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The Unturned Stone of Healthcare Reform: Primary Care Practices That Compete on Price & Quality

The U.S. government finally has announced intentions to become involved in our $2.2 trillion healthcare system. Now everyone wants to say something.   Most longtime players in healthcare indignantly rebut any new input and opinions with “How dare you! … You stay away from my holy cow of entitlements (insured patients), or salary (doctors), or bonuses (insurance companies), or profits (pharmaceutical companies), or the ability to sue (lawyers.)”

I join my voice to President Obama’s statement that the single most important problem to solve in our healthcare systems is cost. The tidal wave of catastrophe rushing towards America is the expenditure of healthcare dollars doubling every 7-10 years.

Few will argue against the ideal of universal health coverage, yet this noble ideal comes with an enormous price tag and many less than honorable behaviors by all players in the system.  The wasted and misallocated money lost every year in healthcare makes Madoff’s Ponzi scheme look like child’s play, and yet it continues.  We finally have awoken the dormant giant of politicians to do what no one else says they will do, and the government’s intervention in the form of healthcare reform seems imminent.

Doctors were captains of the healthcare system until 1980s. They were dethroned because health care costs had doubled every seven years since 1945. Then insurance companies gladly took the helm.  Guess what? After 20 year of their leadership, the price of healthcare has continued to double on average of every 10 years. Now the government is positioned to step in and fix it.

Big Brother might “force” each of us healthcare players to be held accountable including all of us as patients.  This fear of change leads  to finger pointing, name calling, blaming, grandstanding, and claiming, “Oh the ridiculous price healthcare …  it’s not my fault and I shouldn’t have to change or fix it.” Nothing could be further from the truth. We all have to fix healthcare, and never forget, it’s about the price.

How do we create a health care system that provides the widest access, the best bang for the buck, the fairest distribution of money, and inflates at the same speed as the rest of the economy?

For primary care, two pathways are clear: the career path or the professional practitioner path. With the career model, doctors can work for someone else (like Kaiser, Medicare, an insurance company, or a hospital), and can expect a salary and benefits. In return, these employers oversee and influence how career doctors do their jobs, their hours, their interactions with patients, how they communicate with patients, and often what medications should be prescribed.  We have 20 years of experience with the “career pathway.”  We allowed others to interfere in the doctor patient relationship, help us ”manage” our patients, and decide what’s “reimbursable.”  The soul of our work and the trust of our patients evaporated. Many believe this pathway will spell the extinction of the primary care “specialist.”

The other pathway is the primary care doctor as a professional, with a mission that focuses on the patient not just for quality, but for trust and price, and following these key objectives:

  • Restoring the soul and viability of the doctor patient relationship,
  • Delivering the highest quality care, and
  • Restoring a pricing integrity which reduces cost.

This professional primary care doctor will restore the patient-doctor relationship with a modern office that is mobile, can be reached anywhere and anytime, has virtually no staff, minimal overhead costs, transparent pricing,  and is powered through a customized software that finds the patient chart, instantly looks up any pharmacy or radiology center, can contact any specialist, can instantly look at differentials, drug interactions, gets notifications when patients have something “due,” has a large number of patient education resources that can be emailed to the patient including articles from the medical literature and refereed internet sites that can educate patients, and does all the billing from the same platform the moment that the note is closed.

An individual’s day-to-day health is not “best managed” under third-party payers. We need insurance or government to manage expensive problems or catastrophe, like cancer, serious injuries or ongoing health problems. Yet sixty years of conditioning has left most unable to see the obvious: extract the day-to-day care cost  from the insurance model and return these funds to all Americans (about $700 billion/year), stop holding the consumer hostage, make doctors compete again for the consumer on price, quality, knowledge, access, convenience, relationship — just like every other service industry. Finally, bring an end the  $20 co-pay mentality for the patient and “the funnel” for the doctor.

This is possible, and is being done today with the practice I founded, doctokr Family Medicine, (www.doctokr.com). Our patients pay out-of-pocket for all the primary and urgent care healthcare services they receive. We charge on a transparent time-based fee basis, where five minutes of the doctor’s time costs around $25. Our patients can contact or see us anytime, day or night, and consult with us via phone, email, in our offices or by house calls, with over 50% of all of our patients’ healthcare issues being resolved by phone or email.  About 75% of our patients pay less than $300 per year for all of their primary and urgent care needs. We’ve built a relationship with each patient and spend as much time as they want with us.

