Category Archives: Patients

Medicaid: Program for the poor should not impoverish doctors and hospitals


Medicaid beneficiaries deserve the same access to healthcare services and products as people with commercial insurance or Medicare. But since Medicaid pays doctors and hospitals 27 to 65 percent less than commercial health plans (according to a new GAO report), it makes it awfully difficult for providers to be payer agnostic. Sure enough, we see even supposedly mission-driven non-profit healthcare systems looking to maximize their share of the commercial population by catering to that group.

That’s a real public policy problem as the proportion of patients with Medicaid increases, and it presents providers with an unreasonable dilemma.  In many states, doctors or hospitals that take care of a high proportion of Medicaid patients will find themselves in financial distress. That’s not fair to them or the Medicaid recipients. Frankly it’s also unfair to the commercial customers who may be overpaying to compensate for Medicaid underpayments.

Compare Medicaid with the Supplemental Nutrition Assistance Program (SNAP), aka Food Stamps. SNAP recipients don’t bankrupt supermarkets. That’s because the government pays the same price for groceries as any other customer. The SNAP program doesn’t demand that the grocery store sell products below cost, nor should it. SNAP recipients have to be savvy about how they use their benefit, seeking out high value products and retailers to stretch their dollar.

Realistically we won’t see the disparity between Medicaid and commercial payment rates erased any time soon. It would be just too expensive. But there are steps that can and should be taken:

  • Narrow the gap over time from the current 27 to 65 percent to something more like 10 to 15 percent
  • Introduce more progressive payment mechanisms –like Medicaid Accountable Care Organizations– that provide health systems with incentives to contain costs and improve quality. Healthcare systems that figure out how to help Medicaid members become healthier for a lower cost will prosper –analogous to what Walmart does with SNAP payments
  • Provide incentives for Medicaid beneficiaries to seek lower cost, higher quality care. Let’s not be paternalistic and assume that people on Medicaid aren’t capable of identifying high quality, low cost services.. I’ll venture to say that many lower income Americans are savvier shoppers than average consumers, if only due to necessity

The GAO report should be a wakeup call. It’s time to do something about these disparities beyond simply shrugging our shoulders.

photo credit: nffcnnr via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

Health Business TV: Cash for specialists, eVisits again, nursing shortage mythology this fifth episode of Health Business TV, I discuss my interview with HelloMD about cash payments to specialists, the long and slow evolution of eVisits, more on the nursing shortage myth, the United Independent Party in Massachusetts, and an update on the proposed 29% health insurance premium hike for our business..

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By healthcare business consultant David E. Williams of the Health Business Group


eVisits: the 30 year march?

This guy moves faster than eVisit adoption

This fella moves faster than eVisit adoption

When I first started working in healthcare I was told that innovations can take a long, long time to be adopted. Now I’m old enough to have experienced it for myself.

The big news in the Seattle Times this week?

“To cut medical costs and diagnose minor ailments, WellPoint and Aetna, among other health insurers, are letting millions of patients get seen online first.”

“In a major expansion of telemedicine, WellPoint this month started offering 4 million patients the ability to have e-visits with doctors, while Aetna says it will boost online access to 8 million people next year from 3 million now.”

This has been a long time coming, and we’re still at the early stages of adoption, with plenty of naysayers remaining. I first worked on eVisits (or webVisits) in 2001, when Healinx (now RelayHealth) commercialized them. Researchers at Stanford and UC Berkeley studied the webVisit and concluded that their use cut total medical costs while improving patient and physician satisfaction. Here’s a press release from January 2003 on the study (Final Results: webVisit(SM) Study Finds RelayHealth Reduces Cost of Care While Satisfying Doctors and Patients).

Here’s what I said about it five years ago (eVisits continue their slow, steady rise) –before the iPad, Meaningful Use, or the Affordable Care Act:

It’s interesting to be in late 2009 and see e-visits described as a “disruptive innovation” that “the medical establishment is fighting.”  It’s a sensible concept, fairly straightforward to implement, efficient, and effective for certain situations. Yet growth has been slow. Part of the issue is that it’s health care we’re talking about, where innovation tends to be retarded when it involves changing physician practices. Another, related problem is that there’s no great financial incentive for the physician or patient to make a change. Health plans that do cover e-visits often charge the same co-pay for patients as for in-person visits, even though they often reimburse physicians at a lower rate.

