TECH: Why physicians don’t want email from patients

Headline: Patient-Doctor E-mail Could Cut Income for Physician Practices. Kaiser Permanente Northwest’s Clinical Systems Planning and Consulting group did a study on its patient-physician email use in its NorthWest region and found that it worked as it was supposed to. Visits down 7-10%. Phone calls down 15%.

This is of course great news. Productivity goes up, patients are happier and their care is probably better. Of course in the bizzaro world of health care that we live in, this would translate into a 7–10% decline in primary care physicians’ incomes. Which is why RelayHealth et al raise suspicion of their potential customers, and why we have to get them off the fee-for-service treadmill ASAP.

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  1. I’m a professor of electrical engineering and a student economics. Therefore, I’m intelligent but not that knowledgeable on health care except for the rants of my opthamalogist uncle and having spent about $150k of out-of-pocket on my family over the last 8 years.
    I mainly want to defend the practicioners. So from my lay, but logical and cold point of view, here are some observations:
    1) People don’t want to die, and now that we have knowledge around to prolong life, we spend more and more money to stay alive whereas in the past we would just get sick and die with spending virtually nothing. This is an exponentially growing issue – why can’t we let people die in comfort instead of spending $500k keeping them alive 6 more miserable months. (I add that i would value a child’s life above that of a 90-year-old man, but that’s another issue)
    2) The government could mandate we all get beach-front property (or health care, say) but that doesn’t mean there is enough to go around. Why doesn’t anyone seem to understand this?
    3) Most physicians (not “doctors,” 😉 are highly intelligent, driven, and can do almost whatever they want in life. Medicine is about as esoterically rewarding as business as law as engineering, etc. (E.g. a businessman provides jobs to people, which is just as important as saving lives). It has to pay well to get good people – I’m sorry, that’s reality. They shoudl get paid in proportion to how good they are – this isn’t the Soviet Union, I hope (we all get two bags of grain right, even if we don’t like grain?).
    4) Insurance companies add no value to the patient-physician relationship. They siphon off funds through the inefficiency they create from the idealism of “everyone one should get care.” They are an unnecessary middle-man and an efficient market-based system would eliminate them quickly. An efficient middle man is like a distributor, say Wal Mart, that makes getting what you want easier and cheaper, not harder and more expensive.
    5) I have tenure at a major university – that’s damn close to an intern-like experience of medicine. Sacrifice and commitment way beyond what most people will do. There just aren’t that many people willing or able to do it. The supply is scarce, so the price paid for it is high DUH.
    6) On the more offensive side, I don’t care if we wake physicians up at 3AM anymore. That’s what you’re paid for – e.g. usually we’ve called the nurse because we are scared about something with a kid and they tell us to call the physician, who grumbles at us to go to the ER, where we wait 2 hours and the physicians there glare at us for not having a big enough emergency (like we would know). Of course, if we bring the kid in the next day, we get glared at for waiting so long – the kid could’ve dehyrdated.
    If you don’t like being woken up at 3AM, sign up for a job that lets you sleep (there are few, by the way, that pay $150,000 or more).
    Bottom line: please observe reality. There is not enough to go around, and to lie to ourselves creates an expensive myth that results in actually less care.

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  3. I worked for KP in the mid-1990s and remember getting emails from my doctor way back then! I also remember being so impressed that the doctors took their medical notes on a PC that was in each exam room.
    A neurologist my PCP sent me to for migraines (in the same building, about 2 hours after my initial office visit) told me that he liked KP because he could “practice medicine, not billing.”
    I was also impressed by the rule that no patient should wait for a scheduled appointment for more than 20 minutes without an explanation and offer to re-schedule. Remember, this was about 10 years ago.
    Since then, none of my employers use KP but I will ONLY go to doctors who believe in both email and electriconic files. I did go to an “old fashioned doctor” for a short time but fired him after one too many hour-plus waits in his crappy waiting room (he also used hand-written, largely illegible notes). I now go to a semi-boutique practice where I pay a yearly membership fee but my records are electronic, waits are nonexistant, and I never wait more than 48 hours for an appointment.
    KP also offers free classes on stuff like asthma management for adults and kids, diabetes management, childbirth prep, etc. It’s a great program.

