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Primary Care Docs Ask Permission To Be Next In Line: We Need A Bailout

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By Alan Dappen, MD

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Alan Dappen, MD

Believe it or not, this headline paraphrases the recent lead article from the American Medical News,  covering a comprehensive, white paper published  by the American College of Physicians (ACP).  The article reviews the state of primary care physicians.  The conclusion: since primary care doctors are essential to control the spiraling costs of health care, a bailout is necessary to shore up their rapidly shrinking ranks.

To understand why they argue a bailout is needed, we must look at what caused the crisis. Primary care doctors are drowning in red tape, as my partner Steve Simmons mentioned last week.  Over the past 20 years have come bureaucracies and regulations with acronyms like OSHA, CLIA, HIPPA, CPT, ICD-9, P4P.  Drops led to trickles: more complex certification and increasing malpractice risk.  Then trickles formed streams of data that is required of practitioners: quality reporting, management reports, productivity measures, electronic medical record systems, billing reports. Finally, the flood of information needed to stay in compliance with Medicare, Medicaid and insurance regulations swamps primary care providers.

The creative and intellectual focus of primary care physicians has been diverted to understanding this new world order of business contracts, negotiated rates, billing details, payment denials, coding, and non-compensated services. This is no game. It means the difference between medical practices staying afloat or going under. There are now thousands of reasons a doctor can lose money by getting fined, sued, or refused reimbursement.

Family doctors and internists have grown weary. They feel underappreciated by their patients, undervalued by the specialists, underpaid by the insurance company, overworked to meet expenses, and overexposed to malpractice risk.  U.S. medical graduates entering family medicine residencies dropped by 50% over 10 years and are now filled mostly by non-US trained physicians. American medical graduates now rush to specialties where they make better money, gain higher status and/or achieve better control of their work schedules. To keep primary care doctors in adequate supply, so the argument goes, system subsidies and readjustments are needed.

Outsiders easily “get” what went wrong the auto and financial industries.  These industry execs standing in line for handouts make most of us angry. They refused to do so many things to avoid their plight: innovate, stand up to wrongs, worry about sustainability, take responsibility, invest in a new future, even ”bending the truth” and turning  a blind eye was fine as long as there were profits. They say that Americans didn’t want “the truth.” They want us to believe that they are victims of circumstances beyond their control. What should we think of primary care doctors who put themselves on the same playing fields as these execs asking for a bailout?

Internists and family doctors are the backbone of a vibrant healthcare system that is cost-effective [see later blog post to learn why]. But, for far too long we in primary care have piggybacked on the insurance systems, relying on them to pay the bills, even when the costs of administering that is more expensive than the care provided in most cases.  This has slowly weakened our doctor-patient relationships and our advocacy for patients, thus compromising our power and professionalism. By casting its lot with third party payers, primary care essentially has announced that it wants someone else to fix the problem of affordable care.

I feel that the solution to primary care is simple. We should not be looking for a bailout. Instead, primary care doctors must step up to initiate change. Personally, I stopped waiting for someone else to rescue me or tell me how to do my job, promising they could make me happy. The restructuring I’m suggesting to revitalize primary care is that patients retain control of the funds they (and their employers) have been giving to the insurance companies for their day-to-day care (which now account  for about 30% of total costs), and directly purchase the services they need from doctors who serve them best. Doctors in Oregon (, New York City ( and Northern Virginia  ( already have set up such practices. These doctors have developed innovative business models that deliver better care to patients at much lower cost.  But these will only spread on a large scale if patients understand the value of these new business models, and flock to support them.

More details about the changes needed can be found on our website or by listening to our story with “The Story” on National Public Radio, and in this blog in the coming weeks.

Until then, I remain yours in primary care,

Alan Dappen, MD

Primary Care Wednesdays: Where Did Marcus Welby Go?

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By Steve Simmons, M.D.

Photo of Steve Simmons, M.D.

Steve Simmons, M.D.

