I have felt from the start that this practice model is far better than the one I had in my former life, including:
- Better experience for the doctor
- Better experience for the patient
- Better care quality
- Savings for the patient and for the system.
The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice. This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against).
Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get. This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model). I realize that this does not constitute a proof of concept, but it is not without meaning.
PATIENT 1. MEDICARE. AGE: 90+
Pt had a head injury and came to my office wondering if they should go to the ER. I assessed the mental status did an exam, determining that this was not necessary. Set up imaging study that day (CT without contrast) which came back negative.
In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this.
Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price.
Savings: Avoided ER with head injury work-up. Cost: ? (More than $300 by far).
PATIENT 2: SELF-PAY (HAVE HIGH-DEDUCTIBLE AND HSA). AGE 10
Pt fell and injured arm. Mom sent message to me over weekend wondering about ER visit. I told them to come in on Monday and I’d evaluate. Evaluation was not conclusive, so I sent for x-ray, which showed small fracture. I suggested ortho, but mother messaged me back saying she talked to a friend who was an ortho and they said to just splint this. I checked on the recommendation and agreed. Child was in splinted, had repeat x-ray which was better, and given permission to do sports again.
In my old office, without messaging mom would likely have chosen to go to the ER. If not, would have seen me and would not have communicated with me about her friend’s advice (and I wouldn’t have had time to listen), so cost would have been quite a bit higher.
Cost: 2 x-rays of the forearm – cash price of x-rays $80 each, so total cost of $160
Cost savings: Avoided ER visit and specialist visits.
PATIENT 3: SELF-PAY. AGE: 40’S
History of migraines, better with Topamax as a prophylactic drug. Can’t take it due to monthly cost. I found a cheaper cost, but then the price went up dramatically. Pt came to me saying they had to stop the medication, as it was costing more than $120 per month. I personally called pharmacy, who said that the cost for them was high, but then noted another local pharmacy had it on their $4 drug list and that they would match anyone’s price. I passed this on to the patient.
In my old office would have required payment for an office visit to talk to me about this, and would not likely have had time to research the cheaper price.
Cost: $4 per month.
Cost Savings: $116 per month and significantly improving quality of life.
PATIENT 4: COMMERCIAL INSURANCE. AGE: 40’S
Significant head injury with out loss of consciousness. Pt had some change in mental status (dazed), some nausea, dizziness. Came to my office directly. I evaluated, determined low risk for subdural bleed, more likely concussion injury. Ordered noncontrasted CT of head and stayed in office for 2 hours before test could be done. We re-evaluated over time and progressively got better. CT scan was negative. I called and did phone follow-up over the next few days and pt recovered completely.
Cost: CT of head: $300
Savings: ER visit and workup for head injury with altered mental status. Cost: ?
PATIENT 5: COMMERCIAL INSURANCE. AGE 50’S
Past history of bleed from A-V Malformation in brain. Pt was out of town and had sudden onset of headache and dizziness, wondered if needed to go to the ER. Spoke at length, told them to call neurology, but wasn’t convinced ER was necessary, as symptoms had improved significantly. Pt never reached neurology, but called me the next day when back in town. I called neurologist personally and decided ER was not necessary. Set up noncontrasted CT to see if there was new bleed. CT negative, and now plan set-up to see specialist per neurology recommendation to have issue addressed in a way it couldn’t be done with initial bleed >15 years ago.
Cost: CT of head: $300
PATIENT 6: MEDICARE. 70’S.
In hospital repeatedly with heart failure prior to coming to my new practice (was patient in old practice). Husband produced a spreadsheet he made to follow this, which I set-up to be filled out online, having results sent to me on daily basis. Have since managed this over past 8 months, with patient losing over 30 lbs, coming off of oxygen, and becoming munch more active. Have had to delicately balance diuretics, blood pressure medications, and kidney function. Husband hugs me when he comes in office, and son-in-law relates a “dramatic” difference in how she is now.
Cost: Nothing.
Savings: Avoiding likely multiple hospitalizations due to fragile CHF.
PATIENT 7: MEDICARE. 90’S.
