April 29th, 2009 by AlanDappenMD in Primary Care Wednesdays, Uncategorized
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In early 2006, four years into running my current medical practice, doctokr Family Medicine, I got a call from my medical malpractice carrier. Just weeks before I’d received a notice that my malpractice rates could go up by more than 25%. The added news of a pending investigatory audit was chilling. In 25 years of practicing medicine I’d never been audited.
“Is there a complaint, or a law suit against me that I don’t know about?”
“No,” the auditor told me over the phone, “We’ve never seen a medical practice like yours and feel obligated to investigate your process from a medical-legal perspective.”
“Great,” I thought, with a weary sigh. “I’m already battling the insurance model, the status quo of the medical business model, and slow adoption by consumers who are addicted to their $20 co-pay. All I’m trying to do is to breathe life into primary care and get the consumer a much higher quality service for less money than currently subsidized through the insurance model. And now this.”
The time had arrived to add the concerns of the malpractice companies to the list of hurdles to clear if a new vision of a medical care model was ever to catch flight.
I frequently am asked the question “Aren’t you afraid of the malpractice risk?” when I explain my medical practice model, which is based on the doctor answering the phone 24/7, resulting in the patient’s medical problem being solved by the phone more 50% of the time. The simplest counter to this question is to analyze the risk patients incur when the doctor won’t answer the phone. What happens when the doctor is the LAST person to know what’s going on with patients? The answer is obvious. But malpractice companies could have concerns beyond patient safety. Buy-in from the malpractice companies would be critical to the future viability of all telemedicine.
I prepared a summary paper, which included 12 bullet points, explaining how a doctor- patient relationship based on trust , transparency, continuous communications and high quality information systems significantly reduce risk to the person you’re trying to help.
Bullet 1: The industry standard is that 70% of malpractice cases in primary care center on communication barriers. My medical team deploys continuous phone and email communications and 7 days a week- same day office visits when needed between doctor and patient thus significantly reducing these barriers.
.
The remaining bullets could be summarized by the conclusions from the Institute of Medicine’s visionary book Crossing the Quality Chasm: A New Health System for the 21st Century using a table developed by The American Medical News when they reviewed the book. I carefully plotted our practice standards compared to the traditional business model as it stands today based on this table:
The auditor showed up, spent 4 hours reviewing our practice, electronic medical records, compliance to HIPPA, our intakes, on-line connectivity, procedures, and practice standards. While the auditor reviewed, I sat as unobtrusively as I could, feeling my brow grow damp with perspiration, as I carefully answered her questions. During the auditor’s time, I never moved to sway her to “my way.” I just let the data that I had accumulated from four years of practice do the talking.
Once the auditor left, I waited for two weeks for the results. By the time their letter arrived, I was scared to open it. The news arriving made me jubilant. The medical practice company announced a DECREASE in my premiums because we used telemedicine and EMR to treat patients so fast (often within 10 minutes of someone calling us we have their issue solved without the patient ever having to come in).
I will admit that I felt, and actually still do feel, vindicated by having my malpractice insurer understand fully the value that the type of telemedicine my practice offers to our patients: round-the-clock access to the doctor, speed of diagnosis, and convenience, which all led to healthier patients and lower risk.
Doctors answering the phone all day for their patients, it’s not just lower risk, it’s better health care at a better price. It’s a win-win-win strategy whose day is arriving.
Until next week, I remain yours in primary care,
Alan Dappen, MD
April 22nd, 2009 by AlanDappenMD in Primary Care Wednesdays
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By: Valerie Tinley, MSN, RNFA, FNP-BC
House calls have long been associated with primary care providers (PCPs), the proverbial “black bag,” and days gone by. Unfortunately, house calls are often just a memory or something we watch in reruns on the television.
Those people that best remember the prevalence of house calls, the elderly, may be the same population whose needs will bring house calls back from the brink of extinction and return them to the mix of services offered by PCPs.
House calls should be a core offering of PCPs, since by nature we help patients from cradle to grave. Therefore, some of these patients may not be able to come to see us because they are too old or too sick or immobile.
Why then can’t PCPs go to these patients? We certainly can solve the majority of primary care problems where our patients want or need to be seen, including in their homes, whether these problems are run of the mill day-to-day issues; or those associated with chronic, continuous care diseases; or even many urgent care issues.
Unfortunately house calls are rarely offered because many PCPs view them as too time consuming and therefore too costly to conduct.
The need for house calls for these populations will not go away. The populations that house calls can help include:
• those that are bed bound, very old, who want to age at home rather than a nursing home;
• those suffering from dementia;
• those recently discharged from the hospital, and unable to be mobile short term or long term; and
• those that are receiving hospice care.
Many of these people cannot leave their home, or more importantly, should not leave the home, to go to the doctor’s office for an office visit. It is important to understand how very expensive this is for the caregiver, in terms of time, lost hours on the job, effort and transportation costs, all to actually get them to the medical provider’s office, because their loved ones have problems with mobility or other hindrances.