In the early 70s Marcus Welby MD, embodied the expectations of patients and the hopes of doctors seeking to emulate his bedside manner.  Sadly, when we look at medicine today, patients and doctors alike are left wondering what happened to Welby’s style of patient-focused medicine.  Much has changed in healthcare during the nearly 40 years since the show first aired.  Patients are more informed and expect to be included when clinical decisions are made.  Insurance companies and government bureaucracies have wrested control of the patients from their doctors.  Doctors must now focus on business and mind-numbing paperwork to the detriment of their medical knowledge and patients.  Runaway costs and an impersonal health care system dominate the landscape of the early 21st century.

The interests of the patient should be paramount and the doctor-patient relationship sacrosanct; however, by inviting a third party into this relationship the interests of the patient are frequently subverted.  The office meetings of the past, where difficult medical cases would be discussed, have been replaced with business meetings, insurance coding seminars, and a parade of experts reminding physicians to sit during the office visit to create the impression of more time being spent with their patient.  The inevitable frustration patients feel is directed towards their physician, who in turn has been saddled with his own frustration trying to merge ethical and business concerns.

Doctors are leaving primary care in droves, half planning to work less, become administrators, or retire.  A survey of medical students discovered hectic clinics, burdensome paperwork, and systems that do a poor job of managing patients with chronic illness as reasons for not choosing primary care medicine. Only 2% of students plan to select general internal medicine as a career. Most students are becoming specialists, where they can make more money, glean respect, and better control their schedule. If national healthcare becomes a reality, today’s critical shortage of primary care doctors will become problematic when the uninsured start looking for a doctor.

What qualities do we want in a primary care physician and what role do we need him to play in our lives?  A succession of TV doctors: Welby, Hawkeye, and now, House, share the virtues of diligence, attention to detail, and moral courage.  They can help us track the evolution of our patient’s expectations over four decades.  Dr. Welby’s patients willingly followed his guidance and instruction, while Dr. House’s patients live in the Information Age and have probably searched the internet before seeking his help.  Unfortunately, the admiration felt for Dr. House helps demonstrate that an entire generation expects an aggressive and uncaring doctor, thinking it the norm.

In 1979, Alan Alda gave the commencement address at Columbia University Medical School, titled, “On Being a Real Doctor.”  He said, “We both study the human being and we both try to offer relief–you through medicine, and I through laughter–but we both try to reduce suffering.”  Few believe today’s healthcare system is focused on suffering.  Third party payers are holding on to the money, controlling care, and this influences doctors. Patients like physicians have lost focus on what really matters: to ease suffering.

I sometimes imagine Dr. Welby practicing medicine today.  Towards the end of his day I see him sitting behind his desk, entangled in red tape, frustrated by his inability to untie the knot binding medical and financial realities.  His waiting room is full of patients, dragging the same red tape behind them. 

Fortunately, if one doctor’s argument is correct and all primary care physicians are Marcus Welby, we have reason to hope.  Our healthcare system is broken, but not irrevocably. Doctors and patients can stop wrestling against their constraints, turn away from their frustration, and find each other.  Patients will use access to information and drive health reform forward; many are speaking up today.  Doctors would do well to remember we are all patients but the onus of explaining the healthcare crisis and proposing meaningful change falls on physicians.  In our practice, doctokr Family Medicine, we try to cut red tape wherever we can, striving for an open and transparent practice, placing the doctor-patient relationship central in everything we do.  I believe you can find a doctor like Marcus Welby in your community and hope our posts will encourage you to try.

