April 29th, 2009 by DrAlanDappen in Primary Care Wednesdays, Uncategorized
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In early 2006, four years into running my current medical practice, doctokr Family Medicine, I got a call from my medical malpractice carrier. Just weeks before I’d received a notice that my malpractice rates could go up by more than 25%. The added news of a pending investigatory audit was chilling. In 25 years of practicing medicine I’d never been audited.
“Is there a complaint, or a law suit against me that I don’t know about?”
“No,” the auditor told me over the phone, “We’ve never seen a medical practice like yours and feel obligated to investigate your process from a medical-legal perspective.”
“Great,” I thought, with a weary sigh. “I’m already battling the insurance model, the status quo of the medical business model, and slow adoption by consumers who are addicted to their $20 co-pay. All I’m trying to do is to breathe life into primary care and get the consumer a much higher quality service for less money than currently subsidized through the insurance model. And now this.”
The time had arrived to add the concerns of the malpractice companies to the list of hurdles to clear if a new vision of a medical care model was ever to catch flight.
I frequently am asked the question “Aren’t you afraid of the malpractice risk?” when I explain my medical practice model, which is based on the doctor answering the phone 24/7, resulting in the patient’s medical problem being solved by the phone more 50% of the time. The simplest counter to this question is to analyze the risk patients incur when the doctor won’t answer the phone. What happens when the doctor is the LAST person to know what’s going on with patients? The answer is obvious. But malpractice companies could have concerns beyond patient safety. Buy-in from the malpractice companies would be critical to the future viability of all telemedicine.
I prepared a summary paper, which included 12 bullet points, explaining how a doctor- patient relationship based on trust , transparency, continuous communications and high quality information systems significantly reduce risk to the person you’re trying to help.
Bullet 1: The industry standard is that 70% of malpractice cases in primary care center on communication barriers. My medical team deploys continuous phone and email communications and 7 days a week- same day office visits when needed between doctor and patient thus significantly reducing these barriers.
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The remaining bullets could be summarized by the conclusions from the Institute of Medicine’s visionary book Crossing the Quality Chasm: A New Health System for the 21st Century using a table developed by The American Medical News when they reviewed the book. I carefully plotted our practice standards compared to the traditional business model as it stands today based on this table:
The auditor showed up, spent 4 hours reviewing our practice, electronic medical records, compliance to HIPPA, our intakes, on-line connectivity, procedures, and practice standards. While the auditor reviewed, I sat as unobtrusively as I could, feeling my brow grow damp with perspiration, as I carefully answered her questions. During the auditor’s time, I never moved to sway her to “my way.” I just let the data that I had accumulated from four years of practice do the talking.
Once the auditor left, I waited for two weeks for the results. By the time their letter arrived, I was scared to open it. The news arriving made me jubilant. The medical practice company announced a DECREASE in my premiums because we used telemedicine and EMR to treat patients so fast (often within 10 minutes of someone calling us we have their issue solved without the patient ever having to come in).
I will admit that I felt, and actually still do feel, vindicated by having my malpractice insurer understand fully the value that the type of telemedicine my practice offers to our patients: round-the-clock access to the doctor, speed of diagnosis, and convenience, which all led to healthier patients and lower risk.
Doctors answering the phone all day for their patients, it’s not just lower risk, it’s better health care at a better price. It’s a win-win-win strategy whose day is arriving.
Until next week, I remain yours in primary care,
Alan Dappen, MD
March 25th, 2009 by DrSteveSimmons in Primary Care Wednesdays
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Anyone working in healthcare has a moral responsibility to do the right thing, for the right reasons, and at a reasonable price; however, this is not happening. Today’s healthcare system is too expensive and it is broken. If it wasn’t broken, the current administration would not be focusing so much money and effort on fixing it. Likewise, 42 million Americans would not be uninsured creating two different standards of care within our country. Many decisions have already been made: providing government backed insurance coverage for the uninsured, encouraging the use of electronic health records systems (EHRs), and creating comparative effectiveness research boards (CERs). Much of what has been suggested sounds good but was passed by our legislature before seeking the input of those responsible for implementing these new policies and plans. Fortunately, President Obama’s administration is seeking input now and it is the responsibility of anyone working within the healthcare system to speak up and be heard.
