Cooperating for better care.

American Academy of Family Physicians

Tag Archives

Direct primary care seen as partial safety net



For Kaiser Health News


Darrell Kenyon had been punting for years on various medical issues — fatigue, headaches, mood swings. The 43-year-old uninsured carpenter was particularly worried about his blood pressure, which ran high when he checked it at the grocery store. Then he heard about a different type of physician practice, one that provided regular primary care for a monthly fee.

“Insurance for the self-employed is through the roof,” Kenyon told Dr. Loy Graham, as she examined him one morning in August. Two years ago, Graham had hung out her shingle in this central Texas town of nearly 1,400, about 40 miles north of Austin.

Under the practice model, called direct primary care, patients are charged monthly — typically $20 to $75, depending on age, in Graham’s practice — for basic, office-based medical care and frequently cell phone and other after-hours physician access. Proponents of the model, which is also supported as a practice option by the American Academy of Family Physicians, say it can provide a safety net for those with limited treatment options, including the uninsured and people in the country illegally. The alternative is particularly helpful in states such as Texas that haven’t expanded Medicaid access, the advocates add.

But there’s a sizable catch: Direct primary care is not insurance.

Carolyn Engelhard worries that strapped individuals will decide the easier access to primary care is “good enough” and won’t investigate insurance options. “It can be a false security,” said Engelhard, who directs the health-policy program at the University of Virginia School of Medicine, in Charlottesville. “There’s sort of the illusion that it’s kind of like insurance.”

Lower-income Texans would be better off with coverage on the Affordable Care Act’s insurance exchange, where they could get a subsidy to reduce the cost of their premiums, Engelhard said. The policy would have a deductible, “which they might feel that they can’t afford,” she said. “But they would be protected if they got cancer or if they had an automobile accident.”

Graham estimates that at least three-quarters of her roughly 450 patients lack insurance, even though she advises them to carry some kind of catastrophic coverage for major health expenses. But the cost for such policies can be daunting. Like Kenyon, some of Graham’s patients are self-employed with fluctuating incomes or work for businesses that don’t offer coverage. Even if their employer offers affordable coverage for the employee, premiums for dependents might make coverage financially out of reach. Roughly 1 in 5 of her patients speak primarily Spanish. Some are undocumented, working in construction and other labor-intensive jobs in the region.

Despite her concerns, Engelhard said, such flat-fee practices might offer “one of the few viable options” for those living here under the radar, given they’re not eligible for ACA-related coverage. “So they are completely dependent on paying out-of-pocket for medical care,” she said.

‘Better Than Nothing’?

Nationally, direct primary care is relatively new and very much a niche option. Nearly 3 percent of family physicians practice it, according to a 2017 survey by the American Academy of Family Physicians. Some critics have questioned whether the model’s growth is already stalling, after one of its earliest providers, Seattle-based Qliance, closed its clinics this year.

Graham, who practiced traditional medicine in central Texas for decades, said she was drawn to the option after growing weary of packing too many patients into each day. She was considering leaving medicine and had started developing a lavender farm as an alternative source of income when she heard about direct primary care.

In 2015, she opened her practice in a small strip mall in Jarrell, figuring that nearby residents — with limited access to primary care — might take a chance on the different style of medicine.

John Bender, M.D., an academy board member who is part of a larger practice that’s transitioning to direct primary care, said that the low monthly fees are attracting patients who view insurance as out of reach. “I think something [in terms of medical care] is better than nothing,” said the Fort Collins, Colo., family physician, who estimates that roughly half of the practice’s 800-plus direct primary care patients are uninsured.

“I can spare them quite a few urgent care and emergency room bills,”  Dr. Bender said, noting that his office handles anything from strep throat to stitches for minor gashes. Moreover, the cost is within reach of people on tight budgets, he said. “In fact, a carton of cigarettes runs $49, which just happens to be the price of my monthly subscription fee [for adults].”

