September 2nd, 2009 by AlanDappenMD in Primary Care Wednesdays
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My early childhood memories hit and miss like a receding dream until four years of age when I boarded my first airplane flight. Our family landed in Mexico City to live. The experience was the first of many jolts which awakened my dreamy complaisant memory.
Within weeks I started kindergarten. That first day was filled by my ceaseless crying. Much to my relief, I had mastered the art of playing hooky by the next morning. A week later I matriculated into the American school. Scary but at least fifty percent of the day was in English. It wasn’t long before a Mexican classmate invited me to his birthday party, complete with a piñata. I was too young then to understand that a piñata holds as much in life metaphors as candy and little did I realize then that this metaphor would resurface again in my life decades later as the efforts to reform the embattled U.S. healthcare system.
Like so many things that first year in Mexico, the piñata held excitement mystery and possibility. At that first party I was an eyewitness to a mob. The instant the piñata broke open the school of piranha-like children devoured the innards so fast that I was left dejected, clutching only a little scrap given to “the gringo” by some benevolent adult.
At the next party, when it was piñata, time, I was in the mix; I dove in before the final coup de grace and caught a piece of the bat. My strategy turned upon being first one in but missing the bat, only to learn that this transferred the piñata to the one embracing almost all the candy. I was jumped, kicked, whacked, gouged, and crushed to smithereens while all those greedy hands and bodies piled on me and plied the precious treasure for my hands. Once again I emerged with tears and a few scraps.
Finally by the fourth party I’d gotten adept with the bat and with a super satisfying whack disintegrated “the Toro” to shreds. Pay dirt at last. By the time, my blindfold was off, the scrum was well underway. The school of hard knocks was one more time teaching me a lesson.
Few activities can compete with a piñata party in a child’s imagination. It offers the opportunity of unimaginable candy treasures. After years of practice and experience the master can be picked from the crowd. This child can be seen as cool, calm, and collected. They bat early, never trying to break the treasure open but enough to soften it up. Once back in the pack they make subtle repositioning moves as the batter swings in different directions blindly thrashing at the swaying and bobbing papier-mâché animal idol. At the right moment they dive into the scrum usually coming up with a lot of candy. Winners keepers losers weepers. That’s the rules.
There are many strategies at the piñata party, the imagination of greed can get the best of you when all those marbles (or candy or money) sit inside that single collective pot.
Fifty years later I cannot help but reflect that the rules and spiritual lessons gained within the piñata experience are very applicable to the US healthcare system. With thirty years of healthcare experience I remain awe struck at observing the same sets of behaviors demonstrated at children’s piñata parties.
Be you the patient, doctor, hospital, pharmaceutical company, lawyer, supplier, coder, consultant, or insurance company, each party fully play out their perfect, “what’s in it for me” expression, “Don’t worry what this is costing, we’re just attacking the piñata. Everything in the party has been fully covered. Cracking a few of heads to reach the object of my desire is just good party fun, no offense.” We have become piñatas inside of piñatas, with of course the patient metaphorically becoming the ultimate piñata, after all the party is thrown for each and every one of us willing to pay entrance to the ever increasingly expensive party.
Next week I will start with my personal experience and then move to the global great American health care healthcare piñata gala bash. Let me get the party invitations sent out and also invite you to attend the grand gala 2009 healthcare piñata party.
I’ll let you bring the pinata to my party if I can bring mine to yours.
Until next week I remain sincerely yours in primary care,
Alan Dappen, MD
August 26th, 2009 by AlanDappenMD in Primary Care Wednesdays
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Health care’s most important problem (and repeat ad nauseam) is the cost. How do we make health care affordable, cost less, and not inflate three times faster than the background economy? While politicians and insurance companies rant and rave about saving health care from the top down, there is a nascent movement of doctors who are approaching the same puzzle from the bottom up.