Well known to me, anxious, calls fairly frequently. I cared for patient when spouse died a few years back, and pt has voiced a desire to die and be with spouse. Pt sought me out when I left for new practice. Recently change home situation. Called me with chest tightness and shortness of breath. Caretaker thought this was related to the recent move, but was afraid to not go to ER. I spoke with patient, explaining that I thought this was probably anxiety, but that even if it wasn’t, if it was a real heart problem, if she went to the ER they would hook her up to IV’s, do lots of tests, and maybe even admit to the ICU. Patient told me, “oh no, I wouldn’t want them to do that,” (which I knew). I advised them to take a little extra anxiety medication and that I’d call back the next day. Fortunately, things had improved and the pain was probably due to anxiety.
Cost: Nothing.
Savings: At least the cost of an ER visit and possibly a full admission for something the patient absolutely didn’t want done.
These are just some of the cases recently that have come up. I think it explains how having a doctor available to help deal with crises or decisions for care will help patient make better decisions and save money.
So, to the insurance companies (including CMS) I say: You are Welcome.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where an earlier version of this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
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Thanks for sharing your experiences, Rob. Fascinating business model, and I’ll be checking in to see how it goes and how you troubleshoot major problems.
A link describing the practice model to which you are referring would have been useful.
Rob, I agree with you, but those that make the rules and regulations will ignore these experiences. Both you and I would consider them facts, but many of our brethren and the industry and government will just label them anecdotes.
That’s the sad truth.
I think it’s time to invest in a reconditioned CT unit. Or atleast negotiating a relationship with area imaging center.
That is great post. It’s very nice. Thanks for sharing your ideas.
The anecdotes themselves are not proof at all, but they are examples of what I can do in my office that I could not do in my previous office. I assume I am at not at increased risk of having an adverse event, actually having a significantly higher amount of time to make sure of care quality with each patient. The point of this was more an illustration of how the process is different, and better processes lead to better outcomes.
Rob, those are all good examples. Now take the opposite situation, what if one of those patients had an adverse event? What then? What level of liability? Standards of care? Assuming you make the right assessment 100% of the time. After all that’s what is expected of of.
While these are well documented examples by you and I agree and applaud you for documenting this, taking the time to present this here and paying attention to the issues, this will be viewed as nothing more than anecdotes by most physicians. So very often our personal experience and observations and assessments are blown off as just that, anecdotes.
I have been in practice for almost 9 months and have incurred an average cost of $70 per family unit. Let’s say I care for 350 patients over that time, getting a total of $14,000 per month (assuming a little less than 2 people per family). How many hospitalizations would it take for me to offset that cost? How many ER visits? The important thing is that I am financially motivated to keep the cost down, as my customer is not Medicare or the insurer, but the patient. Patients absolutely want to avoid the ER, want to not pay deductibles, want to keep their cost as simple and inexpensive as possible.
In some ways this practice model works better and makes more sense for those for whom spending time in the ER or hospital is most likely, and that is, to some extent, who I have attracted. I have two patients on the list for a kidney transplant, 6 patients with insulin pumps, 2 patients with active hepatitis C, several people with heart failure, and a bunch of other complex patients. You are right that this system is slower to justify its benefit in a relatively healthy population, but the main difference in what I do is that I am actively trying to keep cost down and not wait for problems to allow me to justify my billing.
I am presently in discussion with someone to do research on the patients who were with me prior to my move and made the change with me. What was their cost (with me) prior to coming to see me, and what has their cost been afterward? I am not sure, and there certainly is a chance for spurious results (for and against me) as a single hospitalization (or progression of disease) could offset any savings. But I am certain of one thing: I had no time to offer most of the things listed above in my old practice, and now it is a major part of what I do. I am motivated by the fact that my patients could leave me any time if they don’t feel like I’m giving enough value.
But, to your point: yes, data would be nice.
Rob –
Those are all good examples of avoided costs, especially for ER visits and other hospital based care. However, the experts tell us that in any given year fully half of the population uses little or no healthcare. Even within the Medicare population, the healthiest 50% of seniors account for only 4% of the program’s costs in a given year.
So, if this healthy population’s payers were paying a doctor like you $60 per month vs. the next to nothing in cost that they would likely incur, how would that aggregate incremental cost compare to the avoided cost for patient encounters similar to those you described? I have no idea but it appears to be a similar conundrum to the cost of routine screenings like colonoscopies and mammograms. How many patients do we need to screen to avoid one premature cancer death or find one serious illness early when we can treat it more easily and cost-effectively?