In Texas, 16.6 percent of the state’s residents were uninsured as of 2016, the highest rate nationally, according to the most recent Census Bureau data. The Lone Star State didn’t expand Medicaid access and has one of the nation’s lowest income-eligibility cutoffs. A single mother with two children can’t earn more than $3,781 annually to qualify for coverage herself, according to a 2017 Medicaid report by the Center for Public Policy Priorities, an Austin-based nonprofit research and advocacy organization.

Dr. Felicia Macik, who launched her direct care practice in 2014 in Waco, estimates that 10 to 15 percent of her patients are uninsured, including some who drop coverage because they can’t afford the premiums. “I’m frightened for them,” she said. “It could decimate a family if something happened and they didn’t have any coverage.”

But Macik pointed out that getting regular primary care, rather than avoiding the doctor entirely due to lack of insurance, might avert costlier complications like an asthma attack or a diabetic crisis.

Uninsured individuals who sign up for these practices are rolling the dice, said Dr. Mohan Nadkarni, an internist who co-founded the Charlottesville (Va.) Free Clinic, which treats lower-income individuals. “For routine regular care, it may work out,” he said. “But it’s gambling that you’re not going to get sicker and need further care.”

Two years ago, Dr. Loy Graham opened a flat-fee primary-care practice in Jarrell, Texas. She estimates that at least 75 percent of her patients lack health insurance.  (Photo by Charlotte Huff.)_

For instance, a patient can develop severe heartburn and require further tests and referrals to specialists to look for the underlying cause — potentially anything from an ulcer to esophageal cancer — that could quickly run up a hefty bill, Nadkarni said. Another patient with chest pain might need a similarly costly work-up to rule out heart problems, including a potentially life-threatening blockage, he said.

Graham said that her monthly fees cover anything that she can handle in the office. During Kenyon’s visit, she froze a small growth off one ear. Shortly afterward, she gave a steroid injection to an older woman with a painful, swollen wrist.

She has negotiated low fees with a local laboratory; the battery of blood tests and urinalysis she ordered for Kenyon cost him just under $40. “This is concierge medicine for normal people,” said the 61-year-old family physician.

Physician enthusiasts maintain that jettisoning the paperwork and other overhead costs associated with insurance enables them to take on fewer patients — roughly 600 to 800 for direct care practices compared with 2,000 to 2,500 typically, according to the family physicians academy — and thus spend more time with each one.

As A Safety Net, It’s A Stretch

Erika Miller first came to see Graham two years ago for severe headaches. The 30-year-old mother of three, who is working on her college degree and has a full-time job, doesn’t have insurance.

Graham diagnosed high blood pressure. Getting that under control helped alleviate her headaches, Miller said. She also has shed 50 pounds under Graham’s guidance.

But Graham can’t handle everything for her patients. Last year, Miller went to the emergency room at Scott & White Medical Center, in nearby Temple, with severe abdominal pain. It was her appendix, which had to be removed. The safety-net hospital started Miller on a payment plan based on her income, totaling roughly $500.

“If the question is: `Is [direct primary care] better than nothing?’ Then I would say, ‘Yes,’” Engelhard said. But along with leaving uninsured patients financially vulnerable to a medical curveball, she said, these smaller practices — by seeing fewer patients per doctor — risk aggravating the nation’s primary care shortage if they become more common.

Graham countered that she nearly left medicine, but these days — as she continues to build her practice — she’s reaching some patients who had previously fallen through the health system’s cracks. On that summer morning, Kenyon left Graham’s office with a prescription for a blood pressure medication and an appointment to return in several weeks to discuss his lab results.

Kenyon and his wife, Denise, later described how they had signed up last year for a family policy through the Affordable Care Act. But the monthly premium was $750 and the deductibles were $3,500 per person, Denise Kenyon said.

She called around and couldn’t find a family doctor who would take the coverage. After several months, they stopped paying the premiums, figuring that the money they saved would pay for a lot of medical care.

Both are now patients of Graham’s; their combined monthly bill totals $125, which they can budget for, Darrell Kenyon said. “I do have good months and bad months, as far as pay is concerned,” he said. “If I have a bad month, it’s still affordable.”

