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A Time for Doctors to Stand up and be Heard


Over the centuries, many societies have elevated the medical profession in thought and deed.  Not that long ago this was true in the U.S., when our citizens showed more respect for doctors as professionals and fellow citizens than is demonstrated today. Now, everyone seems to agree that healthcare reform is drastically needed, and many are speaking out. Yet, the frank indifference to the opinions of doctors by those outside the medical profession mutes the voice and counsel of doctors on the subject.  The AMA (American Medical Association) and many other physician groups are speaking out on reform, but their voice is diluted by a cacophony of assumptions, opinions, and by legislation existing and proposed. A new healthcare system has been formed, in large part, without seeking the input of those needed to make it work:  practicing physicians.

Recently, I overheard a discussion regarding healthcare reform while eating lunch at a local restaurant.  The debate hinged on who is most qualified to make healthcare-related decisions.  The following consensus was reached:  no one today should complain about the government taking over healthcare because allowing insurance companies to make all the decisions in the past resulted in a broken healthcare system.  Those surrounding this particular lunch table agreed that the time had come for government to have their turn, while opposition could best be characterized as siding with the insurance companies. I wonder: can the debate really be so simply framed?

Saddened by the realization that such a discussion could be loudly and passionately debated without mentioning doctors, I resisted the urge to point out that physicians had made the healthcare decisions before insurance companies gained control.  The fact physicians were not even mentioned attests to the sad truth that for many people doctors are merely seen as one part of a broken healthcare machine.  Most physicians see their lot differently, and consider themselves as being in a veritable state of conflict with health insurance companies; however, our participation in a failing healthcare system has afforded these very same companies with the opportunity to put physician’s faces on their failed practices, with public opinion supporting this assumption.

Regardless of your opinion on Medicare, this last major government intervention into healthcare can help illustrate the very point that I am trying to make.  On May 20, 1962, President Kennedy argued for Medicare, addressing a crowd of 20,000 at Madison Square Garden. The President was televised gratis by the three major networks reaching an additional 20 million people in their homes.  Two days later, the AMA rebutted his argument, purchasing thirty minutes on NBC, with their speaker reaching an estimated audience of 30 million people. This broadcast, more far-reaching and influential than the President’s, delayed the proposed Medicare system by several years.  Forty-seven years ago, people in this country wanted to know what doctors had to say before major decisions regarding healthcare were made.  Today, they do not.

As the discussion about healthcare reform continues, practicing physicians must be heard from to interject real medical experience into the debate and, hopefully, guide the future of healthcare by influencing legislation existing and proposed.  I am trying to remain optimistic despite the concern I feel in noting that the American Recovery and Reinvestment Act of 2009, section 3000 (pages 511, 518, 540-541) exemplifies the minimization of medical practitioners, using terminology like “Meaningful” ‘USERS’ to describe physicians.

The question is now raised: what should medical practitioners do to be heard, to influence healthcare reform, to play a leadership role in this time of change?  When I write next time; I will share some of our ideas, put them on the table, if you will.  But, I would encourage you to proffer those suggestions that you might have.  It appears we can either speak up now or choose to be “meaningful” later.

Until next week, I remain yours in primary care,

Steve Simmons, MD

Sneaky Things Doctors Do To Survive: Financial Reality Part 3

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By Alan Dappen, M.D.

What Goes On In the Back Office

The Funnel” details how physicians’ must treat patients if they expect to stay in business. Herding patients through “The Funnel” is meant to depersonalize every problem into 10-15 minute slots. It’s not that doctors don’t care, in fact, morale on the assembly line of primary care is terrible. It’s just that there seems to be no solution doctors have found to sustain the financial realities they face under the insurance-driven system. I’d like to show you some cold hard numbers.

The healthcare system has been a gold rush of opportunity.  In sixty short years the healthcare has brought wealth to lawyers, drug reps, insurance companies, malpractice coverage, transcriptionists, billing specialists, authorization departments, performance evaluators, and certification organizations, just mention a few.  Each fill their niche, presumably to add value and quality to the service.  As they’ve tagged along in the healthcare system, the patient’s $20 co-pay covers less and less, while a physician’s office pays for more and more.  Those that are making money off of the healthcare system are often predatory, inadvertently driving up the cost to the patient, hence causing insurance premiums to double by 2016.

