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American healthcare reform debates are focused on strategies to provide “access” to medical services for all. Lack of insurance (or under-insurance) seems to be the primary focus, as it is falsely assumed that coverage provides access. Unfortunately, the situation is far more complicated.
Once a person has health insurance, there is no guarantee that they will receive the medical services that they need. Not because their plan is insufficiently robust, but because the roadblocks for approval of services (provided in the plans) are so onerous that those providing the service often give up before they receive insurance authorization. In my experience, whether or not the patient gets the service, test or procedure that they require often depends on the individual will and determination of their physician. And that’s something we need to talk about.
Take for example, admission to an inpatient rehabilitation facility. Brain-injured patients aren’t much different than those with broken bones. We all know that bones need to be set (or surgically repaired) right away so that they will heal correctly. The brain is very similar – once injured, it needs to be rehabilitated in an intensive, multi-disciplinary environment at the earliest chance for it to achieve its best healing. Nevertheless, insurance companies regularly deny brain injury rehab to patients in the critical healing time frame. They will approve nursing home care for them, but not the intensive cognitive rehabilitation that they need, unless the rehab physician fights an epic authorization battle that can take 10 days or more to overturn the denial of services! Imagine if your orthopedist had to beg, lobby, and testify for 10 days to fix your broken hip (while the insurance company simply approved you go to a nursing home)? Would he or she be willing to do this? What would happen to your hip in the mean time?
The “prior authorization” process for imaging studies and non-formulary medications is also designed to wear down the providers and passively deny services to patients, thereby saving costs for the insurers. Patients don’t realize that getting an MRI might mean an hour of automated phone system “hell” for their physician, waiting to speak to an insurance customer service rep with an algorithm that determines whether or not the patient is eligible for the service – unrelated to the physician’s judgment or the particulars of the patient case. In the average American primary care practice, an estimated 20 hours per week is spent by physician and staff, attempting to secure insurance approval for necessary tests and medications. Will your physician have the endurance to prevail? That might be the difference in diagnosing your cancer early or not.
“Oh,” but the insurance companies say, “we had to put these bumps in the road to prevent over-testing and abuse of the system.” I agree that there are some bad actors who should be identified and stopped. Think of the phony durable medical equipment providers, bilking Medicare and private insurers by prescribing unnecessary and expensive wheelchairs, scooters, and other devices. These bad apples are rare, but because of them – all the “good guys” are being hen-pecked to death just to get a walker for a patient with multiple sclerosis.
Unfortunately, there is no incentive for the private insurers to lift the pre-authorization burdens from the “good guy” physicians. Therefore, this will probably have to be achieved through legislation. With big data, it should be fairly easy to identify extreme provider outliers – and have their practices reviewed. For the rest of us, our pattern of judicious prescription of tests, services, and procedures should win us a break from the daily grind of begging, wheedling, and cajoling payers to allow us to get our individual patients what they need, every single time we order something. Until this freedom to practice medicine is achieved, true access to healthcare will not simply be a matter of having health insurance, it will be whether or not your physician has the will to fight for your needs. A “good doctor” has to be more than an excellent diagnostician these days – she must be a savvy, health insurance regulatory navigator and relentless patient advocate. Keep that in mind as you choose your next physician!
I receive a significant amount of email in response to my blog posts about locum tenens work. Curious colleagues (from surgeons to internists and emergency medicine physicians) ask for insider insight into this “mysterious business” of being a part-time or traveling physician. I am always happy to respond individually, but suddenly realized that I should probably post these conversations on my blog so that all can benefit.
The most common question I receive is: How do the agencies compare with one another? Followed closely by: Where should I start? There is no online rating system for this industry, and so grade-focused physicians (taught to value performance ratings) feel at a loss as to where to begin. One day I hope we’ll have a locum tenens quality website, but for now I can offer you my N=1, “case study” experience.
I’ve been doing hospital-based, locum tenens work for 6 years in the field of inpatient rehabilitation medicine. I have accepted 14 assignments through the following agencies:
CompHealth, Weatherby Healthcare, Jackson & Coker, Medical Doctor Associates, LocumTenens.com, and All Star Recruiting
I have had extensive conversations with recruiters at the following agencies, but have not ended up taking an assignment through them:
Staff Care, Delta, Onyx, Barton Associates, and Farr Health
I have summarized my experiences in this table:
| Agency Name | Number of Assignments | Quality of Client (Hospital or Employer) | Quality of Recruiter(s) | Salary Provided (percent of what I would consider standard) |
| Comp Health | 4 | B,B,C,C | A | 80-100% |
| Weatherby Healthcare | 3 | A,B,C | A | 85-100% |
| Jackson & Coker | 3 | A,C,D | C | 85% |
| Medical Doctor Associates* | 1 | A+ | A | 100% |
| LocumTenens.com* | 2 | A,D | B | 50-100% |
| All Star Recruiting* | 1 | B- | A | 150% |
| Self-Negotiated | 3 | A,B,D | N/A | 175% |
*These agencies use VMS systems.