Until next week, I remain yours in primary care,

Dr. Steve Simmons, doctokr Family Medicine

Where Have All the Family Practice Doctors Gone? First Aid for Primary Care


By Alan W. Dappen, MD; Steve Simmons, MD; Valerie Tinley, FNP of Doctokr Family Medicine

We are a family doctor, an internist and a family nurse practitioner working on the front line of the American health care system. We share a moral and ethical duty to protect the health of our patients along with all our colleagues who labor daily doing the same.We as Americans are proud of what has long been considered a first-rate health care system. Sadly, this system is broken despite our best efforts. Americans spend much more per capita for care as any other country. The World Health Organization has graded our care as 37th “best” in the world. Even worse, American citizens were the least satisfied with their medical care compared to the next five leading socialized industrialized countries, including England, Germany, Canada, Australia and New Zealand. There are many things wrong. Let’s examine a few:

Primary care medicine in America is gasping for its last breath. Internists, family doctors, pediatricians (whom health experts consider essential to a robust and cost-effective delivery system) are leaving primary care in droves. The number of newly trained generalist doctors has plummeted so fast that extinction of the generalist doctor has been forecasted within 20 years by both the American Academy of Family Practice and the American College of Physicians.

Patients are angry and exasperated with long delays, poor service and confusing and redundant paperwork. To date 17% of us are uninsured and this number will quickly grow in a deepening recession.

Employers face a huge cost burden as health insurance prices go through the roof. CEOs consistently say the runaway costs in health care benefits (which double in price every seven to ten years) threaten the viability of their companies. Since 2000, the number of small businesses offering health insurance has dropped 8%.

Health insurance companies are making so much money that several states have motioned legislation compelling insurance companies to disclose the percentage of premiums spent on actual medical care. Not surprisingly, their lobbyists are resisting. It is not uncommon for insurance companies to keep 30-40% of every dollar for “administration” and profits. Many of these companies are on record reaffirming their commitment to shareholders and short-term profits.

Doctokr (“doc-talker”) Family Medicine is a medical practice that was created to respond to the conflicts and problems listed above. We have worked to resuscitate the soul of the Marcus Welby-style patient-focused physician while adding technology to deliver fast, responsive and informed care. All fees are transparent and time-based and are the responsibility of our patients to pay. All parties that interfere with the doctor patient relationship or increase our costs have been removed from the equation. The practice delivers “concierge level” services: 24/7 access, connectivity to the doctor no matter where our patients are located, same day office visits for those that need to be seen, even house calls for those unable to get to our office. By removing the hurdles and restoring transparency and trust, 75% of our clients get their entire primary care needs met for $300.00 a year.

This post is written by three medical professionals who stopped waiting for someone else to find a solution and are actively changing primary care in ways that dramatically improve quality, convenience and access, while drastically reducing costs. The US deserves excellent health care and it must be done right. To understand why we would bother to “walk the walk,” we ask your indulgence and participation while we “talk the talk.” We hope this format will educate and inform you in ways that move you to participate in your care. Health care is about you, just as much as it about us, because we are all patients. We all have a stake in shaping the inevitable need for reform.

The next upcoming topics:

  1. Where did the Marcus Welby, MD-style of primary care go and how can we get it back?
  2. How have you as a patient lost control of your body and health?
  3. Turning the primary care model upside down: What does primary care need to do to reinvent itself so that it serves its patients without other conflicting interests?
  4. Begin the exploration of the unexamined assumptions of health care….

Until next week, we remain yours in primary care.

– Alan, Steve, and Valerie


Primary Care Wednesdays: Pioneering PCPs Offer Insights On Healthcare Reform

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I’m really proud to announce the addition of my very first, regular guest blogger team: the healthcare professionals of Doctokr Family Medicine. Each Wednesday they will bring us new insights from the frontier of primary care – their cash-based, high tech, low cost service meets the needs of thousands of local patients at an average yearly cost of only $300. These primary care providers are happy, unhurried, and unfettered by insurance paperwork. They provide 24/7 care by phone, email, office visits and house calls. They’ve negotiated affordable rates with local labs and radiology services and pass on those savings to their patients. Their prices are transparent, affordable, and membership fees are very low.

Sound too good to be true? Well, check back every Wednesday to see what the doctors and nurses of an American primary care revolution have to say.

Their first post will be featured live at 8am, Wednesday, December 3rd.

Left to right: Alan Dappen, M.D.; Steve Simmons, M.D.; Valerie Tinley, N.P.


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