August 26th, 2009 by AlanDappenMD in Primary Care Wednesdays
No Comments »
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 19th, 2009 by Toni Brayer, M.D. in Better Health Network, Opinion, True Stories
No Comments »
Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.
But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to “cognitive, diagnosing, talking” physicians makes the idea of expansion untenable.
May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief…22 pages for a change of address. It is now mid-August and I still do not have the “approval” for my address change.
I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.
I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information “overnight, registered” because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my “bank officer” and a utility bill from the office. Mr President, I don’t have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients…but I certainly did comply.
I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.
I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.
Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.
A loyal American ,
Internal Medicine (aka: primary care) physician
*This blog post was originally published at EverythingHealth*
August 19th, 2009 by SteveSimmonsMD in Health Policy, Primary Care Wednesdays
3 Comments »
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.
August 5th, 2009 by AlanDappenMD in Primary Care Wednesdays
4 Comments »
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 DrRob in Better Health Network, True Stories
No Comments »
A recent oft-cited study showed that doctors who who apologized for mistakes were less likely to be sued. My initial reaction to that is to file it under “duh.”
But then I was greeted with a note lying on my desk.
Dr. Rob:
First, I want to tell you that for the majority of the many years my family has been patients of your practice, I believe we received excellent care and you always had our best interests in mind. Further, we appreciate all that you and your staff have done for us.
However, it is with great regret that I find myself in the position of writing to you with a problem I see as pervasive in your practice…
Ugh. This is not the way to start my day.
The letter went on to describe a problem with communication of a concern the patient had about a medical problem that was very worrisome to her. It didn’t point the finger of blame at my nurse, nor any one else in the office. It wasn’t at all angry in its tone to me. It simply expressed the disappointment of a patient who felt let-down by her physician.
The letter ended with:
I look forward to speaking with you about this issue early in the week of July 20.
Thank you in advance for your attention to this matter.
I put off calling her until the end of the day. I knew she would be reasonable overall, but beyond the fact that I hate calling people on the phone at all, I hate calling when I know I have to apologize. The problem in this case was not with my staff or with confusion in the office. The problem was with a physician who simply dropped the ball and did not follow-up as promised.
I finally called:
Hi.
First let me say thank you for the letter you sent. I mean that sincerely. I would much rather hear about problems in our office than to simply having people get angry and leave. This is something I needed to hear.
Second, let me say that the blame is 100% mine. I really wasn’t worried about the problem and so I honestly just let it slip my mind. I did tell you I’d contact you and would send you to a specialist if things weren’t clear after the tests I ordered. I’m sorry about that.
I went on to discuss the situation and that I didn’t think anything was serious at all. She still wanted to go ahead with the consultant because of some stuff she had heard about the condition. I told her that I have no problem with that, as I see my job as one of giving my advice and perspective; but not as making the final decisions. The most important thing is that her worries are addressed and that she feels comfortable that everything is OK. If it takes a consultant to do that, then I have absolutely no problem with that.
I also explained that communication in a medical office is very difficult – and has gotten much harder as we have gotten busier. It is our plan to eventually have communication by e-mail, but that is not ready for prime-time. This is not an excuse, I told her, but an explanation and a promise that I do see the problem and we are doing something about it.
As expected, she was gracious about the situation and was thankful for the apology. I didn’t do it to avoid lawsuit or to protect myself. I like this family and didn’t want to lose them as patients. Beyond that, though, I owed her an apology. I had let her down. I hadn’t done what I promised I would do. She had been kind enough to send me the letter and deserved a quick resolution to the situation.
I still hated picking up the phone, though. It isn’t easy to admit fault, no matter how accepting you know the other person will be.
As obvious as it seems that apologizing will prevent lawsuit, it is a hard thing to do.
But I am glad I did.
*This blog post was originally published at Musings of a Distractible Mind*