Confused, irritated patients caught in insurance revolving doors




“The Scream,” by Edvard Munch.


For Kaiser Health News

Andrea Schankman’s three-year relationship with her insurer, Coventry Health Care of Missouri, has been contentious, with disputes over what treatments it would pay for. Nonetheless, like other Missourians, Schankman was unnerved to receive a notice from Coventry last month informing her that her policy was not being offered in 2017.

With her specialists spread across different health systems in St. Louis, Schankman, a 64-year-old art consultant and interior designer, said she fears  that she may not be able to keep them all, given the shrinking offerings on Missouri’s health-insurance marketplace. In addition to Aetna, which owns Coventry, paring back its policies, UnitedHealthcare is abandoning the market. The doctor and hospital networks for the remaining insurers will not be revealed until the enrollment period for people buying individual insurance begins Nov. 1.

“We’re all sitting waiting to see what they’re going to offer,” said Schankman, who lives in the village of Westwood. “A lot of [insurance] companies are just gone. It’s such a rush-rush-rush no one can possibly know they’re getting the right policy for themselves.”

Doctor and hospital switching has become a recurring scramble as consumers on the individual market find it difficult or impossible to stay on their same plans amid rising premiums and a revolving door of carriers willing to sell policies. The instability, which preceded the health law, is intensifying in the fourth year of the Affordable Care Act’s marketplaces for people buying insurance directly instead of through an employer.

“In 2017, just because of all the carrier exits, there are going to be more people making involuntary changes,” said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation, a New Jersey philanthropy. “I would imagine all things being equal, more people are going to be disappointed this year versus last year.”

Forty-three percent of returning consumers to the federal government’s online exchange,, switched policies last year. Some were forced to when insurers stopped offering their plans while others sought out cheaper policies. In doing so, consumers saved an average of $42 a month on premiums, according to the government’s analysis. But avoiding higher premiums has cost many patients their choice of doctors.

Jim Berry, who runs an Internet directory of accountants with his wife, switched last year from Blue Cross Blue Shield of Georgia to Humana after Blue Cross proposed a 16 percent premium hike.

Despite paying Humana $1,141 in premiums for the couple, Berry, who lives in Marietta, a suburb of Atlanta, said they were unable to find a doctor in the network taking new patients. They ended up signing up with a concierge practice that accepts their insurance but also charges them a $2,700 annual membership, a fee he pays out of pocket. Nonetheless, he said he has been satisfied with the policy.

But last month Humana, which is withdrawing from 88 percent of the counties it sold plans in this year, told Berry his policy was not continuing, and he is unsure what choices he will have and how much more they will cost.

“It’s not like if I don’t want to buy Humana or Blue Cross, I have five other people competing for my business,” Berry said. “It just seems like it’s a lot of money every year for what is just basic insurance, basic health care. I understand what you’re paying for is the unknown — that heart attack or stroke — but I don’t know where the break point is.”

To be sure, the same economic forces — cancelled policies, higher premiums and restrictive networks — have been agitating the markets for employer-provided insurance for years. But there is more scrutiny on the individual market, born of the turmoil of the Affordable Care Act.

Dr. Patrick Romano, a professor of medicine at the University of California at Davis Health System in Sacramento, Calif., said the topic has been coming up in focus groups he has been convening about the state insurance marketplace, Covered California. Switching doctors, he said, “is a disruption and can lead to interruptions in medications.”

“Some of it is unintentional because people can have delays getting in” to see their new doctor, he said. “Some of it may be because the new physician isn’t comfortable with the medication the previous physician prescribed.”

Dr. John Meigs, an Alabama physician and president of the American Academy of Family Physicians, said that whatever the source of insurance, changing doctors disrupts the trust a patient has built with a physician and the knowledge a doctor has about how each patient responds to illnesses. “Not everything is captured in a health record” that can be passed to the next doctor, Meigs said.

