A "HealthTweep" Pulse Check

On Tuesday, December 8th, 2009 I had the please of speaking with Bryan Vartebedian, MD, a pediatric gastroenterologist, active in the social media space via Twitter @Doctor_V, his personal blog 33Charts.com, and periodic contributor to Get Better Health.

We spoke via Blog Talk Radio on his calling to medicine, pediatrics in particular and more recently his attraction to the social media space. Doctor_V has both interesting and witty insights on the medium. Some of his more recent tweets are noteworthy:

When I mention SM to other physicians they just giggle and look confused

LinkedIn may be a good first step for socially retarded physicians

Social media is the fancy awning that hangs from a building; human interaction is the bricks & mortar (a re-tweet)

For more of ‘Doctor_V’s insight, wit and early ‘do’s and don’ts’ for physicians considering a social media presence, listen in to the full interview here.

OK Tweeps in the movie ‘What the Bleep‘ do we know, the line transitioning to the theme of the flick proffers:

it’s time to get wise.

Well the same holds true with respect to the ‘resistance is futile’ health care borg aka ‘the tapeworm medical industrial complex’ economy. Our health care system is at risk of collapse; with 46 million uninsured, 25 million under-insured, primary care physicians bailing on the system daily, health care premiums sky rocketing, while benefits are being reduced and cost shifted from the plan to the employee. No one is happy with this status quo, quite to the contrary of some public opinion polls that tout we have the ‘best health care system’ in the world!

Surely we have the best high tech or ‘rescue care’ medicine that can be found. But when it comes to the ‘value proposition’ the story gets a little more complicated, and requires a bit more than sound-bytes or political grandstanding to get at the truth.

Money Driven Medicine is a primer for such a rational conversation. If we thought the Senate Finance Committee hearings followed by the debate of Chairman’s mark was exhausting, just wait for what’s in store from the special interests, and their ‘Quack-er’ proxies in the Senate during the impending floor debate of the merged bills.

So why not get current and be a part of the solution? Watch Money Driven Medicine and get WISE!

While the political theater slogs towards it’s ‘battle fatigue’ finale in Washington, D.C., and elswhere in the United States of Amnesia, one American, who also happens to be a politician has decided to approach our health care conundrum in the spirit of the Cluetrain Manifesto and from the footprint of the human experience via a story telling process, i.e., the human narrative.

The name is Congressman Alan Grayson, and the site is Names of the Dead (dot) com. While some will immediately look to party affiliation, and standing with respect to the health reform bills before the Congress to position how they’ll ‘receive’ (or discount via an ideological filter) his message, I encourage you to watch some if not all of the videos.

They are personal stories of Americans who died directly as a result of delayed access to medical care. An empirical basis for the claim that lack of health insurance is associated with mortality is provided in the peer reviewed study Health Insurance and Mortality in US Adults.

The publishing of this report is a timely and top of mind topic, since as a male I am one of the 47 million Americans without health insurance, and a boomer in his 50s, who has occasion to think about the 1 in 6 prospects of prostate cancer in my future. Specifically I have pondered, and have avoided to date, submitting to a PSA test. And yesterday via virtual participation in the TEDMED hashtag stream (#tedmed) I came across a prostate CA piece from theVisualMD dot com, which only further affirmed my fear, and stoked a somewhat borderline despair.

Why ‘borderline’ despair? A few illogical and perhaps ‘magical thinking’ reasons come to mind:

• I am avoiding the test since ‘ignorance is bliss, and I am uninsured?’ Ergo, if I or any lab for that matter doesn’t know, then it can’t be confirmed as a pre-existing condition, right?; and
• If I am a positive, then what? I am not insured and can’t afford the treatment. So county here I come? No thanks, I don’t subscribe to the ‘John Goodman theory’ about the mythology of the uninsured in America.

So my choices are to sit with the 1 in 6 odds and continue as I am, pretending not to be concerned. After all, my history is disease free, and as a health care ‘insider’ I avoid interacting with the health care delivery system as a general rule, staying active and eating healthy for the most part.

