Doctor’s Blog

Many complain about our current healthcare system but little has been accomplished to make it patient centered. I believe that a patient centered healthcare system can be accomplished by using a patient owned healthcare cooperative model that is free from the constraints of the CPT codes used for billing and by providing financial incentives to patients to be compliant and lead a healthy lifestyle. Physicians rather than insurance companies and administrators should be responsible for care and would be compensated based on results. Profits from the cooperative would belong to the patients rather than an insurance company. One vision of  healthcare in the future is described below. Changes could begin incrementally, starting out with a conventional healthcare cooperative. Utilization of these changes should be voluntary on the part of the patient.

Screening for disease.

An annual physical examination including physical and mental fitness, weight, vital signs and age appropriate screening tests would be performed. If disease is found, appropriate treatment is begun.

Acute Illness

Rather than making an appointment to see a doctor or go to the ER/ Urgent Care, the patient can tap an app on the smartphone and talk to a physician in a few minutes. The patient would grant access to the physician to his/her medical record. The patient would report the symptoms as well as vitals signs – Blood pressure, pulse and temperature. (every patient would have the means of measuring these.) The physician could take the history and do a telemedicine exam; order lab tests and imaging; summon an ambulance; supervise the EMT’s; order transport to the hospital as necessary and treat the patient during transport.

If patients are well enough, they can go to the imaging center that also has a drawing station for blood work by car or  “cabulance”. Alternatively, blood work, EKG, plain x ray and ultrasound can be performed at home. This would all be performed the same day or night.

Most patients will not be very sick and simply need a diagnosis, reassurance, oral medication or first aid instruction. If necessary, diagnosis can be aided by AI.

Simple procedures e.g. suture of laceration can be provided by skilled technicians that come to the home and supervised by the physician

Sicker patients can be cared for at home with an aide to help with routine care and food preparation. Nurses can administer intravenous treatment; oxygen therapy and medication.

They can draw blood and help physicians perform telemedicine exams. The original doctor can call in specialists that can consult via telemedicine or if necessary in person. If necessary, treatment can be guided by AI.

Patients with unstable vital signs will still need transport to hospital for treatment of major trauma, heart attacks, GI bleeding, pulmonary emboli, acute stroke. Hospitals will be better equipped to handle these patients in the ER by avoiding the clutter of patients that do not have a life threatening emergency.

Chronic illness  e.g. diabetes, obesity, hypertension, seizure disorder, mental illness

A treatment team supervised by a specialist would care for the patient. Members of the team would consist of the patient, dieticians, physical therapists, psychologists, social workers, clergy, personal trainers, medical assistants, nurses or other skilled people necessary to care for the illness. A physician designed algorithm would help guide treatment. Problems with treatment compliance could be addressed by team members as well as the physician. Visits to the physician office would be rare. Results of treatment would be measured in terms of end organ damage e.g. to the heart, kidney, brain,musculoskeletal system.

Diagnostic Problem Cases.

When a patient has a symptom that is not resolving with initial treatment or where the diagnosis

Is not clear e.g. cause of dizziness, cause of anemia, breast lump found on mammogram, a diagnosis should be arrived at in a few days and appropriate treatment begun. This can best be accomplished if the patient goes to a facility where tests and specialty consultation can be performed in a few days. This facility would not provide nursing care or overnight stay. But would have a quiet space for patients to study and read; other space for a gym, TV, video games or other entertainment. There would be Exam rooms for specialists. Laboratory and imaging would be available on site with a 24 hour turnaround. Specialists would see the patient the same day or next day. This is similar to a hospital without beds, nursing care and bedside food service. Once the diagnosis is made, a treatment should be established and begun in 24-48 hours. The center would be judged on accuracy of diagnosis as well as efficiency.

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A Brief Look at the Numbers: Average cost of hospitalization in 2018 was about $10K; the average charge with private insurance was about $20K (The average charge to the uninsured ranges from $40K to $60K) Average number of hospitalizations per year was about 9/100 for ages below 64.

Total annual payments for hospitalization/100 people= 9x20K= $180K

Annual outpatient charges are estimated at $500

Total annual outpatient charges/100 people= $500×100=  $50K

Annual drug costs across the population estimated at $1200. We can reasonably assume

that drug costs are higher for the over 65 population. We would estimate this to be $500

In the under 65 population.

Total annual drug charges/100 people =$500×100= $50K

Total costs of reinsurance with $50K deductible+purchase of PPO discounts=$20K

If we add these costs together, we find the total charges/100 people= $300000

Notice this is the total cost. Insurance typically pays about ⅔ of the cost; ⅓ of the costs are paid out of pocket in the form of copays and deductibles.

The very cheapest Blue Cross policy for a 31 yo male in zip code 77096 was $257/month or

$3084/yr. The cost for 100 people would be $308K annually but would have a $7400 deductible.( At age 50, the cost was $4000 annually.) The high deductible means that outpatient care is not paid for and that the insurance only pays for the reinsurance and hospitalization costs of $200K.

The gross profit for the insurance company is at least $100K (income per 100 patients of at least $300K less claims of $200K)

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The United States has taken an important step in reducing the cost of health care by mandating price transparency. Unfortunately, people are not incentivized to care about the actual cost of health care under the current system of insurance and care plans. This lack of incentive is one of the major reasons why the cost of health care has risen to its current height. People are allowed to focus solely on the price of their deductible, copay, and out-of-pocket maximum for their insurance instead of the actual cost of care. However, focusing on these things doesn’t change the price of their care or the fact that someone needs to pay it in full. Let’s discuss the effect this has on people who require care.