The result? There are many in need of medical care that cannot receive it. This increases medical problems and mortality. When healthcare is ignored or foregone for the most routine of problems, more expensive and much more serious healthcare issues arise in its place.
A recent article in the New York Times reported that keeping geriatric patients out of the hospital and getting them the care the need at home can result in a cost savings of between 30% and 60%. In addition, a house call program, piloted by Duke University, has reduced the number of hospital admissions for those patients unable to get to the doctors office by 68% and the number of emergency room admissions by 41%. These patients are thereby healthier, and even safer, working with a PCP that makes house calls.
Several organizations currently offer house calls as a core part of their services offerings, like Urban Medical in Boston, or the practice I am with, doctokr Family Medicine. Also there are beginnings of pilot programs for house calls, like the one at Duke’s Medical School which was mentioned earlier.
But these are only a few providers, and the movement needs to be widespread. Our aged population needs it and we as primary care providers should be listening to their needs and providing for these needs. Otherwise, we are falling short.
Until next week, I remain yours in primary care,
Valerie Tinley MSN, RNFA, FNP-BC
April 15th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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
March 26th, 2009 by Dr. Val Jones in Expert Interviews, Opinion
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When most people think of “cash-only” medical practices, plastic surgery and dermatology procedures are top of mind. But there is a small contingent of primary care physicians who offer low-cost “pay-as-you-go” services. Yearly physicals, well-child visits, screening tests, vaccinations, and chronic disease management are all part of comprehensive primary care options available. And this costs the average patient only $300 a year.
It is estimated that 75% of Americans require an average of 3.5 office visits per year to receive all the medical care they need. If the average office visit is 15-20 minutes in length, then that averages out to 1 hour of a physician’s time each year. How much should that cost? Dr. Alan Dappen (founder of Doctokr Family Medicine, a cash-only primary care practice in Vienna, Virginia) says, “$300.” But insurance premiums are often closer to $300 per month for these Americans, and that doesn’t include co-pays for provider visits.
So why aren’t people buying high deductible insurance plans, saving thousands on premiums per year, and flocking to cash-only primary care practices? Dr. Dappen says it’s a simple matter of mindset – “People have been conditioned to believe that if they pay their insurance premiums, then healthcare is ‘free.’ In reality, their employers are taking out $3600 or more per year from their paychecks for this ‘free’ care. But since employees don’t see that money, they don’t miss it as much.”
A high deductible health insurance plan (where insurance doesn’t kick in until you’ve paid at least $3000 out of pocket in a given year) costs about $110/month for the generally healthy 75% of Americans (you can check rates at eHealthInsurance.com). That’s a savings of at least $2280/year for those who switch from a regular deductible plan to a high deductible plan.
What are the odds that the average, reasonably healthy American will outspend $2280/year? I asked Alan Dappen how many of his 1500 patients spent more than $2000 on his services per year. The answer? Three.
“Most Americans who buy-in to low deductible plans pay a lot more in premiums than they’ll ever use. They’re essentially betting against the casino, and we all know who wins on those bets.”
So I asked Alan Dappen if “the casino” was making most of its money on the “healthy” 75% of its enrollees to subsidize the cost of the sick 25%.
“Sure they are. And I suppose if enough people saw the light and switched to high deductible plans with cash-only physicians, it might force change in the health insurance industry. Perhaps the government would use our taxes to help subsidize the sicker patients.
The bottom line is that at this very moment, 75% of Americans could be saving thousands of dollars per year on their healthcare costs – and have their very own cash-only primary care physician available to them 24-7 by phone, email, home visit, or office visit. The cash-only doc can afford to offer these conveniences because they are paid by the hour to do whatever the patient needs done, without forcing the relationship to conform to insurance billing codes. In fact, the physician saves a bundle on coding and billing fees – and can pass that on to the patients.”
I wondered about the outrageous costs of laboratory fees and radiology charges for people who don’t qualify for the insurance company negotiated rate. Dappen explained:
“My practice has negotiated similar rates with local labs and radiology groups. Screening tests and x-rays are very reasonable.”
I asked Dr. Dappen who uses his services.
“I see both ends of the spectrum. The high-powered executives who don’t have the time to wait in a doctor’s office and enjoy the convenience of handling things with me via phone or house call. For them, time is money, and by losing half a day or more traveling to a doctor’s office and waiting for their 15 minute slot, they might lose $5000 in billable work time. On the other end I see patients with no insurance or high deductible plans. They enjoy the same conveniences, and end up paying an average of $300/year for their healthcare. This is high quality care that they can afford.”
I guess the only thing preventing this model of healthcare from taking off is the courage of individuals to try something new. I myself have switched to a cash-only practice with a high deductible health insurance plan, and have saved myself thousands a year in the process. I love the convenience of knowing that my doctor has all my records in his EMR, I have his cell phone number, and he can renew my prescriptions with a simple email request. I can’t imagine why more people aren’t doing this.
Alan Dappen says, “They just have to wake up out of the Matrix.”
**For more in-depth coverage of the rising trend in cash-only practices, check out MedPage Today’s special report.**
March 18th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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