Below details the monthly expenses for a typical primary care physicians practice (not supporting obstetrics). Most of the expenses listed are in line with a those costs for running a typical business. However, what is alarming are the salaries for administrative, or non-physician, staff salaries, which consume about one third of the incoming money received. Many members of this staff are billing specialists needed to negotiate the ever-changing rules and regulations of the third-party insurance providers and receptionists, as well as schedulers and managers to get you into The Funnel.


Table based on both Medical and Dental Income and Expense Averages, 2004 Report Based on 2003 Data, published by the National Association of Healthcare Consultants; and expense records provided by doctokr Family Medicine.

Doctors, like all of us, can’t work for free, and want to receive a paycheck that will allow them to live comfortably, raise a family and pay off their large debts from medical school. Let’s say the above medical office paid their doctor a yearly salary and benefits of $162,750, the office then would need to bill $36,845 a month to stay in business. Since a doctor can only physically see patients a total of six hours per day (or 120 hours per month), this equates to a doctor needing to bill $307/hour to simply break even. At a more granular level, each minute costs the doctor roughly $5. Doctors have figured out that they can further reduce this per minute cost if they band into larger group practices.

But here’s the rub: the patient pays for 3-4 minutes of the physicians overhead (the $20.00 co-pay), leaving the doctor and his staff to bill and fight for every dollar they can make from the insurance company. Six hours of “patient care” translates to another four hours of uncompensated work while the physician completes medical notes, follows up with hospitals, specialists, and labs, answers patient call and prepares for the next day. The standard work week is 50+ hours before adding nights on call and weekend coverage which is done for free.

How do doctors survive? They employ billing specialists, they speed up their visits, they “upcode” their notes when possible. But most importantly, doctors deploy “The Funnel,” which brings us back to where we’ve started.

Until next week, I remain yours in primary care,

Alan Dappen, M.D.

Beyond the Five-Digit Codes: The Art of Putting Patients First


By Steve Simmons, M.D.

Last week my partner wrote about The Funnel, and illustrated how patients are squeezed through a healthcare system that focuses on specific problems without allowing enough time to treat patients as individuals.  We have shown how frustrating this is for doctors and demonstrated that a shortage of primary care physicians is a reality.  However, we don’t believe it’s too late to reverse this foreboding trend. Today, my partner and I at doctokr Family Medicine are building a practice to care for our patients as individuals first.  We have also added our voice to a growing chorus of physicians sounding ever louder, explaining the necessity of a healthcare system that places the art of caring for patients first.

The next time you sit in a doctor’s waiting room, look around and consider what, and more importantly who, you see.  You might see a sick child or his worried mother. Our healthcare system does not see two people, rather it sees a 5-digit CPT and ICD-9 code.  ICD-9 (International Classification of Diseases) codes were originally created by the World Health Organization (WHO) to track diseases across the globe. Today, CPT codes (designating patient difficulty) are combined with the ICD-9 codes by third-party providers to standardize the reimbursement process. Although over 17,000 ICD-9 codes exist to classify various illnesses, there is no code for compassion. More concerning, the system does not allow any time to ease the worries or fears of a mother.

The focus of a primary care doctor’s medical practice should be on the art of patient care. An individual should be treated as a whole and not the combination of their individual problems.  But, a time may come when we must focus on one specific medical problem and seek the help of a specialist; such as an endocrinologist for diabetes or an orthopedist after an accident.  Yet, without a primary care physician to coordinate our care and speak on our behalf, a patient’s wants and needs as an individual might not be considered in reaching a particular treatment decision.  I can speak as a doctor, son, or patient when I say that anyone’s health can suffer at the hands of brilliant physicians working without the guidance of a coordinating physician who knows us well.

My mentor in medical school was an experienced family physician near retirement who offered me the following insight.  There are two types of doctors and I would consciously or sub-consciously choose which one to be.  One type of physician makes medical problems central in their patients’ lives and thus forces the individual to revolve around their problems.  The other type works to keep the patient’s life central and tries to make problems rotate around the individual.

