Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

Better Health Sponsors Blogger-Politician Healthcare Reform Discussion At National Press Club

To join the event live, please contact Seating is limited…


Congressman Paul Ryan


Media Personality Rea Blakey

Thursday, July 9, 2009

Health Care Reform: Putting Patients First

Elected Officials Join America’s Top Medical Bloggers to Discuss the Real,

Clinical Impact of Health Care Reform

    WHAT: As the health care debate heats up on the Hill, join Representative Paul Ryan as he sits down with top medical bloggers from across the country to discuss health care reform and its impact on practicing clinicians. This keynote discussion will be followed by two panels of physician and nurse bloggers who will highlight the importance of putting patients first.  Topics covered will include key barriers to health care quality, affordability, and access as well as the potential pitfalls of a new public plan and ways to fix the current system without investing billions in a new one.

WHEN: Friday, July 17, 9:00 a.m. to 12:00 p.m.
WHERE: The National Press Club, Broadcast Operations Center 4th Floor, 529 14th St. NW, Washington, DC
WHO: Keynote: Representative Paul Ryan, (R-WI), House Budget Committee Ranking MemberModerator: Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health

Host: Val Jones, M.D., CEO and Founder of Better Health

Policy Expert: Robert Goldberg, Ph.D., co-founder and vice president of the Center for Medicine in the Public Interest (CMPI)

Primary Care Panelists:

Kevin Pho, M.D., Internist and author of KevinMD

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr.Wes

Rich Fogoros, M.D., Cardiologist and author of CovertRationingBlog

And Fixing American Healthcare

Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor


For more information on Better Health, visit

A Primary Care Provider’s Dilemma: The Decision to Opt Out of Medicare

We often are asked in our practice, “Why don’t you accept Medicare?”  The immediate answer is simple: we cannot afford to. We opted out of Medicare because the service won’t pay for phone consultations, won’t pay for email consultations, barely pays for an office visit, and does not pay nearly enough to cover a house call.

All of these services are critical to our medical practice. Medicare would require us to hire too many staff, as well as require us to do too much paper work and administration. I cannot afford to invest in either and still manage to operate in the black. Medicare has too many regulations and rules; we can’t understand a lot of them, and frankly, Medicare doesn’t seem to understand them most of the time either.  If I would accepte Medicare, then they have the right to audit our notes and then fine us for non-compliance for infractions that are not readily clear. Their external auditors get paid for every infraction they find which means the temptations for fining doctors are irresistible.

Yet the truest answer as to why we do not accept Medicare is that the service does not focus on what we feel is paramount: practicing effective and efficient medicine in order to ultimately achieve and maintain the good health of our patients. The service’s paltry reimbursement structure coupled with its impossible to-adhere-to regulations doesn’t allow us to offer a complete service to our patients. This complete service includes wellness care as well as the ability to take the time to understand each patient’s unique medical needs and circumstances.

The crux of the issue is that Medicare worries about the forest, in other words, the internal process, money management, reimbursement and policing agreements, data mining, and organizing dozens of internal bureaucracies. These agendas and policing policies help the Medicare service to manage the forest, however these are often in direct conflict with what we feel is key to effective healthcare: taking care of the individual, or each tree.

I do want to make clear that being afraid of audits, punitive actions and the vagaries of no one understanding all the rules is never a reason to leave Medicare — after all, patient care is filled with risk. However, it became clear to me that I, a single doctor voice, dealing with the collective frustration almost all doctors feel when dealing with Medicare (and most insurance companies) had three divergent paths to choose from:

  1. Do nothing. Ignore the conflicts of interest and the lack of patient-centered care and swallow frustration for a paycheck. Just do your best or what Medicare tells you to do.
  2. Work towards reforming Medicare from within through involvement in the process and by working with your professional associations.
  3. Ignore the payers altogether. Work outside the system, returning to the roots of primary care, reforming the business of primary care one person at a time.