Many hard-to-answer questions should have been asked before solutions were posed. Why is healthcare so expensive? How can the intervention of government lead us to better and more affordable healthcare? Although integrated EHR systems may prevent the duplication of tests and procedures, how can medical practitioners best use these systems to prevent mistakes? How will future decisions be made - between doctor and patient, or will the new CER Boards grow to do more than merely advise? How would the American people react to more controversial ideas, such as health care rationing to control exorbitant costs incurred at the end of life?
In my last post, I closed with a promise to share some ideas regarding healthcare reform. First, we should try to reach a consensus as to what is broken before implementing solutions. In Maggie Mahar’s book, Money-Driven Medicine (2006), her concluding chapter is titled, “Where We Are Now: Everybody Out of the Pool.” This title screams for change as she makes a convincing argument that all parties involved in healthcare need to rethink how we can work together to fix a broken healthcare system which seems focused, not on healthcare, but on money. Today, Uncle Sam has jumped into the pool feet first, creating quite the splash, and he is spending large sums of money to lead healthcare reform without first reaching a consensus as to what is broken in this system.
The American Recovery and Reinvestment Act of 2009 will direct $150 billion dollars to healthcare in new funds, with most of it being spent within two years. Health information technology will receive $19.2 billion of these dollars, with the lion’s share ($17.2 billion) going towards incentives to physicians and hospitals to use EHR systems and other health information technologies. According to the New England Journal of Medicine, the average physician will be eligible for financial incentives totaling between $40,000 and $65,000; this money will be paid out to physicians for using EHRs to submit reimbursement claims to Medicare and Medicaid, or for demonstrating an ability to ‘eprescribe’. This money will help offset the cost of implementing a new EHR, which can cost between $20,000 and $50,000 per year per physician. However, after midnight, December 31, 2014, this “carrot” will turn into something akin to Cinderella’s pumpkin, becoming a “stick” that will financially penalize those physicians and hospitals not using EHRs in a “meaningful” way.
At our office, doctokr Family Medicine, we use an EHR, but consider it a tool, much like a stethoscope or thermometer, used to facilitate the doctor-patient relationship, not a tool to track our reimbursement activities. I would not argue against EHRs, but there is no evidence they will make healthcare more affordable and improve the quality of care delivered - unless you believe the $80 billion dollar a year savings “found” in the 2005 RAND study (paid for by companies including Hewlett-Packard and Xerox- incidentally, companies developing EHRs). I believe it will take far more than EHRs, financial incentives, and good data to fix our broken healthcare system.
Difficult decisions await those willing to ask the hard questions but don’t expect any easy answers to present themselves on the journey towards effective healthcare reform. My partner and I believe we have found answers to some questions and are moving forward, in our own practice, now. Asking why healthcare is so expensive and feeling frustrated with the high cost of medical software, we have written our own EHR, containing costs for our patients by keeping down our overhead expenses. Our financial model is based on time spent with the patient, not codes and procedures, which helps us to avoid ‘gaming’ the system and wasting time.
A familiar adage states that there are no problems, only solutions. I suggest, though, that there can be no solutions without problems. Find the right questions and opportunities abound. Earlier in this post, I asked how government intervention can lead us to better and more affordable healthcare. It can’t, at least not without the help and guidance of doctors, patients, industry, insurance companies, hospitals, and anyone who understands what is at stake with health care reform. We all share in the responsibility to try.
Until next week, I remain yours in primary care,
Steve Simmons, MD
March 18th, 2009 by DrAlanDappen in Primary Care Wednesdays
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The U.S. government finally has announced intentions to become involved in our $2.2 trillion healthcare system. Now everyone wants to say something. Most longtime players in healthcare indignantly rebut any new input and opinions with “How dare you! … You stay away from my holy cow of entitlements (insured patients), or salary (doctors), or bonuses (insurance companies), or profits (pharmaceutical companies), or the ability to sue (lawyers.)”