What I mean by the bottom up is that doctors and patients are working together to build an independent system whereby they solve the typical day-to-day, or primary care, problems of health care without anyone else’s help or permission. From the bottom up also means that patients expect to be in control of their day-to-day care. This means paying for the service directly, which is the only real way to gain control. It means doctors are employed by the client, have transparent pricing, look the patient in the eye to explain the charge, and are better able to justify the cost. For the bottom-up means competition and a drive towards quality improvement and pricing that will cost a lot less than having ten people between you and getting what you need.
Here’s a simple example. You have a bladder infection. You had these exact symptoms a year ago so you know what’s wrong and what you need. Yet you’re held hostage by the health care “system” and are unable to get the medicine that has worked in the past. You’re not alone: these type of infections account for 8.3 million doctors visits a year, primarily among women of reproductive age.
Here are three potential ways that this common problem could be handled:
1. The Existing Model: Your symptoms of burning and frequent urination coupled with barely being able to leave the bathroom are funneled though the appropriate gauntlet: receptionist, scheduler, in window, nurse, doctor, out window, billing specialist, insurance company, payment administrator, adjustor, and finally paperwork mailed to you acknowledging payment. Along the way you’re likely to get a urinalysis and several urine cultures.
Since you’re not paying for these tests, under insurance you don’t mind and consider this “good care.” Your co-pay is $20. The insurance company pays $60 for the visit and the lab tests add another $30. You’re given three days of antibiotics and the problem’s resolved. The cost is $110.00 and 5 hours of your time assuming no major delays in getting into the office.
2. The Reformed Model: This would look very similar to the above system, but might include layers of oversight, fraud detection, pay-for-performance measurers, and “quality” assessment reviews, if one is to believe the rhetoric of people talking about “fixing” health care. Universal coverage likely will delay the wait time to be seen. The current delay for seeing a family practice physician in Massachusetts (the closest thing we have to Universal Coverage) is 63 days.
It’s difficult to believe that this added oversight can reduce costs but let’s pretend it pays for itself by eliminating the unnecessary labs that evidence based standards repeatedly say provide no added benefit to outcome for simple bladder infections. Cost: at minimum $110.00 and your time: at least 5 hours for a three day treatment of antibiotics.
3. The Bottom-Up Model: Patient calls her doctor who answers the phone and listens to the story. This diagnosis repetitively has been shown to be most accurately diagnosed through history alone. Exam without other contributing factors is not helpful. Urine and cultures are not more sensitive or specific than the history. The antibiotics are called to the pharmacy. Because you and your doctor know each other and work together to get you the best health care at the best price … and you care about the price … your doctor might say “By the way I’ll call in a ten-day supply of antibiotics so you can keep a reserve treatment in the future whenever you get this again. This would give you two additional treatments in the future.
Before the conversation with your doctor, he sends you a follow-up email offering an overview of the diagnosis and complications when you should contact him. Cost: $45. Time from call until taking the first pill: 1 hour.
Do the math. Eight million cases times $110.00/ UTI infection case/year. Don’t forget the human toll of 40 million human hours/year wasted in the funnel (link). The lawyers will want to add a value for pain and suffering too.
Compare this to a direct pay system — innovation wave one from the bottom-up, where you can reach your doctor day or night or even a weekend, take your dose of a prescription within an hour of calling, and have a reserve treatment for the future when inevitably you get the infection again. Imagine being treated like an adult. Frankly, $45 for the convenience is a steal compared to what’s being subsidized now.
Not all cases of bladder infection are cured through this simple formula, but seeing them in the office doesn’t reduce this chance either. Conservatively, more than half of the cases could be done this way, meaning hundreds of millions of dollars saved each year on this diagnosis alone. Don’t forget the guesstimated 20 million hours of lost productivity, plus the lost opportunities of railing about how someone else should “fix my health care.”
Going forward, we’ll see what the bottom up has to say about upper respiratory illness, poison ivy, low back pain or tick bites.
