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Telemedicine As The Cost-Saving Foundation To Healthcare Reform

A Keynote Address To The American Telemedicine Association September 25, 2009

The following is a summary of Alan Dappen, MD, keynote address at the mid-year meeting of the American Telemedicine Association (ATA). His keynote, billed as “Private Practice And Telemedicine: A Success Story” discusses how Dr. Dappen’s practice, DocTalker Family Medicine, which is a fee-for-service practice that deploys telemedicine for over 50% of its patients needs, has enjoyed growth and has received numerous awards and media attention. You can check out Dr. Dappen’s full address on the site.

On to the highlights of Dr. Dappen’s talk:

“This is my third visit to an American Telemedicine Association (ATA) event. I’ve been a proud member for seven years. Two years ago I presented the fundamentals my medical practice DocTalker, where the doctor is chief cook and bottle washer.

“Our practice mirrors the recommendations outlined by the Institutes of Medicine’s book
Crossing the Quality Chasm and those purporting the ‘medical home’ model.

“We believe our medical practice can:
1.    Reduce the burden of illness because our medical team is the first one to hear what’s wrong with you rather than the last.
2.    Improve the quality of care because we use advanced information systems that allow us to have the information we need to see in seconds to help manage your care.
3.    Improve trusting and personal doctor-patient relationships by removing barriers that interfere with that trust.
4.    Reduce the system cost of primary care by 50% over current system costs.

“We are crazy enough to make a stand against nonsense and stop waiting for someone else to fix, solve, or give permission to how a doctor and patient should work together to get excellent primary health care at the best price that continues our mission to extend this service to others. Our practice focuses on transformation from the bottom up meaning we removed all conflicts of interest interfering with our mission to truly be back in relationship with our patients. Unfortunately this means we are not preferred providers for any insurance plan or for Medicare.

“We stay in business through one simple standard: patient satisfaction; patients deciding they’d rather use our service than get care through the most highly subsidized economic model ever created on earth. We charge people through one simple and transparent measurement: Time. Time is time. It’s policed and controlled by our patients. All our prices are posted on the website.

“If you don’t want to pay me to do the right thing and do it for the right reason, then go get care in the regular system and do it on their terms. Come back and see us when you’ve taken enough abuse.

“We now have 3500 patients that pay cash for their service. The average person needs about an hour of time per year, meaning they owe us $300. If you don’t need any care this year, you don’t owe us a cent. Pay me when you need help.

“Two years ago I presented these details of the DocTalker practice at the ATA. The response was mixed with several people expressing the following sentiment:  “Alan, you’re a real rabble-rouser and I’m not sure why you’re even here because the American Telemedicine Association isn’t about any of your ideas at all.

“Today this rebel extends a humble “Thank You” of appreciation to the ATA leadership for inviting me to present once again at what I believe will be one of the most revolutionary tools in a doctor’s bag: a telephone. I know the video conferencing that most of you talk about is important too, but let me explain why a simple telephone and what a few of us are doing on the trenches of health care are relevant to the ATA.

“In 2001 I organized a study in my old practice to analyze the importance of the physical exam over just plain conversation.  The results confirmed my suspicions and are no surprise to anyone in this room:
1.    66% of patients could have easily been handled through phones or email alone.
2.    The longest “physical” was 10 minutes.

“It’s the implications of this data that made me start questioning the 2500 year old tradition, a paradigm designed before Hippocrates even knew about phones:

•    Implication #1: Health care doubles in price every 10 years. Certainly getting on the phones and immediately talking with our patients could reduce cost and improve outcomes by reducing delays.

•    Implication # 2: Patients were being placed into this highly dysfunctional model where healing is supposed to be the front and center. Instead it seemed largely built around billing and fulfilling someone else’s agenda: This is great for doctors and insurance companies but compromises peoples care not to mention the frustrations they must endure to get this care.

•    Implication # 3: Primary care medicine was no longer a viable profession, people were retiring in record numbers, no one graduating from med school wanted to do it and the American Academy of Family Practice and the American College of Physicians were both predicting the extinction of competent primary care specialists by 2025. At the core of the extinction was the loss of control while everyone else dictated to them how they were going to do their job.

•    Implication 4: I suddenly could see our health care system with new lenses and clarity and could no longer condone the secrets or our game playing.  My mission and duty was to do my best for each patient, one at a time. They were entrusting themselves to me to do so.

“I could see no way that I could alter the system, it’s too big, too powerful, with too many invested interests and conflicts of interest. Instead I could work on myself with the mantra:
‘Physician heal thyself.’  I resigned from my job at a large family practice group and started DocTalker.  That’s my bottom-up story.

“So here is why I’m relevant to the ATA.  Health care reform could start with this single, simple idea right now, today!  It could be implemented immediately… a telephone or an email between a doctor and a patient.

Imagine every American being able to call their primary care physician or specialist and expecting a prompt response.  

Imagine having this service available to you weekends, nights or whenever you need it.

Imagine convenience unparalleled and access that is almost immediate into the medical system.

Imagine reducing the burden of illness by the speed of response to getting the care you need.

Imagine delays being measured in minutes rather than days, weeks, or months.

Imagine better care that really saves billions of dollars. Yes–Billions!

“This is the ‘American TELE-medicine Association.’ The answer lies with you, the core group of innovators. Today while we sit in this room, one million Americans, each of them with a cell phone in their pocket, will make an unnecessary office visit. Eventually that means you and me and the people we love most will be asked to play this game too; gamble their health or stay sick a little bit longer so that someone can fulfill their agenda about our health or create a billable  service. This is what I could not condone and here is where I want you to help.

‘We practitioners who have made the leap or want to make the leap need your support, to create partnerships, to become early adopters of the services, to spread the word, to educate the public about what’s really happening with peoples personal day-to-day health and to bring the idea to every citizen. Shout from the mountain tops, “You could get the help you need right now, this minute, just pick up the phone and call your doctor.” It’s nothing more than a doctor and patient who know each other communicating on a telephone. Restore a true partnership. We need to make this idea part of ‘the standard of care.’

“If 100 years after the invention of a telephone we’re still debating, talking and questioning how to integrate this simple idea into the mainstream of medicine, then imagine the road ahead as we develop more sophisticated telecommunication systems when we can’t even get a telephone to be part of the business model of health care.

“I applaud all of you and the ATA for working to bring a solution for better and more convenient care from the top down, but 100 years of experience brings a cautionary tale to not invest all our marbles in that basket. We should also start investing in those who have started on the bottom and are working up.  We can both race for the middle.

Until next week I remain yours in primary care.

Alan Dappen, MD


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