April 15th, 2009 by AlanDappenMD in Primary Care Wednesdays
Tags: Doctokr Family Medicine, Dr. Alan Dappen, email visits, Primary Care, Primary Care Wednesdays, Remote Access Visits, Telemedicine, telephone visits
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The most revolutionary tool in primary health care, for almost all out patient care for that matter, is something so common, so mundane, so overlooked that it’s like the nose on your face, you never see it. This tool is not the computer, the internet or a killer software application.
It’s the phone. Why? The answer is equally as simple: The phone allows for 24/7 communication between a doctor and patient who know each other. Likewise, the patient can access the health system with an expert from anywhere and most of the time get what they need.
The American Telemedicine Association (ATA) estimates that 70% of medical problems can be resolved with phones. Almost everyone thinks phone medicine is reserved for an arctic explorer or a poor citizens living in Timbuktu. This assumption ignores how life transforming it would be for every American citizen to pick up a phone, and expect to speak to their doctor anytime from anywhere, at work, on the metro, even on travel, or vacation and expect to resolve their issue instantaneously! No wait, no hassle, no waiting room, no bureaucracy. At least 70% of the time it should be that easy!
Telephone medicine is not to be misconstrued for talking to a stranger. It is not impersonal, nor meant to avoid seeing patients. In reality, it is simply one way of many to get good health care. Sometimes you need a hospital, an emergency room, a specialist, an office visit. However, more than half the time you only need a phone visit, preferably with a doctor or medical practice you know and trust. Even emails are appropriate at times.
That telephones could so easily replace more than 50% of all office visits is so unexamined, so foreign, so shocking, that a predictable series of objections arise:
1. If it was so safe why isn’t it being done already? Of course this begs the reality that our health care system doesn’t pay — or underpays — a doctor to do this. It’s as simple as following the money. Right now the money is in seeing you, so an office visit it must be.
Doctors also answer phones on weekends and night. In fact more than half of the week they are practicing “free telemedicine care,” and that means phone medicine has more real time, more experience in any week than office visit time. It’s just been always deemed “free.” No money means no mission. The doctor, saying, “We’ll schedule you an office visit,” is code for, “Come on in so I can get paid.” That’s a business fact!
2. Isn’t the doctor afraid that he/she’ll miss something? First, office visits miss things all the time. For the sake of not missing something, shouldn’t it mean every problem needs doing a full body scan, complete blood work, and parading every medical problem in front of three separate specialists. If each problem was hospitalized too, maybe that would mean not missing something.
The answer of course, is that to every problem there is a season of reasoning; a triage of appropriateness. Many problems arise where physical exam is irrelevant. If you or the doctor thinks you should be seen, then a face-to-face visit should be arranged but when both people agree what’s going on and that an office visit is not needed, then a phone visit makes sense, which is true over 50% of the time.
3. Isn’t it dangerous for a doctor to answer the phone? To which no one asks the converse question: What’s the experience when the doctor doesn’t answer the phone? If this occurs, then the most knowledgeable person about healthcare, becomes the LAST person to know. This means exposure to the Hippocrates business model of care: long delays, hassled waits, rushed visits. Illness is not a static problem but evolves. The reality of how you feel this minute in front of the doctor often is rendered irrelevant tomorrow when something dramatically changes “Waiting and communicating change” is critical to medical decision making and treatment. Most doctors bring you back in to “see how you’re doing” and make sure they get paid again. It’s not the doctors’ fault, It’s the way the system pays them.
4. Telemedicine, doesn’t that mean higher chances for malpractice? You’ll love the answer to this, but that will need to wait ‘til next week.
Until next time, I remain yours in primary care,
Alan Dappen, MD
April 8th, 2009 by AlanDappenMD in Primary Care Wednesdays
Tags: Add new tag, Dr. Alan Dappen, Primary Care, Primary Care Medicine, Remote Access Visits, Telemedicine
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Back in 1983, as a third year medical student, I read a study stating that 80% of medical visits were not needed. After finishing the text, I remember thinking, “Hmm, there aren’t that many hypochondriacs in our office!”
It wasn’t until I had practiced medicine for 20 years that I finally understood this statement for what it really meant: doctors were not helping patients through remote means, instead insisting on seeing patients in the office for all medical issues, even the most routine of issues out of habit, out of fear, out of how to get paid.
