Deconstructing Medical Practice

Bill Crounse 2007 04 On Super Bowl Sunday, I received an e-mail from one of my physician colleagues, Dr. Thomas Gumprecht.  I’ve provided information on HealthBlog before about Dr. Gumprecht and his ENT practice in Redmond, Washington.  Tom and I share a passion for the use of contemporary communication and collaboration technologies in healthcare delivery.  We both understand how a medical practice can be transformed when physicians use every means available to them in the care of their patients.  That means phone, fax, messaging, e-mail, web visits and tele-health applications in addition to traditional face to face visits with patients in the office. Even more so, Tom and I share a strong conviction that physicians must be paid for delivering services to patients when using any of these modalities.

image Here in Washington state, Dr. Gumprecht has been successful in getting many insurance companies to go along with this.  No, I don’t mean that private insurance will necessarily pay for services rendered using technology (although some do).  But they will allow physicians to bill patients for these services provided that the physician has written, signed documentation in the patient’s chart that she or he understands and agrees to the fact of being charged when such services are provided.  According to Dr. Gumprecht, even CMS allows for private billing when patients have been so informed and the documentation is in the chart.

Dr. Gumprecht e-mailed me to vent his frustration that so many docs are still unaware of this opportunity to deconstruct their practices and transform the way they deliver medical services.  He wrote:

image There is a huge universe of need for medical services of every type and variety. Medical offices should reconfigure themselves into "call centers/communication centers (phone, fax, email, texting etc.)" wherein the patient is contacting the office for some sort of service. With this new policy the secretaries/nurses are not incentivized to channel every request for service into an office appointment. Especially with an EMR data base, the requests for service can be fielded, sorted through by the secretary/nurse as to what seems to be the most appropriate way to provide the service, format it for doctor review and response and the service provided---by phone call, fax, email, or in office visit whatever is proper. And an appropriate bill generated and sent to the patient. The office revenue would not be limited to just what can be seen in office. If the doctor fields 5 phone calls, 5 prescription refills, and 5 emails in a day in addition to his office visits, the doctor would have a better paycheck to show for the genuine work he/she has done. It would reward true "medical homes". It would help rectify pay inequities in medicine.

If you look through the comments the last time I vetted this on HealthBlog, you’ll see we hit a nerve.  One doctor wrote:

As a Family Doctor, I spend a significant portion of my clinical time on purely cognitive services (counseling and education). These are currently reimbursable only when conducted face-to-face in the office. Requiring a patient to leave work and drive to the office for a 15-30 minute discussion seems unfair. But it is equally unreasonable that a physician couldn't collect for that time if the same services are provided telephonically or electronically.

We lose the subtle clinical cues: body language, gross neurologic inspection, skin color, etc. But much of the time, even these are not needed.

Do I need the patient sitting across from me to counsel on travel vaccines? Motion sickness medications?

Is there anything negligent about following up with a stable depression patient by telephone or video-conference?

I always feel a little guilty requiring office visits for these types of services, but it is my only option right now if I am to stay in business.

These are services I would love to provide remotely, but there are some obstacles:

1) Insurance contracts still won't pay for "virtual" visits

2) Most of my patients, for reasons I can't grasp, expect that telephone services and consultations should be free.

Even over the phone, I still spend the same amount of my professional time. I still accumulate the same liability (maybe even more). And I require the same level of cognitive work.

The potential downside of expanding access to tele-health is that patients will begin to expect more services in this fashion.

image Yes, patients appreciate not having to make appointments and come into the office for every little thing they need. Time is money on both sides of the equation. Especially when an office visit co-pay is already involved, how many patients would trade convenience over the hassle factor if you charged a similar amount for services by phone, e-mail or on the web?

The longer physicians hold on to the notion that only office visits generate revenue, and the longer they continue to give away their cognitive services when using any other modality (or steer patients to expensive office visits that they really don’t need) the misery will continue. Dr. Gumprecht and I believe that our professional societies need to step up, and start training physicians how to deconstruct their practices and avail themselves of the contemporary communication and collaboration technologies at their disposal. In any other professional services industry this happened long ago. Just ask your tax preparer, attorney, or accountant.

Bill Crounse, MD Senior Director, Worldwide Health Microsoft

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