There is little research about whether switching doctors leads to worse outcomes, said Dr. Thomas Yackel, a professor of medicine at Oregon Health & Science University in Portland. In some cases, he said, it can offer unexpected benefits: “Having a fresh set of eyes on you as a patient, is that really always a bad thing?”

With the shake-up in the insurance market, access to some top medical systems may be further limited. Blue Cross Blue Shield of Tennessee, which has included the elite Vanderbilt University Medical Center in its network, is pulling out of the individual marketplace in the state’s three largest metro areas: Nashville, Memphis and Knoxville. Bobby Huffaker, CEO of American Exchange, an insurance firm in Tennessee, said so far, no other carrier includes Vanderbilt in its network in the individual market.

In St. Louis, Emily Bremer, an insurance broker, said only two insurers will be offering plans next year through Cigna’s network includes BJC HealthCare and an affiliated physicians’ group, while Anthem provides access to other major hospital systems, including Mercy, but excludes BJC and its preeminent academic medical center Barnes-Jewish Hospital.

“These networks have little or no overlap,” she said. “It means severing a lot of old relationships. I have clients who have doctors across multiple networks who are freaking out.”

Aetna said it will still offer policies off the exchange. Those are harder to afford as the federal government does not provide subsidies, and Aetna has not revealed what its networks will be. In an e-mail message, an Aetna spokesman said the insurer was offering those policies to preserve its option to return to the exchanges in future years; if Aetna had completely stopped selling individual policies, it would be banned from the market for five years under federal rules.

Even before St. Louis’ insurance options shrunk, Bremer said she had to put members of some families on separate policies in order for everyone to keep their physicians. That can cost the families more, because their combined deductibles and maximum out-of-pocket payments can be higher than for a single policy, she said.

“Every year our plan disappears,” said Kurt Whaley, a 49-year-old draftsman in O’Fallon, Mo., near St. Louis. After one change, he said, “I got to keep my primary-care physician, but my kids lost their doctors. I had to change doctors for my wife. It took away some of the hospitals we could get into.”

Brad Morrison, a retired warehouse manager in Quincy, Ill., said he has stuck with Coventry despite premium increases — he now pays $709 a month, up from $474 — because the policy has been the cheapest that would let him keep his doctor. “That’s the one thing I insisted on,” he said. “I love the guy.”

With Coventry leaving the Illinois exchanges, Morrison is unsure whether his alternatives will include his physician. His bright spot is that he turns 65 next spring. “I’m trying to hold out until I get to Medicare,” he said.

Lack of risk for physicians boosts CareFirst PCMH initiative


Physicians like Baltimore/Washington, D.C.-based CareFirst BlueCross BlueShield’s patient-centered medical home (PCMH) initiative because it offers financial incentives but includes no penalties or risks for providers, says  President and CEO Chet Burrell.

FierceHealthPayer reported: “Speaking to the American Academy of Family Physicians (AAFP) last week, Burrell explained that CareFirst’s PCMH model, which began in 2011, requires participants to form groups of five to 15 physicians known as panels, which are graded based on patient access, patient engagement and appropriate use of services.

“In 2014, the average participating practice received $41,000 in revenue from the program, in addition to the flat 12 percent participation fee each practice receives every year. Importantly, the program does not reduce payments for practices that receive low or average scores, Burrell noted,” the news service reported

“No physician in his right mind ought to take insurance risk,” Burrell said.

“Though the program is voluntary, Burrell says 90 percent of the plan’s 4,400 physicians have chosen to participate, meaning it now covers 3.4 million individuals in Maryland, Virginia and the District of Columbia. CareFirst itself has also benefitted, as its PCMH program saved the insurer $40 million in its first year, and years later, continues to produce “remarkable and energizing” medical cost trends, Burrell said last July.”


CMS orders physicians to hunt down overpayments


Medscape reports that new rules from CMS say that “physicians must not only return Medicare overpayments within 60 days of identifying them but also actively look for overpayment through self-audits and other forms of research….”

“If a physician fails to hand back overpayments within 60 days, he or she risks getting sued by the government under the False Claims Act (FCA).”