My guess is that over the next decade we’ll see e-visits become common. Why?

  1. Adoption will follow the typical S-shaped curve, and we’ll soon get to the steep climb almost regardless of other changes
  2. More patients and physicians will simply expect to communicate online, as they do in every other area of their personal and professional lives
  3. Payment systems will evolve to support e-visits, rather than penalize them
  4. Adoption of electronic systems in physician offices in general will enable e-visits
  5. Supporting technologies will evolve and emerge. These include remote monitoring, higher bandwidth, personal health records, and mobile applications

Enjoy the next decade and don’t expect things to change too quickly.

Halfway into the decade these five factors are still playing out. Having said that I could probably have just reposted the article and changed the date and no one would have noticed.

Will things speed up dramatically over the next five years? In 2019 will we still be reading articles about this “novel” approach? I hope not but fear that we may.

photo credit: Nasitra via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group



HelloMD helps patients with cash jump the line for better treatment

Mark Hadfield, HelloMD CEO and founder

Mark Hadfield, HelloMD CEO and founder

Mark Hadfield makes no bones about the fact that the US is moving to a two-tiered medical system, where those with the means to pay more get better, faster treatment. His company, HelloMD helps in-demand doctors –mainly specialists– opt out of the third-party reimbursement system and serve the more lucrative, cash-paying patients.

In this podcast interview, Hadfield describes how his company is addressing the high end of the market. He explains how HelloMD fits in the broader ecosystem of concierge practices, medical tourism and high-deductible plans. And he shares HelloMD’s geographically-focused strategy to build a marketplace to serve its niche.

By healthcare business consultant David E. Williams of the Health Business Group


Where cash is king, what happens to patients?

How can I help?

How can I help?

I’ve started hearing more about physician practices that are opting out of the health insurance system and taking cash for services. See Cash-only looks good to doctors in Healthcare Finance News as an example. I can understand the appeal. After all, it’s an expensive and frustrating hassle to deal with health plans and Medicare, and can interfere with the doctor/patient relationship. In theory physicians should be able to offer the same level of care while reducing overhead costs and splitting some of the savings with patients. If those patients have high-deductible plans it should work out for everyone.

To some extent in primary care that’s exactly what’s happening, and it’s a trend I support. The logic is especially strong there since third-party reimbursement offers very little in the way of reward for a lot of work. A patient co-pay may equal the amount that gets reimbursed by the health plan; with a high-deductible plan the insurance company may contribute nothing. (Note that this picture is slightly changed by the Affordable Care Act, which mandates full coverage for preventive services –although in my experience the physician office often gets confused about this and ends up collecting a co-pay anyway.)

The Healthcare Finance News article cites a practice in Austin that doesn’t take insurance and has no administrative staff. Result: office visits for $30, which is about the typical co-pay. Well done.

But I do worry about other physicians in both primary care and now specialty care that are moving to more of a concierge model. If it happens in any great numbers there will be a serious capacity problem in the system. That’s because the shift is often accompanied by a dramatic reduction in the number of patients served. It’s sometimes an order of magnitude.

The same article describes a practice that cut its patient panel from 8000 to 1000. I’ve heard of primary care physicians going from 3000 to 350 patients. The big question is what’s going to happen to all the patients who lose access to those physicians –the slack will have to be picked up by other providers. In primary care, maybe the emergence of concierge practices will have a silver lining by boosting compensation for primary care in general and drawing more physicians into the field, helping to correct an historic imbalance in pay ratios between primary care and procedural specialties.

Specialty physicians opting out of insurance is more concerning, but for other reasons. As difficult as insurance companies are, sometimes they do add value by making doctors and patients jump through hoops before approving lucrative –but often unnecessary– procedures like spinal surgery. And there is a tendency to price gouge–which will be only partially mitigated by “transparency” tools that are coming into vogue.

For patients who are willing to spend more money for better care the best value may be in joining a concierge primary care practice rather than opting for cash-only specialists. The primary care doctor will have the time and skill set to consider the patient from a holistic standpoint, to refer to the right specialists and make sure the patient gets seen, to coordinate second opinions and follow-up and to offer their own views about topics such as whether to have surgery.