Personally, I had to reject Option 1. I was witnessing too many wrongs among my colleagues and for patients. Primary care, a profession I am passionate about and believe in fully, would never have a future under this model. Hoping that things would work out if we just worked harder and harder while blindly submitting to Medicare’s interests and demands meant surrendering my patients’ trust, primary health care’s future, and my soul for a salary. There had to be a better way of making a living.

Working towards Option 2, trying to create reform from within the Medicare system, was nothing but futility on immediate analysis. The ability for me personally to influence the debate for what needs to be done in Medicare for primary care would be a David v. Goliath story without the biblical ending.

In the end I am just one family doctor, that’s what I know, that’s what I’ve spent my life doing and studying. Option 3 chose me. Opting out is financially the riskiest since it requires patients to do something that they have been socialized against for three generations, which is to pay directly for medical services (as they do with nearly everything else in our capitalistic economy). Doctors are well aware that 95% of patients will fire any doctor who refuses to accept Medicare.

This decision meant I might lose my shirt and put my home and small life savings at risk, something thousands of Americans in other professions do everyday. If they could take the risk, then my risk is nothing less than a trivial American story.

The United States was built on this: a country of immigrants fleeing an “old establishment” to build something new. It’s a group of people declaring: “You can’t tax us without representation!” It’s a government that permits us to challenge established norms, challenge power without being jailed or shot. The question today in health care for all of us as patients is will we stampede towards the utopian ideal of  “free care” while ignoring the predictable consequences that nothing is free.

The question put to primary care doctors by Medicare is clear at the moment: Will you let us at Medicare regulate care, dictate “best” treatments and control individual health and choices since we know what’s best. Can you, doctor, be our “yes man?”

Eight years ago I cast my vote and opted out of Medicare. Predictably my journey has not been easy but I have never regretted the decision.

Until next week, I remain yours in primary care,

Alan Dappen, MD

Welcome To The Information Age, Primary Care

For 18 years, primary care providers steadily have been eclipsed by “specialists.”  It is no longer rare to hear calls for these competent generalists to drive straight to the scrap heap in order to be refitted as procedural, money-making Humvees.  What may be implied by this scenario is that primary care providers are selling out so as to allow nurse practitioners to be a more economical, efficient and smarter primary care provider. In fact, such ideas are not impossible if primary care doesn’t take control of their own destiny and invest in their own future. Technology will prove such a pivotal investment.

In my June 10 post, I discussed the five cornerstones of 21st century medical care as presented by a book published by the Institutes of Medicine entitled Crossing the Quality Chasm: A New Health Systems for the 21st Century.  The first cornerstone presented a communication-centered medical practice and abandoned the traditional brick-and-mortar idea that “the answers to all medical questions must be delayed until the patient is seen in the office.” Rather than the doctor being the last person to know what’s happening to a patient, a communication-centered model puts doctors at the front of the office, answering phones, emails and internet-generated questions through the day, allowing the practitioner to be the first ones to know what’s happening with our patients. This model could eliminate up to 66% of today’s office visits while simultaneously improving speed of delivery of care, convenience, access, quality and reduce costs.

The second cornerstone that primary care needs to invest in and build is an advanced information management system, which still does not exist.  An electronic medical record (EMR) that replaces a paper chart does not adequately explain the real potential of a tool that could transform the generalist.

Information in the communication-centered practice is managed differently than in traditional models.  The health care provider, surrounded by phones and computers, is linked to a powerful network with electronic medical records, health information databases,  sensitivity-specificity measurements, medical literature, and information about local facilities such as laboratories, pharmacies  x-rays, and consultants and their costs, just to name a few linkages.

