American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, November 15, 2013

'You are welcome'

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+

Patient 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 insurance and a health savings account). Age 10

Patient 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: 40s

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. Patient 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: 40s

Significant head injury without loss of consciousness. Patient 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 patient 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 50s

Past history of bleed from A-V Malformation in brain. Patient 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. Patient 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. 70s

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 much 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. 90s

Well known to me, anxious, calls fairly frequently. I cared for patient when spouse died a few years back, and patient has voiced a desire to die and be with spouse. Patient 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.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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