The Doctor Won't See You Now. And That's a Good Thing

It has been 6 months since my practice fully embraced digital medicine. Whenever possible we give patients the option of being treated without coming to the office. Several times a week we review text photos of medical conditions from rashes to pink eyes and respond with treatment plans. On a daily basis we treat high blood pressure and diabetes through secure email. Patients whose blood pressure was poorly controlled due to difficulty coming to the office are now perfectly controlled. Being busy is no longer an obstacle to care and patients are responding.

Thinking I am on to something, I have been sharing our new policy with other doctors. Everyone is interested in the idea but most don't think we are charging enough for the service. Our $120 a year annual fee leads to the conclusion that they would lose money if they adopted a similar practice. My reply that patients deserve this more convenient option is not persuasive.

I expected hesitancy and reluctance from my colleagues but one doctor’s response caught me off guard. When I told him that I was only requiring compliant hypertensive patients to come to the office once every two years he replied, “Sure, but you still have them come in for their annual physicals, right?”

I replied with a puzzled expression, “No, people don’t need physicals every year.”

“I know they don’t,” he said, “but we get paid for annual physicals.”

“But why bring them into the office if they don’t need to be there?” I replied, still not following his logic. 

“Because we make money and it doesn’t cost them anything!”

“It costs them a day off of work!” I replied.

After a few more minutes of debate I gave up. We have completely different views on the business of medicine. I walked away from the conversation with a new understanding of the problems our society faces as we try to address increasing health care costs. Doctors and hospital groups talk about lowering costs but want to make as much money as they can. If they get paid to do something most of them are going to do it, even if it is useless. 

It is easy to point fingers at doctors, but they are responding to basic economic instincts. They do what they get paid to do. Which means a large part of the blame should falls on those who pay for medical care. Insurance companies and government programs are a large part of the problem. Misguided wellness programs require healthy young patients to come to the doctor once a year and pay doctors handsomely for the visits. Obamacare requires insurers to offer physicals every year at no cost to the patient. Doctors know a cash cow when they see one and willingly go along with the program.

While willing to spend millions on unnecessary visits for healthy young people, most insurers do not pay anything at all for digital care. Many patients also fail to see the value in the service. When confronted with our annual fee over half of our patients were unwilling to pay the equivalent of $10 a month for the service. Modern healthcare access is not worth as much as their monthly Netflix or latte expenditures. Physicians who want to make a good living are left forcing patients to come to the office unnecessarily, because that is what they get paid for. 

My hope is that my pilot projectwill eventually catch on. As my patients tell their friends about the benefits of digital care perhaps the demand for such services will go up. If it does, other doctors may eventually follow. Even if they don’t, I will continue to provide these services to my patients. Having seen the benefits of this care for my patients I am convinced it is the right thing to do.

- Bart

Thanks for reading and for sharing with others. To read more about our digital access plan, you can read the explanation on my office blog. Comments and questions are welcome.

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Life Lessons from Kathy Griffin

How to ruin your life, as demonstrated by Kathy Griffin

1-      Firmly take a position held by some and rejected by others.

2-      Surround yourself with people who agree with your position.

3-      Only read news reports and websites that share your view.

4-      In private and with your friends mock and belittle those who disagree with you.

5-      Tell yourself that those who disagree with you are not just wrong, but evil, bad, stupid, and less than human.

6-      Take your views public, assuming that everyone agrees with you.

7-      Blame others for the backlash when it comes.

It is easy to say that Kathy Griffin deserves all of the consequences from her symbolic beheading of Donald Trump, to shake our heads and wag our fingers and say she should have known better. The truth is that we are a lot like her. Almost all of us follow the first 5 steps on the list. The difference is that we do not have as big of a platform on which to display our ignorance and arrogance.

If there is a lesson to learn it is that we should question ourselves more and attack others less, and that we should strive to treat everyone with respect, especially those with whom we disagree.

-          Bart

Too Many Doctors in the Room

I don’t like doctors. I always feel uncomfortable around them. When I am a patient I find myself second guessing everything the doctor says, wondering if he is getting it right. When one of my patients is a doctor I second guess everything I say, wondering if I am getting it right. It is extremely stressful.

As stressful as it is doctors are people and people need to go to the doctor, which is why I occasionally find myself seeing physicians in the office. One came in recently for an annual exam. I don’t know if he was nervous, but I was.

I did my best to treat him as I would any other patient in my practice. I asked about his health history and I asked about his family. He started to share some of the issues he was facing, at one point pausing to say “You don’t need to hear all this.”