I’m actually considering a concierge practice for my own care, but I may be too late. A single-doctor primary care practice I spoke with is not taking new patients. Emails I sent to two other local concierge practices inquiring about becoming a patient there were ignored.
photo credit: volperic via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

Hospital Clowns meet the Boston Globe

Hearts & Noses

Hearts & Noses

The Hearts & Noses Hospital Clown Troupe, where I’m chairman of the board, is a great organization that provides professionally trained volunteer clowns to hospitalized children in Massachusetts, and trains other hospital clowns from around the US and the world.

So I’m excited to see a feature article about the clowns (Getting silly where the work is serious) on the front cover of the Boston Globe’s “g” section. Author Joseph P. Kahn does an excellent job of explaining what the clowns do to empower children, and the amount of effort and training that goes into preparing the clowns for their gigs.

I’m particularly proud of the work we do with some of the most severely ill and disabled children, and that we are now working with children who are hospitalized for mental illness –kids who have no outsiders but us visiting them. The article quotes our medical director, Dr. Michael Agus (a critical care physician) and Dr. Albert Hyman (child psychiatrist) along with several clowns, our executive director, and me.

Oh, and if you’d like to donate to this great cause, please click here!

By healthcare business consultant David E. Williams of the Health Business Group

First Opinion: Online doctor consults for the masses (interview transcript)

This is the transcript of my recent podcast with First Opinion COO, Dr. Vikram Bakhru.

Hey doc, let's chat

Hey doc, let’s chat

David E. Williams: This is David Williams from the Health Business Group. I’m speaking today with Dr. Vikram Bakhru, chief operating officer of First Opinion, an app that allows patients to text with doctors. Users get one free consult per month and keep the same doctor from visit to visit. Additional consults are as low as $2 per month and unlimited sessions are $25 a month.

Vik, do I have that right? And if so, how do you do it?

Vikram Bakhru: That’s exactly right. Our founder, McKay Thomas, basically set out to figure out a way to get people access to healthcare affordably and on their own schedule, as opposed to having to go and wait in stuffy waiting rooms.

In January 2013, he started First Opinion, and it’s come a long way since then. The app was officially launched in December 2013 and it’s been a wild ride over the last six months. Specifically, we enable families to text the doctor anytime, day or night, with simple and complex questions. We are there and able to get people answers quickly in under five minutes.  That is what we strive for.

The one free question a month is basically a way to get people oriented to the service and then if they like it, they can absolutely go ahead and get some more.

Williams: It’s obviously a broad market. You can go in any direction. However, I do notice on the app it focuses on families with kids. I noticed that all the doctors you advertise are moms, and when you get on the app it asks questions like how many kids do you have? Is it really focused on families? Tell me a little bit about the thinking on that positioning.

Bakhru: Right now, we are focused mainly on moms and moms-to-be. The idea there was that the mom is really the center of the household. They are the ones who are coordinating care and making sure everyone’s healthy and fed and doing a lot of the typical functions that we see in our country. What better way to support them than to provide them with easy access to a doctor anytime they feel they need to reach out and get information instead of having to jump on a video conference call or search the Web and sit for an hour trying to find the answer.

We want to provide accurate, credible information very quickly and we’re getting there. We’re off to a good start.

Williams: There are all sorts of permutations for telehealth or the telemedicine model. Some use physicians, others nurses, or nurse practitioners or PAs. Some are real-time, some asynchronous. Some are charging a large amount or a small amount, whether it’s incorporated with the insurance or not, whether it’s US practitioners or those that are overseas.

Can you help the listeners to understand where First Opinion fits in the overall eco-system of telehealth or however you define your broader universe?

Bakhru: Sure. We believe we provide the most accessible way to get in touch with the doctor. These doctors have graduated from some of the world’s top medical schools. They are not all based in the United States but they are all moms. As we discussed earlier, they really understand the people that are trying to get in touch with them and they’ll respond. They’re there to answer whatever is on the user’s mind and to actively go back and forth.

In our space many other companies are pursuing a limited model where users get access for ten minutes or get access to a follow-up with the company emailing them. What we really have strived to do is give direct access to the doctor. That’s really what it’s about. We have immense respect for other providers in our healthcare eco-system as you put it. We also believe that there’s value in just communicating to the doctor, just texting back and forth and getting information from the person users trust a great deal. And through our service, we’ll hopefully gain the trust as users get to know them better.