In the weeks ahead I invite all readers and colleagues to consider the road less traveled. Consider primary care doctors standing-up, reclaiming their profession, embracing and being embraced by the American population. And imagine happier patients and doctors, healthier patients and that the delivery of that care costs 50% less than now.

Until next week, I remain yours in primary care,

Alan Dappen, MD


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9 Responses to “The Unturned Stone of Healthcare Reform: Primary Care Practices That Compete on Price & Quality”

  1. swdowling says:

    Dr. Dappen,

    I applaud your practice and its transparency. To what extent do you advertise or otherwise publish your prices for all services offered?

    Insurance needs to do the same.

    I would point out that your model is quite similar to the way health care and health insurance were handled prior the advent of government involvement with Medicare in the middle sixties. There existed no such thing as Major Medical insurance. One paid for doctor services from their pockets and had Hospitalization insurance should the need arise to be treated at the hospital.

    Further, doctors' and hospitals' requirements for signing a contract to assign insurance benefits prior to treatment is the root cause of insured patient's disregard for cost and as you say, sense of entitlement. We need to go back to detailed billing being sent to patients so they can pay the bill. Insurance will reimburse to the insured. This should be a focal point of reform.

    All stakeholders have ground to give. The system is dysfunctional including the regulatory process regarding insurers. States must give up oversight to eliminate redundancies. Groups must allowed to form aside form Government entities, Unions and Employers. If individuals are free to choose groups away from their employer, there exists no need to have individual insurance coverage.

    Much needs to be done on all sides. Your efforts are proof that the free market will solve the issues without any further government involvement. What's more, yours proves that government involvement has been at the root of the problems (i.e. Medicare) and is not necessarily the solution.

  2. Dr. Dappen,

    While I applaud, and support your primary care model practice, I think you unfairly paint a distinction in values between employed and independent primary care practitioners. As an academic FP, I still see patients and, when I do, I believe I have the same values that you indicate are the responsibility and the focus of practicing primary care professionals.

    Furthermore, committed academic career physicians are working hard to preserve and articulate the values, regulations, testing, evaluation, credentialling, and reimbursements that will allow our primary care specialties to train professionals and thrive into the next decades.

  3. swdowling says:

    Dr. Dappen,

    I applaud your practice and its transparency. To what extent do you advertise or otherwise publish your prices for all services offered?

    Insurance needs to do the same.

    I would point out that your model is quite similar to the way health care and health insurance were handled prior the advent of government involvement with Medicare in the middle sixties. There existed no such thing as Major Medical insurance. One paid for doctor services from their pockets and had Hospitalization insurance should the need arise to be treated at the hospital.

    Further, doctors' and hospitals' requirements for signing a contract to assign insurance benefits prior to treatment is the root cause of insured patient's disregard for cost and as you say, sense of entitlement. We need to go back to detailed billing being sent to patients so they can pay the bill. Insurance will reimburse to the insured. This should be a focal point of reform.

    All stakeholders have ground to give. The system is dysfunctional including the regulatory process regarding insurers. States must give up oversight to eliminate redundancies. Groups must allowed to form aside form Government entities, Unions and Employers. If individuals are free to choose groups away from their employer, there exists no need to have individual insurance coverage.

    Much needs to be done on all sides. Your efforts are proof that the free market will solve the issues without any further government involvement. What's more, yours proves that government involvement has been at the root of the problems (i.e. Medicare) and is not necessarily the solution.

  4. Dr. Dappen,

    While I applaud, and support your primary care model practice, I think you unfairly paint a distinction in values between employed and independent primary care practitioners. As an academic FP, I still see patients and, when I do, I believe I have the same values that you indicate are the responsibility and the focus of practicing primary care professionals.

    Furthermore, committed academic career physicians are working hard to preserve and articulate the values, regulations, testing, evaluation, credentialling, and reimbursements that will allow our primary care specialties to train professionals and thrive into the next decades.

  5. alan dappen says:

    Response to SW Dowling:

    Our prices a are posted on the website.

    All charges are time based ( time is money) There are no added charges for procedures except for supplies ( about 30% mark-up over our costs.)

    Time is time means time spent in the office or phone, or email is charged the same so that we are not incented to “game” people into unnecessary office visits when they aren’t necessary. Forcing people into the office to be charged is THE MOST unexamined assumption in all primary care and includes most out patient specialists as well. Time based billing also means that we can be policed by our user and challenged if something doesn’t seem right to them.