There are typically two types of people who use the health care system, those who avoid the system until they need it, and those who rely on it regularly. Both types of people are relatively insensitive to the actual cost of their health care.

Those who avoid it until they need it usually have very little experience with the health care system, and typically only rely on it for emergencies. They may have little knowledge of how it works and what everything costs, but prices are of little concern to most people in an emergency. These people focus on insurance premiums, deductibles, and their copay rather than the actual price of the emergency care they’ll receive, and they rarely will (or can) shop around for the best price.

Those who rely on the health care system regularly are people who need care for extended periods of time or have chronic illnesses. These people have much more experience with the health care system but are still relatively insensitive to the actual price of their care. This is because instead of focusing on the price of care, they only have to focus on their deductibles and the out-of-pocket maximum of their insurance plan. After paying the out-of-pocket maximum, their care is paid for entirely by their insurance for a period of time.

In both cases, the health care system doesn’t incentivize people to care about what the actual cost of care will be. Price transparency can be very helpful for people (mostly those who fall somewhere between the two types of people described above), but it can only go so far in helping the problem. Creating coordinated health systems that stop the fragmentation of care for chronically ill patients can drastically reduce the actual cost of care for each patient. In addition to this, proper preventative care can reduce the overall cost of care for those who avoid the health care system.

Houston Healthcare Initiative (HHI) is an organization of physicians and other medical professionals that is actively trying to fix this problem by increasing coordination, being transparent about our pricing, and much more. Contact HHI today for more information.

The Pfizer and Moderna vaccines against the Covid-19 virus use an mRNA technique to guard human beings against the disease. The technique “teaches” human cells to make a protein that triggers an immune response, hence antibodies that attack the virus. Now, according to The Week, BioNTech has developed a treatment using the same approach that appears to stop multiple sclerosis in mice. If the same treatment can be made to work in humans, it could be a game-changer in treating the debilitating disease.

MS causes the immune system to attack the myelin, a protective sheath that covers nerves and spinal cords. Depending on how the disease progresses, patients can lose the ability to walk, speak, see, or perform other functions. No cure exists for MS, but current treatments can stave off the disease’s progression and help recovery from attacks. However, these treatments can compromise the immune system, placing patients at risk for infections.

The mRNA treatment for MS has been shown to stop the symptoms of the disease in mice and prevented further deterioration of the test subjects. Mice that were given a placebo exhibited typical symptoms of MS.

According to Healthline, roughly one million people in the United States and two and a half million worldwide are living with MS. The progression of the disease cannot be well predicted. It often makes itself apparent, then goes into remission, only to manifest later. Twice as many women as men suffer from MS. Scientists do not well understand what causes the disease.

If a treatment such as has been developed by BIONTech can be brought into a clinical setting, people suffering from MS may be able to live far more normal lives than before. It may not be a “cure” in the sense that it is one and done. Further research needs to happen to determine how long a treatment can stop MS. But anything that can treat the disease without side effects will be a boon to humankind.

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The EMR has several advantages over the paper charts that it replaced. It is legible, cannot be misplaced and it eliminated paper prescriptions and paper orders. However, the current iterations have several disadvantages. 

1. The information density is very low in that a physician trying to understand the clinical course of the patient finds it difficult to access the relevant facts. It is laced with legal documents, consent forms, appointment verifications and other administrative information.
2. The physician has become a data entry clerk. In addition to doctoring the patient he/she has to doctor the chart. It contributes to physician burnout and raises the cost of medical care.
3. The information quality is poor in that physicians are poor data entry clerks and much of the physician’s notes are copied and pasted to save time and are thus inaccurate.
4. As each provider be it doctor, hospital or imaging center has its own EMR, the patient’s medical record is scattered about. A physician trying to care for the patient almost never has full information. Much time and effort is necessary to acquire information from the various sources. This also increases the cost of care.
5. The EMR is expensive with monthly fees paid by providers.
6. The patient has no access to his records.                  

Why is this? It surely is not a technical problem. We can understand the problems better when we realize that the main purpose of the EMR is to facilitate billing. The rule is “If you did not document it, you didn’t do it.” and thus you will not be paid. We need an EMR that is patient centered and not connected to billing at all. Such an EMR will not work with the current insurance system. 

An employee owned healthcare cooperative can correct most of the problems of the current EMR. If the cooperative maintained the EMR, all patient records would be in one place. The various providers could access and add to the EMR with no cost to the provider. Patients could have access. The information could be arranged with ease of access by providers the primary goal. With modern technology, the office visit could be recorded including the Chief complaint (reason for the visit) and the history. The physician could orally record the pertinent positive and negative physical findings and the conclusions. The recorded discussion with the patient about further testing and procedures would complete the visit. A data entry clerk working for the cooperative can then enter the diagnoses on a diagnosis list and record new medications on a medication list; Vital signs can be entered by the doctor’s office as well as by patients. Sections for lab and imaging would be maintained by clerks. No longer would doctors be adding data; they would be free to spend more time with patients. The copy and paste repetition of data would not clog the record. Administrative data would not be part of the EMR and could be stored independently by each provider.