Williams: Another piece that I found interesting is that it seems that when somebody is assigned to a physician, they actually stick with the physician. So it’s not just an “on-demand, who’s available” model like most companies inside healthcare or outside of healthcare. Do I have that correct?

Bakhru: Yes, our clients, the moms and dads who use our service are constantly giving us the feedback that it is awesome to not have to explain what was going on three days ago, for example. The fact that we’re able to provide that consistent access to a doctor is really important to the people who use our service today.

We are really excited that we’ve been able to figure out a way to do that and most telehealth providers haven’t yet. Like you said, you get in touch with a different doctor each time you call in and it can be $40 or $50. On our platform, it is $25 a month, or $2 to $4 as you noted previously, which is very affordable for the majority of America.

Williams: If you look at what you’re doing, it seems to be in stark contrast to the way primary care is moving in general. If I look at the typical primary care practice, they’re focused on having the physician be the quarterback and then there’s all sorts of other professionals, whether they are nurse practitioners, physician assistants, nurses, administrative folks, or social workers for example, that are being leveraged, partly with big investments in electronic medical records, and other kinds of information technologies to get there.

On the other hand, it seems like what you have is more of an individual physician. From what I can tell anyway, it is light on the data side of things and more focused on responsiveness, accessibility and dealing directly with the doctor. Is that the approach?

Bakhru: That’s an accurate summary for the most part. We certainly have stayed away from big expensive electronic medical records that are so impersonal and don’t really allow you to connect to another human being, to a doctor who can provide the most immediate, accurate information.

We feel that we’ve taken on a different approach than what the trend is and I think we’ll find over time that the two actually are complementary. You do need a model that we’re moving in the direction of that allows you to connect with different providers based on the severity of what is going on. But when you’re at home, sitting on the couch, dealing with a child that has a 103 fever and wondering whether you need to go to the ER or whether you should call your pediatrician’s office a fourth time – because by the way you already called them three times and now you’re really wondering if you should reach out again – we’re there for you in those moments and we’re there to help provide clarity.

We don’t see ourselves as providing advanced cancer care. We certainly aren’t the company to call if you need in-depth analysis of a very complex illness. We are helping you get access to the primary care.  Seventy percent of office visits are informational, so let us be that provider of information for you and you can get that information by talking or texting to a real doctor instead of searching WebMD.

Williams: Let me follow up on that point about how what you do may be complementary to primary care practice. I know I’m not the only one who has good insurance, good relationship with the primary care physician and practice and still has situations like you described where you are wondering is it really worth the trouble to go and try to connect with the physician’s office? A minor or unexpected issue still involves a lot of activity in order to get it dealt with. And so, I and I think many others like me may have a physician or a nurse or somebody in their family that they turn to instead of an office visit.  I’m sure looking at your background, you probably have family members that do the same thing.

Are you positioned in a way that you can be complementary to a primary care practice and complement the activity with the patient’s physician’s office? In other words, might the doctor from First Opinion actually be in direct contact or help the patient be in contact with their primary care office?

Bakhru: We haven’t ruled that out from the realm of possibility. But today, we provide an accessible service directly to moms and dads who need access to a doctor right away. And over time, I would love to see us be able to insert ourselves into the normal flow of patient care. But today we’re a new company. We’re a year-and-a-half old and we’re doing a lot with a lot of different families.

Right now, we’re focused on making sure we provide a really great service and do it really well to the people who rely on us.

Williams: I’ll go back to my first introductory point about it seeming to be too good to be true in a sense. You’re offering quite a lot for not a lot of money. I want to delve into that a little bit more. One way that it could be done is this is a teaser rate and once people are used to the service, the price is going to go up. Another possibility is that you’ve got some other sort of business model, where you’re doing for example, some sort of data mining that’s going to be of use to marketers. Another way is certainly finding places where physicians are not as well-compensated as they are in the US.

Are some or all of these the case? I noticed that when I tried out the service, my physician was overseas in India. But what about those other pieces? Is it a teaser? Is there some business model above and beyond the actual just fee-for-service?

