Access Controversy

A recent Journal of the American Medical Association study showed that patients with online access actually scheduled more visits.   The authors, when tallying the results, let out a massive and collective “WTF?”.   They didn’t know why this happened but their theories included:

  • Maybe patients who signed up for online access were sicker than those who didn’t, although his study tried to control for that.
  • It could be that doctors who aren’t used to an online give-and-take with patients asked them to come in more often to clear things up.
  • It could be that the new online relationship between doctors and patients means that, together, they’re catching important health indicators that were getting missed in the past, and patients are getting better care.

In the NPR article I cited above, Judy Murphy was quoted.  She is an information technology coordinator at the Department of Health and Human Services, the federal agency that’s requiring doctors to start offering patients online access, and says that online access to doctors will mean fewer visits for some and more visits for others.   It doesn’t matter to the DHHS.  Most importantly, the government’s intent in requiring doctors to offer online access isn’t to drive the overall number of office visits up or down, but to improve the relationship between doctors and patients by improving communication.

You know what, she actually  is right.  The problem is that the government and insurers AREN’T PAYING for these online visits.   Can you imagine being on call covering 20,000 patients (like I used to do) and not only answering pages but also emails?  I can.  It will suck UNLESS you do it for your own panel of cash-paying, direct care patients of less than 1000 and you know them all.  You don’t mind because you are being paid on a monthly fee without the gov’t or insurers interference.

More to tell you about that, on a personal level, in about six to eight months………

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  13 comments for “Access Controversy

  1. Bob Rakov
    December 28, 2012 at 5:59 pm

    Wave of the future baby.
    I have no doubt that about 5 minutes after I summon up the courage to go “Galt” the feds will move to make that illegal.

    • January 1, 2013 at 12:31 pm

      Hi Bob,
      Thanks for the support. I understand the concern that gov’t won’t be as supportive of our model. When the pain of the status quo is greater than the pain of change, people will be receptive to change.

      I am cautiously optimistic that the gov’t will see the enormous savings potential of our model and consider how we can work to improve the system.

      Again, we over unlimited visits, no copays, all procedures in office free, and up to 95% discount on medications and labs. This savings allows for up to a 50% savings on health insurance.

  2. Kurt
    December 27, 2012 at 3:01 pm

    I caught the NPR spot on that group. Sounds fine and dandy for an uncomplicated patient. But, if one is dealing with a generally non-compliant, obese, diabetic culprit who is going into CKD4 and needs services of a specialty group (spell that nephrology), unless they have coverage for those services, Atlas is screwed. The representatives in the news report did say they recommended people have “some kind of” catastophic insurance. But again, if that diabetic culprit insists that Atlas deals will all their problems and they have a poor result, the pissed off relative from California can coerce the “victim” into a liability suit. Who at Atlas does their
    diabetic teaching for the “new” diabetics? I like the idea but if the physician group can’t get specialty help when it is needed and/or the patient can’t or won’t pay for it, it lends itself to a costly legal situation. Being in K.C. I guess they can refer their problems on to the “university”. I for one can’t cure all the world’s problems and need backup for the medical stuff that is beyond my skills. If it’s not there, I get uncomfortable.

    • January 1, 2013 at 12:45 pm

      Hello Kurt,
      Thank you for your opinions. You’re correct, this is both fine and dandy for health patients. However, I’ll disagree with the assumption that this does not work well for sick patients. We are selling healthcare and the heaviest consumers of healthcare are in fact ill patients. Thus, we offer an unprecedented level of access and affordability to those with the most need.

      Our ability to offer unlimited visits, no copays, all procedures** free, and up to 95% discount on medications and labs is an obvious benefit to our sickest members. The low monthly membership of $50/adult/month is often surpassed by the savings mentioned above.

      **Included procedures: laceration repair, biopsies, joint injections, ekgs, holter monitor, spirometry, dexa scans, audiometry, urinalysis, rapid strep testing, minor surgical procedures, medical laser treatments, cryotherapy, wart/skin tag removal, home sleep apnea testing and more…

      I agree with your statement that complex patients need complex specialty care. We have worked on a system that allows for “free/included” dermatology consults and would like to expand that system.

      We recommend patients have at least major medical so they are covered for the major medical problems. Unfortunately, no system is 100% complete. Poor patients with major illness may fall through the cracks. We should keep working on finding innovative ways to help them.


  3. mamadoc
    December 26, 2012 at 8:15 pm

    Whoopee, all the liability and none of the money. Unless I get paid for it, #$%^ NO!

