it costs less to call a stranger and receive a prescription via phone than it does to be examined by a physician in an office setting. But he is wrong that this represents quality healthcare. As I wrote in my last blog post, much is learned during the physical exam that you simply cannot ascertain without an in-person encounter. Moreover, if you’ve never met the patient before, it is even more likely that you do not understand the full context of a patient’s complaint. Access to their medical records can be helpful, but only so much as the records are thorough and easy to navigate. As the saying goes: garbage in, garbage out. And with EMRs these days, auto-populated data and carry-forward errors may form the bulk of the “narrative.”
Telemedicine works beautifully as an extension of a previously established relationship. Expanding a physician’s ability to connect with his/her patients remotely, saves money and improves access. But bypassing the personal knowledge piece assures lower quality care.
I currently see patients in the hospital setting. I run a busy consult service in several hospital systems, and I have access to a large number of medical records, test results, and expert analyses for each patient I meet. Out of curiosity, I’ve been tracking how my treatment plans change before and after I meet the patient. I read as much as possible in the medical record prior to my encounter, and ask myself what I expect to find and what I plan to do. When medical students are with me, we discuss this together – so that our time with the patient is focused on filling in our knowledge gaps.
After years of pre and post meeting analysis, I would say that 25% of my encounters result in a major treatment plan change, and 33% result in small but significant changes. Nearly 100% result in record clarifications or tweaks to my orders. That means that in roughly 1 in 4 cases, the patient’s chief complaint or diagnosis wasn’t what I expected, based on the medical record and consult request that I received from my peers.
If my educated presumptions (in an ideal setting for minimizing error) are wrong 25% of the time, what does this mean for telemedicine? The patient may believe that they need a simple renewal of their dizziness medicine, for example, but in reality they may be having heart problems, internal bleeding, or a dangerous infection. Let’s say for the sake of argument that the patient is correct about their needs up to 75% of the time. Are we comfortable with a >25% error rate in healthcare practiced between strangers?
Goodman’s cynical view of the Texas Medical Board’s blocking of telemedicine businesses for the sake of preserving member income does not tell the whole story. I myself have no dog in this fight, but would side with Texas on this one – because patients’ lives matter. We must find ways to expand physician reach without eroding the personal relationship that makes diagnosis and treatment more customized and accurate. Texas is not returning healthcare “to the middle ages” but bringing it forward to the modern age of personalized medicine. Telemedicine is the right platform for connecting known parties, but if the two are strangers – it’s like using Facebook without access to friends and family. An unsatisfying, and occasionally dangerous, proposition.
Like most physicians, I feel extremely rushed during the course of my work day. And every day I am tempted to cut corners to get my documentation done. The “if you didn’t document it, it didn’t happen” mantra has been beaten into us, and we have become enslaved to the quantitative. It’s tempting to rush through physical exams, assuming that if there’s anything “really bad” going on with the patient, some lab test or imaging study will eventually uncover it. Just swoop in, listen to the anterior chest wall, ask if there’s any new pain, and dash off to the next hospital bed. Then we construct a 5-page progress note in the EMR, describing the encounter, our assessment, and plan of care.
Focused physical exams have their place in follow up care, but I strongly urge us all to reconsider skimping on our exams. A fine-toothed comb should be used in any first-time meeting – because so much can be missed as we scurry about. Some examples of things I discovered during careful examination:
1. A pulsatile abdominal mass in a woman being worked up for dizziness.
2. New slurred speech in an edentulous gentleman with poorly controlled hypertension.
3. A stump abscess in a 2-year-old leg amputation.
4. A bullet lodged in the scrotum.
5. Countless stage 1 sacral decubitus and heel ulcers.
7. Rashes that were bothering the patient for years but had not previously been addressed and cured.
8. Early cellulitis from IV site.
9. Deep venous thrombosis of the calf.
10. New onset atrial fibrillation.
13. Peripheral neuropathies of various kinds.
14. Lateral medullary syndrome.
15. Surgical scars of all stripes – indicating previous pathology and missing organs of varying importance.
16. Normal pressure hydrocephalus in a patient who had been operated on for spinal stenosis/scoliosis.
17. Parkinson’s Disease in a patient with a fractured hip.
18. Shingles in a person with eye pain.
19. Aortic stenosis in a woman with dizziness.
20. Pleural effusions in a man complaining of anxiety.
Oftentimes I don’t find anything new and exciting that is not already a part of the patient’s medical record. But a curious thing happened to me the other day that made me reflect on the importance of the physical exam. After a careful review of a complex patient’s history, I discussed every scar and “abnormality” I discovered as I did a thorough head-to-toe review of his physical presentation. His aging body revealed more than he had remembered to say… and as our exam drew to a close, he reached out and offered me a fist-bump.