Many physicians, already drowning in paperwork, will not be pleased by this latest CMS mandate.

“This requirement would be extremely burdensome for physicians as it would impose a boundless duty to troll medical records in search of innumerable vulnerabilities,” the American Medical Association and dozens of other medical societies wrote CMS in 2012.

“CMS did not cut organized medicine any slack in its final regulations, but instead said what physicians did not want to hear. The agency also warned that some healthcare providers might avoid self-scrutiny for the sake of not discovering money they would have to return,” the publication reported.

“We disagree that this rule creates a requirement for any formal compliance plan or audit strategy,” CMS said. “Rather, it requires that providers and suppliers maintain responsible business practices and conduct a reasonably diligent inquiry when information indicates that an overpayment may exist.”

Wanda Filer, M.D., president of the American Academy of Family Physicians, one of the signatories to the 2012 letter to CMS, told Medscape that she hopes the agency will “interpret ‘clear duty’ very gently,” lest, as the publications put it, “physicians find themselves with more administrative work that reduces face time with patients”

“Patients have one clear duty, and that’s taking care of patients,” Dr Filer told Medscape.  “CMS has a clear duty to protect the Medicare trust fund. How we strike the balance…will be the art of this.”

And now, concierge care for the masses




For Kaiser Health News

A growing number of primary-care physicians, spurred by the Accountable Care Act and frustrations with insurance requirements, are bringing a service that generally has been considered “health care for billionaires” to middle-income, Medicaid and Medicare populations.

It’s called “direct primary care,” modeled after “concierge” practices that have gained prominence in the past two decades. Those feature doctors generally bypassing insurance companies to provide personalized healthcare while charging a flat fee on a monthly or yearly basis. Patients can shell out anywhere from thousands to tens of thousands of dollars annually, getting care with an air of exclusivity.

In direct primary care, patients pay about $100 a month or less directly to the physician for comprehensive primary care, including basic medication, lab tests and follow-up visits in person, over email and by phone. The idea is that physicians, who no longer have to wade through heaps of insurance paperwork, can focus on treating patients. They spend less on overhead, driving costs down. In turn, physicians say they can give care that’s more personal and convenient than in traditional practices.

The 2010 health law, which requires that most people have insurance, identifies direct primary care as an acceptable option. Because it doesn’t cover specialists or emergencies, consumers need a high-deductible health plan as well. Still, the combined cost of the monthly fee and that plan is often still cheaper than traditional insurance.

The health law’s language was “sort of [an] ‘open-for-business’ sign,” said Jay Keese, a lobbyist who heads the Direct Primary Care Coalition. Before 2010, between six and 20 direct primary care practices existed across the country. Now, there are more than 400 group practices.

The total number of physicians participating doctors may exceed 1,300. The American Academy of Family Physicians estimates 2 percent of its 68,000 members offer direct care.

“This is a movement — I would say it’s in its early phase,” said AAFP President Wanda Filer, a doctor in Pennsylvania. “But when I go out to chapter meetings, I hear a lot more interest.”

But questions persist about feasibility. The lower fees could still be a non-starter for people earning minimum wage or on a limited budget, said Robert Berenson, a senior fellow at the Urban Institute. “Can people afford this? Or is it [still] just for well-off people?”

The American College of Physicians advises doctors to consider whether direct primary care can work within their practices, but also urges physicians to recognize how it could affect poorer patients and look for ways to keep care affordable.

Direct primary-care doctors say they see patients across incomes. Dr. Stanford Owen, of Gulfport, Miss., treats “waitresses and shrimpers, as well as doctors and lawyers.” He charges $225 for initial visits, $125 for a follow-up, if needed, and then about $50 per month after.

Owen and other physicians report positive experiences, triggering other efforts to apply direct care more broadly. Although most of these doctors eschew dealing with insurance, some have been trying the model with Medicaid and Medicare patients.

If those experiments work — and save money and improve health — they could mitigate concerns about who can afford direct primary care. Berenson pointed out that partnering with insurance or public programs is key to making direct care affordable for lower-income people.

