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Making Health Care Affordable From The Bottom Up

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

Is “Plan” A Four-Letter Word When It Comes To Healthcare Reform

On Saturday, Breitbart.com posted an article about President Obama’s most recent town hall meetings and closed with the following paragraph: Obama is yet to reveal a detailed plan, but promises to expand coverage, control spiraling healthcare costs, rein in insurance companies and prioritize preventative care.”

I’ve been looking for an actual plan since Health Care Reform was seriously proposed. In July, Rahm Emanuel, Obama’s Chief of Staff, was quoted in the Washington Post, stating that the Administration had decided against having an actual plan for Reform since it would expose the administration to criticism. Yet, I remained optimistic about Reform, and relished the chance to debate the facts as our Nation turned its focus upon a topic I have long been passionate about.

Unfortunately, my optimism waned as an honest and forthright debate about how to implement Reform has become ever-elusive. Disappointed in the turns this debate has taken on its journey through our national consciousness, I am leery of the simplistic viewpoint portrayed so often… “You are with Obama or against him” …. “You’re a Republican or a Democrat” … “You are for Reform or against it …”

Determined to find Obama’s plan, I began my search by reading his speech to the AMA, surfing the White House website, watching his ABC infomercial all the way through Nightline, and observing a number of town hall meetings. I went on to plaster the walls of my home office, to the amusement of my wife, with everything the President had said, color-coded on poster boards.

By July, as I looked around my office I realized that I was surrounded, not by a plan, but by a group of wishes, beliefs, hopes and ideals. I love the way it sounds when I say “prioritize preventative care” and I long for a day when the $100 million salaries of insurance company CEOs has been “reined in.” However, I am not naïve enough to expect this to happen without a coherent plan.

I used to believe the White House would propose a bona-fide plan. Instead they are implementing a strategy that combines the president’s rhetoric with the defensive tactic of refuting critics of Congressional plans or the President’s zeal.

Even after the House passed their Reform bill (the first actual HC plan to come out of Washington), I can’t make myself take down all of those poster boards leaving me surrounded by inspiring and hypnotizing ideals. Yet I fail to see how the House bill will transform these beautiful ideals into reality as it creates multiple new government agencies and burdens doctors’ offices with more clerical responsibilities — new for the busy doctors of tomorrow: the physician quality reporting initiative, cultural and linguistic competence training, financial disclosure reports between providers and suppliers, and national priorities for performance improvement.

John Mackey, CEO of the Fortune 500 company Whole Foods, wrote an op-ed piece about HC reform for the August 11 Wall Street Journal. His editorial includes understandable plans, worthy of intelligent debate while being based in large part on the health care benefits Whole Foods currently has in place for 36,000 of its employees, and includes the following recommendations:

1. Promote high-deductible health insurance plans and HSAs by removing legal obstacles.

2. Equalize the tax laws so those buying individual insurance can enjoy the exact same tax break employer related insurance customers receive.

3. Encourage competition by allowing insurance companies to compete across state lines.

4. Enact tort reform since insurance costs, frequently over $100,000 per doctor, are passed back to all of us in the form of higher prices for health care.

5. Make costs transparent so we can all understand what health care treatments cost.

6. Enact Medicare Reform.

7. Whatever reforms are enacted it is essential that they be financially responsible.

Three days later, instead of arguing the merits or demerits of Mackey’s plan, an ABC News story focused on the controversy his editorial had stirred up after briefly touching on some of his ideas. Spcifically, the ABC story focused on the boycott by many of his customers with one expressing the following belief, “I think a CEO should take care that if he speaks about politics, that his beliefs reflect at least the majority of his clients.” Another described Mr. Mackey’s position as a slap in the face to millions of progressive-minded consumers. The author quoted four customers pledging to not buy their food at Whole Foods anymore and added them to the implied masses gathering on Twitter and Facebook.

Fortunately, one customer, Frank Federer, was quoted as saying, “At a time when most folks are more inclined toward rancor than discussion of facts, I applaud John Mackey.”

So do I.

A realistic map showing us how to get from point A to point B is missing in the Health Care Reform debate. Facts are one thing in short supply to plot a course on this map. While the main ingredient in the fertilizer used to grow Whole Foods produce is in abundance, there’s just not enough for some of Mr. Mackey’s customers.