I told them I did want to hear it, that it was important to know all of the issues in his life. We spoke for quite a while about his work, his wife and his children. We talked about the challenges of balancing family life and medical practice as well as the work required to maintain a healthy marriage.

I did my best to encourage him but found myself wondering if I had succeeded. It is one thing to give guidance about a medical issue. Encouragement about personal issues is different. There is a significant risk of offense or coming across as condescending, especially with a colleague.

A few weeks later I received an email from the doctor. In it he thanked me for the personal advice, telling me that one thing I shared had truly impacted him. He wanted me to know that my personal touch had made a difference and that he hoped I continued to encourage others in the same way.

His note accomplished its intended purpose. I was encouraged. He reminded me that I need never be afraid to love and encourage the patients that God brings to my office. In the midst of the making diagnoses and developingtreatment plans I must never forget that sometimes caring is the most important part of medical care.

-          Bart

Young and Without a Voice in Church

When Lisa and I were newly married we became a part of an adult group at church dedicated to our demographic. Each Sunday we gathered together with other couples under the age of thirty for conversation and fellowship. It was a remarkable group. It seemed almost everyone there had a passion for the Bible and knew it well. Several had degrees from Bible colleges and many had attended seminary. In this group my knowledge was unimpressive. I did not stand out at all.

In spite of the wealth of Bible knowledge and spiritual commitment there was something we lacked compared to young people today. None of us felt entitled to a voice in church leadership. No one talked about being an elder or leading a ministry and all of us accepted the fact that it was not yet our time. We knew we needed to grow and learn, that leadership positions were in our future, not our present. We were willingly taught each week by older men in their fifties and sixties, confident that they possessed wisdom and experience we lacked.

This is in stark contrast to the current young generation, many of whose members are quite antagonistic to mature church leadership. A friend of mine recently shared a post on why it is that Millenials are not going to church. Written by a Millenial, it unintentionally clarifies the arrogance of the current generation.

Here are some of the reasons given for young people turning away from the church-

-  Millennials value voice and receptivity above all else. When a church forges ahead without ever asking for our input we get the message loud and clear: Nobody cares what we think.

-  Millennials are told by this world from the second we wake up to the second we take a sleeping pill that we aren’t good enough. We desperately need the church to tell us we are enough, exactly the way we are. No conditions or expectations.

Throughout the post runs the theme that the current millennial generation has something special to offer, a special insight into the church and the culture that is being missed by the older generations. The author is confident in his assertions that older believers are driving younger believers away and believes himself to be offering effective solutions. He appears to be sadly blinded to the arrogance of his assertions.

When I was 24 the church didn’t care what I thought either. No one sought my input on anything. I didn’t mind because I recognized the truth- At the age of 24 my opinion wasn’t worth much. I lacked the experience and wisdom that comes with age. I understood that as a young person in church it was a time for me to hear and learn. The time for being heard and teaching would come later, if I was faithful. If I wanted a voice I could earn it through a life of service and godliness. Even though I was a bright young man at the time 30 years later I look back and see the foolishness of many of my young thoughts and opinions. Passion and commitment were not substitutes for wisdom and experience.

Millennials have grown up being taught that they are important and deserving of attention and praise. Parents and teachers have celebrated modest accomplishments. Christian youth have grown up in an "everyone gets a trophy" world that teaches them their youthful opinions matter, that they have something to say and deserve to be heard, and that they are enough "just the way they are." They have embraced this worldview without realizing that these are the teachings of the world and not the teachings of Scripture. Passages such as 1 Peter 5:5-6, “Young men, in the same way be submissive to those who are older. All of you, clothe yourselves with humility toward one another, because, "God opposes the proud but gives grace to the humble. Humble yourselves, therefore, under God's mighty hand, that he may lift you up in due time", are a clear reminder of how God moves within the church.

Just as Millennials are struggling with where they fit into the church so is the church at large struggling with how to respond to them. To the church at large I offer this warning- Do not try to appeal to or appease wrong thinking. The brilliant Christian author Michael Horton, in his book Ordinary, says it well-

“It is nothing new when young people want churches to pander to them. What is new is the extent to which churches have obliged. In previous generations elders- both officers and simply older and wiser members- wouldn’t let that happen. They took young people under their wing and taught them by word and example what it meant to begin to accept the privileges and responsibilities of membership in Christ’s body.”

Horton then identifies the core reason young people are abandoning church-

“For the first time in the history of the church it is now possible to go from the nursery to children’s church to Sunday school to the youth group and college ministry without ever actually having experienced church membership. Shocking surveys abound reporting that many of our children are dropping out of church by their college years. But maybe it shouldn’t be so shocking if they were never actually involved in church to begin with.”