Those policy makers determining the future of healthcare should follow my mentor’s advice.  Today’s health-care system has devolved to focus solely on problems and disease, often to the detriment of individuals and families.  As decision-makers explore revamping our current healthcare system they could continue, unaware, in this same direction. But, I have to believe they would choose the other direction if they could remember how it feels to sit in a doctors waiting room surrounded by other people – individuals all.  Nothing will change the fact that healthcare is ultimately about people, and not codes or a specific problem.  Healthcare should help patients and their primary care doctors make good health and wellness decisions while basing them on an individual as a person.

Until next week, I remain yours in primary care,

Steve Simmons, MD

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.

Time Not Well Spent: How Health Insurance Keeps Doctors From Patients


By Steve Simmons, M.D.

Last week, my partner wrote about a game played between doctors and insurance companies. After reading his post, I recalled the time I first learned that modern medicine was something altogether different than what I had expected. I began my career as a primary care physician in 1996.  Fresh out of residency, I was optimistic, naïve, and unaware that a very real game was being played. As time passed, I became a player in this game, but slowly realized that something of value was lost by my patients trying to translate their insurance coverage into health care.  Likewise, the struggle to interpret the healthcare system for my patients caused me the same frustration that has led many doctors to leave primary care today.

Early in my practice I was eager to begin my career, relieved that my training was over.  However, my training in the game had just begun. To my consternation, insurance company demands soon usurped the time I spent on everyday clinical problems. Often, I’d find my office stacked deep with charts waiting for my review and approval, a consequence of an insurance company changing a drug formulary involving dozens of patients. It seemed a day couldn’t pass without administrative staff requiring an explanation for a treatment I had already recommended so they could arrange pre-authorization.

Insurance coding was not taught in medical school or residency, yet it’s the primary language used to communicate with insurance companies. I needed to learn this ‘skill’ on the fly, using a code book to translate each medical diagnosis into a five digit number, with an additional number serving as a cipher to explain the type of work I had done for a patient.  This code book does not contain some diagnoses and many of its diagnostic codes inaccurately describe medical conditions, causing inevitable mistakes that led to non-payment.

In Money-Driven Medicine, Maggie Mahar describes the 1990s as the time of HMOs, when reimbursement became paradoxical. Then, an HMO gave a primary care physician $10 a month per patient, regardless of what we did or did not do for that patient. If we saw our patient in the office we kept the co-pay, but nothing else was reimbursed.  If we admitted a patient to the hospital, we received $0, resulting in lost office time, lost opportunities to see other patients, and lost revenue.

Some wonder why primary care physicians don’t go to the hospital anymore. Here’s why:  They can’t afford to leave the office.  They must stay put and move people through their office, which resembles an assembly line, if they want to stay financially afloat. When I observed that the only way to earn money caring for someone in an HMO was to never see them, my partner looked at an older colleague, smiled, and said, “He finally got it.”

Navigating nonsensical limits and rules became infuriating.  One young man, brought to me by his tearful father, was hearing voices. Soon into my exam I realized he suffered from a mental illness. His plan stipulated the patient only could initiate mental health benefits, not a family member. However, the voice was telling him not to call; yet he agreed to see a psychiatrist if someone else would call. I spent well over an hour pre-authorizing his mental health benefit.

Examples include physical illnesses too. I diagnosed a cancer in a woman whose HMO offered only one specialist; someone I would not have consulted. With no choice, I referred her. Days later, she returned in tears stating that she would never see someone who knew less about her problem than she did. I agreed and spent the rest of the afternoon wrangling with her insurer to get a different specialist approved.

When I moved to the Washington DC area, I left primary care.  For ten years I worked in urgent care, earning a steady paycheck while avoiding overhead expenses. I could go home without being followed by the constant frustration of trying to untangle impossible knots.  Yet, I missed the opportunity to build relationships with my patients and was not using the skills I had developed. When given the chance to work in primary care again without the endless hassles, I seized it.  Today, I am gratified to have returned to my calling. It is more rewarding to practice medicine outside of the current insurance model and I remain thankful to my partner at doctokr Family Medicine for the opportunity to do so.

Today, much is lost between patients and doctors.  If physicians and patients could connect without so many distractions, primary care would, again, resemble a calling more than a job and the primary care shortage would not be reaching a crisis point. Too much time and effort is spent on a game controlled by endless rules and regulations; time that could be focused on the patient — who should be the true focus, after all.

Until next week, I remain yours in primary care,

Steve Simmons, MD

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