Until next week, I remain yours in bottoms-up primary care,
Alan Dappen MD
August 12th, 2009 by AlanDappenMD in Primary Care Wednesdays
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The year is 1989. I drive cautiously along the rutted, pot-holed, brush-overgrown trail in my four drive “Suzy Trooper,’ threading through Tsavo, Kenya’s largest National Park, to one of its most remote and premier rock climbing areas, Kitcwha Tembo. Next to me sits my friend and climbing partner Iain Allan, a crusty and adventurous Kenyan who prefers the bush to civilization.
To this day, I remember exactly the moment he makes his pronouncement. Maybe it’s the lighting, or the elephant that has just blocked our road passage moments ago, or the fact that vigilance is critical to not being left stranded and risk becoming part of the food chain. On the other hand, Iain is always colorful. “ Alan,“ he said, reminiscing about his more than twenty years of guiding foreigners on adventure safaris through Kenya. “Don’t get me wrong. Americans are great people. They are friendly, generous, and love to laugh. But in a nutshell there’s one thing that sets Americans apart from other nationalities. Americans don’t like surprises. If just one thing happens, even a flat tire while on safari that wasn’t predicted, it ruins the rest of their day. They can’t take a surprise. If you can predict every flat tire, they might be able to adjust with a few hours warning.”
The “pronouncement” has clung to me ever since: Americans don’t like surprises. Since then I am reminded of the pronouncement frequently. Traveling in an airport offers some of the best examples. Cancelled flights are met with enraged customers screaming and accusing ticket agents as if they hold the power of “no surprises.” I’ve seen plenty of patients leave a trail of brow-beaten staff but smile warmly once the doctor walks in the room. Most days I can feel the truth of the pronouncement as our national debate takes on tones of “Please don’t let anything bad happen to us. Please protect me, take care of me, feed me, keep me comfortable, reduce my stress, and no matter what: please no more surprises … ever!”
The no surprises stereotype might sum up the way the rest of the world sees us, but we’re blind to this. I cannot stop thinking about “the pronouncement” as it applies to health care reform. To expect fixing health care without accidents and surprises is unrealistic. Americans might be able to adjust to all the upcoming flat tires if they are given adequate warning and have an understanding of what’s really at stake.
Here are three economic conundrums to the health care debate, and whose solutions will be rife with surprises:
- The U.S. spends 17% of our GDP on health care. No where else in the world even comes close to this, with 90% of other nations spending less than 10% of their GDP on healthcare. How much money is enough? How much of the economy can be allocated to healthcare and still have a functioning economy that covers housing, food, vacation, education, energy, retirement, and the security of basic needs.
- The amount of money spent in the U.S. on healthcare doubles every ten years and has been doing so for six consecutive decades. If we don’t understand what drives these inflators, how are we to address solutions that curb the staggering unaffordable care heading our way?
- Whatever the amount of money is decided upon for healthcare in a year (and for arguments sake, let’s just say we’ll keep it at our current $2.4 trillion level for a year or two) what’s the best way to distribute this money, giving people the most options and coverage and personal choice?
I can see my friend Iain mulling these economic problems over, his face reflected by a campfire’s glow after a difficult but thrilling 5.10 climb and an unarmed descent through dense brush filled with creatures that only haunt most people’s dreams. Here sat a man who embraces danger knowing that life is nothing without surprises. How would he handle these kinds of conundrums with Americans?
“Well,” he’d say in his Scottish-Kenyan accent, “If you can predict every flat tire, they might be able to adjust within a short while. Americans are a great people… they only need to better prepare for the surprises in life.”
“That’s too bad,” I would reflect. “It feels like Americans aren’t even close to understanding the surprises that await them in the healthcare bush.”
The terrain ahead is dangerous and riddled with surprises in all directions. There are the insurance lions, lawyers ready to strike with any misstep. Let’s not forget the elephant politicians who can stomp you to death no matter the objection. Of course there are the innocent wallowing, but vicious hippos, the cape buffalo, the hyenas, the vultures… to all the animals there is a purpose and a reason, each feeding and jealously protecting their part of the $2.2 trillion per year corpulent health care body. Lastly there are all of us patients who must journey the bush, hoping that the guide we bring might be as competent as Iain.