  4. To get back to the email finding in the original post and the comment about FFS … When I left KP (I’m not a doc, I am professional staff) I was struck by how different an environment I landed in at a traditional medical center. Kaiser docs had sometimes griped about the bureaucracy, but not often and certainly not terribly venomously. They were so much more CALM than the docs in the old fashioned setting. The KP docs truly felt they could focus on patient care instead of feeding or fighting the administration (which was the hobby of the docs in the traditional practices, who were not actually employed by the medical center but had privileges there).
    The general consensus is that to get excellent care at KP you must be good at working bureaucracies, finding the truly great docs amongst the rest and being persistent and not taking no for an answer when needed.
    Same is true out of KP. No mention was made in the post above of whether the Kaiser docs like using email, but I bet they do! I’ll take my docs by email (if they know how to be clear writers!) and with lower blood pressure, thanks.

  5. I’ve practiced as a salaried physician for twenty-five years for three organizations. I’m not rich, but I’ve done alright. Every specialty is a bit different, of course, but I like not having my income directly tied to whether some child gets sick or injured.

  6. Pretty soon (the next 5-8 years) most of the docs who provide emergency care (gen surgeons, orthopedic surgeons, neurosurgeons, urologists) will be gone. The average age of surgical specialists is 56. This means that in five years this population will be 1/2 its present size. There are few new surgical specialists willing to take ER call. Gen Surgeons become bariatrists, or plastic surgeons. Orthopods become total joint or spine surgeons or sports medicine docs. Neurosurgeons burn out after the tenth lawsuit. Also, over 1/2 of new MD’s are women, who tend to pursue less time demanding medical careers. So, no matter what system you pick to pay the docs, noone will be around to do the most urgent work.

  7. As for the salary vs. FFS debate, I can only speak as a person who works for a living.
    If I pursue an MBA I am likely to make more money. However, if I’m going to engage in more graduate education, I’m old enough, wise enough, and well-enough off, that I want it to be in something that fascinates me. For me that would be an MFA. Perhaps I’m ignorant of the reasons other people pursue advanced education but I’ve always assumed that doctors slog through the years and years of school and the hell of internship and residency because somehow, deep down, they were fascinated by the act of providing medical care.
    At least that is what I, as a patient, hope. I doubt I’m alone.
    The way I see it, doctors have invested a big chunk of their lives, and frequently incurred a buttload of debt, in order to A) have a career they enjoy, and B) get paid enough to make the aforementioned worthwhile.
    Joe Blow, it’s not rational to be an advocate of the free enterprise system but expect a sub-set, especially a sub-set as vital to the general well-being of a society as health care providers, to be exempt from the opportunities for economic growth. Or perhaps, as Dimitriy suggested, you feel the entire US economy should be reengineered. That is certainly a whole different scenario.
    I think there are more practical ways to fine tune the current economics of health care. We could start with consumer information. In an ideal world, patients would have access to at least as much information about health care as they can readily obtain while buying a car. Granted medicine is a bit more complicated, but I for one would like to be treated as though I am a consumer, not a captive audience. I want information about the product, and I want the freedom to choose my own health care providers without being penalized by my insurance company.
    In my little health care Utopia, I’d know which doctors specialize in treating a particular illness, where they’re located, how successful they are in that treatment, how happy their patients are with their services and office staff, how much they charge for various services, and how much my health care subsidy (insurance, Medicare, employer contribution) would pay for those services.
    Allow me to build a scenario here (using strictly fictious numbers). Pretend I’m a diabetic. In my ideal universe, I would be able to determine that there are 1000 doctors in the US who specialize in diabetic retinopathy. I would know that their fee for an office consult ranged from $500 to $50. I would know that ten of them were within 25 miles, but that according to their health care outcome ratings, the top ten were all 50 to 600 miles away.
    I would also know that my health care subsidy would reimburse up to $120 for that consult.
    Depending on my preferences, the impact of my health condition on my quality of life, my economic circumstances, and how much time and access to transportation I have, I would make a choice that met my particular set of needs.
    I might be willing to fly 600 miles and pay my share of a $500 office consult. Or I might not be able to travel at all and would need to find a reasonably high quality specialist on my local bus route. I might decide that my relationship with the doctor I see most frequently is more important than his overall health care outcome statistics, especially if I’ve been a diabetic for a long while and I already understand the limitations and possibilities for care.
    The thing about the current system is that for the patient it’s like playing Blind Man’s Bluff. We don’t know which doctors are truly knowledgeable, which ones are more interested in their afternoon poker game, or whose office staff will get on our last nerve. We don’t know how much they’re going to charge. Worse, we don’t know how much the insurance company will allow (unless we belong to an HMO… but that’s a whole separate set of issues) and most people can’t figure out what percentage their insurance is going to pay. It gets even more complicated if hospitals, therapists, diagnostics, anesthesiologists, et al are involved.
    The current compensation system for doctors isn’t the reason that US per capita health care costs are so absurdly high, and the overall quality of the system is so lackluster. It’s just not that simple.
    It is however pretty easy to see that as long as patients lack the information and freedom necessary to make appropriate choices, the only players in the game will be the health care providers, medical product companies, and the health plans/Medicare/Medicaid. Maybe I’m the one oversimplifying things now, but it seems like all of the patient advocacy groups may have a point. It might be time for the conversation to be about more than money. Naturally it should include money, but not *just* money.

