August 5th, 2009 by AlanDappenMD in Primary Care Wednesdays
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When I describe our medical practice, most people really like the concept: Our medical team at DocTalker (board certified doctors and a nurse practitioner) answers all the incoming patient phone calls and emails directly, solving over 50% of our patients needs remotely and conducts office visits and house calls when needed even at night and on weekends. People ooh and aah, offering praise: “What a good idea!” … “You’re really ‘retro’ — just like the quaint, old-fashioned doctor my grandparents used to describe so fondly” … “I wish my doctor did that!”
Yet there is a point at which our concept “loses” people, and it is when we describe that we have opted out of Medicare and sign no contracts with insurance companies. We are not preferred providers for anyone except our patients, and therefore no one is interfering with our relationship or telling us how to do our job. We have dismissed all of the parties that create conflicts of interest between ourselves and the patients, including those that add higher costs (e.g. drug reps or pay-for-performance administrators); or create conflicts of interest that interfere with the doctor- patient relationship (e.g. insurance) and the ability to deliver accessible, high-quality care (e.g. billing, coding, and administration organizations).
Instead we have moved to a transparent, time-based fee structure so that our clients can police our charges. Time is time. We make our living offering advice and time, no gimmicks, no sales. It’s that simple. If you don’t want to pay us for the time it takes to do the right thing for the right reason, or to be in control of when and how and who controls your health decisions, then we’re not the practice for you.
After this explanation, we typically get one of two responses:
1) “Thank you very much, but I just lost interest.”
or
2), “Oh, you’re a concierge doctor.”
We have come to expect the first response. The idea of paying directly for a service in healthcare remains foreign to most. The vast majority of Americans have been “socialized” over the years that paying monthly insurance premiums and adopting a co-pay model protect them from worrying about price from the often predatory and non-transparent pricing habits of the healthcare industry at large.
To the second response, we say that we are like a concierge practice … just priced for almost everyone. To begin with, we deliver a concierge level of care: comprehensive primary care, answering phones and emails directly, trying to deliver care whenever wherever and however its needed, seeing patients on the same day, being available to talk 24/7 no matter where a patient may be in the U.S., and even coming to a patient’s home at 3 AM if needed. We are doctors and want to do what’s best for our patients.
But after this point, the DocTalker model and others like it add a whole new dimension to the concierge model, thus requiring a category unto itself. We offer this high level of care for almost everyone because we make accessing quality care so affordable. About 75% of the members of our practice get all the day-to-day health care they need every year for less than $300/year. This is much less than the amount of money than the $1500/year membership fee required of many concierge practices which basically puts a premium price on access before they even begin to bill your insurance company.
Practices like ours expect to be busy, have to take care of many people of all ages and socioeconomic status, maintain active panels of patients approaching 2000, don’t expect to make tons of money while trying our hardest to give you the best service at the best price we can. We love primary care, want the best for our patients, and this is why we do it.
Our “Back to the Future” medical practice restores an integrity, balance, affordability and quality to healthcare that people need. It also delivers concierge level of service at a price that’s much less than most out there. Even President Obama says he’s looking for examples of better access, higher quality, at a lower price. There are others like us out there, including HelloHealth and Greenfield Health.
It’s not complicated to get accessible, affordable care and high quality primary care again once all the layers are eliminated of well intended administrators and obfuscators getting in the way of a doctor and any one seeking help.
It may not be complicated, but it’s not easy to find. There just aren’t enough of us yet. In the meantime, please excuse my sensitivity to the word “concierge.” I prefer phrases for this emerging movement like “patient-controlled primary care,” or “no nonsense care,” or ”patients first.”
Until next week I remain yours in primary care,
Alan Dappen, MD
August 4th, 2009 by DrRich in Better Health Network, Health Policy
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Before the election, the right-wing commentators insisted to us that Barack Obama was a closet socialist. They hounded us repeatedly with the notion that Mr. Obama hung out with the likes of Jeremiah Wright and Bill Ayers, and that in fact virtually all of his acknowledged friends and advisors were dangerous leftists. When Mr. Obama innocently told Joe the Plumber that he wanted to “spread the wealth around,” you’d have thought he’d announced his intention to replace the Constitution with the Communist Manifesto.
And the righties have been even more vociferous since President Obama took office. In high dudgeon they beseech us to notice (dear God!) that in six short months he has gathered into the grasping embrace of his government a good chunk of the American economy, from GM and Chrysler, to Fannie Mae and Freddie Mac, to the world’s largest banks and investment houses – and in short order he intends to take over the entire healthcare system, now fully 16% of our economy and growing rapidly.
