Blog | 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.