  8. I can answer that. Kaiser’s health care email is on a secure internal email server and network. You have to log onto their site to access the email service. Of course anything can be hacked if the programmer is determined enough, but it seems to be a sincere effort to keep patient health information private.

  9. Just to be clear…are we talking standard, unencrypted, email? I don’t know what Kaiser, or others, offer.
    If so, that would not be a good way to communicate personal health information, and may be against HIPPA.

  10. I have Kaiser and I like the email feature.
    I have many other things to do besides sit next to my telephone waiting for a phone call from a Dr. It’s one of those things where if you have one meeting that day, that will be when they try to call you.
    I like being able to look at my lab results online, and print them off.
    I like not having to tell my problem to the receptionist while I’m sitting in the cube farm at work with everybody else listening in.
    I’ll also add that when I emailed about my PCP ordering a lab test for me she emailed back and informed me that she was also ordering blood lipids to be done because I was due for those, and she wanted me to come in and get the results so we could review them.
    Count me as please with the system!

  11. “Peter needs to spend a month in my shoes trying to get reimbursement from Medicare. I don’t know where he gets his information from, but the studies I have seen looking at how good a payer Medicare all are all biased in some ways. I see thousands of patients a year and Medicare is just as bad at weaseling out of “covered” services, delaying payments and is the worst at customer service.”
    DrThom, I guess you assume that I agree with the way the present Medicare system operates. In Ontario Canada physician audits became a problem, or at least a perceived problem. Here is an article from 2002:
    Now here is an article from 2005:
    Do you think you can get the same response from Medicare/Private Insurance at solving you billing problems with Medicare/private insurance as docs got under the government system in Ontario Canada?

  12. I’m just curious joeblow, what do you do for a living that you have all the answers for healthcare and doctor’s salaries? My guess is that we won’t be impressed.
    I can tell you that many current physicians may continue to work for the salaries your plan would offer because it would be the path of least resistance and care would not suffer so much in the short term, but it would discourage many people from starting medical training (Look at components of the current nursing shortage-one aspect is increasing salaries). Why would I (and I am in my last year of pathology fellowship training, so 9 years after college and very much in the hole financially) forego a decent salary for so many years only to make less than a dentist, a pharmaceutical sales rep, or a lawyer? Altruism? Maybe, but probably not. Altruism doesn’t put food on the table or your kids through college. And don’t forget, you only take the oath to take care of people once you’re into the health care system. So if you don’t attract people to the profession in the first place, then there will be no one bound by that oath.
    Your solution may work well for a little while, but once the number of docs starts bottoming out and the population continues to grow, and fat people get fatter and smokers keep smoking, the demand for health care will far exceed supply, and salaries will have to go back up in order to get peoplpe into medicine, and then you’re right back to where we are. It’s simple economics.
    I am very curious as to what you do joe blow, that you have such a low opinion of what we have sacrificed to get to where we are. Please enlighten us.