It was charming and unexpected – but made me realize the true importance of the thorough exam. I had gotten to know him in the process, I had earned his trust, and we had built the kind of therapeutic relationship upon which good healthcare is based. No EMR documentation effort was worth missing out on this interaction.
You may not uncover a new diagnosis on each physical exam, but you can gain something just as important. The confidence and respect of the patient.
With the news that Wellpoint, one of the largest insurance companies in America, will cut off annual 8% payment increases to about 1,500 hospitals if they fail to “test” high enough on 51 quality measures, they have officially defined “quality” health care as checkboxes.
You see how do insurers know if we offer each of our patient’s nutritional guidance or exercise counseling?
Well, they check to see of doctors have clicked on a yellow warning box advising we do this. If we have, then not only is that doctor a fine, “quality” doctor, but the hospitals (and it’s computer system and scores of administrative staff that compile and submit this data) are real, fine, “quality” hospitals.
That’s all there is to it.
Never mind if we don’t have time to actually perform the counseling.
* click * * check * * click *
Simple as pie. Efficient, too.
Beautiful bureaucratic quality.
Good luck with that.
*This blog post was originally published at Dr. Wes*
Imagine yourself a patient 2400 years ago. By chance, Dr. Hippocrates is your “preferred provider.” You and Dr. Hippocrates have a long standing relationship, and you’ve seen him in person many times, including for a comprehensive check-up and medical history. Since his office is located 20 miles away, getting there requires a Herculean effort. With the help of friends, donkeys, walking and several days of delay you luckily arrive before closing time at 4 pm on Wednesday. You remember well the weekends, the evenings and the holidays that you got to the office sicker than a dog, only to be left in the street until the clinic re-opened.
When you arrive, many sick patients greet you, their expressions fatalistic. All have made similar journeys, and some are very sick. A line strings out the waiting room door that is two hours long. Dr. Hippocrates is rushing to finish the day’s work, see the last person and go home to supper and his family. With so many people to see and not much time, Hippocrates flies through the patient histories, relying only on his memory, knowledge and expertise to prescribe treatments and cures, moving quickly from one patient to the next.
For you, an herb is prescribed and you make the arduous journey home. Two days later you’re feeling worse. Maybe it’s the herb, maybe it’s the wrong diagnosis, maybe it’s the exhaustion from the ordeal. Yet one thing is for sure, taking the trip back to Hippocrates is too daunting to consider.
Fast forward to present day, and consider yourself as patient. Fortunately, the science of medicine has changed exponentially. Sadly the business model and the experience of getting that care is egregiously similar. Every time you need to use health care in today’s world, a gauntlet of obstacles stands between you and the service. First, there’s the receptionist answering the phone, then the scheduler fitting you into a limited number of times to come to the office, with all available slots being at least two days in the future. Upon arriving at the office, a waiting room stuffed full of sick patients greets you. Next, the person at the in-window verifies your insurance eligibility. On to the nurse who greets and reviews your history, then a wait again for the hurried doctor to rush in, and in 10 minutes or less, reduce your problem to a prescription. You’re ushered out and to the window where the co-pay is made and next a follow-up visit scheduled. The bill proceeds to the billing specialist and somewhere along the way (often months later) you might get an insurance adjustment charge. The next day you wake up with a rash. Maybe it’s the drug, maybe it’s the wrong diagnosis, but taking that trip back through that system is going to give you pause and it’s not just the pause of your time or life interrupted. For most day-to-day health care this story has repeated itself ad infinitum from antiquity until today.
A huge unexamined question in primary health care revolves around the requirement of “forced” office visits. Why do you think you are going to the obligatory ritual of the office visit for every medical problem be it a prescription refill, poison ivy rash, allergic runny nose, tick bite, urinary tract infection among thousands of other problems. Do medical experts really need to “see” you to protect you, themselves, or build a relationship?
The answer to this conundrum once analyzed is simple: No. As a matter of fact, the majority (over 50%) of routine primary care health problems can be taken care remotely, by phone, email, IM, or even online chat, if the doctor and patient have a pre-existing relationship. And why don’t more primary care practitioners use the convenience of remote access to get their patients the fastest initial and follow-up treatments possible? It’s about the money. Insurance companies pay a doctor to help you by seeing you face-to-face. Since doctors are beholden to insurance companies payments to cover the cost of your visit and since your copay doesn’t even get close to covering the cost of running the business. So the primary docs elect to put you through The Funnel.