Yet, I can’t help but think about those stories that Grayson is sharing with America and asking myself, will I be on the list soon?

So while we debate and more accurately obfuscate the nature of the problem we face vis a vis health reform solutions, people die daily. The ‘dead man walking’ queue witnesses some 122 new recruits each and every day.

The health reform imperative is real tweeps. Unfortunately the dividing line all to often seems to be between those who are employed, and have health insurance (aka, the I got mine crowd) and those who do not; many of whom are employed or self employed but none-the-less locked out of the system due to obscene health care costs or opportunistic underwriting and/or retrospective rescission schemes.

So what’s it going to be peeps? As a society, who will we value and install as the ‘anchor’ tenant in medicine? Will it be (generically speaking) a Mayo model, or the status quo, volume incented, quantity driven series of competitive fee-for-service sweat shops, dba ‘McAllen’s’ (generically speaking of course)?

So what’s a ‘preferred hospital’ anyway?  A fair question, since ‘beauty’ is for the most part in the mind of the beholder!

Preferred Hospitals remains a conceptual ‘on the come’ value proposition at this point; but when I first thought of the idea, I had in mind structuring a network of participating hospitals and physicians directed primarily to the 47 million Americans without health insurance. The network’s ’secret sauce’ consisted of providers who contractually committed to a substantially discounted (equivalent to the best or “most favored nation’s”) rates, otherwise extended to ‘wholesale buyers’, i.e., health plans, with the greatest group purchasing leverage.

In the economics of managed care, the more members a health plan trafficked in a specific market, the greater provider discounts they could expect. Most favored nations rates often equated to 50 cents on the dollar (or less!) , i.e., a 50% discount. Thus, the value proposition (to the uninsured) was twofold: (1) the contract rates would be actually honored, and therefore the member would receive a benefit in exchange for the modest dues paid vs. told ‘we don’t participate with that plan’; and (2) the provider’s rates would be adjusted to ‘fair value’ at least as determined by the entities with the greatest purchasing power in that market.

The great irony is hospitals and physicians too often (whether by design or not) reserve their ‘retail book’, i.e., billed charges, for the least able to bear the burden of charge based ’sticker shock’. Many offer cash discounts as a courtesy in the +/- 25% range, but too often fail to present that option upfront before the downstream litany of collection calls.

At the time I originally entertained the idea, the discounted medical plan marketplace (DMPO) was populated with flimsy players, many of whom where exposed by the Georgetown University Study ‘Discount Medical Cards: Innovation or Illusion?‘ So it appeared this idea would have traction in the marketplace. While I enthusiastically jumped in, I found myself banging my head on the wall, over and over again. The value proposition seemed so apparent to me; especially linking the emerging growth of retainer, concierge or micropractices to a targeted and under-served market that contrary to popular wisdom was not a indigent demographic per se. Further, I reasoned (incorrectly I might add) that many of the forward thinking, and compassionate hospital systems (especially the one I worked for in DFW), forged under benefit of tax exemptions would proactively embrace a solution designed to reach an underserved market, and thus make a material deposit into the ‘community benefit’ bank. With IRS and the Congress on the non-profit hospital trail (i.e., Chuck Grassley, et al) looking into the veracity of 990 filiings, certainly these hospitals would see the light and embrace the greater good this model so obviously afforded; not!

None-the-less, I began to negotiate ‘upstream’ with several national PPO network managers, who in search of incremental revenues, and fighting ’silent PPO allegations’, were electing to ‘rent’ and private label their networks in exchange for a per member, per month (PMPM) fee that ranged at that time between $3.50 – $4.00. Yet, as a start up with no membership, it became solely a cat and mouse affair. The PMPM basis was a function of the membership base which at that time was zero. From their perspective, it was a pure play ‘on the come’ business model, and good intentions not withstanding, we could not come to terms.

