The Informed Patient

The Informed Patient


Yes, don’t confuse the value of Google with your Medical Degree. For instance, Google can search through every medical article ever written on migraines in seconds and I can add my symptoms to narrow down the effects of the disease and then I can discuss with others suffering from the same effects.

Yes, you do have the Physician Desk Reference (PDR), but how much time did you actually spend on Migraines in Medical School, if you were a Family Medicine Physician? Maybe a day or two on headaches?

Much like the politics of the time, the debate should be focused on what we can do better and not why either option is not the best solution. We are at a point in medicine where we need to leverage technology and physicians to create solutions for patients. It’s not an either or answer, but a 1+1+1 = 5 equation.


If you see this sign in a physician’s office, run. Find a doc who wants you to be educated and can spend talking about your disease and your concerns. How many of us would pay another $40 for 15 minutes of time just talking to our doctors about our lives and how this may affect your diagnosis. I can’t believe physicians (and more importantly the physician’s office staff) don’t ask before your appointment, “Do you have anything you need to discuss in more detail?” Physician’s bill office appoints in increments of time like a consultant. If you need more time, ask for more time and be ready to pay a little extra. The best value point is 40 Minutes or the 99205. You get 15 more minutes for ~$40.

New/Established Patients Time
99201/99211 10/5 Minutes (~$20)
99202/99212 20/10 Minutes (~$50)
99203/99213 30/15 Minutes (~$80)
99204/99214 45/25 Minutes (~$110)
99205/99215 60/40 Minutes (~$150)

We as consumers, haven’t leveraged the revenue cycle mentality of the healthcare system to get better care.

In an age of technology, the physician’s ego has been battered and bruised. Where once a patient went and whole heartedly trusted the physician’s advice and followed that advice to the nth degree, now we have the informed patient who, given some time and focus, can be very informed about a particular disease they are struggling with. The real art of medicine occurs when the patient, the physician, and the technology are one.

Facebook is full of stories related to people who found the right answer faster than the medical community (physician, lab, imaging, tests). It happens every day. I have my own stories.

Most of the time when I go to the physician’s office, I know what my symptoms are and what I am suffering from. They take blood and confirm my initial diagnosis. There are many other documented cases where the patient had no idea they were suffering from cancer, growing slowly in their body.

So in an age of technology, isn’t it time we merged the best minds of the physicians and the best mind of circuit board? Is this the time for Telemedicine to close the gap so the patient can have a meaningful conversation with a physician who will listen to their needs?

Physicians are also growing discontent as they try to keep up with all the literature in their specialty areas. ““Medicine has a TL;DR problem (Too Long; Didn’t Read),” said Nate Gross, MD, co-founder of Doximity. “It would take 20 hours of reading each day for the average physician to comb through everything published in their specialty.”1

There are several tech companies, some with local ties to Nashville, who are trying close the gap between consumers and physicians:

Sharecare – Patient Engagement Platform

ZestHealth – Patient Navigation

WiserTogether – Patient Diagnosis

Doximity – Physician Education

Physician Office Coding

An Example of what your Explanation of Benefits from an office visit might look like on your bill.

Codeset: CPT

Code: 99201

Description: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.2


  1. Survey: How Doctors Read and What it Means to Patients (July 22, 2014)
  2. Perception Health’s phCoder

The post The Informed Patient appeared first on Perception Health.

Source: Perception

Price Transparency

A complicated story

If you want to go buy a car, you simply walk up to the car and there is a sticker in the window showing how much the car cost, the options available on the car, and the delivered total. There is still some haggling to be done, but CarMax and Carvana are working to eliminate this part of the equation as well.

Juxtapose, the automotive industry with the healthcare industry, and the industry is arguably plagued by the most complicated price formula of all sectors. The price of healthcare is hidden by the fog of complexity.

This is how it goes for the typical patient: you get sick, go to the Emergency Room, get admitted as an Inpatient, get discharged, then you receive a 42 page bill showing you owe a bunch of money. As patients, we should have a right to know how much this procedure is going to cost me before we arrive.

One problem in healthcare is that we have an intermediary. It is not a transaction between me and the hospital. In healthcare, the provider charges an amount and the insurance company negotiates to pay their share and then you have your share of the price. What many people don’t understand and is hidden from the consumer are all of the contractual adjustments which are negotiated by the Insurance Company and the Provider Organizations. This benefits the insurance company, but not necessarily the patient who is taking on more risks and a greater share of the payment every day.

According to CMS, “National Health Expenditures grew 5.3% to $3.0 trillion in 2014, or $9,523 per person, and accounted for 17.5% of Gross Domestic Product (GDP).” The consumer’s “Consumer out of pocket spending grew 1.3% to $329.8 billion in 2014, or 11 percent of total expenditures”. The report goes on to note “the largest shares of total health spending were sponsored by households (28 percent) and the federal government (28 percent). The private business share of health spending accounted for 20 percent of total health care spending, state and local governments accounted for 17 percent, and other private revenues accounted for 7 percent.”