Imagine information no longer limited by what is in the doctor’s head, but rather, doctors who can access and find the answer to any medical question within seconds by having bookmarks that extend through an entire medical library, and searching for answers would be as easy as:  The evidence based guidelines treatment for this problem is “click”… The differential diagnosis for night sweats is “click”… The medicines known to cause “weird smells” as a side effect are “click”… The cost of that test is “click”… The three labs closest to your home where I could fax the order are “click”…The sensitivity and specificity for this test or that symptom or that physical finding to be associated with lupus is “click”…The recommended treatment for this fracture is “click”…The three best articles for helping patients manage and educate themselves about their cholesterol are “click”… The telephone number to arrange setting up the test is, “click”… The facts and comparison for this medicine is… “click” The video link demonstrating the Canalith repositioning maneuvers is in your email box… “click.” Primary care providers help patients work through this information, discerning what is of utmost importance to their medical situation and issue. As it is said, “The role of the expert is to know what to ignore.”

Excellent primary health care requires continuous communication between doctors and patients so as to respond through the evolving and unpredictable twists and turns of illness and treatment . Doctors likewise need connection to the highest quality information and recording systems so as to actualize the science of best “healers”. The idea that doctors should always know the answer to a problem by using memory alone is as misguided as insisting mathematicians return to pencil and paper calculations to prove that they are “real” mathematicians.    Despite the potential, primary health care has remained timid to challenge the unexamined assumptions behind the limits of  Hippocrates medical practice. Were Hippocrates to return today I imagine him asking, “What have you done?”

Our patients need doctors to step up to the plate and go to bat for them. We as doctors need it too.

Until next week, I remain yours in primary care,

Alan Dappen, MD

Micromanaging Nonsense: What It Takes To Swallow A Pill

There was an old lady who swallowed a pill
I know why she swallowed a pill.
To keep her alive.

There was old lady who mailed in her Rx
with wiggles and scribbles written on it.
She mailed the Rx to fill the pills.
I know why she swallowed the pill.
To keep her alive.

I know an old lady who ran out of pills, had no pill to swallow
How absurd she was left to wallow.
She’d mailed the Rx with wiggles and scribbles written on it.
She mailed the Rx to fill the pills
I know why she swallowed the pills,
To keep her alive.

I know an old lady who swallowed her pride
Wouldn’t have cried, she had too much pride.
She called Express Scripts to explain she had nothing to swallow.
She’d mailed the Rx with wiggles and scribbles written on it.
She mailed the Rx to fill the pills.
I know why she swallowed the pills .
To keep her alive.

There was an old lady who swallowed a whopper
“Your Rx was rescinded by your doctor.”
Imagine that, he canceled the order
With wiggles and scribbles written on it!”
She’d mailed the Rx to fill the pills.
I know why she swallowed the pills.
To keep her alive.

I know an old lady who swallowed frustration calling her doctor
She must be off her rocker to call her doctor.
She asked him to swallow his pride she knew he had nothing to hide.
To call Express Scripts about the Rx with wiggles and scribbles written on it.
She’d mailed the Rx to fill the pills.
He fully understood why she needed to swallow the pills.
To keep her alive.

I know the doctor who spent half a day
I dunno why there was such a delay
But a recorded voice during the stall
Said “Faxing an order might get you home before nightfall.”
He wrote another Rx with wiggles and scribbles written on it.
He again faxed the Rx to fill the pills
Saying she had to swallow the pills.
To keep her alive.

I know the old doctor who got back a fax
Saying, “Sorry Charlie. We’re sending this back.”
This medicine doesn’t need “Authorization. “
Just resubmit the Rx with wiggles and scribbles written on it.
What a nightmare to be trapped in midair
And so the doc did, with exclamation points!!!! written on it.

But the old lady  never did get those pills,
Finally had to buy them herself.
To keep her alive.

Afterwards, from the above true story:
Generic cost to buy a 90 day supply of the medicine: $ 30
Insurance CEO payment:  $30
Local pharmacy payment:  $30
Cost of hospitalization without meds: $40,000
Cost to doctor for another “check-up” with his mental health “Provider”: $200
Number of hours of lost human productivity for this case alone: 10
Estimated average annual cost of lost productivity per/ primary care physician  managing nonsense: $64,859
Physicians who smile and put up with it:  98%
The gaggle administrators, interfering in the doctor patient relationship: Priceless!

