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Thidwick’s Horns & The Diminishing Autonomy Of Primary Care Physicians

thidwick-tmWhen I think of the plight of primary care practitioners, particularly in the light of today’s discussion of healthcare reform, I often think of a Dr. Seuss book. My mother read it to me as a child recovering from the chicken pox.  I read it to my two sons when they were young. And I encourage you to read it too, even if you’re an adult. The book is entitled Thidwick The Big-Hearted Moose. To me, this 1948 story almost perfectly mimics  the overburdened lives of  primary care physicians and the innumerable squabblers who’ve come along for the ride in the misguided world of healthcare.

For those who haven’t read Thidwick, here’s a recap of the story: Thidwick is a kind “big hearted” moose blissfully grazing with the rest of his herd on Lake Winna-Bango, minding his on business. One day a Bingle Bug asks if he can ride upon Thidwick’s enormous antler rack for free. Read more »

Insights From Harvard’s Primary Care Innovators Round Table

In 2005, I was invited to participate in an innovators’ workshop by the Harvard Interfaculty Group, funded through a grant from the Robert Wood Johnson Foundation. The question at the meeting was this:

“If primary care is critical to a vibrant and cost effective healthcare system, and
If primary care is going extinct, which most now predict;
Who is out there innovating new primary care systems and what is their vision?”

During the four years since this conference, I’ve found that this question is first and foremost when it comes to changing primary care.

I felt honored and surprised to be invited to the meeting. After all, our practice and its innovations are simple and are based on the following: Read more »

For Lack Of Transparent Prices

I am approaching an important anniversary of my heart attack. Until then, I had missed but a single day of work due to illness since starting medical school in 1975. Even in the middle of the heart attack, I played an entire ice hockey game, slept a few hours, had a business meeting with a fellow doctor at Starbucks, and went back to the office to see patients.  In retrospect, my actions could be labeled as folly, bravado, machismo, denial, and lucky. I accept all labels as true. Without a trace of shame I have shared this archetypal story with friends, and patients hoping that by laughing hard enough at me, I might prevent at least one person from dropping dead from stupidity. Read more »

Telemedicine As The Cost-Saving Foundation To Healthcare Reform

A Keynote Address To The American Telemedicine Association September 25, 2009

The following is a summary of Alan Dappen, MD, keynote address at the mid-year meeting of the American Telemedicine Association (ATA). His keynote, billed as “Private Practice And Telemedicine: A Success Story” discusses how Dr. Dappen’s practice, DocTalker Family Medicine, which is a fee-for-service practice that deploys telemedicine for over 50% of its patients needs, has enjoyed growth and has received numerous awards and media attention. You can check out Dr. Dappen’s full address on the site.

On to the highlights of Dr. Dappen’s talk:

“This is my third visit to an American Telemedicine Association (ATA) event. I’ve been a proud member for seven years. Two years ago I presented the fundamentals my medical practice DocTalker, where the doctor is chief cook and bottle washer.

“Our practice mirrors the recommendations outlined by the Institutes of Medicine’s book
Crossing the Quality Chasm and those purporting the ‘medical home’ model. Read more »

Journey of the Piñata Master Part 2: The Great American Health Care Bash

As I mentioned in my post last week, Journey of a Pinata Master, The lessons of a piñata party are many and subtle, where children must acquire sufficient skill and insight to reach the highest status. Let me show you how the custom of the Mexican piñata, stuffed with candy and used to placate children, has been adopted unwittingly by the U.S. healthcare system to create the Annual American Healthcare Bash. At this gala, candy replaces money and adults represented by special interest groups fill in for children.

The American Healthcare Bash is hosted yearly by insurance companies and the government. These two organizers start asking for donations. In 2009, the piñata will be stuffed with $2.4 trillion (give or take a few billion). In 1999, the piñata held a measly $1.2 trillion. By 2019, piñata is expected to hold $4 trillion. Party planners already are worried about finding a rope strong enough to hold this massive elephant piñata (or donkey, depending on which animal you prefer to hit).