We all want Lexus care at Chevy Spark prices. With increasing demand on the consumer to pay more, we are likely to get more involved in pricing discussions with providers. This is the first of several blog posts related to the future of healthcare.

Today, many young technology companies are trying to bring price transparency to the health industry. There are applications like Healthcare Blue Book where the consumer can receive a fair price option. The industry is hampered by data delays (in our price example below, we had to cobble together 2014 and 2013 data to do the analysis). This makes the concept of real-time pricing nearly impossible.

The Role of Medical Coding – Simplified

Depending on your medical situation, the healthcare industry’s pricing begins with the type of diagnosis or procedure being performed.

An example of a frequent diagnosis is knee pain. A common procedure in the US is a Total Knee Joint Replacement, which is largely a surgical episode. However, medications will be used to treat swelling and rehabilitation and physical therapy will follow the procedure. There are multiple DRGs to describe joint replacement. The Diagnostic Related Groupings (DRG) are determined by the combination of ICD10 CM and ICD10 PCS codes. For Knee Replacement, a code of 470 will be used. If a complication or major complication was determined to be present, then a 469 would be used to describe the overall care episode for a hospitalization. DRGs are important because the facility will charge the patient based on the DRG and the Insurance company has a set price that it will pay the hospital for treating a patient with the DRG in question. The DRG combines all services from the hospital into a payment that covers bed rate, surgery, radiology, rehabilitation, and physical therapy to name a few areas. In addition, a patient will receive a separate bill from the attending physician and the surgeon. All of this will ultimately determine the price of not living with knee pain.

Definition of Diagnosis and Procedure

Medical Diagnosis is based on the International Classification of Diseases (Clinical Modification V10) managed by the World Health Organization. There are 91,737 diagnosis descriptions.

Medical Procedures are defined by Procedure Coding System (PCS). There are 72,822 medical procedures, which can be performed and coded.

Sample Price Table

Commercially Insured Medicare
Total Charges $75,084 $62,074
Average Payments $28,350 $20,100
Physician Charges $14,000 $11,500
Total Payments $43,350 $31,600
Consumer Out of Pocket $2,500-$5,000 $1,000


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Source: Perception

Re-Imagining Care Networks

Re-Imagining Care Networks

Can you imagine not knowing how a customer came to be a customer? In many ways, this is the problem hospitals have faced for many years. Hospitals relied on the referring physician to be loyal to their facility and in return, refer patients to them. Unfortunately, consumers have a mind of their own; insurance plan designs steer to the low-cost setting and physicians have begun to do more procedures in their offices. How does the hospital today have a co-operative (collaborative and competitive) relationship with its very lifeline to the patient?

The provision of care is taking on a life of its own. Traditionally, providers were focused on driving patient volume to the hospital by working directly with physicians. They used any and all legal measures to attract and retain physicians to their Medical Staff like preferred parking spots, operating room slots, food in the physician lounge, space in on-campus medical office buildings, etc. When necessary, providers have used additional financial strategies to attract physicians to practice medicine at their hospital including the purchasing their practices as well as an outright employment to bond the physician and the hospital.

Usually the attempt to understand the inherent consumer selection process involves examining demographics, health status, and existing healthcare infrastructure. Today, there is an evolving care network science, which has proven to be a better way to understand how local community care networks evolved and where they are heading. This science studies the providers who deliver care in the community. A critical component of this endeavor is understanding referral patterns around local primary care physicians, specialists, lab, radiology, skilled nursing facilities, home health, hospice and hospital systems. New tools like phTeam help the network of providers understand, analyze, and visualize the complex referral relationships that exist in every community. This deep understanding of a local market empowers providers to deliver a more efficient and effective product to their community.

While referral patterns primarily help us understand a patient’s journey through the healthcare system, they also shine a light on a physician’s preference for specialists and a specialist’s preferred place to deliver care. Today’s executive needs to be able to visualize vast amounts of information in one graphic. This view of the pre- and post-acute care business helps the quarterback of the community care network understand where the best treatment options exist based on access, quality, and cost. These patterns allow care managers to engage providers about their referral patterns and ask the most important behavioral health question: Why are you doing this?

Once you discover the reasons for “leakage” outside of your network, the next logical step is to quantify a dollar amount being lost due to this pattern of behavior. This process is accomplished by investigating a physician’s typical charges and collections and extrapolating these values out to their leaked cases. For example, it may be prudent to investigate an acquisition strategy or investment in new technologies or infrastructure if your network is losing millions of dollars in potential revenue due to doctors’ referrals patterns.

Another way to increase efficiency is to understand your physician’s coding habits. Comparing a physician’s distribution of CPT codes to national averages in their specialty provides insight on whether a physician is under-coding and losing potential revenue or over-coding and risking potential investigation.

Making sense of large amounts of complex data is a task every healthcare organization struggles with today. It is paramount to analyze these relationships and provide visual representation in a way that promotes clarity, which suggests a strategy and creates a clear path to execution.


–Luke Wylie, Data Scientist, Perception Health



*Originally published by HIMSS – Tennessee Chapter (TN HIMSS Newsletter May 2015)

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Source: Perception