“The idea of setting up stronger primary care services for patients is very exciting and very much needed,” said Ann Hwang, director of the Center for Consumer Engagement in Health Innovation, an outpost of the consumer advocacy group Community Catalyst. But, she added, “This is so new that I think the jury is still really out on whether this will be successful.”

In Seattle, a company called Qliance, which operates a network of primary-care physicians, has been testing how to blend direct primary care with the state’s Medicaid program. They started taking Medicaid patients in 2014. So far, about 15,000 have signed up. They get a Qliance doctor and the unlimited visits and virtual access that are hallmarks of the model.

“Medicaid patients are made to feel like they’re a burden on the system,” said Dr. Erika Bliss, Qliance’s CEO. “For them, it was a breath of fresh air to be able to get such personalized care — to be able to talk to doctors over phone and email.”

Qliance has a contract with Centene, an insurance company in the state’s Medicaid program. That Medicaid coverage pays for the monthly fee, which covers primary and preventive care, and for other specialty and emergency services. If patients need a specialist, they’ll get referred to one who accepts Medicaid. Advocates in other states — such as North Carolina, Idaho and Texas — are watching the outcomes and costs while considering rolling out similar programs.

There’s little data so far. Bliss estimated participants will cost Washington state 15  to 20 percent less than traditional Medicaid. Before launching the Medicaid pilot, Qliance contracted with some companies that provide insurance to their employees — in those cases, employees who opted for Qliance cost about 20 percent less than employees in traditional health insurance. Because patients get better care upfront, the theory goes, they’re less likely to develop expensive chronic illnesses.

Still, expanding this approach is tricky. The number of participating physicians is low. There’s already a nationwide shortage of primary-care doctors. In this model, physicians see fewer patients, potentially exacerbating that shortage’s impact. Also, Medicaid negotiates the monthly payment rate, which could be less than what doctors might set independently.

In New Jersey, a pilot program using direct primary care is launching in 2016 for state employees, like firefighters and teachers. It’s a hybrid: When consumers pick a primary doctor, they can choose a direct primary care-style practice, which gives around-the-clock access to preventive and primary care services. The monthly fee is undetermined.

Participants will get benefits such as same-day appointments for non-emergency visits. But when they pick this plan — which will be administered by Aetna and Horizon — they will have access to specialists that participate in the insurers’ plan networks.

In New Jersey, about 800,000 people will be eligible to enroll in the direct primary care program. The state’s hoping to attract and accommodate at least 10,000 in the first year.

That’s appealing, said Mark Blum, executive director of America’s Agenda, an advocacy group that helped develop the project. He cited interest in California, Texas, Pennsylvania and Nebraska. “There are a lot of eyes on New Jersey right now.”

Meanwhile, direct primary care is finding traction with Medicare Advantage, the private health plan alternatives to traditional Medicare. Iora Health, a direct primary-care system that contracts with unions and employers, a year ago launched clinics in Washington and Arizona catering to Medicare Advantage patients.

Iora’s setting up similar clinics in Colorado and Massachusetts.

Despite its potential, the direct-care model faces the challenges of integration into existing payment systems and attracting more participating doctors. And navigating Medicare and Medicaid rules can deter physicians.

“It’s not for the faint of heart,” said Dr. Rushika Fernandopulle, Iora’s CEO.

How it evolves from here will vary across the country, said Filer, the AAFP president.

“There are some parts of the country where it is working very well,” she said. “But there are other reasons a physician might decide, ‘This is not for my patient base.’”

Why your physician probably won’t ‘friend’ you


By SHEFALI LUTHRA, for Kaiser Health News

Physicians’ practices are increasingly trying to reach their patients online. But don’t expect your doctor to “friend” you on Facebook – at least, not just yet.