In 1996, I set out to prove that allowing established patients to remotely access doctors for care would improve their medical outcomes. I convinced my medical partners to let me conduct an experiment: I would work a few half days on the phones, fielding medical-related calls from our HMO patients. Since HMO plans paid us a flat rate to take care of them, bringing these patients to the office cost us money and offering these patients medical consults by phone instead, for routine issues, would be more cost-effective for us and a lot more convenient for them.
At that time, the front desk fielded over 500 patient calls a day. I sat next to the four receptionists, and the HMO screened patients with straightforward medical problems would be triaged to me. I then would speak to the patient, review their medical history and address their medical issue and get them what they needed. I was able treat 90% of the screened patients I spoke over the phone, while determining that the other 10% needed face-to-face appointments. During a typical 3.5 hour shift, I routinely spoke to 25 patients, and immediately helped 23 of those patients with their medical issues thereby avoiding an office visit.
Unfortunately, the experiment didn’t last long. To the business managers of the practice, we lost $500 in co-pays while I logged half days on the phone, not billing a single dollar for the practice. Where I saw opportunity and a new paradigm, they saw lost income.
Thus, I returned to my routine day, seeing 25 patients a day in person, day after day. But drudgery of this led to deepening despair. So many unnecessary office visits, patients upset with their delays, apologies for running late, and meetings about how to see more patients, see them faster, charge the insurance companies more. In some cases all the delays had led to a complication that could have been avoided with more timely care.
Not undeterred, I discretely planned a study in 1999. For two weeks I collected data on each patient I saw. Recording data on a laptop during each visit, I analyzed three questions: How long did we talk, how long did the exam take, how often did I already know what to do through history alone and not due to findings from the face-to-face exam.
Here are the results: I saw an average of 23 patients a day. The longest office visit was 45 minutes, and the longest physical examination of a complicated patient took 10 minutes. Sixty-six percent of my patient visits had no reason to be in the office, with my diagnosis relying on patient history and not being influenced by my physical exam.
On reflection of the data, the implication of the data awoke me to a new realization. I must step outside the “Matrix” that I had been a part of: a healthcare system that often delayed and even held hostage 2 of 3 patients I saw each day.
But making the decision to step outside this system was not easy: why should I risk my medical career as I knew it, and my financial security to do what is best for my patients and deliver them the quality they care they needed?
It was my wife, who, in 2001, finally convinced me to move on. She wrote a resignation letter to my medical practice, a practice filled with respected friends and colleagues. As I sat pondering the risk I’d confront by handing in the letter, my wife reminded me of a familiar refrain, “Ships are safe at harbor, but that’s not what ships are for.”
And so, in 2002, I founded doctokr Family Medicine, a practice that does step outside the typical paradigm of healthcare. My patients control how and when they are seen by our medical team. At doctokr, all of the patients establish their care through a face-to- face visit at the office. We gather their history, review their records and do an exam. After that, all established patients are free to email or call the doctor directly, 24/7. Over half of patients’ issues are resolved remotely, via phone or email. Our medical team also sees patients if they want to be seen, or if we feel we need to see them 7 days a week.
As a medical practice with 3000 pioneering patients, we sail on empty oceans but with full faith that we will not have done so in vain. Our experience has shown happier and healthier patients, providers with a mission and passion again and pricing that is 50% less than the current system price of healthcare.
For doctors and patients, staying “safe” behind the many unexamined assumptions in health care makes such harbor risky indeed.
Until next week, I remain yours in primary care,
Alan Dappen, MD
April 1st, 2009 by AlanDappenMD in Primary Care Wednesdays
Tags: Dr. Alan Dappen, Primary Care, Primary Care Wednesdays, quality healthcare, Telemedicine
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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
March 25th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
Tags: American Recovery and Reinvestment Act of 2009, comparative effectiveness research, Doctokr, Dr. Steve Simmons, Electronic Medical Records, Healthcare reform, Policy, uninsured
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Anyone working in healthcare has a moral responsibility to do the right thing, for the right reasons, and at a reasonable price; however, this is not happening. Today’s healthcare system is too expensive and it is broken. If it wasn’t broken, the current administration would not be focusing so much money and effort on fixing it. Likewise, 42 million Americans would not be uninsured creating two different standards of care within our country. Many decisions have already been made: providing government backed insurance coverage for the uninsured, encouraging the use of electronic health records systems (EHRs), and creating comparative effectiveness research boards (CERs). Much of what has been suggested sounds good but was passed by our legislature before seeking the input of those responsible for implementing these new policies and plans. Fortunately, President Obama’s administration is seeking input now and it is the responsibility of anyone working within the healthcare system to speak up and be heard.