These “data” are highly subjective, of course, but there are a few important points to be gleaned:
The bottom line is that part-time and short term physician assignments can prevent physician burnout and overwork. The pay is generally very good, and agencies can make the experience as painless as possible. Those who desire higher hourly rates can achieve them if they’re willing to take on more responsibility for paperwork and logistics. Whether this “do it yourself” movement is enhanced by online marketplaces, or good old fashioned cold-calling to find work – physicians hold the cards in this high demand sector. I suspect that more of us will be ready to play our cards in the locum tenens space in the upcoming years, because full time medical work (at the current pace) is, quite ironically, simply not healthy.
The New Yorker recently featured a long essay about a popular new episodic work style sweeping America: the “gig economy.” The gig economy unbundles units of work previously tied to an employer or specific job. Online platforms serve as conveners to match task requests with those seeking to complete them. The New Yorker notes:
TaskRabbit, which was founded in 2008, is one of several companies that, in the past few years, have collectively helped create a novel form of business. The model goes by many names—the sharing economy; the gig economy; the on-demand, peer, or platform economy—but the companies share certain premises. They typically have ratings-based marketplaces and in-app payment systems. They give workers the chance to earn money on their own schedules, rather than through professional accession. And they find toeholds in sclerotic industries. Beyond TaskRabbit, service platforms include Thumbtack, for professional projects; Postmates, for delivery; Handy, for housework; Dogvacay, for pets; and countless others. Home-sharing services, such as Airbnb and its upmarket cousin onefinestay, supplant hotels and agencies. Ride-hailing apps—Uber, Lyft, Juno—replace taxis. Some on-demand workers are part-timers seeking survival work, akin to the comedian who waits tables on the side. For growing numbers, though, gigging is not only a living but a life. Many observers see it as something more: the future of American work.
The pluses and minuses of this kind of work are fairly straight forward. On the positive side there is speed and convenience (both on the part of the worker, and the one who needs the work done). Rapid matching of task to worker occurs in an online environment that promotes competition and favors those with high ratings and a track record of success. There is flexibility for the worker – he or she can commit to as much or as little work as is convenient, and there is the opportunity for augmenting earnings as small, paying “gigs” can be added to already existing work. Variety provides challenge and interest.
On the negative side, choosing to do gig work full-time leaves the gigger without employee benefits (such as health insurance) and an insecurity of income stream. Without a large, trusted company as the agent for work, there are fewer guarantees of service (or protections) for both the hiring entity and the worker. With freedom comes insecurity. And then there’s the question about career advancement and long term economic effects of short-term work.
It seems to me that for most people outside of the healthcare marketplace, the gig economy works best as an income supplement, not replacement. In medicine, however, full time gigging may actually have more pros than cons.
In a system where fee-for-service healthcare is rapidly being replaced with bundled payments, shared responsibility, and accountable care, it is ironic that the workforce is moving in the opposite direction. Although initially physicians were driven to become hospital employees (instead of independent practitioners), now the pendulum is swinging in the gigging direction. Primary care is embracing the “direct pay” model, and more and more physicians are joining locum tenens agencies. I myself was an early adopter of both concierge medicine and locum tenens work.
Direct primary care is efficient – patients pay only for what they need (presumably from an HSA account), and there are incredible cost savings involved for providers, not having to code and bill insurance companies for services. As I’ve said previously, using health insurance for primary care is like having car insurance for windshield wipers. Expensive overkill.
As far as locum tenens is concerned, there is no better way to prevent burn out and overwork than to reclaim control of your work schedule. Short term work assignments may be accepted or declined at the physician’s convenience. You can travel as far and wide as you have interest (there are international locums assignments available too), and gain exposure to various practice styles and locations. You set your hourly rates, and the pay is fair and transparent. No more uncompensated hours of extra work that fuel resentment towards your employer.
New companies such as Nomad Health are poised to revolutionize the gig economy for physicians. By directly linking physicians with job opportunities in an online marketplace, agency costs are avoided, saving money for hospitals and allowing for higher doctor salaries. The question remains if they will gain the user volume necessary to compete with agencies. Nomad Health will succeed if it can convene sufficient numbers of hospitals and physicians to make it worth the time on the site.