Physicians generally draw a line: Public professional pages – focused on medicine, similar to those other businesses offer – are catching on. Some might email with patients. But doctors aren’t ready to share vacation photos and other more intimate details with patients, or even to advise them on medication or treatment options via private chats. They’re hesitant to blur the lines between personal lives and professional work and nervous about the privacy issues that could arise in discussing specific medical concerns on most Internet platforms.

Some of that may eventually change. One group, the American College of Obstetricians and Gynecologists, broke new ground this year in its latest social-media guidelines. It declined to advise members against becoming Facebook friends, instead leaving it to physicians to decide.

“If the physician or health care provider trusts the relationships enough … we didn’t feel like it was appropriate to really try to outlaw that,” said Nathaniel DeNicola, M.D., an ob-gyn and clinical associate at the University of Pennsylvania, who helped write the ACOG guidelines.

But even the use of these professional pages raises questions: How secure are these forums for talking about often sensitive health information? When does using one complicate the doctor-patient relationship? Where should boundaries be drawn?

For patients, connecting with a physician’s office or group practice on Facebook can be a simple way to keep up with basic health news. It’s not unlike following a favorite sports team, your child’s middle school or the local grocery store.

One Texas-based obstetrics and gynecology practice, for instance, uses a public Facebook page to share tips about pregnancy and childcare, with posts ranging from suggestions on how to stay cool in the summer to new research on effective exercise for post-birth weight gain. Practices have also been known to share healthy recipes, medical research news, and scheduling details for the flu shot season..

“I have people come up to me and say, ‘I follow you on Facebook — thank you for posting this particular article. It helped me and my husband and my family,’” said Lisa Shaver,  M.D., a primary-care physician based in Portland, Ore.

But unless they’re already friends, she won’t add patients to her personal account — where, she said, she posts less health information and more cat videos.

Historically, professional groups including the American College of Physicians and American Academy of Family Physicians have advised against communicating through personal Facebook pages. The American Medical Association notes that social media can be a valuable way to spread health information, but urged doctors in its 2010 guidelines  to separate their personal and professional online identities to “maintain professional boundaries.”

Finding ways to use Facebook and other forms of social media to connect with patients — even if it may just be through professional pages — fits a trend in which patients seek more equal footing with their doctors, said Zack Berger,  M.D., an assistant professor of medicine at the Johns Hopkins School of Medicine who studies patient-doctor relationships and social media. It also follows what James Colbert, M.D., a hospitalist at Massachusetts-based Newton Wellesley (Mass.) Hospital, described as the growing consumer approach to medicine — including the notion that patients should be able to reach their physicians at all hours. Colbert is also an instructor at Harvard Medical School who researches how patients want to fit social technology into their health care.

Email can be particularly convenient method, though it isn’t without concerns. Eva Schweber, 44, emails her doctor from a personal account and sends messages through an online portal — a more digitally secure system that is being adopted by a growing number of practices. The portal, she said, is for discussing complex, specific information. She’ll email her doctor from her personal email for less private concerns: scheduling, filling prescriptions and asking if certain symptoms might warrant a check-up.

“The unsecure email is easier, in that I can do it from my phone, my tablet, whatever,” said Schweber, of Portland, Ore.

In a recent study published in the Journal of General Internal Medicine, almost 20 percent of patient respondents reported trying to contact doctors through Facebook, and almost 40 percent through email. “Patients want to communicate with doctors [in whatever way] is convenient,” said Joy Lee, a postdoctoral research fellow at the Johns Hopkins Bloomberg School of Public Health, and the study’s lead author.

Doctors don’t yet seem to share that enthusiasm, Colbert said.

Meanwhile, security questions persist.

Social-networking platforms aren’t usually digitally encrypted, increasing the odds they could get hacked or shared with third parties. The same worries hold true for other, casual forms of online communication such as email and text-messaging.

That means doctors who discuss specific health concerns with patients through those could break the Health Insurance Portability and Accountability Act, the patient privacy law.

“Those concerns are always going to be there,” said David Fleming, past president of the American College of Physicians. “How private is it when we share, when we talk to people? … Once I’ve written it or once I’ve emailed it, it’s gone, and I have no control.”