The generation that has been taught it is all about them desperately needs to be confronted with that lie. It is not about them. It is about God. It is about what God says, what God proclaims and what God commands. God’s commands, while never burdensome, challenge our comfort and disrupt our lives. 

Bart

Thanks for reading and sharing. I can be followed on Twitter @bartbarrettmd, and many of my sermons can be watched on my vimeo page, www.vimeo.com/bartbarrett. In addition I am available as a guest speaker and can be reached through this website via the contact page.

The complexity of the Pre-Existing Condition Problem

I have several pre-existing conditions which are not covered by my insurance. I am signed up with Medi-Share, a health coverage co-op which is allowed to impose such restrictions. When I applied for the coverage I was told that my knees were not covered due my history of injuries and potential need for surgeries in the future. My anxiety disorder was also excluded. I signed up anyway.

I signed up because my private work-based "cover everything" Blue Shield plan cost $1800 a month for full family coverage. It also had a deductible of $3000 a month, which meant I would spend over $24,000 a year before I had any true health benefit. The Medi-share plan, in part because it restricts pre-existing conditions, cost $480 a month for a $5000 deductible. I decided that the $16,000 of premium savings a year was worth the risk of paying cash for future treatment on my knees.

I confidently made this bet because my pre-existing conditions do not require ongoing care. Unlike diabetics, cancer patients and patients with congenital conditions, I can go years without paying anything for my knees. In the event I do need such care it will not be urgent and I can re-enroll in another plan to get better coverage. If I need a knee replacement I can game the system and enroll in an ObamaCare plan in November, have the surgery in January, and disenroll in February. 

I am not the only person who has figured out that delayed enrollment may be the best financial option. Many healthy Americans are choosing to forego insurance completely. Because they know that they can wait until they get sick to buy insurance, or in the case of emergency know that emergency care will be given regardless of their ability to pay, they roll the dice and do not sign up for coverage. They pay cash for the occasional sick visit and save thousands of dollars a year. 

While this no-insurance decision is beneficial for these individual families it is devastating to the insurance industry and the health care system. All insurance industry profits come from healthy patients. As more and more of these patients drop out of the insurance pool insurers are increasingly struggling to cover expenses. The only option they have is to further raise their premiums, which causes more healthy patients to opt out. Patients with pre-exiting conditions, especially chronic diseases, do not have such a choice. They have to pay the higher premiums.

(I have heard many people say that the solution is to eliminate insurance company profits. As appealing as this option may seem, it will do nothing to solve the problem. The insurance industry’s profit margin is about 3%. Cutting this to zero would take only $30 a month off of a family’s $1000 premium. This is not the answer.)

The current system is designed to fail. Millions of Americans have health coverage through their employer. This is incentivized by a tax policy that makes this type of coverage a deduction to the employer and tax free to the employee. Individuals purchasing insurance on the individual market get no such benefit. When people with chronic illnesses leave their jobs they take their pre-existing conditions with them. When they try to buy insurance on the individual market they find insurance difficult to get and expensive.

ObamaCare attempted to address this by forcing insurers to cover pre-existing conditions. While this seemed nice, lawmakers ignored the reality that the money has to come from somewhere and that somewhere is from healthy patients. This has caused sky rocketing premiums in the individual market. Faced with such high premiums many healthy patients opt out of the system, resulting in even higher premiums.

The reason this failure is predictable is that this system results in the financial burden falling on healthy people regardless of income. Younger people are on average the healthiest people but they are not the wealthiest. The current law limits the ability of insurance companies to charge higher premiums based on age so the young and healthy are effectively subsidizing the health costs of older, sicker and oftentimes wealthier people.

ObamaCare attempted to address this by trying to force all people to buy insurance. Uninsured Americans are faced with penalties if they do not purchase coverage. Since the cost of the penalty is far less than the cost of insurance and is essentially uncollectable, this part of the law has been ineffective. Too many healthy individuals do the math and opt out.

Left out of all of the current laws and proposals is an important reality. All of the proposals I have read expect all healthy people to pay the same, regardless of income. This seems fair on its face, but is no longer feasible. Health care costs have reached the point where many families simply cannot afford the premiums. I am reluctantly left with the conclusion that we need a system in which contributions to health care costs are based more on income than they are on health. As people are not likely to do this on their own, I expect the ultimate solution will come as a result of a government program or tax.

As unpalatable as this is, if the remaining option is to limit insurance to only those who can afford it, it is a pill we will all need to swallow.

Bart

thanks for reading and sharing! comments are welcome!