The gig economy is the natural evolution of our modern culture. As technology enables an on-demand lifestyle, work is becoming as modifiable as our media consumption. Will chopping work up into smaller bits have a net positive or negative effect? For the companies creating the niche platforms that support the work marketplaces, the outlook seems positive. Uber, for example, is currently valued at about $28 billion. They have drawn inspiration from video games to psychologically incentivize drivers to work longer hours, contributing to their success – and perhaps downfall. By maximizing their own profits at the expense of the drivers, their gigging community is beginning to look for greener pastures at Lyft. Competition is a critical part of the gig economy.
In healthcare, I worry that a significant physician shift towards gigging could be disruptive to care continuity and result in higher costs and poorer outcomes. That being said, the alternative of physician burn out, early retirement, and flight from clinical medicine is not acceptable. I suspect that the gig economy is going to change how physicians engage with the healthcare system – and that within a decade, a large segment of the workforce will be part-timers and short-timers. This may provide a sustainable way for older physicians (or those with family or childcare demands) to continue working, which could substantially improve the physician shortage.
Gone are the days of cradle-to-grave relationships with primary care physicians – I mourn the loss of this customized, deeply personal care, but I stand ready to embrace the inevitable. I just hope that I can connect with my “short-term” patients so that my advice and treatment captures their medical complexity (and personal wishes) correctly. With all the technological tools to personalize medicine these days, it is ironic how impersonal it can be when you rarely see the same physician twice. The gig economy forces us to be perpetual strangers, and that is perhaps its greatest drawback.
At the risk of vilification by my peers, I’m going to say something extremely unpopular. We physicians have it pretty good financially. Our salaries are generous, and we have a much higher standard of living than most others in America. When I read online physician complaints about student loan debt, I cringe a bit. Because of all the people in debt, we are some of the most likely to be able to pay it down quickly.
Medical school and residency are emotionally, mentally, and physically exhausting. There is no doubt that we are severely cash-strapped during those years, and yearn for the day when we can go out to a nice restaurant and order anything we want from the menu. Most of us are eager to splurge on ourselves the minute we get our first job, and do not think about loan repayment. However, the truth is that if we gutted it out (living “like a resident”) for a mere 2 more years, most of us could pay off our student loans completely.
Let’s say we have an annual salary of about $200K and a student loan debt of about the same. What is the average household income in America? About 51K? Maybe if we lived on that amount for 2 years, and put all the rest (after taxes) into our loans – we’d be debt free.
I feel worried for young Americans who have a similar total student loan debt as physicians, but graduate with much lower earning potential. Students should soberly consider educational debt against their likely ability to repay it. We must all choose our education wisely, as it may have life-long consequences for our standard of living.
Physicians have many legitimate gripes, student loan debt (in my view) is not one of them.
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Over 1 million virtual doctor visits were reported in 2015. Telehealth companies have long asserted that increased access to physicians via video or phone conferencing saves money by reducing office visits and Emergency Department care. But a new study calls this cost savings into question. Increased convenience can increase utilization, which may improve access, but not reduce costs.
The study has some obvious limitations. First of all, it followed patients who used one particular telehealth service for one specific cluster of disease (“respiratory illness”) and narrowed the cost measure to spending on that condition only. Strep throat, coughs, and sinusitis are not drivers of potentially expensive care to begin with, so major cost savings (by avoiding the ER or hospitalization) would not be expected with the use of telehealth services for most of these concerns.
Secondly, the patients whose data were scrutinized had commercial insurance (i.e. a generally healthier and younger population than Medicare beneficiaries, for example), and it is possible that the use of telehealth would differ among people with government insurance, high-deductible plans or no insurance at all.
Thirdly, the study did not look at different ways that virtual doctor visits are currently being incorporated into healthcare delivery systems. For example, I was part of a direct primary care practice in Virginia (DocTalker Family Medicine) that offered virtual visits for those patients who had previously been examined in-person by their physician. The familiarity significantly reduced liability concerns and the tendency for over-testing. Since the doctor on the other side of the phone or video knew the patient, the differential diagnosis shrank dramatically, allowing for personalized real-time treatment options.
I’ve also been answering questions for eDocAmerica for over 10 years. This service offers employers a very low cost “per member per month” rate to provide access to board-certified physicians who answer patient questions 24/7 via email. eDocs do not treat patients (no ordering of tests or writing prescriptions), but can provide sound suggestions for next steps, second opinions, clarifying guidance on test results, and identify “red flag” symptoms that likely require urgent attention.