  13. If our patients want to contact us, they must use email, we don’t use the phone. For three days after an appointment and for special circumstances determined at the time of the visit (for which they are given a code) they may email us for free. After that, it is $25, refunded if I can’t answer their concerns satisfactorily. Questions are answered within 24 business hours. I haven’t had one complaint and though my practice is closed, I have requests daily to take patients.
    If they want to use my services, then they are going to have to pay. If the government wants to pay me, fine, I am going to do an excellent job with as few patients as I can and go underground if necessary to treat others who opt out of the system. I have provided millions in unreimbursed care in my career and have many times paid back society for the resources invested in my education through my labor. See how the system works.
    By the way, my decisions are influenced only by the excellence and efficiency of care I can obtain for my patients. The narrative of our country is that if you are honest, work hard and are prudent, you should be able to afford quality care you need, not what you want but what you need. Once that narrative is disrupted, once I see that I am responsible for the consequences of the actions of others, then I will once again pay for others healthcare.

  14. Interesting discussion
    Peter needs to spend a month in my shoes trying to get reimbursement from Medicare. I don’t know where he gets his information from, but the studies I have seen looking at how good a payer Medicare all are all biased in some ways. I see thousands of patients a year and Medicare is just as bad at weaseling out of “covered” services, delaying payments and is the worst at customer service. It is only through a sense of service imbued by my training that I take it at all.
    The rest of you seem to understand that if you change the system you will change the doctors and their habits. There will be a trade off good and bad, but you can’t honestly expect a salary based system to meet the demands of a culture otherwise socialized in the importance of customer service.
    Also any such system will have to change the risk of practicing medicine. Suing a doctor will have to become just like suing any other government employee for doing their job. Folks will have to give up the Jackpot mentality and so will attorneys. I am not saying it won’t happen just that if you go to single payer, it must and that will require a sea change.

  15. The bottom line is that doctors are far more valuable as professionals than any other group. Thats why we constantly see proposals for univeral healthcare, but we never see any proposals for universal engineering, or universal accounting, or universal law.
    Thats implicit recognition that what doctors do is FAR more important than what engineers, lawyers, or accountants do.

  16. “For ONCE can we TAKE the MONEY out of the equation? It’s about healing people. It is about a solemn oath taken to help people.”
    Ok, take the money out of the equation. Can I get an exemption on rent, payroll, taxes, and the cost of supplies? How _will_ my bills be paid, then? Or should this be taken out of the equation too? Come up with a number, discount the worth of a profession, because they are committed. And then let them run with it. Costs? who cares! They will get enough money, we shouldn’t consider costs, because they are so committed, they will find a way!
    Please – be honest. Yes, docs are committed. But committment and drive do not pay this years cost-of-living increase for the office staff. Neither do they repay my ridiculously high student loans. Only when committment and drive result in increased income, LIKE ANY OTHER PROFESSION, do these goals get met.
    Why are we so willing, as a culture, to apply communist principles (to each according to his need, from each according to his ability) to one group of people. It is a slippery slope. Next will be mandated “salaries” for emergency service workers and first-responders, after all, we all need police and firefighters, paramaedics, and EMTs. Next will be municipal employees – pay them all the same, across the country. Why not? We have a consitutional guarantee for criminal defense attorneys, which is more than the Constitution says about healthcare, so they are next, with fixed, federally mandataed salaries. No opting out allowed.
    As all of these people find that they cannot afford the things they once could, they will clamor for price controls, and we will have it, enforced by regulating the salaries of workers in other industries.