I join my voice to President Obama’s statement that the single most important problem to solve in our healthcare systems is cost. The tidal wave of catastrophe rushing towards America is the expenditure of healthcare dollars doubling every 7-10 years.
Few will argue against the ideal of universal health coverage, yet this noble ideal comes with an enormous price tag and many less than honorable behaviors by all players in the system. The wasted and misallocated money lost every year in healthcare makes Madoff’s Ponzi scheme look like child’s play, and yet it continues. We finally have awoken the dormant giant of politicians to do what no one else says they will do, and the government’s intervention in the form of healthcare reform seems imminent.
Doctors were captains of the healthcare system until 1980s. They were dethroned because health care costs had doubled every seven years since 1945. Then insurance companies gladly took the helm. Guess what? After 20 year of their leadership, the price of healthcare has continued to double on average of every 10 years. Now the government is positioned to step in and fix it.
Big Brother might “force” each of us healthcare players to be held accountable including all of us as patients. This fear of change leads to finger pointing, name calling, blaming, grandstanding, and claiming, “Oh the ridiculous price healthcare … it’s not my fault and I shouldn’t have to change or fix it.” Nothing could be further from the truth. We all have to fix healthcare, and never forget, it’s about the price.
How do we create a health care system that provides the widest access, the best bang for the buck, the fairest distribution of money, and inflates at the same speed as the rest of the economy?
For primary care, two pathways are clear: the career path or the professional practitioner path. With the career model, doctors can work for someone else (like Kaiser, Medicare, an insurance company, or a hospital), and can expect a salary and benefits. In return, these employers oversee and influence how career doctors do their jobs, their hours, their interactions with patients, how they communicate with patients, and often what medications should be prescribed. We have 20 years of experience with the “career pathway.” We allowed others to interfere in the doctor patient relationship, help us ”manage” our patients, and decide what’s “reimbursable.” The soul of our work and the trust of our patients evaporated. Many believe this pathway will spell the extinction of the primary care “specialist.”
The other pathway is the primary care doctor as a professional, with a mission that focuses on the patient not just for quality, but for trust and price, and following these key objectives:
- Restoring the soul and viability of the doctor patient relationship,
- Delivering the highest quality care, and
- Restoring a pricing integrity which reduces cost.
This professional primary care doctor will restore the patient-doctor relationship with a modern office that is mobile, can be reached anywhere and anytime, has virtually no staff, minimal overhead costs, transparent pricing, and is powered through a customized software that finds the patient chart, instantly looks up any pharmacy or radiology center, can contact any specialist, can instantly look at differentials, drug interactions, gets notifications when patients have something “due,” has a large number of patient education resources that can be emailed to the patient including articles from the medical literature and refereed internet sites that can educate patients, and does all the billing from the same platform the moment that the note is closed.
An individual’s day-to-day health is not “best managed” under third-party payers. We need insurance or government to manage expensive problems or catastrophe, like cancer, serious injuries or ongoing health problems. Yet sixty years of conditioning has left most unable to see the obvious: extract the day-to-day care cost from the insurance model and return these funds to all Americans (about $700 billion/year), stop holding the consumer hostage, make doctors compete again for the consumer on price, quality, knowledge, access, convenience, relationship — just like every other service industry. Finally, bring an end the $20 co-pay mentality for the patient and “the funnel” for the doctor.
This is possible, and is being done today with the practice I founded, doctokr Family Medicine, (www.doctokr.com). Our patients pay out-of-pocket for all the primary and urgent care healthcare services they receive. We charge on a transparent time-based fee basis, where five minutes of the doctor’s time costs around $25. Our patients can contact or see us anytime, day or night, and consult with us via phone, email, in our offices or by house calls, with over 50% of all of our patients’ healthcare issues being resolved by phone or email. About 75% of our patients pay less than $300 per year for all of their primary and urgent care needs. We’ve built a relationship with each patient and spend as much time as they want with us.