“Iain,” I say, “What climb should we try tomorrow? Maybe we shouldn’t make it a surprise.”
Until next week, I remain yours in primary care,
Alan Dappen, MD
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
July 29th, 2009 by AlanDappenMD in Primary Care Wednesdays
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Few business models can top the inefficiencies, high costs, and overuse of manpower as primary health care. Every minor infection, cut, runny nose, goopy eye, hack, itch, rash, low back pain, stomach ache, urinary tract infection, tick bite, bee sting … ad infinitum must run the required gauntlet of the five-office-staff “touch points” in order to be treated. Let’s count them:
1. Scheduler,
2. Reception / intake window,
3. Nurse,
4. Check-out window, and
5. Billing specialist
Once you’ve seen your doctor and interfaced with all of the “touch-point” staff, next comes the game of musical chairs between the patient, doctor, and insurance company to see who’s going to pay the bill. This game often lasts months and includes pitched battles before a resolution is reached, typically when someone gives up resentfully from sheer exhaustion. All this hassle might be understandable for a surgery, hospitalization or very expensive procedure, but instead we play this game for the simplest booboo. For day-to-day care, this translates into the American people playing this game at least 5 million times a day.
Every practicing family physician/internist’s office employs roughly 4.5 full-time people per provider who slog through the piles of paperwork needed in a third-party driven model. On the insurance side, it can be an even higher body count, with staff lined up to review the claims, police transactions, audit doctors’ notes, data mine patients’ data, review negotiated rates to be paid to each physician, and cut the checks. Instead of a model where the patient gets a direct service and pays an immediate and transparent price, we create the illusion that health care is “free” and then wonder why it costs so much money to see the doctor. Just look at the people we need to pay in order to receive our free care.
Automation has not reached health care as it has with nearly every other U.S. industry. Rather than streamlining healthcare through technology, we instead keep adding new layers bureaucracy, including administrators who find purpose by helping to improve the authorization process, or the reminder systems for patients not to miss their appointment, or the services which broker the whopping cost of care if the patient gets stuck with the bill, or act as navigators of “the system” for people who need to figure out who to see next in the process of care. To stay viable, twenty-first century medical care will have to address these inefficiencies because they create barriers to rapid and transparent care.
The ideal future family doctor’s office will be automated and render most office staff obsolete. Patients will schedule an appointment online without the hassle of a receptionist. Doctors and nurse practitioners will answer incoming phones and emails from their patients thereby immediately addressing medical questions, thus reducing delays and getting 50% of people what they need without an office visits when one isn’t needed. Patients will log-in and get copies of their personal health records that are linked to the doctors’ electronic medical record so that they can have a copy of their labs, vaccines, and update their own personal information whenever they need it. The bill for service will become transparent, immediate and mostly policed by the patient who has a personal stake in the price. No one cries “foul” faster than a person who sees a bill and wonders if he’s been ripped off.
By re-engineering the dynamics of the office visit, far fewer doctor’s office of the support staff are required. Instead of the 4.5 full-time staff per provider, a practice set up like what we’ve done at DocTalker Family Medicine requires only one employee per provider. The DocTalker model, which is a cash-only practice, uses computer, telecommunications and internet technology to enable the clinician to perform functions previously done by the front and back office staff, such as the receptionist, scheduler, in-window, out-window, billing specialist, and office assistant. Thus a person’s care is centralized through one person (the doctor) rather than many, leading to efficiency and reduction in overhead costs. If competition is encouraged, this process will only get better and less expensive.
Shouldn’t this be a consideration when overhauling cost efficiencies for healthcare reform?
Let us hope that it is.
Until next week, I remain yours in primary care,
Alan Dappen, MD