  17. Yah know. I’m really tired of the “put them on salary and they’ll stop working, market-based greed is the only incentive” canard. Fear of dire financial consequences is NOT the best incentive. Fear of starving to death for lack of marketable skills is a form of dire coercion, not a cause for celebration.
    Look. It’s about this one profession. No one becomes a doctor by accident. No one does it on a whim, or casually decides to change careers one day and goes out, takes the correspondance course and gets the ticket to doctor. It requires commitment and study and a grueling apprenticeship. It takes a drive, a will. It means helping people or cheating death or whatever is the overwhelming life-long motivation. It is not like real-estate speculation.
    Never mind that “consumer-based” healthcare is a lie, given that an “incorrect buying decision” might not reveal itself for decades, at which point it’s kinda late to ask for your money back. Nor that anyone can boycott critical care as a form of economic protest. These arguments are pure, greed-driven bunk. Stop it. You know you’re wrong. Stop lying to us.
    Meanwhile, maybe we NEED doctors not to work so hard. Maybe more people would become doctors if the craft wasn’t so wrapped up in entrepreneurial BS. Maybe, just maybe, this isn’t ABOUT MONEY. For ONCE can we TAKE the MONEY out of the equation? It’s about healing people. It is about a solemn oath taken to help people.
    If a doctor doesn’t believe in that oath and only wants the cash, s/he can go be Donald Trump. I’ve seen plenty 0f doctors do both, and they disgust me.

  18. I think the reason docs resist any improvement in healthcare cost control from their side, such as emails, is that their reimbursement from insurance companies is so low that a drop in patient volume will deduct from income while their overhead stays the same. I don’t see where FFS brings in more patient visits unless docs are scheduling unnesseccary follow-up appointments or getting kick-backs from labs, drug companies or hospitals (could that be so?). FFS or salary should not affect if a patient needs to see a doc – the patient’s health condition should determine that. Docs can compensate for low insurance reimbursements by increasing patient volume, but are they just building a larger practice or running through the same patients more times? FFS and salary have pros and cons. How do you compensate for higher skills and better results?
    I don’t think FFS in the present U.S. system is the cost driver. A single pay gov. system with FFS would benefit both docs and system costs. Docs would be garanteed no collection problems, one set of rules, and a set reimbursement rate. They could then also negotiate what the FFS rates are. That would leave it up to them to build practices and attract patients if their drives, skills and outcomes are better. In theory at least the good docs would steal patients from the bad docs.
    None of this will come about until this country changes the presednt paradigm that we need the private insurance industry in healthcare. But the other paradigm, that our politcal system needs bribery to function, will have to change first.

  19. There is a great article giving more details on the pros (patient benefits, respectful use of email) and cons (billing hassles) of physician email experiences at: http://www.acponline.org/journals/news/jan-feb07/online.htm
    I’ve also written a broader commentary on why insurance inhibits useful innovations in retail medicine (part of a rant against universal health mandates) on my blog at: http://consumerfocusedcare.blogspot.com/2007/07/mandatory-health-insurance-tax-on.html
    The overall takeaway (relevant to email) is that the actuary-based claims reimbursement system isn’t meant for an everyday retail health system…and stifles innovation in services that smooth everyday doctor/ patient interactions…The way to fix it would be to remove the insurance payment system for this market (patient satisfaction and communication blooms in both cash-pay and boutique care). It really is a structural issue that needs to be fixed to align incentives.

  20. Joe blow: Apparently you don’t realize that most procedural interventions… gasp… have a purpose. There are a few that may be significantly overperformed (colonoscopies), but most are necessary. Completely slashing any incentive to work hard and driving large portions of the physician workforce to leave/retirement at a time when the number of elderly is increasing greatly is basically the same as telling them to go die. If you don’t understand now, you probably would when your parents were told “Sorry, there’s a 3 week wait to get that coronary artery unblocked”.

  21. Whats Funny is The amount of Time they actually spend with us…. Heck I swear one time I would of had more time with the Doctor if he would of emailed me..

  22. Salary system is the only way to keep costs under control. Its either that or we can start reimbursing colonoscopies at $2.50 a pop. Your choice.
    A fee for service system GUARANTEES that the reimbursement per procedure will get cut every year by the federal government. Its the only way under a FFS system to curtail the massive increased utilization that docs participate in to jack up their incomes.
    Personally I think you docs would be much happier and better off under my salaried 40 hour work week system. Think about it. You dont have to chase patients anymore. You dont have to spend half your practice doing paperwork for a thousand different insurance companies.
    The number of colonoscopies has gone up by 15% every year for the last 5 years. Thats during a time period when the screeening recommendations for colon cancer have remained unchanged. Medicare has no choice except to cut reimbursement every year until the volume of procedures slows down. Trust me, at this rate Medicare will eventually pay $2.50 for a scope, less than a Happy Meal at McDonalds. Is that what you want? Because thats whats coming. Government has no other option to control costs except cut back on reimbursements.
    Or, you can ditch the FFS rat race and go to the salaried system. Everybody benefits. Healthcare costs would plummet overnight under my system. Docs would have much better working hours now that they dont have to chase patients and schedule 10 minute booking slots trying to squeeze in more “customers”