Many hard-to-answer questions should have been asked before solutions were posed. Why is healthcare so expensive? How can the intervention of government lead us to better and more affordable healthcare? Although integrated EHR systems may prevent the duplication of tests and procedures, how can medical practitioners best use these systems to prevent mistakes? How will future decisions be made – between doctor and patient, or will the new CER Boards grow to do more than merely advise? How would the American people react to more controversial ideas, such as health care rationing to control exorbitant costs incurred at the end of life?
In my last post, I closed with a promise to share some ideas regarding healthcare reform. First, we should try to reach a consensus as to what is broken before implementing solutions. In Maggie Mahar’s book, Money-Driven Medicine (2006), her concluding chapter is titled, “Where We Are Now: Everybody Out of the Pool.” This title screams for change as she makes a convincing argument that all parties involved in healthcare need to rethink how we can work together to fix a broken healthcare system which seems focused, not on healthcare, but on money. Today, Uncle Sam has jumped into the pool feet first, creating quite the splash, and he is spending large sums of money to lead healthcare reform without first reaching a consensus as to what is broken in this system.
The American Recovery and Reinvestment Act of 2009 will direct $150 billion dollars to healthcare in new funds, with most of it being spent within two years. Health information technology will receive $19.2 billion of these dollars, with the lion’s share ($17.2 billion) going towards incentives to physicians and hospitals to use EHR systems and other health information technologies. According to the New England Journal of Medicine, the average physician will be eligible for financial incentives totaling between $40,000 and $65,000; this money will be paid out to physicians for using EHRs to submit reimbursement claims to Medicare and Medicaid, or for demonstrating an ability to ‘eprescribe’. This money will help offset the cost of implementing a new EHR, which can cost between $20,000 and $50,000 per year per physician. However, after midnight, December 31, 2014, this “carrot” will turn into something akin to Cinderella’s pumpkin, becoming a “stick” that will financially penalize those physicians and hospitals not using EHRs in a “meaningful” way.
At our office, doctokr Family Medicine, we use an EHR, but consider it a tool, much like a stethoscope or thermometer, used to facilitate the doctor-patient relationship, not a tool to track our reimbursement activities. I would not argue against EHRs, but there is no evidence they will make healthcare more affordable and improve the quality of care delivered – unless you believe the $80 billion dollar a year savings “found” in the 2005 RAND study (paid for by companies including Hewlett-Packard and Xerox- incidentally, companies developing EHRs). I believe it will take far more than EHRs, financial incentives, and good data to fix our broken healthcare system.
Difficult decisions await those willing to ask the hard questions but don’t expect any easy answers to present themselves on the journey towards effective healthcare reform. My partner and I believe we have found answers to some questions and are moving forward, in our own practice, now. Asking why healthcare is so expensive and feeling frustrated with the high cost of medical software, we have written our own EHR, containing costs for our patients by keeping down our overhead expenses. Our financial model is based on time spent with the patient, not codes and procedures, which helps us to avoid ‘gaming’ the system and wasting time.
A familiar adage states that there are no problems, only solutions. I suggest, though, that there can be no solutions without problems. Find the right questions and opportunities abound. Earlier in this post, I asked how government intervention can lead us to better and more affordable healthcare. It can’t, at least not without the help and guidance of doctors, patients, industry, insurance companies, hospitals, and anyone who understands what is at stake with health care reform. We all share in the responsibility to try.
Until next week, I remain yours in primary care,
Steve Simmons, MD
March 18th, 2009 by AlanDappenMD in Primary Care Wednesdays
Tags: cash-only practices, Doctokr, Doctokr Family Medicine, Dr. Alan Dappen, Health Insurance, Healthcare reform, Physicians, Policy, Primary Care
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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