Donations arrive through taxpayers, employers and anyone willing to gain admission to the festivities. Before the party starts, insurance companies remove 20% of the money as their “set-up fee” for hosting and establish the basic game rules. During the event, they take turns controlling the rope holding the piñata.

Any American who contributed to the party, including everyone over 65, is invited to watch the spectacle as the myriad special interest groups (SIGs) take turns batting the piñata. These SIGs include ad almost infinitum: primary care doctors, nurse practitioners, radiologists, imaging specialists, laboratory services, pharmaceutical companies, durable medical suppliers, lawyers, software engineers for electronic medical records, coders, billers, patient navigators, receptionists, schedulers, nurses, billing specialists, hospital administrators, HIPPA compliance “police,” pay-for-performance analysts, the American Medical Association delegates, and hundreds of other professional organizations and credentialing specialists.

Every year, more SIGs have been invited to the gala for their turn to bash the piñata. Most thank the public for such an extravagant event, repeating the chorus, “Don’t worry what this is costing, we’re not hurting you, we’re going after the piñata.” This piñata promises more loot than any other in America.

One by one, players are blindfolded and spun in dizzying circles by the insurance companies or government. Patients start the play and then hand we doctors the bat saying, “Good luck! Give your best shot at whacking what you can from that piñata! I could care less because I’m “protected” by my insurance plan.”

Each player swings wildly, sometimes accidentally bashing the others crowding around the bobbing target. The crowd roars its approval while some SIGs scream instructions of where to aim as the batter swings away. The rope jerking increases as more skilled batters take their turn. When money pours from the breaking hull of the piñata, hordes of SIGs dive in a feeding frenzy. After decades of careful construction, the piñata has been compartmentalized so that no single player can knock out too much money at once.

As the party winds down, most SIGs have received a “fair “ amount of money, but they are angry, never satisfied with their share. Of course, there are a few masters in the crowd, who are grinning ear-to-ear.  When the party closes, the insurance companies take the piñata to another room and remove, behind closed doors, the remaining money (profit) of the day.

After counting its loot, the insurance companies emerge, announcing that it’s been another successful party, drinks all around! Then they say, “The party next year will cost only 8% more. Before you leave tonight, pay up.” Feeling threatened, taxpayers and employers reach deep into their pockets to pay for next year’s gala. Why ruin a great American tradition? If you get sick or don’t pay “your fair dues,” then hasta la vista.

As we grow up, most of us move past the need to gorge candy. Contrarily, when it comes to healthcare, few can limit how much they want to consume, nor recognize its often empty promises. Americans watch with fascinated horror at what’s happening in healthcare while remaining paralyzed to move cohesively towards change.

No matter how well intended and dedicated the doctors and nurses or how amazing the technology and medical breakthroughs to which the  “insured” have access, the unrelenting piñata party lure inevitably results in a mass psychology of “How much money can I make?”

If you, dear reader, are scared of change and continue to support the current  American healthcare piñata party, then be prepared to be beaten to a pulp. Now that you’ve paid your $20 co-pay entrance fee to the party and have emptied your wallet to the insurance company for what you believe is unlimited access to care, you have unwittingly turned yourself into the piñata.

Personally, after lots of experience and practice, I developed a healthy cynicism regarding the greed of this kind of parties.  Ten years ago, I no longer could support the American Healthcare Bash. We built a new practice where the only focus is the patient; the patient pays transparently for the time they need. This idea delivers better care, 24/7 immediate access whenever and wherever you need help at a price that is almost 50% less than the current model.  We need a lot more healthcare professionals and patients to invest in a new future of responsibility. A growing mantra is needed among patients and doctors alike, ”Do the right thing, for the right reason at the right price.” Unlimited wealth, and unlimited health are nothing but mirages, the deepest secret of all stuffed inside the piñata.

Until next week, I remain yours in primary care,

Alan Dappen, MD

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