    • January 1, 2013 at 12:48 pm

      Hi MamaDoc,
      Actually, we feel that the liability is the same or better b/c the volume of patients is less so our focus on each patient is greater.

      Furthermore, as mentioned above, we can offer an unprecedented level of access and affordability to our patients, thus letting us care for them even more. This in turns limits the liability for each patient. Not to mentioned we enjoy caring for our patients more and they are bonded to us as well. And as the saying goes, happy patients don’t sue.

      Plus, we are able to realize a 30-50% greater income than our local peers depending on their contracts.


  4. Richard W. Mondak
    December 26, 2012 at 10:47 am

    Would it be unethical to have a Pay-Pal account to bill for “electronic consultation”?

    • January 1, 2013 at 12:51 pm

      Great question Mr. Wondak. I’m not sure why it would be unethical to take electronic payment for an electronic visit. Very similar to electronic payment (i.e., Credit cards) for a typical visit.

      Also, many clinics say that patients can not be seen unless they pay a copay up front before their visit.

      If you wanted to be kinder, you could have a generous return policy to maximize customer satisfaction. Many teledocs find their patients are very satisfied b/c their consumers value ease and access over other factors. Thus if you’re able to offer great care that is easily accessible at a reasonable price, I believe many patients would appreciate that service.


      • Richard W. Mondak
        January 2, 2013 at 10:26 am

        As of 2008, there are CPT codes for telephone care, although some payers aren’t keen on reimbursing for them. I suppose we could use them anyway. Carefully read the descriptions to codes 98966-98968 and 99441-99443. Some of the follow-up services may be “global” under the original ICD and / or CPT and are not billable separately. As always, the key is careful and complete documentation in our notes.

        Before billing (uninsured) patients for such services, it would probably be necessary to have a standing policy in place. When they previously got “for free” and now are getting notice of payment or a bill for service, the incoming phone calls won’t be all that pleasant. In other words, we should not bill retroactively.
        Hopefully our Coding / Billing experts will be able to assist with this.

  5. D. Thomas
    December 26, 2012 at 10:24 am

    :It will suck UNLESS you do it for your own panel of cash-paying, direct care patients of less than 1000 and you know them all. You don’t mind because you are being paid on a monthly fee without the gov’t or insurers interference.”
    So how much would you charge these individuals to maintian your level of income? They will still need hospital insurance. I think you idea is flawed as shown by the few people who have signed up for a personal physician already.

    • Doug Farrago
      December 26, 2012 at 10:53 am

      email Josh
      It is more affordable, better care and only the tip of the iceberg now

      • January 1, 2013 at 1:54 pm

        Thanks Doc,
        yes i believe this is only the beginning. As we branch free of insurance based care for primary care, we’ll open up a wave of innovation in medicine. This renaissance will bring doctors back to primary care and improve care while lowering cost for patients.


    • January 1, 2013 at 1:52 pm

      Hello D. Thomas,
      Thank you for your input.

      As a doctor practicing this model, i can tell you it does not suck. In fact, its incredibly enjoyable and rewarding. A busy day is seeing 4-6 patients in the office, but perhaps for 30-90 minutes each. The rest of the day we are available for emails and phone calls from our patients. Few things make a patient happier than when their doctor answers their phone call directly 😉

      We average about $40/pt/mo across our age ranges ($10-150/mo for kids through 65+). 40×600=24k/mox12mo=288k – expenses of about 90/yr/doc (overhead for us is higher than it needs to be for variety of reasons). You could alter your offer to patients to see 1000 pts so you can charge less etc.

      In fact, the volume allows us to be on call for our patients essentially all of the time 24/7. Of course, I can fwd my calls to my partner for vacations and such. But patients love knowing they always get THEIR doctor.

      Yes, they still “should” have health insurance for the car wrecks, cancers, and heart attacks of life. The big stuff. But we’re able to do so much for them that now they can get health insurance for up to 50% off. If and when ins companies start working with us, we’ll get that cost down another 50% I believe.

      Flawed b/c few have joined? According to Tom Blue of the, we’re one of the fastest growing ‘concierge’ practices in the country. 930 active patients in just over 2 years. Each doctor will be full soon. Not bad for a clinic model that 3 years ago doctors told me would never work.

      I speak with physicians that are critical of ‘concierge’ medicine frequently. Typically, they are more interested after I explain what we do and how we do it. If you ask a doctor, would you like to slow down, take better care of patients, while offering them a lot more services for a fraction of what they are currently paying…they typically see how this is a win:win:win:win (patients, doctors, employers and ins companies).


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