At the same time (they insist) he is doing everything he possibly can to stifle American business. He is raising business taxes during a deep recession, and is pushing Cap and Trade, which will put American businesses at a huge disadvantage in the world market. They say that the massive deficits Mr. Obama is accumulating at unprecedented rates will place our economy in grave jeopardy within a decade, and that our children and grandchildren will never be able to extricate themselves from the pit of debt he will have left them. They point out that Fidel Castro and Ceasar Chavez, avowed Communists, look at Mr. Obama’s doings with great awe and respect bordering on jealousy. The right-wing commentators say lots of other stuff, too, to prove Mr. Obama is a radical lefty, but for DrRich all these allegations blend together after awhile, and it becomes difficult to recall the specifics. (One thing they hardly ever mention is that the first step in the Great Government Takeover of Everything was taken by President Bush. Mr. Obama has merely accelerated the pace down this path from a saunter to a sprint.)
DrRich must admit that, even for someone as objective and open minded as he is, it can become easy to view the incredible flurry of policy achievements Mr. Obama has pushed through so far, and his aspirations for even bigger ones still to come, and wonder whether, perhaps, this great experiment of unprecedented government spending, and huge new entitlements that will continue on down through the generations, might not be just a tad risky.
And it is even more disturbing to consider that, if one indeed wanted to bring down the American system in order to have the opportunity to remake it from scratch (this time, emphasizing equity of outcomes rather than individual freedom as a central organizing principle), then burdening the system with crushing entitlements and crushing debt would seem to be a pretty serviceable method for achieving it. And this is exactly what the right-wing commentators would have us believe is President Obama’s real aim. (Which is why, they say, they dare commit the very grave sin of publicly hoping President Obama will fail. Only Democrats, it seems, are permitted, with political correctness, to voice such hopes about opposition presidents.)
So even DrRich (a paragon of objectivity) was beginning to have his doubts about Mr. Obama’s real commitment to the American experiment.
But in his press conference last week Mr. Obama allayed all DrRich’s fears, and made him ashamed he had ever entertained such doubts. If he really meant what he said in that press conference, it is impossible for President Obama to be a radical leftist.
Recall his typically eloquent words: “You come in and you’ve got a bad sore throat, or your child has a bad sore throat or has repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”
Now, don’t you feel better? DrRich certainly does.
Of course, certain short-sighted physician groups immediately and unproductively took offense at this comment. There is no reason to. After all, Hillary pronounced 16 years ago that the problem with the American healthcare system is: Too many greedy doctors using too much expensive technology. And that’s pretty much been the sum of it ever since.
So even if Mr. Obama meant to insult doctors with his comment, he was simply restating one of the chief premises dearly held by most healthcare reformers. He wasn’t breaking new ground in any way. So doctors shouldn’t be acutely insulted here. (They should be chronically insulted. )
If there’s anything to regret about Mr. Obama’s statement, it’s that it reveals a sad misunderstanding of one important aspect of how the healthcare system works. Kids with sore throats don’t go directly to the greedy otolaryngologists, the guys who get paid “a lot more money” if they take the kid’s tonsils out. Rather, they go to primary care doctors, often pediatricians, who (if anything) are punished for sending too many kids to the greedy otolaryngologists. (DrRich knows several fine pediatricians, and not one of them any longer possesses those nasty looking tonsil scoops, or whatever those dire instruments are called which are used for removing the offending glands.) So the system is actually geared toward having kids suffer with chronic sore throats until the PCP just can’t ignore the problem any more. The ones who are finally referred to the greedy specialists often really, really need to have their tonsils out. The pediatricians aren’t referring patients for tonsillectomy all willy-nilly, and the greedy otolaryngologists (even if one supposes they always rip tonsils out first and ask questions later) must find other means of paying for their speedboats. DrRich’s point being: In the real world, using the abuse of tonsils as an example of run-away healthcare spending just doesn’t work very well.
It seems a shame that Mr. Obama does not have even a basic understanding of the system of incentives that exists today within the healthcare system, especially since he aims to fundamentally change it. But then, since he allows that he hasn’t even personally read the healthcare reform bills he’s urging Congress to make into law, one cannot really expect him to have an intimate understanding of the present system, which he hopes to soon render obsolete anyway. It would be a waste of his valuable time to come entirely up to speed on a system which is apparently in its last days.
Back to the point of this post, and it’s a point that – sad to say – every other commentator seems to have missed. (Proving, once again, how lucky DrRich’s readers are to have him.)
When President Obama declared that greedy physicians will commit surgery on unsuspecting and innocent children just because the reimbursement rate is higher, nobody seems to have noticed that what he was saying was, “Doctors respond to fiscal incentives.” And since a committed egalitarian like the President would surely not believe that doctors are fundamentally different from every other type of human person, he was really saying, “People respond to fiscal incentives.”
There it is. Mr. Obama explicitly and publicly believes the one thing that no committed Communist or radical leftist is permitted to believe, namely, that people respond logically to fiscal imperatives.
