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The Thrifty Patient: A Doctor’s Guide To More Affordable Healthcare

No matter the outcome of the presidential election this year, it’s likely that Americans will be spending more of their money on healthcare going forward. Dr. Davis Liu, a family physician at the Permanente Medical Group in California (and a contributor to this blog), has written a primer on how to get the most bang for your healthcare buck. The Thrifty Patient: Vital Insider Tips For Saving Money And Staying Healthy is a helpful little book for those smart enough to read it.

The first step to becoming a “thrifty patient” is to reduce your need for professional healthcare services. This lesson is perhaps the most important of all: lifestyle choices are the largest controllable determinant of how much healthcare you will consume. Daily exercise, healthy eating, and preventive care services (such as vaccines and screening tests) are the most effective ways to avoid expensive healthcare.

Dr. Liu offers tips for selecting a doctor, questioning the necessity of tests and procedures, choosing less expensive treatments, getting a second opinion, and learning to get the most out of a short doctor visit. He explains why annual check ups may not be necessary, and lists all the preventive health screening tests you’ll need (according to age) to maximize your chance of avoiding many major diseases or their expensive outcomes.

According to Liu, an excellent primary care physician (PCP) can be the best ally in avoiding unnecessary medical costs. Without a PCP’s guidance, 60% of patients select the wrong specialist for their symptoms or concerns. This can trigger a costly cascade of extra testing and referrals. Liu recommends trustworthy websites that can aid in disease management and patient education – suggesting that “Dr. Google” may not be so bad after all, armed with a correct diagnosis from a healthcare professional and links to credible sources of information.

Being thrifty isn’t necessarily “sexy” – but practical tips for avoiding unnecessary and expensive interactions with the healthcare system could add up to some pretty amazing savings (both financially and emotionally). Anyone who takes Dr. Liu’s advice to heart is likely to live longer and better – I just hope that the people who could benefit most from these tips find their way to this book. Perhaps you know someone who needs an early Christmas gift? 😆

The Thrifty Patient can be purchased here on

Another Ridiculous Article From The Economist: Doctor Shortage Is A Win For Patients?

I don’t read The Economist frequently enough to be sure that I dislike its entire staff of writers, but I have been repeatedly disappointed by its health coverage. In this latest article, “Squeezing Out The Doctor” the writers describe the increased healthcare needs of an aging western civilization, combined with a relative shortage of physicians to care for seniors. The conclusion? This is a “win” for patients.

Now, in case you find that conclusion as irrational as I did, let me summarize how they arrived there. The argument goes something like this: doctors have been unfairly controlling the practice of medicine for the past century, and now with the oncoming flood of patient need (and relative MD shortage), they won’t have time to do everything they have in the past. Physicians will therefore be forced to narrow their scope and outsource many of their current tasks to nurses and support staff. This is a win for patients because they will have shorter wait times for care and lower healthcare costs with the same care quality because most of what doctors do can be replicated by ancillary staff. At last we will be able to remove the self-important, over-educated, control freak physicians from the delivery of healthcare!

Oh, here’s another great idea: why don’t we improve our school systems by squeezing out the teachers?  Who needs teachers when mature students could train others in the same subject matter? Most of what teachers do is just baby sitting, right? We could easily outsource that to daycare centers or teens with a little baby sitting experience. The few teachers we retain should be reserved for only the most difficult cases: severe learning disabilities. Just think of the cost savings in teacher salaries! Imagine the improved access to schools if we didn’t have to adhere to some arbitrary teacher to student ratio. What a win for students. The only possible downside is that teachers may lose some of their current social standing, but so what?

The oncoming physician shortage will not bring the glorious improvements in healthcare delivery touted by The Economist. More likely it will create a two-tiered system whereby the poor and underinsured will get a substandard level of care. If you think that only doctors balk at long hours for low pay, try pitching that deal to nurses. They are just as savvy as physicians about personal economics. Having them take over primary care under the current (or worsening conditions) will burn them out just as quickly and nurses will specialize or quit nursing in droves. There is no magical, “let’s just get someone else to do it for less” model in healthcare when we’re already scraping the bottom of the barrel in terms of ROI for providers of any stripe.

Physician scarcity can be ameliorated by setting doctors free to spend more of their time in patient care, and less of it on distractions (such as excessive documentation for coding and billing purposes). But the solution is not necessarily outsourcing that work to someone else. It’s killing it all together. Radical idea? My practice is doing that now and growing a thriving business to boot.

Primary care doesn’t have to be expensive. Most patients need less than a full hour of a physician’s time per year, an annual cost of about $350. In my practice, we bill for our time and we spend it however it makes best sense for the patient – via phone, email, office visit, or house call. It’s in our interest to see as many patients as possible, and therefore we are increasing access to services. Office wait times are non-existent because many issues can be handled via phone (patients are not required to come to the office for every and any request for the sake of billing).

What’s the catch? We don’t accept insurance. Patients can submit claims to their carrier for reimbursement for our out-of-network services, but we have opted out of public and private insurance plans so that we can spend our time with patients instead of coding, billing, and being beholden to third party documentation requirements and regulations. This system works marvelously for any patient open-minded enough to see that a high deductible health insurance plan (for catastrophic coverage only) saves them thousands per year in premiums, while their primary care “out of pocket” will cost a few hundred or less. The math works for all. Access is improved, costs decrease, quality is maintained.

Now that’s a true win for patients.

Considering A Non-Fatal Patient’s Quality Of Life

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, Read more »

*This blog post was originally published at Musings of a Dinosaur*

Nurses And Physician Assistants Are Increasing Their Market Share Of Outpatient Medicine

The percentage of hospital outpatient department visits seen only by a physician assistant or advanced practice nurse rose from 10% to 15%, while the percentage of joint physician/nonphysician clinician visits remained at about 3%, health researchers found.

Among other findings in the Centers for Disease Control and Prevention report:
–About three-fourths of the more than 103 million hospital outpatient department visits in 2008-2009 were seen by a physician and 18% were seen by a physician assistant or advanced practice nurse;
–Among visits to a non-physician, 65% were seen by an advanced practice nurse and 35% were seen by a physician assistant;
–The percentage of outpatient department visits attended only by physicians declined from 77% in 2000-2001 to 72% in 2008-2009; and
–The percentage of visits not seen by a physician, physician assistant, or advanced practice nurse remained the same (10%).

Following previous trends, physician assistants or advanced practice nurses are the only provider for visits more often in rural areas, and with younger patients. Read more »

*This blog post was originally published at ACP Hospitalist*

Efforts To Improve Health Care Must Involve Patients

Here’s the bad news: We will not benefit from the health care services, drugs, tests and procedures available to us unless we pay attention, learn about our choices, interact with our clinicians and follow through on the plans we make together. And that “following through”part?  We have to work at doing that every day, whether we feel sick or well, energetic or tired out. And if we can’t do it, we’d best find a spouse or parent or friend or social service agency who can step in to do the things we can’t manage.

OK.  For some people, this is not bad news.  This is how we think it should be: “Nothing about me without me.” For others, our personal encounters with tests and treatments and illness have taught us that this is just the way it is.

But for many of us, this news – should we have reason to attend to it – is inconsistent with our idealized vision of health care that, tattered as its image might be, will step in, take over and fix what ails us. Most of us, after all, are mostly well most of the time and our exposure to health care is minimal.

Efforts to improve the effectiveness of health care and contain its cost have produced Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

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…

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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…

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Latest Book Reviews

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

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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…

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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…

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