Creating Cost-Efficient Primary Care Medical Practices By Using 21st Century Technology

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

The Difference Between Short and Long Term Medicare Savings for Health Care Reform

Robert Blendon, Professor of Health Policy and Political Analysis at the Harvard Kennedy School of Business, speaking on funding for Health Care Reform, July 8, 2009

“Potential sources for this (health care reform) are new taxes on people or businesses, substantial short-term savings from the existing Medicare and Medicaid programs, or increasing the deficit”

After Last week’s passage of Health Care reform plans by committees in the House and Senate, attention has turned to the Senate Finance and House Commerce Committees to see how congress will pay for reform in a deficit neutral way, as mandated by President Obama.  The price tag over ten years–$1.2 Trillion–is paired with the observation that a shortage of $240 billion currently exists.  This assumes that $948 billion already has been found.

The only way to ‘find’ $948 billion without increasing the deficit is to increase taxes on businesses and the wealthy or by reimbursing less for services provided through Medicare and Medicaid.  I will leave the never-ending tax-rate argument for political pundits, and instead focus this post on short and long-term savings from Medicare and Medicaid because I believe paying less for services than it costs to provide them will negatively impact the quality of medical care in this country.

I was surprised to learn of a battle being waged between the executive and legislative branches on the issue of “long-term savings” from Medicare, as it relates to “Medicare Payment Authority”.  White House Chief of Staff, Rahm Emanuel, has called Medicare payment Authority, “the least talked about, most important issue on the table” and clarified its’ importance by stating, “Structures that fundamentally alter the long-term costs are a must for real health-care reform.”   This issue does not follow party lines with a mix of Republicans and Democrats being in opposition or support of the President, irrespective of party affiliation.

Our Congressional Representatives have the power to set Medicare Payments, outside of any pre-set rules or regulations by simply passing legislation.  The Washington Post describes this power as “one of their most valued perks….a powerful tool on the campaign trail”.  President Obama’s administration wants to either transfer payment authority to MedPac (the Medicare payment advisory commission) or create an independent Medicare Advisory Council, reporting to the executive branch so lawmakers can no longer tailor Medicare spending to address local concerns.

Before leaving office, Senator Ted Stevens secured a permanent 35 percent increase in Medicare payments for Alaskan physicians only.  The political benefits to an incumbent running for reelection need not be explained while it is easy to see the inefficiency in such a system.  At a time when politicians are admonishing those working in the Health Care Field to be more efficient, I would urge congress to take a dose of their own efficiency medicine and support the current administration in their efforts to curtail long-term spending by surrendering this power.

According to the White House, $622 of the $948 billion will come from short-term savings squeezed out of existing Medicare and Medicaid programs through one of two ways: by improving efficiency (309 billion) or enacting policy changes (313 billion).  The Medicare Fact Sheet posted on the White House website, states that one policy change will have the added benefit of encouraging efficiency:  “incorporate productivity adjustments into Medicare payment updates”.  This policy change measures the productivity of the entire U.S. economy, as measured by subtracting the hours worked from the amount of product created and extrapolates it to Health Care (a profession which does not produce “products”).  This idea justifies the withholding of 110 billion dollars from “providers” with an unexplained benefit stated in the closing sentence describing this policy, “This adjustment will encourage greater efficiency in health care provisions”.

I found it difficult to believe that anyone could suggest paying less would encourage greater efficiency in caring for the infirm and old until Boston Medical Center, a hospital serving thousands of indigent residents, sued the state of Massachusetts one week ago, charging that the state is now reimbursing only 64 cents for every dollar spent treating those covered under Medicaid or Commonwealth Care (the state subsidized insurance program for low-income residents).  This should be of great concern to us all since the House’s plan adds 11 million people to Medicaid and cuts funding while reformists tout Massachusetts as an example worth following, being the only state with universal coverage today.  Before state wide reform was enacted this hospital had operated for 5 years without a loss.  However, when the hospital showed losses over two years of 138 million dollars, state officials observed the hospital had a 190 million dollar reserve (not for long it appears) and suggested that Boston Medical could reduce costs by operating more efficiently.

The above example demonstrates the willingness of government bureaucrats, inexperienced in providing actual medical care, to give flippant advice while failing to appreciate how fiscal efficiency, doing more with less, impacts medical efficiency, caring for the ill effectively.  To be sure, something must be done to curtail run-away costs in health care and I agree with the president when he says, “The status quo is unsustainable. Reform is not a luxury, but a necessity”.  However, reform needs to focus on sustainable Short-term and Long-term savings in such a way that prevents hospitals and doctors from having to make a choice between providing sub-standard care or going out of business.  Furthermore, I would hope that Congress take an honest look in the mirror regarding long-term savings before only enacting short-term savings which could negatively impact the care available to us all.

Until next week, I remain yours in primary care,

Steve Simmons, MD

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

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