In the weeks ahead I invite all readers and colleagues to consider the road less traveled. Consider primary care doctors standing-up, reclaiming their profession, embracing and being embraced by the American population. And imagine happier patients and doctors, healthier patients and that the delivery of that care costs 50% less than now.
Until next week, I remain yours in primary care,
Alan Dappen, MD
March 11th, 2009 by DrSteveSimmons in Primary Care Wednesdays
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Over the centuries, many societies have elevated the medical profession in thought and deed. Not that long ago this was true in the U.S., when our citizens showed more respect for doctors as professionals and fellow citizens than is demonstrated today. Now, everyone seems to agree that healthcare reform is drastically needed, and many are speaking out. Yet, the frank indifference to the opinions of doctors by those outside the medical profession mutes the voice and counsel of doctors on the subject. The AMA (American Medical Association) and many other physician groups are speaking out on reform, but their voice is diluted by a cacophony of assumptions, opinions, and by legislation existing and proposed. A new healthcare system has been formed, in large part, without seeking the input of those needed to make it work: practicing physicians.
Recently, I overheard a discussion regarding healthcare reform while eating lunch at a local restaurant. The debate hinged on who is most qualified to make healthcare-related decisions. The following consensus was reached: no one today should complain about the government taking over healthcare because allowing insurance companies to make all the decisions in the past resulted in a broken healthcare system. Those surrounding this particular lunch table agreed that the time had come for government to have their turn, while opposition could best be characterized as siding with the insurance companies. I wonder: can the debate really be so simply framed?
Saddened by the realization that such a discussion could be loudly and passionately debated without mentioning doctors, I resisted the urge to point out that physicians had made the healthcare decisions before insurance companies gained control. The fact physicians were not even mentioned attests to the sad truth that for many people doctors are merely seen as one part of a broken healthcare machine. Most physicians see their lot differently, and consider themselves as being in a veritable state of conflict with health insurance companies; however, our participation in a failing healthcare system has afforded these very same companies with the opportunity to put physician’s faces on their failed practices, with public opinion supporting this assumption.
Regardless of your opinion on Medicare, this last major government intervention into healthcare can help illustrate the very point that I am trying to make. On May 20, 1962, President Kennedy argued for Medicare, addressing a crowd of 20,000 at Madison Square Garden. The President was televised gratis by the three major networks reaching an additional 20 million people in their homes. Two days later, the AMA rebutted his argument, purchasing thirty minutes on NBC, with their speaker reaching an estimated audience of 30 million people. This broadcast, more far-reaching and influential than the President’s, delayed the proposed Medicare system by several years. Forty-seven years ago, people in this country wanted to know what doctors had to say before major decisions regarding healthcare were made. Today, they do not.
As the discussion about healthcare reform continues, practicing physicians must be heard from to interject real medical experience into the debate and, hopefully, guide the future of healthcare by influencing legislation existing and proposed. I am trying to remain optimistic despite the concern I feel in noting that the American Recovery and Reinvestment Act of 2009, section 3000 (pages 511, 518, 540-541) exemplifies the minimization of medical practitioners, using terminology like “Meaningful” ‘USERS’ to describe physicians.
The question is now raised: what should medical practitioners do to be heard, to influence healthcare reform, to play a leadership role in this time of change? When I write next time; I will share some of our ideas, put them on the table, if you will. But, I would encourage you to proffer those suggestions that you might have. It appears we can either speak up now or choose to be “meaningful” later.
Until next week, I remain yours in primary care,
Steve Simmons, MD
January 14th, 2009 by drval in Primary Care Wednesdays
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By Steve Simmons, M.D.
Gordian Knot: 1: an intricate problem ; especially : a problem insoluble in its own terms —often used in the phrase cut the Gordian knot 2: a knot tied by Gordius, king of Phrygia, held to be capable of being untied only by the future ruler of Asia, and cut by Alexander the Great with his sword
Generations ago, the American Medical Association’s (AMA) Code of Ethics stipulated that allowing a third party to profit from a physician’s labor was unethical. This tenet resides in a time when house calls were common place; when trust and respect helped forge an immutable bond between doctor and patient; and when it would have been unthinkable to allow anyone other than the doctor, family, or patient to have a role within the doctor-patient relationship.