Fundamentally, socialism requires people of ability to work very, very hard for the public good, to support those who cannot or will not work hard, and as a reward they can expect to receive praise from the ruling class.* Knowing their toil is for the good of everybody should suffice as incentive aplenty. This is precisely why radically left-wing social systems (which DrRich has always thought in principle to be a very nice idea) have never worked – and never will work.
For no system of societal organization can work well for long that requires, as a first premise, a fundamental change in human nature.
So right-wingers who have railed against the overt left-wing policies of Mr. Obama, and the more moderate people who have been starting to have their own doubts, should now breathe a great sigh of relief. Whatever else our President may be, he cannot be a committed leftist.
Even though the cost of learning this vital fact was another insult to the basic integrity of doctors, it was really just one more insult superimposed on a world view that defines doctors to be fundamentally greedy and inconsiderate of their patients’ actual needs. No big deal. For the cost of that small price, we now know that President Obama must be – has to be – a committed capitalist after all.
*In practice, of course, those who take risks and work hard for personal gain are never actually praised for their contributions to the public weal, even if those contributions are enormous and stifling. Rather, they need to be demonized; otherwise some would think it unfair to take their hard-won gains from them.
*This blog post was originally published at The Covert Rationing Blog*
August 4th, 2009 by DrRob in Better Health Network, Opinion
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They gathered around the figure who was lying with face toward the ground. Holding stones, they demanded justice – that the sin of this person be exposed for what it is: inferiority. Her sin had been exposed for all to see and the righteous rage of those who were pointing fingers and holding stones was pounding at her on the inside, just as the stones would soon pound her on the outside.
“Her BMI is over 30! It may even be over 40!” one of them cried out. The others responded to this with a howl.
“How can she be fit for leading the country’s health if she can’t even fit into her pants?!” another asked, causing raucous laughter to echo from the crowd.
Nearby, a news reporter spoke into a camera: “People are questioning her fitness for surgeon general, as she obviously is overweight. The president had initially hoped the popular TV doctor would take the job, but fell back on Dr. Benjamin as a substitute. Clearly a president, who himself is a closet cigarette smoker, doesn’t see the fact that she is overweight as a disqualifying factor. These people, and many others around the country, disagree with that assessment.”
———————–
Forty years ago, people would also have cried out about this nomination. They would have said that a woman shouldn’t be in charge of the nation’s health, or that a black person doesn’t have the wherewithal to manage such a big task. Times have changed, as her nomination shows – nobody is talking about these facts that have nothing to do with her ability to do this job. We have truly progressed.
Sort of.
This objection, of course, is that her weight shows that either she doesn’t understand what is causing her obesity, or that she doesn’t have the moral fortitude to successfully fight it. Either way, she’s disqualified for the job. Right? It’s a sign of weakness to be overweight, and we certainly don’t need someone with a personal weakness to be in a leadership position!
It is clear that some view the overweight (which, by the way, constitute 2/3 of our adult population) as being emotionally weak and somehow inferior to everyone else. After all, study after study has shown that the way to beat obesity is simple: eat less and exercise more. It’s simple; and those who don’t do it are weak, lazy, dumb, or just plain pathetic.
It angers me to hear these suggestions. Racist and sexist people put down others because of the fact that they are different than themselves. But the moral judgment against the overweight and obese is not meant to be a judgment against something inherent in the other person; it is a judgment against their character, their choices, and their weaknesses. The implication is that they are somehow either smarter, stronger, or just plain better than the overweight. The implication is that the other is weak and they are not.
There is a word for this attitude: hypocrisy. A bigot is a person who hates those who are different; a hypocrite is one that hates others for something they themself have, but choose to ignore. Both mistakenly act as if they have the moral high-ground. Both disqualify themself from any argument based on morality.
Healthcare exists because of human weakness. We all are weak in various ways, and we all will eventually die when one of our weaknesses overcomes us. Obesity exists because of human weakness – either the genetic or biological miscalibration of the person’s metabolism, or the inability of that person to act in ways that are in their own best interest.
I have to say that I probably fall in the latter category, as my lack of desire to exercise and my exuberant desire to eat rich foods make it so I have struggled with my weight for years. Somehow the prescription: eat less and exercise more, is not very helpful for me. Yes, it is simple; but it is not easy. Having others explain it to me at this point is not only unhelpful, it is insulting. Of course I know that my weight is a problem! Of course I know I should exercise more and avoid that cookie dough in the refrigerator!
To successfully fight the battle against obesity in our country, we have to stop the condescending finger-pointing and instead ask the question: why is it that we humans don’t always act in our self-interest? Why do smokers smoke? Why do alcoholics drink? Why don’t people take their medications, eat enough vegetables, or go for walks instead of watching The Biggest Loser on TV? This seeming self-destruct switch is, to some degree or another, present (in my opinion) in everyone. It is the same drama with different actors and props. We all sell our birthright for some soup at times. We all go the route of easy self-indulgence rather than personal discipline.