    We explain to all our patients that keeping a prepaid account of a few hundred dollars means we will discount our service fees by 25%. These accounts are fully reimbursable if someone wants to leave the practice. I have learned to explain to my customers that if they don’t want to pay me to do the right thing for the right reason, then they should look for help through the traditional business model which is not transparent, will force every interaction into an office visit, tries to limit access and control, does not value the patients time, and gives both doctor and patient about 10 minutes of face to face time to resolve an issue.

  6. alan dappen says:

    Response to Charlie Smith:

    My positioning on the word, “professionalism” in no way is meant to impugn the thousands of incredible primary care physicians working “in the trenches” of their work nor commitment to their patients. Rather it is meant to incite and provoke a reaction about a new vision. Leadership and entrepreneurism is sorely needed from our ranks.

    Insurance companies, patients among many others don’t think doctors are entitled to the current status quo. We have surrendered much of our power to other health care players because primary care providers have never built a new business model which can attract patients.
    This might be understandable from the recent graduates burdened by debt or trying to put their kids through school but many over 50 yo no longer have this excuse.

    If we, as the doctor, the decision maker, the one with the legal and ethical obligation to do the right thing for the right reason, can’t dream of helping someone with a UTI or poison ivy or tick bite or thousands of other scenarios without it going through the receptionist, the scheduler, the wait, the in window, the waiting room, the nurse, the doctor, the out window, to the billing specialist and the bill is still not settled as it heads towards the insurance company who will data mine every “confidential” diagnosis and medicine before they pay the bill and perhaps audit the doctors note to keep him/her honest then we clearly have surrendered our duty to our patients. Extinction of such inefficiency will not be saved by the electronic medical records nor pay for performance or a primary care medical home.

    Primary care physicians will never stop being besieged if they condone or willingly lend their professionalism for advocacy into the camps that guarantee payment with such utter disregard for the patient, efficiency and what it's costing.

  7. alan dappen says:

    Response to SW Dowling:

    Our prices a are posted on the website.

    All charges are time based ( time is money) There are no added charges for procedures except for supplies ( about 30% mark-up over our costs.)

    Time is time means time spent in the office or phone, or email is charged the same so that we are not incented to “game” people into unnecessary office visits when they aren’t necessary. Forcing people into the office to be charged is THE MOST unexamined assumption in all primary care and includes most out patient specialists as well. Time based billing also means that we can be policed by our user and challenged if something doesn’t seem right to them.

    We explain to all our patients that keeping a prepaid account of a few hundred dollars means we will discount our service fees by 25%. These accounts are fully reimbursable if someone wants to leave the practice. I have learned to explain to my customers that if they don’t want to pay me to do the right thing for the right reason, then they should look for help through the traditional business model which is not transparent, will force every interaction into an office visit, tries to limit access and control, does not value the patients time, and gives both doctor and patient about 10 minutes of face to face time to resolve an issue.

  8. alan dappen says:

    Response to Charlie Smith:

    My positioning on the word, “professionalism” in no way is meant to impugn the thousands of incredible primary care physicians working “in the trenches” of their work nor commitment to their patients. Rather it is meant to incite and provoke a reaction about a new vision. Leadership and entrepreneurism is sorely needed from our ranks.

    Insurance companies, patients among many others don’t think doctors are entitled to the current status quo. We have surrendered much of our power to other health care players because primary care providers have never built a new business model which can attract patients.
    This might be understandable from the recent graduates burdened by debt or trying to put their kids through school but many over 50 yo no longer have this excuse.

    If we, as the doctor, the decision maker, the one with the legal and ethical obligation to do the right thing for the right reason, can’t dream of helping someone with a UTI or poison ivy or tick bite or thousands of other scenarios without it going through the receptionist, the scheduler, the wait, the in window, the waiting room, the nurse, the doctor, the out window, to the billing specialist and the bill is still not settled as it heads towards the insurance company who will data mine every “confidential” diagnosis and medicine before they pay the bill and perhaps audit the doctors note to keep him/her honest then we clearly have surrendered our duty to our patients. Extinction of such inefficiency will not be saved by the electronic medical records nor pay for performance or a primary care medical home.

    Primary care physicians will never stop being besieged if they condone or willingly lend their professionalism for advocacy into the camps that guarantee payment with such utter disregard for the patient, efficiency and what it's costing.

  9. Marcia Nelson says:

    Dear Dr Dappen,

    I am very interested in your practice and wish you much success. Am wondering how you deal with emergency cases or admitted patients? Do you see them in the ER/in the hospital?

    Thanks.

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