The landscape of today’s healthcare system and its delivery methods make the authors of the AMA’s forgotten code look prescient. Insurance companies, controlling the purse strings, have become an unwelcome partner within the doctor-patient relationship, frequently dictating what can and can’t be done, and are reaping a healthy profit from their oversight. Obscene salaries and large bonuses are awarded to the CEOs of these companies for keeping as much money as they can from those providing health services, with the CEO United Healthcare being reported as receiving a $324 million paycheck during a five year period. Thus, short-term business strategies are given priority, often at the expense of patients’ long-term medical goals, creating a Gordian knot so entwined that no one – patients, doctors, insurance providers, or government regulators – can see a way to unravel it.
A result of so much money being skimmed off the top is that no one seems to be getting what they need, let alone want. Patients long for more time to discuss problems with their doctor and wish it were easier to get an appointment. Yet physicians are unable to receive adequate reimbursement from insurance companies for their services, and if they do get reimbursement, it’s after months of waiting and often at the high expense of having a posse of back office staff needed to negotiate these payments. These physicians therefore are forced to overload their schedule and rapidly move patients through their office if they are to earn their typical $150,000 per year, pay off medical school debt, and afford the salaries of their office employees. Finally, government agencies, looking for the elusive loop to tug on, ultimately burden physicians further with a myriad of onerous rules and regulations.
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December 31st, 2008 by drval in Health Tips, Opinion, Primary Care Wednesdays
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By Steve Simmons, MD
What do New Year’s Resolutions tell us about ourselves? Will they cast light on our hopes for the coming years or embody regrets best left in the year past? Resolutions tell us about our hopes, about who we want to be, and if made for the right reasons can lead us to the person we wish to be tomorrow. A positive approach utilizing the support of family, friends, and caregivers will help us follow through with our resolutions and improve our chances for success.
For the last two years, resolutions to stop smoking, drinking, or overeating, have ranked only ninth on the New Year’s Resolutions list, while getting out of debt, losing weight, or developing a healthy habit are the top three. If you find this surprising, you are in the company of many physicians. Yet this demonstrates the positive approach preferred by a majority making a New Year’s resolution. For each person making a resolution to stop or decrease a bad behavior, five choose to increase or start a good behavior, instead. We can learn from this and maintain a positive focus when considering and following through on a resolution. Keep in mind that only 40% find success on the first try and 17% of us need six tries to ultimately keep a resolution.
Avoid making hasty New Year’s resolutions based on absolute statements, which all too often meet with failure at the outset. We recommend an approach based on The Stages-of-Change-Model, developed from studying successful ex-smokers. For 30 years, primary care doctors have used this model to help their patients successfully rid themselves of a variety of bad habits. The Model’s foundation is the understanding that real change comes from within an individual.
Below, I’ve outlined the five typical stages a person progresses through in changing a behavior, using the example of a smoker:
1. Stage One/Pre-contemplative: This is before a smoker has thought about stopping.
2. Stage Two/Contemplative: A smoker considers stopping smoking.
3. Stage Three/Preparation: The smoker seeks help, buys nicotine gum, etc.
4. Stage Four/Action: The smoker stops smoking.
5. Stage Five/Maintenance and Relapse Prevention: Still not smoking, but if our smoker smokes again, keeps trying to stop, learning from mistakes.
The family and friends of a resolution maker are an intrinsic part of success and should avoid a negative approach. Instead, help them move through the stages, advancing when ready at their own pace. The following exchange is typical of an office visit where a spouse’s frustration spills over, finding release:
“Dr. Simmons, Tell John to stop smoking!” John’s wife demands of me.
“Mr. Smith, you really should stop smoking,” I request of John.
“Well Doc, I don’t want to and that’s not why I’m here,” John says, pushing his Marlboros deeper into his shirt-pocket, clearly agitated with his wife and me.
“I’m sorry Mrs. Smith, John doesn’t want to stop, perhaps I could hit him over his head, knock some sense into him?”
Once negative energy has been interjected between me and my patient, I struggle to find an appropriate response. Should I use humor to redirect? I have rarely seen someone stop a bad habit after being berated. I would prefer a chance to help him think about smoking and how it’s affecting his health. Does he know that smoking is making his cough worse? Has he been thinking about stopping lately? Nagging seems to be more about our own frustration than a desire to help and should be avoided since the effect is usually the opposite intended.
A resolution can show the path to a happier and healthier life. If you or someone close to you is planning to make a New Year’s resolution, just start slow, stay positive, have a strong support network….and one more thing: Resolve to stay Resolved.
December 24th, 2008 by drval in True Stories
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By Alan Dappen, MD
Twas days before Christmas and all through the house
The doctor was pacing, not telling his spouse.
“It can’t be my heart for it’s healthy and strong;
I exercise, eat right and do nothing wrong.
I’m hurting, I’m worried, have lingering doubt
I guess that I really should check this thing out.”
I did and the doc said, “Sadly it’s true,
That nobody’s perfect and that includes you…”
So starts my tale about life’s infinite ironies. This past week, I, “the doctor,” became “the patient.” My story is classic, mundane, full of denial, of physician and male hubris that it merits telling again. Like Christmas tales, there are stories that are told over and over again hoping that lessons will be learned, knowing they might not. I was lucky. I was granted a pass from catastrophe and this favor was handed to me by my medical colleagues and all who supported me.
My story began six months ago while playing doubles tennis with friends. Suddenly I felt the classic symptoms of chest pain. “This is ‘textbook’ heart pain,” I thought. “A squeezing/pressure sensation dead center in the chest.” Running for shots made the pain worse and stalling between points helped. My friends soon noticed a change in my behavior.
To my chagrin, they refused to keep playing. Instead, they wanted to call for help. Indignant, I informed them that the chest pain was caused by my binge-eating potato chips before the match – a fact only a doctor could know. The sweating was clearly from playing. I was younger and healthier than anyone there. The pain subsided while we relaxed and joked about “the silly doctor who thinks he doesn’t need help.”
In the next week, the discomfort returned often when I exercised, which I regularly do, including jogging, biking, swimming, and weekly ice hockey and tennis matches. Every activity provoked the pain. “Stupid acid reflux!” I thought, contemplating giving up my favorite vice –coffee. Keeping the secret from my wife was easy; she was traveling for business.
Over the next several days I started aspirin, checked my blood pressure (BP) regularly, drew my cholesterol, rechecked my weight. All were normal. Finally I plugged myself into an electrocardiogram (EKG), with the “nonspecific changes” results not reassuring me. I went to a colleague for a stress echocardiogram, and passed. “See!” I congratulated myself. “It was just reflux.”
For five months, all went well, with no memorable pain. But on December 10 “the reflux” came back. On the sly, I restarted aspirin, pulled out the home BP monitor again, and considered cholesterol-lowering drugs “just in case.”
Saturday night into early Sunday morning I played ice hockey. This time the pain was worse. With my team short on substitutes, I played the entire game. I dropped into bed exhausted and pain free at 2 a.m., only to be nagged throughout the night with persistent discomfort. I nearly slept through a morning meeting with a medical colleague at Starbucks. To avoid increasing my “reflux” pain, I passed on coffee.
By noon, a feeling of overwhelming inadequacy enveloped me. I withdrew, and my wife, Sara, asked what was wrong. I had to confess to her – and myself – of the reality of the pain in my chest. Sara coaxed my answers from me with non-judgmental techniques learned from years of experience.
“What advice would you give a patient calling you with these symptoms?” she asked.
“If it was anyone else, I’d send them to the ER,” I responded, wanting to stall longer. “I want to check my EKG at the office.”
Once there, she helped me with the wires, hooked up the machine. She turned the screen toward me with the interpretation to read: “anterior myocardial infarction, age undetermined, ST- T wave changes lateral leads suggestive of ischemia.”
“Stupid machine,” I thought, “there must be something wrong with it.” I insisted Sara redo the EKG. The second reading was the same. I leaned my head into my hand, not willing to believe what I saw. “Sara, let’s do it one more time…please.”
She asked, “What would you tell your patient to do?”
“Call 911.” I said quietly. The words hung there. At last I handed her the keys, saying, “Drive me to the ER.”
So went the gradual erosion of my denial, emerging into a new reckoning. After a catheterization, the cardiologist used a stent to open my 95% blocked coronary artery. Despite all I did to ruin my chances, modern medicine delivered me a “healthy” heart. This holiday season I got a second chance.
Eating healthy, exercising regularly, sleeping well, being happy, praying regularly, even being a doctor does not save us from the inevitable… sooner or later we are all patients. Healthcare is a critical social asset that must be done right, must be affordable, must offer as many of us in America a second, even a third chance. May we all be thoughtful and willing to compromise to achieve this end. Amen.
December 10th, 2008 by drval in Primary Care Wednesdays
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By Steve Simmons, M.D.
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Steve Simmons, M.D.
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In the early 70s Marcus Welby MD, embodied the expectations of patients and the hopes of doctors seeking to emulate his bedside manner. Sadly, when we look at medicine today, patients and doctors alike are left wondering what happened to Welby’s style of patient-focused medicine. Much has changed in healthcare during the nearly 40 years since the show first aired. Patients are more informed and expect to be included when clinical decisions are made. Insurance companies and government bureaucracies have wrested control of the patients from their doctors. Doctors must now focus on business and mind-numbing paperwork to the detriment of their medical knowledge and patients. Runaway costs and an impersonal health care system dominate the landscape of the early 21st century.
The interests of the patient should be paramount and the doctor-patient relationship sacrosanct; however, by inviting a third party into this relationship the interests of the patient are frequently subverted. The office meetings of the past, where difficult medical cases would be discussed, have been replaced with business meetings, insurance coding seminars, and a parade of experts reminding physicians to sit during the office visit to create the impression of more time being spent with their patient. The inevitable frustration patients feel is directed towards their physician, who in turn has been saddled with his own frustration trying to merge ethical and business concerns.
Doctors are leaving primary care in droves, half planning to work less, become administrators, or retire. A survey of medical students discovered hectic clinics, burdensome paperwork, and systems that do a poor job of managing patients with chronic illness as reasons for not choosing primary care medicine. Only 2% of students plan to select general internal medicine as a career. Most students are becoming specialists, where they can make more money, glean respect, and better control their schedule. If national healthcare becomes a reality, today’s critical shortage of primary care doctors will become problematic when the uninsured start looking for a doctor.
What qualities do we want in a primary care physician and what role do we need him to play in our lives? A succession of TV doctors: Welby, Hawkeye, and now, House, share the virtues of diligence, attention to detail, and moral courage. They can help us track the evolution of our patient’s expectations over four decades. Dr. Welby’s patients willingly followed his guidance and instruction, while Dr. House’s patients live in the Information Age and have probably searched the internet before seeking his help. Unfortunately, the admiration felt for Dr. House helps demonstrate that an entire generation expects an aggressive and uncaring doctor, thinking it the norm.
In 1979, Alan Alda gave the commencement address at Columbia University Medical School, titled, “On Being a Real Doctor.” He said, “We both study the human being and we both try to offer relief–you through medicine, and I through laughter–but we both try to reduce suffering.” Few believe today’s healthcare system is focused on suffering. Third party payers are holding on to the money, controlling care, and this influences doctors. Patients like physicians have lost focus on what really matters: to ease suffering.
I sometimes imagine Dr. Welby practicing medicine today. Towards the end of his day I see him sitting behind his desk, entangled in red tape, frustrated by his inability to untie the knot binding medical and financial realities. His waiting room is full of patients, dragging the same red tape behind them.
Fortunately, if one doctor’s argument is correct and all primary care physicians are Marcus Welby, we have reason to hope. Our healthcare system is broken, but not irrevocably. Doctors and patients can stop wrestling against their constraints, turn away from their frustration, and find each other. Patients will use access to information and drive health reform forward; many are speaking up today. Doctors would do well to remember we are all patients but the onus of explaining the healthcare crisis and proposing meaningful change falls on physicians. In our practice, doctokr Family Medicine, we try to cut red tape wherever we can, striving for an open and transparent practice, placing the doctor-patient relationship central in everything we do. I believe you can find a doctor like Marcus Welby in your community and hope our posts will encourage you to try.
Until next week, I remain yours in primary care,
Dr. Steve Simmons, doctokr Family Medicine
December 3rd, 2008 by drval in Opinion, Primary Care Wednesdays
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By Alan W. Dappen, MD; Steve Simmons, MD; Valerie Tinley, FNP of Doctokr Family Medicine
We are a family doctor, an internist and a family nurse practitioner working on the front line of the American health care system. We share a moral and ethical duty to protect the health of our patients along with all our colleagues who labor daily doing the same.We as Americans are proud of what has long been considered a first-rate health care system. Sadly, this system is broken despite our best efforts. Americans spend much more per capita for care as any other country. The World Health Organization has graded our care as 37th “best” in the world. Even worse, American citizens were the least satisfied with their medical care compared to the next five leading socialized industrialized countries, including England, Germany, Canada, Australia and New Zealand. There are many things wrong. Let’s examine a few:
Primary care medicine in America is gasping for its last breath. Internists, family doctors, pediatricians (whom health experts consider essential to a robust and cost-effective delivery system) are leaving primary care in droves. The number of newly trained generalist doctors has plummeted so fast that extinction of the generalist doctor has been forecasted within 20 years by both the American Academy of Family Practice and the American College of Physicians.
Patients are angry and exasperated with long delays, poor service and confusing and redundant paperwork. To date 17% of us are uninsured and this number will quickly grow in a deepening recession.
Employers face a huge cost burden as health insurance prices go through the roof. CEOs consistently say the runaway costs in health care benefits (which double in price every seven to ten years) threaten the viability of their companies. Since 2000, the number of small businesses offering health insurance has dropped 8%.
Health insurance companies are making so much money that several states have motioned legislation compelling insurance companies to disclose the percentage of premiums spent on actual medical care. Not surprisingly, their lobbyists are resisting. It is not uncommon for insurance companies to keep 30-40% of every dollar for “administration” and profits. Many of these companies are on record reaffirming their commitment to shareholders and short-term profits.
Doctokr (“doc-talker”) Family Medicine is a medical practice that was created to respond to the conflicts and problems listed above. We have worked to resuscitate the soul of the Marcus Welby-style patient-focused physician while adding technology to deliver fast, responsive and informed care. All fees are transparent and time-based and are the responsibility of our patients to pay. All parties that interfere with the doctor patient relationship or increase our costs have been removed from the equation. The practice delivers “concierge level” services: 24/7 access, connectivity to the doctor no matter where our patients are located, same day office visits for those that need to be seen, even house calls for those unable to get to our office. By removing the hurdles and restoring transparency and trust, 75% of our clients get their entire primary care needs met for $300.00 a year.
This post is written by three medical professionals who stopped waiting for someone else to find a solution and are actively changing primary care in ways that dramatically improve quality, convenience and access, while drastically reducing costs. The US deserves excellent health care and it must be done right. To understand why we would bother to “walk the walk,” we ask your indulgence and participation while we “talk the talk.” We hope this format will educate and inform you in ways that move you to participate in your care. Health care is about you, just as much as it about us, because we are all patients. We all have a stake in shaping the inevitable need for reform.
The next upcoming topics:
- Where did the Marcus Welby, MD-style of primary care go and how can we get it back?
- How have you as a patient lost control of your body and health?
- Turning the primary care model upside down: What does primary care need to do to reinvent itself so that it serves its patients without other conflicting interests?
- Begin the exploration of the unexamined assumptions of health care….
Until next week, we remain yours in primary care.
- Alan, Steve, and Valerie