Does that mean we are all weak? Yes, in fact, it does. My admission of my weakness has actually made it easier to have frank discussions with patients about their own personal struggles – be they weight, smoking, or other self-destructive behaviors. They listen to me because I don’t insult them with statements of the obvious. If it was easy to lose weight, don’t you think we’d have a little less than 2/3 of the population being obese? Does 2/3 of the people remain overweight because they want to be that way? No, the problem is not that simple; and suggesting otherwise won’t do much to deal with our national problem.
Dr. Benjamin has impressive credentials. She is a practicing primary care physician who cares for the poor. She’s not some subspecialist TV personality; she’s a doctor who has spent a lot of time face to face with the neediest people in our system. She doesn’t just know about the poor and needy, she knows them. She’s one of us; and her weight does nothing to lessen that – for me it actually makes her more relevant, not less.
So put down your stones, people. We are all weak. Having someone who understands the real struggle of the overweight may actually give us a better chance to successfully fight it. And if some of you still hold stones, let me rephrase a famous statement: The person without personal weakness can throw the first stone.
*This blog post was originally published at Musings of a Distractible Mind*
August 4th, 2009 by DrWes in Better Health Network, Humor
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When looking for the cause of atrial fibrillation during a physical examination, not only can the doctor’s olfactory bulb be helpful, but so can the examination of what gets brought into the exam room.
Patient: “Hey doc, it’s just a Pepsi.”
Doctor: “Really? Can I see?”
Nothing a good knife and a piece of scotch tape can’t manufacture.
Case solved.
-Wes
*This blog post was originally published at Dr. Wes*
August 4th, 2009 by John Snyder, M.D. in Better Health Network, Quackery Exposed
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I generally know what’s coming next when a parent asks about altering their child’s vaccine schedule: “I was reading Dr. Sears….”
Dr. Sears is a genius. No, not in an Albert Einstein or Pablo Picasso kind of way. He’s more of an Oprah or a Madonna kind of genius. He’s a genius because he has written a book that capitalizes on the vaccine-fearing, anti-establishment mood of the zeitgeist. The book tells parents what they desperately want to hear, and that has made it an overnight success.
Dr. Robert Sears is perhaps one of the best-known pediatricians in the country. The youngest son of Dr. Bill Sears, the prolific parent book writer and creator of AskDrSears.com, Dr. Robert Sears has become the bane of many a pediatrician’s existence. He has contributed to his family dynasty by co-authoring several books, adding content to the family website, and making myriad TV appearances to offer his sage advice. But Dr. Bob is best known for his best-selling The Vaccine Book: Making the Right Decision for your Child. This book, or at least notes from it, now accompanies many confused and concerned parents to the pediatrician’s office. Parents who have been misled by the onslaught of vaccine misinformation and fear-mongering feel comforted and supported by the advice of Dr. Sears, who assures parents that there is a safer, more sensible way to vaccinate. He wants parents to make their own “informed” decisions about whether or how to proceed with vaccinating their children, making sure to let them know that if they do choose to vaccinate, he knows the safest way to do it. And for $13.99 (paperback), he’ll share it with them.
In the final chapter of his book (entitled “What should you do now?”), after reinforcing the common vaccine myths of the day, Dr. Sears presents his readers with “Dr. Bob’s Alternative Vaccine Schedule.” He places this side-by-side with the schedule recommended by the American Academy of Pediatrics and the CDC’s Advisory Committee on Immunization Practices. He then explains why his schedule is a safer choice for parents who chose to vaccinate their children. Without a doubt, the alternative vaccine schedule is among the more damaging aspects of this book. It’s the part that gets brought along to the pediatrician’s office and presented as the the plan going forward for many parents today. But the book is also dangerous in the way in which it validates the pervasive myths that are currently scaring parents into making ill-informed decisions for their children.
Dr. Sears discusses these now common parental concerns, but instead of countering them with sound science, he lets them stand on their own as valid. He points out that most doctors are ill-equipped to discuss vaccines with parents, being poorly trained in the science of vaccine risks and benefits. He then claims to be a newly self-taught vaccine expert, a laughable conceit given the degree to which he misunderstands the science he purports to have read, and in the way he downplays the true dangers of the vaccine-preventable diseases he discusses in his book. He then provides parents with what he views as rational alternatives to the recommended vaccination schedule, a schedule designed by the country’s trueauthorities on vaccinology, childhood infectious disease, and epidemiology.
So what does Dr. Sears have to say, exactly, about the risks of vaccines, and just how out of touch is he with medical science and epidemiology? Read more »
*This blog post was originally published at Science-Based Medicine*