When the idea is first suggested, most people disbelieve that phone consultation alone between a doctor and patient could handle more than 50% of the medical issues sent through the funnel of the mandatory office visit gauntlet. Don’t misread this, talking with your doctor doesn’t mean that you don’t need to be seen in person sometimes too. Likewise, all patient-doctor relationships should begin first with a face-to-face visit, complete with check-up and the discussion of the patient’s prior medical history. However, just open your eyes to the possibility of a new idea. I’ll let this uncomfortable thought settle in for while and will check back on your progress in my next post.
Until next week I remain yours in primary care,
Alan Dappen, MD
When most people think of “cash-only” medical practices, plastic surgery and dermatology procedures are top of mind. But there is a small contingent of primary care physicians who offer low-cost “pay-as-you-go” services. Yearly physicals, well-child visits, screening tests, vaccinations, and chronic disease management are all part of comprehensive primary care options available. And this costs the average patient only $300 a year.
It is estimated that 75% of Americans require an average of 3.5 office visits per year to receive all the medical care they need. If the average office visit is 15-20 minutes in length, then that averages out to 1 hour of a physician’s time each year. How much should that cost? Dr. Alan Dappen (founder of Doctokr Family Medicine, a cash-only primary care practice in Vienna, Virginia) says, “$300.” But insurance premiums are often closer to $300 per month for these Americans, and that doesn’t include co-pays for provider visits.
So why aren’t people buying high deductible insurance plans, saving thousands on premiums per year, and flocking to cash-only primary care practices? Dr. Dappen says it’s a simple matter of mindset – “People have been conditioned to believe that if they pay their insurance premiums, then healthcare is ‘free.’ In reality, their employers are taking out $3600 or more per year from their paychecks for this ‘free’ care. But since employees don’t see that money, they don’t miss it as much.”
A high deductible health insurance plan (where insurance doesn’t kick in until you’ve paid at least $3000 out of pocket in a given year) costs about $110/month for the generally healthy 75% of Americans (you can check rates at eHealthInsurance.com). That’s a savings of at least $2280/year for those who switch from a regular deductible plan to a high deductible plan.
What are the odds that the average, reasonably healthy American will outspend $2280/year? I asked Alan Dappen how many of his 1500 patients spent more than $2000 on his services per year. The answer? Three.
“Most Americans who buy-in to low deductible plans pay a lot more in premiums than they’ll ever use. They’re essentially betting against the casino, and we all know who wins on those bets.”
So I asked Alan Dappen if “the casino” was making most of its money on the “healthy” 75% of its enrollees to subsidize the cost of the sick 25%.
“Sure they are. And I suppose if enough people saw the light and switched to high deductible plans with cash-only physicians, it might force change in the health insurance industry. Perhaps the government would use our taxes to help subsidize the sicker patients.
The bottom line is that at this very moment, 75% of Americans could be saving thousands of dollars per year on their healthcare costs – and have their very own cash-only primary care physician available to them 24-7 by phone, email, home visit, or office visit. The cash-only doc can afford to offer these conveniences because they are paid by the hour to do whatever the patient needs done, without forcing the relationship to conform to insurance billing codes. In fact, the physician saves a bundle on coding and billing fees – and can pass that on to the patients.”
I wondered about the outrageous costs of laboratory fees and radiology charges for people who don’t qualify for the insurance company negotiated rate. Dappen explained:
“My practice has negotiated similar rates with local labs and radiology groups. Screening tests and x-rays are very reasonable.”
I asked Dr. Dappen who uses his services.
“I see both ends of the spectrum. The high-powered executives who don’t have the time to wait in a doctor’s office and enjoy the convenience of handling things with me via phone or house call. For them, time is money, and by losing half a day or more traveling to a doctor’s office and waiting for their 15 minute slot, they might lose $5000 in billable work time. On the other end I see patients with no insurance or high deductible plans. They enjoy the same conveniences, and end up paying an average of $300/year for their healthcare. This is high quality care that they can afford.”
I guess the only thing preventing this model of healthcare from taking off is the courage of individuals to try something new. I myself have switched to a cash-only practice with a high deductible health insurance plan, and have saved myself thousands a year in the process. I love the convenience of knowing that my doctor has all my records in his EMR, I have his cell phone number, and he can renew my prescriptions with a simple email request. I can’t imagine why more people aren’t doing this.
Alan Dappen says, “They just have to wake up out of the Matrix.”
**For more in-depth coverage of the rising trend in cash-only practices, check out MedPage Today’s special report.**