Until next week, I remain yours in primary care,

Alan Dappen MD

The Five Cornerstones Of 21st Century Medical Care

Eight years ago, the Institutes of Medicine published a paper entitled Crossing the Quality Chasm: A New Health System for the 21st Century, which envisioned the future medical practices. Many of the concepts discussed were adopted and endorsed in years to come by the American Academy of Family Practice, The American College of Physicians,  the American Medical Association, among others.

The five major innovations of care outlined by this study include:
1.    A communication-centered practice model,
2.    Information management,
3.    Technology replacing office staff,
4.    Reduced pricing and transparency in billing, and
5.    Removing external conflicts of interest between doctors/providers and patients.

Complete adoption of these innovative concepts can cut at least 30% of primary care costs while significantly improving patients’ quality of care, and further reduce overall health care costs by offering immediate and highly accessible care that avoids emergency room visits, enhances wellness, manages chronic illness and diagnoses disease early. These cost savings and quality improvements are enabled by utilization of advanced communications and information technology that replace much of office overhead and staff, and encourage patients to seek the most cost-effective and convenient care possible.  Many medical practices have adopted some of the recommendations, yet less than 1% have transitioned to complete and consistent adoption because they frankly have few financial incentives to do so.

These innovations are the cornerstones of retooling our broken healthcare system, and in turn can pave the way to “fixing” many of the issues plaguing this system. The five cornerstones provide for what so many Americans are clamoring for yet are unable to find: continuous access to a medical provider team thus enhancing patient access, control, and convenience of care; increasing the quality and speed of treatment; reducing the cost of care; creating transparency in pricing; and removing external parties that create conflicts of interest between doctor and patient and often interfere with providing quality and speed of care to patients.

I’ve built my own primary care practice on these five concepts, and while all can significantly lower costs while vastly improving the patient experience,  I’d like to take a look at the concept I find to play a pivotal role: a communication-centered practice model.

A Communication-Centered Practice Model
Twenty-first century, day-to-day-primary care starts with the primary care provider being the first in line to answer a patient’s phone call or email. During this call or email, the provider reviews a patient’s history, and bearing in mind that the provider already knows has a professional relationship with the patient, then can make appropriate decisions.  At least 55% of the time, the patient’s situation does not require an office visit, however instead involves going straight to the pharmacy for medications, going to labs for tests, getting an x-ray, or recommending a referral.   In this model of practice, the doctor spends at least half the time of the time answering phones and emails, thereby providing immediate access and convenience to the patient.

If either the clinician or the patient believes there is a need for an office visit, the visit is arranged immediately.  Patients can talk to their medical expert or an on-call member of the medical team 24/7. This instantaneous access can result in patients having most of their day-to-day  issues addressed within 10 minutes of reaching the practitioner, and can expect care from their personal provider from home, work or anywhere in the U.S.

As mentioned above, over 50% of medical issues can be addressed by telemedicine, specifically by phone or email, as long as a patient-doctor relationship exists. This results in people being healthier and on the road to recovery much faster, thus not taking time off from work.   Office hours are flexible and can be arranged day or night and any day of the week including weekends.

The importance, barriers to adoption, and the unexamined assumptions as to why 97% of all  medical care currently occurs in a medical office and nowhere else has been reviewed in several of our prior postings:

Are Face-to-Face Office Visits Really Required to Provide the Highest Quality Care?
In Defense of Remote Access Medical Visits
The Commonplace Tool That Can Revolutionize Health Care
Telemedicine Care: A Malpractice Risk? Au Contraire …
Telemedicine Checks In On Chronic Health Care Problems

In the future, I plan on taking a look at the additional four cornerstones that need to have traction if the Obama administration hopes to restore vitality to the primary care system.

Until next time, I remain yours in primary care,

Alan Dappen, MD

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »