Welcome To The Broken American Healthcare System. Where Dissatisfied Docs Can’t Provide Quality Care.

According to Afshine Ash Emrani, MD, the worst news in healthcare isn’t antibiotic resistance, drug-drug interactions, hospital-acquired infections, and definitely not the alarming rate of obesity in our youth.

No, the worst news is the increasing number of dissatisfied physicians.

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That Didn’t Take Long. Congress Delays ICD-10 Legislation.


Congress is now going to vote to delay the ICD-10 implementation date.

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Do You Have A Chip On Your Shoulder About Cash-Only Medicine? Let Me Get You An MRI.

Originally posted on Kevinmd.com

In 2010, I started practicing Direct Care in Wichita, KS. I steadily built a full roster of subscribers who pay between $10 and $100 per month to see me whenever they need to, for as long as they need to, however they want to (at their home, in my office, or via the Internet), all with zero copay.

Recently, a patient of mine developed ongoing shoulder pain. He’s middle-aged, insured, in good health overall, and as expected, refused to get an MRI.

As a direct care practitioner, I act as my patients’ family doctor — routine checkups, consultation, etc. — and as their personal urgent care physician – lacerations, broken bones, earaches, and stomach flus — I can handle all of this at no extra cost.

I write and fill their prescriptions, some as low as pennies per pill. Patients do pay for their labs and panels, but our wholesale rates come out lower than the copay of most insurance plans.

I even have someone who helps them find super affordable wrap-around insurance plans in case of major trauma.

Just last week this same patient called me up first thing in the morning: He was in severe pain.

“Dr. Josh, I’m ready for that MRI.”

So I immediately made the call to a local lab technician, because I wasn’t fifteen minutes behind my third appointment scheduled for the first hour of my day like most doctors working within the traditional fee-for-service model.

Because of the relationship I’ve built with the lab, my patient owed only $400 for the MRI, instead of the out-of-pocket cost of $1,500 that’s billed standard.

Within 45 minutes, my ailing patient was leaving the lab. Within a few hours, I was reviewing the results [Josh, please tell me the results here > … ].

But critics are probably shaking their head, wondering why this man would want Direct Care when he’s currently insured.

Well, the thing about insurance is that in almost all cases, patients need to meet their deductible in order for insurance to cover things like MRIs. An Obamacare silver plan comes with a $3,000 deductible — twice the amount due! If they went to the same lab and used their insurance, they would owe $1,100 more out-of-pocket.

And they would still owe that monthly insurance premium that’s really only there in case of major trauma.

And they would risk having to go to an overpriced ER if they had any trouble late at night or on the weekend.

It’s worth remembering that insurance is a business and they sell their benefits like every other company. Major Medical will typically offer “free preventative care” in effect saying, “as long as you see an overworked doctor of our choosing, you pay nothing.”

Except you do pay. You pay by waiting 18 days to get an appointment. You pay when doctors talk to you for 7 minutes and have to look down at your chart to remember your name. You pay when these doctors refer you to the same lab for the same MRI and you’re indebted $1,500 because you haven’t met your deductible yet.

That’s why it baffles me when people have knee-jerk reactions to paying cash for medical services.

“Oh, cash-only medicine, that’s only for the rich,” said an associate of mine while we were in L.A years ago. She went on to manage Patient Experience for the prestigious USC Medical Center, a place even the insured might only dream of receiving care.

Then there are critics who say things like, “You doctors seeing fewer patients will reduce access to primary care.”

Or our favorite gripe, “You’re going to create two-tiered healthcare.”

As a Direct Care practitioner I take offense to these attacks because they lack perspective. Do critics of an affordable option that delivers real value want healthcare without any tiers? And what would this tier look like? Millions losing existing coverage, rising premiums for small businesses, cheap Obamacare plans sneaking in absurd drug costs…

To me, this sounds like a universal healthcare system that equally fails all people of all socioeconomic backgrounds.

Why would someone criticize me when I tell people, I’m happy doing what I’m doing, I’m happy to consult other doctors in doing similar work, and I’m happy to motivate students to choose family medicine instead of a specialty?

Critics see affordable cash-only doctors as the root of our doctor shortage. I see us as a viable long-term solution. When students begin to perceive the financial and emotional benefits of practicing family medicine – two things I can personally vouch for their attainability – then this doctor shortage might actually be addressed.

And when critics want to examine the chip on their shoulder, I’ll be glad to negotiate for them.

Yes, The Customer’s Always Right. And That’s What’s Wrong With Fee-For-Service Medicine.

If you’re a patient dealing with insurance, Stephen C. Schimpff has something to tell you. You aren’t really your physician’s customer. That’s because the insurer will decide whether and how much to pay the physician after they’ve seen you. You’re largely a bystander in the relationship, he says. The doctor’s customer is actually the insurer.

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Healthcare Is Broken. But Throwing Pills At It Won’t Solve The Problem.

Kevin Pho knows how to craft a headline. He says on Kevin MD, that patient satisfaction is all the rage, and that it might actually kill.

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The Logic Of Obamacare: Small Business, Unintended Consequences

In his Kevin MD post, Stephen C. Schimpff asks, “Is this affordable health care or is it is the law of unintended consequences?”

Schimpff is former CEO, University of Maryland Medical Center; chair, advisory committee, Sanovas, Inc.; and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Healthcare Delivery- Why It Must Change and How It Will Affect You. He’s got plenty of clout behind him. And he says, “The Affordable Care Act is not so affordable if you own or if you are an employee of a small business.” Read his full explanation of what he believes will happen to small businesses in 2014 and 2015 based on the ACA.

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The Moral Hazard Of American Healthcare

John F. Hunt, MD writes on Kevin MD, “If you learn nothing else today, I would ask you to learn that moral hazard is the cause of medical price hyperinflation.” His is a controversial post, meant to elicit click-through with the title, “The cheapest form of health care is to let sick people die.”

Obviously, Dr. Hunt doesn’t want anyone to die. However, his argument is that so long as it’s the government’s obligation to take care of people, prices will skyrocket. This is due in part to the inherent moral hazard. He explains, “Moral hazard is when the person who bears the economic burden of a decision is not the decision maker.” In healthcare, the moral hazard is a third party payer (insurance/government) bearing the economic consequences of a patient’s decision.

Dr. Hunt makes an excellent point. When there’s moral hazard, the patient cares less about drug and procedure cost, and what doctors charge. As a result, he says, prices rise when the “buyer” doesn’t care about these costs. He compares this to teens given no-reins access to their parents’ credit card. “[Then] if everyone in America let their teenage daughters go shopping for clothes… the prices would skyrocket.”

He explains the catch-22 in play here. So long as the government/insurance are responsible for payment, the actual prices of services will be hyper-inflated. The only way to break this cycle is to make the patient the person who bears full financial responsibility. The problem is that we as a populace need to make that leap of faith. Direct care patients are doing this. Direct care docs are doing this. The question is when will everyone be doing this? Only then will we see prices return to realistic levels. Seriously, the out-of-pocket cost of an ambulance trip alone would break most Americans’ banks.


Posted by: AtlasMD

November 19, 2013

David Do On Why EMR Companies Don’t Care About Usability

In his op-ed blog post, David Do, MD exposes the cold hard truth of EMR failure—their inherent un-usability.
He says, “I overheard nurses praising the pilot of a new technology with the promise of improving communication, safety, and saving on healthcare spending. The innovation: two-way texting. That’s one of the many indicators that hospitals are stuck the technological stone-age.”

Great point. It’s almost embarrassing that these common technologies are BIG NEWS in the healthcare world. You’d think an industry that’s in and of itself a cutting-edge phenomenon (saving lives by doing things that require tremendous education and skillful implementation) would use equally sophisticated tools outside of the operating room. But that’s not the common case. Dr. Do calls out the assumption that new technology will magically make EMR in healthcare automatically better. “In reality,” Do writes, “there’s good and bad technology, and there are good and bad EMRs.”

Sounds about right.

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Posted by: AtlasMD

November 14, 2013

The Story Of The $1,000 Tetanus Shot

The Story Of The $1,000 Tetanus Shot

Olivier Van Houtte is currently a medical student. His blog post about a bike race turned trip to the ER makes for a compelling read. And to answer your immediate question–no, this tetanus shot did not include a band-aid made of pure gold or a side of heavily steeped saffron tea.

Olivier takes a compassionate look at his medical bills, going line item by line item. He’s fine with a $2,500 CT scan because yes it would have saved his life if he had internal bleeding in his brain. And he’s okay with an $800 ambulance fee if only to compensate for the on-site EMTs who immediately attended to him post-accident.

However, he’s curious how a nurse swabbing his arm with alcohol and administering a $15 shot in his arm was marked up to $1,000. Really, come on.


Crickets in the EMR audience…

Zackary Berger is a faculty member of the Johns Hopkins University School of Medicine. He contributed a new post to the Kevin MD blog (yes, we’re fans of Kevin, too!) because his institution recently switched from a home-grown EMR to EPIC, which as you know has been reputed to be an EPIC failure. Supposedly we’re reaching the “nexus” of electronic records and communication, a future where scientists and physicians and patients can give meaningful information and get meaningful insight in return.

Fact is, we think this future might remain for the time being just that, the future. That’s why we’re starting small, focusing our EMR on patients and docs having a meaningful electronic interaction. In time, this might lead to more paths of communication, and more meaning to be derived from digital data. The metaphor we use is this: imagine someone in a time predating the wheel, planning a system of stone roads. For now, maybe we should get the wheel spinning, and then see where we can go with it.

This complex highway of data and boxes and buttons might be a little premature. When Berger read an article by a colleague of his who is researching the use of these new EMRs he noticed something. Patients are given “access codes” in order to tap into the extraordinary benefits of these EMR programs. But guess how many people are actually activating them?

Only 20%. Hmmm, is that even a good number? Berger is wondering the same thing. We’re thinking it’s more like crickets in response to the big sell that is EPIC EMR, perhaps indicative of the disengaging reality of today’s EMRs.