Bakhru: No. Today, our plan is not to increase the price that people are paying for chatting, texting, or consulting a doctor. And you’re right, many of our doctors are overseas, but they’ve gone to some of the best medical schools in the world. They go through a rigorous training and certification process that I, along with the rest of our team, has built. I’m fully confident that we’re offering good information to our users and I remain excited that we can actually do this at a very affordable price.

Our hope is that people come to us, try out the service and decide that they want to be able to purchase and actually continue the relationship with their doctor, and continue to have access to that same person day in and day out. Over the long term, it would be really great for these families to actually get to know the doctor on a level that you just wouldn’t’ be able to achieve, I think, in the current healthcare system, the way it’s set up right now.

To your earlier point, it is far too volume-focused. And the solution to that volume problem seems to be engaging different types of clinicians and practitioners. As I noted earlier, I think that’s appropriate. We are in an environment that allows great care to be delivered by a diverse group of people.  But it’s also nice to just have access to a doctor and be able to just ask a question. Just ask a question when it pops into your mind and reach for your phone and you’re able to get the information that you want.

Williams: Pure texting is a fairly narrow bandwidth communications medium. Is there a way that a doctor at First Opinion can send or receive things like links to other resources? What about reviewing an image of a rash or something like that? Would you expect or is there today the opportunity to go beyond the simple texting and would you see that as a potential place for expansion in the future if not?

Bakhru: Surprisingly, we have found that texting is actually one of the most convenient mediums to go back and forth with someone. I think we are in an environment where people are very accustomed to small bits of information and trying to go back and forth rather quickly. That has served us well so far. Today, we haven’t seen the need to expand that relationship to include a phone call or other media. I can envision that being an add-on service in the future or something that we look to develop based on feedback from our moms and dads that are on our platform.

But today, we are able to actually accomplish about 90 to 95 percent of what people need in a very simple, easy-to-use interface. It allows users to go back and forth with the doctor in just a handful of minutes each time. And there are consultations that people are purchasing, or receiving, one free per month and that doesn’t have a limit of characters or time, or number of questions that you can ask. It is really about convenience and access to a real doctor in real time. So far, that’s been meeting the needs of our users.

I wouldn’t take anything off the table in terms of what we want to do as a company. We’re out to change healthcare and truly allow people the access that they used to be able to receive relatively easy. But now, it just seems as you noted earlier too, a burden to call your doctor. Take a half day off from work, go sit in the waiting room and finally when you get seen you have ten or fifteen minutes of face time, which might be enough for one issue. But what if you have three issues on your mind? All of a sudden, it’s this very delicate dance on trying to respect the doctor’s time but also wanting to get your needs met.

We’re excited about the product that we have today and the simplicity that it offers for moms and dads to just reach out to a doctor about their own healthcare needs, about their kids’ needs, whether it’s a fever or a rash.

To your point, there may be a role for pictures through the platform, especially as we talk about rashes. But that’s also one in twenty questions. The other 19 are usually solved by the simple back and forth of just communicating information. It’s shocking how straightforward healthcare can actually be if you have the right mix of technology and access to doctors that are really, really good and willing to be innovative in how they approach patient care.

Williams: This service is focused on consumers today. Do you see a business-to-business model as well or would you expect it to always remain in the realm of the consumer?

Bakhru: We really like being able to interact directly with the moms and dads who come to us for their questions. But if our goal is to access moms and dads,  we can provide our service to them in a variety of ways. Today it is all about promoting the service and trying to get people to understand what we do and to give it a test run.

But there may be opportunities out there that allow us to bring online content live. To be the next step when someone reads an article and perhaps wants to chat about what they read. Or wants to see if what they have matches what the computer says they have, or the Internet article says they have.

So are there business-to-business opportunities out there? I imagine that there are and I’m excited when the time allows for us to pursue those. But right now, we are just inundated. I wouldn’t say overwhelmed because I think the team is doing a fantastic job managing everything that’s on our plate, but I would say that we’ve got our hands full. It’s been a wonderful six months since the application launched and we are so excited for what the future holds.

Williams: I’ve been speaking today with Dr. Vikram Bakhru. He is chief operating officer of First Opinion.

By healthcare business consultant David E. Williams of the Health Business Group