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First Principles: Listen to your patient

At the University of Tennessee Health Science Center in Memphis where I attended medical school I had many excellent teachers.  These teachers spent countless hours at patient bedsides personally instructing me and my classmates using the principles established by Sir William Osler, MD.  In the early 1900’s, Dr. Osler pioneered the teaching method of bringing students to the patient bedside to learn first-hand how to take a patient history, perform a physical exam, and then develop an appropriate diagnosis and treatment plan.  Among Dr. Osler’s many attributes was his adamant belief that good physicians always centered their care on the patient.  His most well known saying is “Listen to your patient, he is telling you the diagnosis” which emphasizes the importance of the patient and their story.

My practice has always tried to take this principle to heart in both patient care and in the way we run the practice.  This has been such a core belief that they are allowing me to embark on a grand adventure that attempts to solve two of the major hurdles I hear my patients tell me they have: the rising cost of routine healthcare and the growing difficulty of routine communication with me as their physician.  I alluded to this in my last post about Trinity’s planned Hardin Valley clinic which I will staff, and Dr. Smith has recently written about it as well in two recent posts: here and here.

The first major hurdle I hear patients have is the rising cost they are having to shoulder to obtain routine primary care.  Unexpected, serious medical problems are known to be expensive (although that is changing too, check out the Surgery Center of Oklahoma) but what many of my patients have wondered is why routine medical care is becoming more expensive.  In fact however, most routine care has become less expensive in the last ten years while the amount that an average patient is responsible for has gone up.  The percentage that patients pay out of pocket has risen even as the cost has come down.

Across the nation, primary care offices are attempting to solve this problem by transitioning to a model of practice called Direct Primary Care.  As high deductible plans become the norm and many remain uninsured, we realize that patients are getting little benefit in cost reduction at a primary care office from having insurance.  At Trinity the allowable (the amount an insurance company reimburses for services) is essentially the same price that someone without insurance pays.  Since each insurance company has a different allowable we’ve made an effort to make our prices as equitable as possible.  We have fought to keep an even playing field for the insured and uninsured alike.  In many venues, the cash price and the insured price are markedly different bolstering the fear we have of a large medical bill.

But what would happen to the cost of care if we simply decided not to utilize insurance for something they aren’t going to pay for anyway?  For instance, if my daughter sees her pediatrician for strep throat my insurance won’t pay any of that visit due to our high deductible.  What would happen to the cost to provide her care if her pediatrician doesn’t have to try to bill or collect from our insurer.  If the doctor doesn’t have to account for the overhead from dealing with insurance then he could charge less for the same care.  In fact, in a Direct Primary Care model the cost to deliver routine medical care without the burden of a bureaucratic overlord becomes so inexpensive as to only cost about $2 a day for most adults.  Imagine being able to have almost all of a typical adult’s primary care medical needs paid for for less than an average cell phone bill.  Children are even less expensive coming in around $1 per day.

The second major hurdle I hear from patients is the difficulty they have connecting with me when they have a need.  Within Trinity, as we’ve doubled and tripled in size in the last nine years, we expanded our phone room staffing, improved patient’s ability to direct their call, added the patient portal that allows for necessary HIPAA compliant secure direct messaging with the clinical staff, and continued to have 24/7 direct access to the on call physician (740-6436) as many other practices have transitioned to a nurse triage service.  Even still, it can be a challenge to get quick feedback for a patient.  Every patient I have inherently knows that when they call my office there is a 0% chance I will answer the phone.  Wouldn’t it be wonderful if time with your physician in whatever venue seems fitting is valued and encouraged?  Why do only office visits constitute active care?

So what avenues of communication can be utilized if the first major hurdle is overcome by arranging for care outside of insurance?  Virtually any of them.  In many Direct Primary Care practices, patients and their physicians communicate by whatever means they feel are appropriate.  There are no longer restrictions and limitations as the care being provided can be fluid and evolve to fit the need.  Patients often continue to utilize secure messaging through a patient portal but often a direct email to their physician replaces it.  Phone calls to the office change from a phone tree based menu to the nurse (or even physician) having the freedom to answer first.  How much simpler would it be if I could answer my patient’s phone calls directly?

While these changes are bold and drastic, Trinity feels like something needs to be done.  We want to help our patients and continue to listen to their needs; trying to solve these problems as best we can.  So as I embark on the journey of a new satellite clinic in Hardin Valley I will be transitioning to this model of practice.  I’m not sure if I’m the guinea pig or perhaps the tip of the spear but either way I’m stepping out with the support of my colleagues attempting to help our patients.  Trinity Medical Associates of Hardin Valley will be a Direct Primary Care practice while the rest of the physicians at Trinity Medical Associates in Fort Sanders West will continue unchanged in their practice.  We want to innovate and experiment ways to help our patients but aren’t so foolish as to put all our eggs in one basket.  Trinity Medical Associates at Fort Sanders West will remain unchanged in their insurance plans and coverages and staff.  They will continue to provide the high level of primary care our patients deserve.

I’ll be providing the details of my Direct Primary Care office in mailers arriving this week but a short summary of Direct Primary Care principles can be found here.

I know Direct Primary Care solves many problems for patients but it doesn’t solve them all. I think it affords the flexibility to grow into an even better solution as more communities recognize its value.  Trinity has chosen to continue their mission to innovate better healthcare and I’m thankful they are allowing me to build a better healthcare experience in primary care.

mbm

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