July 8th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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:
- 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.
- Work towards reforming Medicare from within through involvement in the process and by working with your professional associations.
- 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
July 1st, 2009 by SteveSimmonsMD in Better Health Network, Primary Care Wednesdays
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When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD
June 24th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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
June 15th, 2009 by DrRob in Better Health Network
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I am a flaming moderate. Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions.
And I am in the mood to rant, so beware.
Living in the deep south, I often seem like a radical communist to those I see. I frequently get patients asking questions like “So what do you think about Obama’s plans to socialize medicine?”, or “I wanted to get in here before Obama-care comes and messes things up.” I usually smile and nod, but find myself getting increasingly frustrated by this.
The house is burning down, folks. Healthcare is a mess and desperately needs fixing. How in the world can someone cling to old political yada-yaya-yada when people are dying? I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together. A solution that comes from a single political ideology will polarize the country and guarantee the “fix” to healthcare will be one constructed based on politics rather than common sense.
No, this doesn’t frustrate me; it infuriates me. The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant. In the mean-time, people are going to be denied care, go bankrupt, and die. Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them. I don’t want to be part of a system that puts ideology above their survival.
So here is what this radical moderate sees in our system:
- The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
- Stupid and wasteful procedures shouldn’t be reimbursed. This is business 101; if you don’t control spending, you will not be able to sustain your system. This means that we have to stop paying for procedures that don’t do any good. Some will scream “rationing” at this, but why should someone have the right to have a coronary stent placed when this has never been shown to help? Why should we allow people to gouge the system for personal gain in the name of “free market”? I got a CT angiogram report on patient today who has fairly advanced Alzheimer’s disease. I twittered it and the Twitter mob was not at all surprised. These things happen all the time. The procedures do no good and cost a bundle. The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
- The government has to stop being stupid. Why can’t I give discount cards to Medicare patients? Why can’t I post my charges, accept what Medicare pays me, and then bill the difference? The absurdity within the system is probably the best argument against increased government involvement. Who invented the “welcome to Medicare physical??” I never do it because the rules are utterly complex and convoluted. If the rules can be this crazy now, how much worse will it be when the government takes over? If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
- The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed. There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn’t get a second-thought 10 years ago. Hospitals stays were longer and procedures were easier to get authorize. So where is the money going?? We do know the answer to this question – there is no single culprit. Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren’t dropping. The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare. Shareholders, CEO’s, and simple corporate greed has bled money out of the system like a cut to the jugular.
- Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies. We stand on different sides yelling our opinions but don’t come up with solutions. Instead of doing what is right for our patients, we join the punching match of politics. Is EMR implementation important? Duh! There is no way to fix healthcare without it. But the systems out there are designed by engineers and administrators and don’t work in the real life. So why can’t we computerize ourselves? Every other industry did. Why must we cling to the archaic paper chart because we don’t like the EMR’s out there? Aren’t we smart people? Aren’t we paid to solve problems? Stop throwing darts and start finding solutions. Med bloggers are terrible in this – they rant constantly against EMR, but don’t ever say what would work. It’s fun to criticize, but nobody wants to propose an alternative.
- We need to get our priorities right. Healthcare is about the health of the patient. Yes, it is a job for a lot of people. Yes, it is an investment opportunity. Yes, it is a good thing to argue about – whether it is a “right” or not. Yes, it is a major political battleground. But in the end, these things need to be put behind what is most important. As it stands, we are more passionate about these other things than we are about the people who get the care. In the end it is about making people well or keeping them that way. It is about saving lives and letting people die when it is time. If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn’t have half of the problems we have.
As a flaming moderate I get to offend people on all sides. We need to fix our system. It is broken. It is not a playground for those who like to argue. It is not a place to be liberal or conservative. This is our care we are talking about, not someone else’s. The solution will only come when we all come to the table as potential patients and fix the system for ourselves.
Is it easy? Heck no. This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote. Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us. No, it may come back to kill us.
*This blog post was originally published at Musings of a Distractible Mind*
June 10th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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