  23. Thanks, Joe Blow. It’s nice to know I am appreciated, but at your rates, I can find other employment.
    I, like many colleagues, have a whole host of experiences which might be valuable to employers in other, or related, fields, outside of practice. We all have somewhere else we could go, it the incentives were right.
    Your logic is so clear: in order to improve access for everyone, reduce access for everyone. Disincentivize people from entering the profession, and “increase the # of doctors too.” And yes, spend the extra three or four years in specialist training. You’ll get a 20K raise! So I can forego four years salary, hmmmm, 480k, and get a 20K/yr raise! Woohoo!
    I don’t know exactly what work you do, but whatever it is, it should also be salaried. In fact, it should be standardized, so that there is no distinction between you and the next idiot doing the same job; no difference betwen the worker with 20 years experience and the newbie with none. Think of all the opportunities you will have to excel and improve your career.. oops, sorry. Nowhere to go in your utopia.

  24. My bank charges me $7 per month to have online access to bill paying and other services. Even though my online transactions are probably less expensive for the bank than processing a check or an in-person transaction, I pay it. The convenience makes it worth it for me. I would gladly enter into a similar arrangement with my PCP if it saved me an office visit. In fact, I can see a business case for employers being willing to pick up some of the cost for such fees if it resulted in less time taken from work for appointments.
    I am all for government intervention into health care coverage and payment reform; I’m just skeptical that I’ll see such (effective) intervention for many years. Therefore, why not encourage some kinds of “concierge care” like pay for email service to allow PCPs to get off the perverse pay-for-visit hamster wheel, save patients time and save employers money?

  25. We should also nationalize roads, factories, farms, homes and supermarkets and send dissenters to Gulag.
    After all, why not?
    This should help get rid of unnecessary private sector overhead and banish profit motive to black market.

  26. “So what prevents physicians from working less hours and seeing less patients?”
    Thats what we WANT to happen. We WANT there to be fewer patients rolling thru factories and fewer procedures. We already spend a ton of money on wasted procedures that dont benefit anybody except the person making $$$ for doing them.
    Thats the whole idea of a shift to salaried doctors. Thats the only way they will have no incentive to pump patients thru and do as many procedures as possible on them to make $$$$.
    So yes, I would expect patient visits and procedures to fall drastically. Thats a good thing, not a bad thing.

  27. So what prevents physicians from working less hours and seeing less patients? If I as a PCP am seeing on average 30 patients per day, if I were to go salaried, why should I work so hard and continue seeing so many patients? I have worked both in the salaried mode and the “pay for work done” mode, and the latter is far more motivating when it comes to dealing with hassles – and physician life is loaded with hassles. I just think your pay scale is unrealistic when compared with the amount of work done on the average day by a physician and it does not take into consideration the de-motivation of being salaried.

  28. Doctors should be salaried employees of the federal government with all the benefits thereof including malpractice coverage paid for by the fed.
    Thats the only way to break the fee for service system that drastically increases costs with no improvements in patient outcomes.
    My salary structure would look something like this:
    1) Primary care doctors: 120k
    2) General surgeons: 140k
    3) Subspecialist surgeons: 170k
    4) Internal medicine subspecialties: 140k
    This framework would still pay docs enough so that they dont levae the profession in droves. Remember that lawyers and CPAs all average close to 6 digits for far less training than a doctor gets so if you reduce doctor salaries by too much they will leave medicine and flood those other fields.
    We will have to increase the # of doctors too, because once you move to a salaried system, you will see lots of doctors shift to part time work and in general drastically decrease their number of surgeries, patient visits, etc. So you still need to keep the pay high to attract people to the profession.