But because HIPAA was written before email and social media’s ascent, it may not address patient preferences or behavior, Colbert said. With more patients becoming comfortable using personal accounts for health needs, he said, the law perhaps deserves another look.

“Should we allow patients to be able to share or send messages without going through these privacy safeguards if they’re willing to do so? Or do we say that that’s not safe and even if patients don’t care about privacy we need to protect them,” he said. “That’s an open question.”

That public nature is a real worry for such patients as Katie Cardenas, 45, who lives in Garner, N.C. She doesn’t think that Facebook is secure enough for personal medical details. For sensitive information, she’ll usually send messages through a patient portal, the more secure website her doctor’s practice has set up.

Doctors could address that, several said, by using social media in other ways. These include maintaining active Twitter presences and professional Facebook pages for less-tailored health tips. That way, patients can get useful information and a sense of their doctors as people, but privacy stays intact and physicians maintain distance.

At the Minnesota-based St. Cloud Medical Group, patients can follow a public page. Doctors who are part of the practice post updates with safety tips and seasonal health reminders, or use the page to coordinate and publicize small projects, such as a week-long initiative geared to reducing children’s screen time.

Julie Anderson, a family physician who is also part of the practice, sees the value in this option, but doesn’t personally befriend patients on Facebook. Beyond patient privacy, she said, she fears blurring her personal and professional lives, or patients using that access to seek extra care when she’s off the clock.

“I’ve known colleagues that have friended somebody and have had inappropriate questions asked online, in terms of kind of abusing service,” she said. “Or abusing that … Facebook friendship, where they’re asking medical advice and you’re not even their physician.”

Insurer mergers seen fueling more provider mergers


“The Colossus,” by Goya.

“It’s a cyclical arms race, until {government} antitrust steps in and says that’s enough.”
Understandably, smaller,  independent providers particularly fear this.
The publication says: “The merger tremors worry  Robert Wergin, M.D., president of the American Academy of Family Physicians. Consumers’ choice of health plans would shrink, and insurers’ cost savings would not guarantee lower premiums for employers and consumers or broader provider networks, he said. ”
“The AAFP wrote a letter this month to the Federal Trade Commission warning that letting health insurers morph into leviathans would result in ‘increased leverage and unfair power over negotiating rates with hospitals and physicians.’ Deals would especially affect smaller physician practice groups like Wergin’s, ” Modern Healthcare said.
Behemoth insurers say they expect to save lots of money in economies of scale in their mergers but “Doug Sherlock, a veteran healthcare analyst at Sherlock Co., said only 15% to 20% of administrative expenses are subject to economies of scale in most mergers, making it important to not overstate potential savings.”
Critics of the merger wave have a point when they complain that consolidation in most fields, airlines and cable TV come to mind, has usually led to higher costs for consumers, not lower.Large hospital groups, for their part, cite the benefits of care coordination stemming from mergers as justification for their growth.

AAFP pushes to defend hospital-employed physicians



The American Academy of Family Physicians has written  a letter to  the the Centers for Medicare and Medicaid Services seeking to defend the rights of family physicians employed by hospitals.

Becker’s Hospital Review reports that in a letter to Andy Slavitt, CMS acting administrator,  AAFP’s board chairman, Reid Blackwelder, M.D.,  argued that hospital-employed physicians have the right to “due process” before being fired from hospitals’ medical staff.

“We believe physicians deserve fair hearings when threatened by termination from a hospital and that fear of retribution may limit or prevent physicians from fully advocating for their patients’ best interests,” Dr. Blackwelder wrote. He added that “physicians with due process rights are more likely to protest fraudulent practices that threaten the integrity of the Medicare and Medicaid programs.”

Becker’s reported that the AAFP is asking CMS to revise the “conditions of participation” form that Medicare-participating hospitals sign, saying that AAFP believes that  hospitals and physician-staffing companies should be prohibited “from including language that facilitates physician dismissal without a fair hearing in physician employment contracts.”


Contact Info

(617) 230-4965

Wellesley, Mass