I also approached several colleagues, and friends in the personalized, retainer model, or concierge medicine market, and attempted to interest them in the business model. Most notably the Society for Innovative Medical Practice Design (SIMPD) was a logical partner or sponsor (I reasoned) to which I ‘pitched’ the idea, though to no avail. They were just not interested in ‘marketing” their nascent member panel at the time, nor reaching out to this underserved market per se.

Thus, no traction developed, and after much time soliticing support, and partner participation, I elected to back off of the business model.

So fast forward a few years and witness the ‘health reform 2.0 moment’ we’re all having. Revived thoughts have surfaced as to what and how a preferred hospitals network might be structured?

Here are a few ‘indicia’ of an emerging preferred hospitals manifesto:

• Commit to pricing, cost and quality transparency
• Adopt social media guidelines to engage and empower patient utilization of the hospital’s services (pre-admission, during and post discharge; especially follow-up concerns)
• Offer ‘members’ most favored nations’ rates via a credible discount medical plan(s)
• Waive where possible, or otherwise, defer collection of all upfront fees, copays, estimated co-insurance, and/or deductibles
• Participate in budget driven and consumer specific time payment programs (as determined by independent financial counselors) via auto-debit direct from the patient’s bank (interest free)

This is only a start. I welcome your thoughts.

Program Note: Due to ‘technical difficulties’ the interview with Jay was disrupted and will be rescheduled shortly! This live web is a continuing experiment and the tech gremlins do tend to appear now and then. My continued apologies to Jay.

Jay Parkinson, MD, MPH, of Hello Health, joins me for a conversation on emerging alternative medical practices from Concierge, Boutique to retainer based models, including the HelloHealth strain. Jay is a pioneer in the adoption, and integration of social media tools into medical practice; and will share his insights, and vision for the promise and pitfalls of social media innovation in medicine.

Amidst the current ‘fever pitch’ buzz of health reform, there is considerable conversation about lowering health care costs, while improving both quality and access. The US health care system is at risk of implosion. Whether we look at it from the underfunded programs of Medicare or Medicaid, or the cost prohibitive employer sponsored health insurance system – which has priced iteslf out of reach absent the planned cost shifting of so called ‘high deductible health plans’ – few are happy campers; and approximately 46 million Americans are without health insurance.

We will connect the dots of emerging medical practice models to the broader health reform agenda by considering the vision and value system of one of medicine’s clear innovator’s.

Join us on June 19th, at 11 AM EDT/ 8AM PDT for a live broadcast that will also archive for later broadcast or RSS subscription to Google Reader, iTunes or other feed aggregator.

It seems not a day goes by without another announcement of this or that primary care medical practice electing to leave entirely, or in part, the traditional model of medical care. Yet, this is a trend most worthy of considerable exploration.

Absent effective health reform (minimally: primary care payment equity, and administrative simplification), the current drip, drip, drip outmigration of physicians from a traditional billing and collections medical practice into these ‘new age’ models has the potential to grow into an outright tsunami in the near term.

Movement by primary care physicians into the boutique, concierge or retainer based medical models is not without a downside. Some say that it is clear evidence of the emergence of an impending ‘perfect storm’ in medicine that will collapse the primary care safety net at the precise time when it anticipates its greatest demand (i.e., retirement of the baby boomer generation).

When one takes into consideration the overwhelming preference for medical students to opt for higher paying specialties vs. the primary care specialties of Family Medicine, Internal Medicine, and Pediatrics, the trend is quite disturbing – health reform incentives (to grow capacity) notwithstanding.

At one level, it is a rational response by physicians to a failed healthcare finance and delivery paradigm; while at the same time, extracting essential primary care infrastructure from a delivery system that completely relies on it’s availability.

There are many models in the retainer or concierge medicine market. Once you’ve seen one, you’ve seen only one; there is no standardization. From MDVIP, to Jay Parkinson, MD, at Hello Health, this is a dynamic and rapidly evolving industry.

We will feature this medical phenomenon from the inside out at one of our next programs. There is much to discuss.