For telehealth applications outside the direct influence of health insurance (such as DocTalker and eDocAmerica), cost savings are being reaped directly by patients and employers. The average DocTalker patient saves thousands a year on health insurance premiums (purchasing high deductible, catastrophic plans) and using health savings account (HSA) funds for their primary care needs. They might spend $300/year on office or virtual visits and low-cost lab and radiology testing (pre-negotiated by DocTalker with local vendors). As for eDocAmerica, employers pay less than a dollar per month for their employees to have unlimited access to physician-driven information.
The universe of telehealth applications is larger than we think (including mobile health, remote patient monitoring, and asynchronous data sharing), and already extends outside of the traditional commercial health insurance model. Technology and market demand are fueling a revolution in how we access outpatient healthcare (which represents ~40% of total healthcare costs), making it more convenient and affordable. As these solutions become more commonplace, I have hope that we can indeed dramatically reduce costs and improve access to basic care.
Keeping people well and out of the hospital should be healthcare’s prime directive. When those efforts fail, safety net strategies are necessary to protect patients from devastating costs. How best to provide that medical safety net is one of the greatest dilemmas of our time. For now, we may have to settle for solving the “lower hanging fruit” of outpatient medicine, beginning with expanding innovative uses of telehealth services.
This blog post first appeared at: Curious Dr. George
Rehabilitation medicine is one of the best-kept secrets in healthcare. Although the specialty is as old as America’s Civil War, few people are familiar with its history and purpose. Born out of compassion for wounded soldiers in desperate need of societal re-entry and meaningful employment, “physical reconstruction” programs were developed to provide everything from adaptive equipment to family training, labor alternatives and psychological support for veterans.
Physical medicine and rehabilitation (PM&R) then expanded to meet the needs of those injured in World Wars I & II, followed closely by children disabled by the polio epidemic. In time, people recognized that a broad swath of diseases and traumatic injuries required focused medical and physical therapy to achieve optimal long term function. Today, cancer patients frequently benefit from comprehensive rehabilitation as they recover from the effects of chemo (neuropathy, weakness, and cognitive impairments), radiation (scarring and range of motion limitations), surgery (flaps, plastics procedures, tumor resection, amputations), and brain injuries (edema, debulking, gamma knife and neurosurgery).
Rehabilitation is a phase of recovery occurring after any major life-changing medical or surgical event. Our bodies are designed to regenerate and repair, though optimizing this process takes skilled guidance. PM&R physicians (also known as physiatrists) are trained to use physical modalities (stretching, strengthening, heat, cold, etc.) to mechanically enhance healing. They prescribe medications to manage pain, spasticity, nerve injury, and cognitive impairments, while also leveraging the power of physical therapy to increase cardiopulmonary fitness, muscle strength and flexibility. PM&R physicians are also experts in neurologic injury, and can adapt exercises to coax spinal cord, brain and peripheral nerve injuries to construct new pathways for movement and repair.
Inpatient rehab’s prime directive is to get patients back home. To succeed at home, patients need to be able to function as independently as possible, using trained assistants for managing the activities that cannot be performed without help. Admission to a rehab hospital or unit offers the patient home practice opportunities – with simulated challenges that can include everything from terrain parks, test kitchens, medication management trials, driving simulators, balance tests, electric wheelchairs and even exoskeletons that allow paralyzed patients to walk again. It is like a robotic Disney World, with endless aquatic and equipment possibilities for restoring movement and independence.
When I discuss admission to inpatient rehab with my cancer patients, I ask them about their goals, motivation, and energy levels. Timing of rehab is important, because it must dovetail with treatment, so that the physical exertion strengthens, not saps, the patient. Often times when a person is newly diagnosed with cancer, they want “everything done” – intensive chemo/radiation/surgery as well as rehab/exercise. But staggering these interventions can be more effective.
In other cases when care is palliative, learning new skills and being fitted with battery or electric-powered equipment can mean the difference between living at home or in an assisted environment. Some successful cancer patients come to inpatient rehab to practice managing their activities of daily living with varied amounts of assistance, preparing for increased needs as time goes on so they can enjoy being at home for as long as possible.
For the physiatrist, cancer is a cause of impairments that can be overcome with creativity and practice, no matter the long-term prognosis. Adaptive equipment, physical exercise, and cognitive retraining may be applied intensively (3 hours a day in the inpatient setting), or at a slower outpatient pace, depending on individual need. Rehab physicians desire to support and sustain patient function at the highest level, and “add life to years.” As such, rehabilitation should be considered an integral part of successful cancer care and management.
