Doctors should charge by time, not transactions

Charging by transactions means the more doctors do, the more they get paid, and the more your wallet suffers. It also means high-speed churn, not high quality, personalized service. And if you go to the doctor, the ER, or an urgent care center, and you’re sent home, and something changes that will affect your outcome, you’ve got to make another appointment and pay for another appointment.

We think that’s unsafe, inefficient, unfair and wrong.

That’s why Sherpaa is now offering two new pricing plans to ensure everyone can access our care:

  • 30 days for $150
  • 1 year for $40 per month

30 days of Sherpaa for $150

Typical issues perfect for this plan are a sprained ankle, strep throat, a skin infection, etc.. Instead of going to the ER or an urgent care center and exposing yourself to more infections or waiting 22 days for a PCP visit, just fire up Sherpaa. It’s an accessible quick fix that helps solve problems in a modern way, but also keeps costs low. Why 30 days? Because things take time to get better. Good care is ongoing communication and check-ins to ensure things are getting better. But sometimes things get worse and you need local, in-person care coordination with specialists. Thirty days is the magic number where the vast majority of these kinds of issues get resolved.

365 Sherpaa Concierge for $40/month

This is for folks who want peace of mind that they always have a direct line to their own personal doctors no matter where they are in the world. It’s also for people who have ongoing needs on a monthly basis and the only option for them is old-fashioned, in-person, expensive office visits, urgent care visits, or trips to the ER. As always, once you’re a member, it’s:

  • Unlimited 24/7 access to your Sherpaa physicians while home or traveling
  • Expedited appointments and care coordination with local, hand-picked specialists
  • Personalized recommended preventive tests ordered and interpreted
  • Personal curation of products and services that maximize your health and lifestyle

I wrote a piece yesterday for Quartz, The Atlantic’s sister site asking the question, “Do I Really Need a Primary Care Doctor?” In a nutshell, my opinion is that it’s impractical and unrealistic for 75% of us. 

Americans know that we’re supposed to have a primary-care doctor. It’s a task as associated with adult responsibility as paying the car insurance and flossing regularly. And yet, when confronted with a form asking us for the name of our primary-care physician at the dentist or the optometrist, many of us leave the space blank.

That may be for the best. Once, maintaining a relationship with a primary-care doctor made sense. But given the nature of our current health-care system as well as changes in the American lifestyle, today, it’s unrealistic for many adults to have one.

First of all, the commonly held belief that we all need a yearly physical is false. An annual physical is not currently recommended for the healthy adults by the governing health bodies in the US, Canada, or the UK.

That’s good news, because the US has a significant supply and demand problem when it comes to general practitioners. America’s physician workforce is composed of roughly 33% primary-care doctors and 67% specialists. Other high-performing health care systems, like Canada or Australia, have more balanced ratios.

In countries where the vast majority of doctors are generalists, it makes sense to expect everyone to have a PCP. They are plentiful, accessible, and effective. But there are good reasons why so many young doctors choose to specialize here in America. Specialists are more respected by the public and in the medical community. And the lifestyle of a specialist is far better, involving less punishing hours while making millions of dollars more over their careers. And so, with a dearth of general physicians, we wind up with situations like Boston’s 45-day wait to see a PCP.

Not only is the supply of primary-care doctors diminishing, the nature of their job is changing. Local hospitals are increasingly acquiring private primary-care practices in order to generate lucrative specialist visits, via PCP referrals, within their walls. When PCPs are no longer their own boss, the loyalty and passion they once dedicated to their business tends to fade. Gone are the days of independent doctors who felt personally responsible for their patients’ well-being at all hours of the day. Now PCPs are largely shift workers, part of a large team of physicians overseeing patients and generating referrals. There are some benefits to this system for the doctors themselves. But ultimately, the transition means that patients no longer have a primary-care doctor. They have a primary-care doctor group, and may wind up seeing a new doctor every time they visit.

There are other obstacles involved in building doctor-patient relationships today. A visit with a primary-care doctor typically lasts 10-15 minutes because, in order to financially stay afloat as a PCP, you’ve got to churn through patients. There’s not a whole lot doctors can achieve in that amount of time, unless the patient’s health problem is quite simple. When the issues are more complicated, doctors typically handle some items on your list and then make you come back for another visit, and another co-pay, to tackle the rest. Meanwhile, the average time that patients have to take out of their day for a doctor visit is conservatively estimated to be 121 minutes.

All relationships, both personal and professional, are built over time. Does it qualify as a relationship if you’ve seen a doctor three times over three years?
But there’s an even larger issue: Our society is becoming more and more mobile. People are constantly moving to new neighborhoods and new cities; they change jobs every two to three years. They frequently change health insurance companies, and therefore doctor networks, as they or their employer search for a solution to rising insurance premiums. Not only does a primary-care doctor need to take Aetna, they need to be in your specific plan’s network within Aetna. And doctors drop and pick up new networks on a monthly basis as they prune low-paying insurance companies from those they accept.
Compounding all these socioeconomic and logistical issues is the fact that it is primarily children and the elderly who need consistent relationships with generalists. Children get sick and hurt all the time. They also have a very set schedule for pediatrician visits to keep vaccinations and check-ins on other developmental milestones up to date. A pediatrician who knows both the child and the parents can more efficiently diagnose and manage frequent issues.
But people in their 20s and 30s face fewer health problems than kids and the elderly, except for the occasional injury or acute illness. People in their 40s and 50s are also frequently lucky enough to stay generally healthy. It is only as we get into our 60s and beyond that we need an old-fashioned, close relationship with an internist again.

Kids need a consistent pediatrician. The elderly need a consistent internist. The chronically ill, no matter their age, need a consistent team and place to receive care. But for the rest of us—around 75% of the population—the old-fashioned “doctor-patient relationship” is unrealistic and largely unnecessary in our society. Rather than spend time and energy trying to pin down a primary-care doctor, it could well make more sense to simply stick with an urgent-care clinic when you come down with the flu.

Americans need a better solution. We need a system that’s as mobile as we are and that stays constant even as we change cities, jobs, local hospital networks, and insurance companies.

This means that we are most in need of access to our own health data and histories. No matter where you get medical care in America, your records should be a part of your personal profile that you own and control access to. Companies like Apple are already, albeit slowly, trying to implement this concept.

When primary-care doctors are no longer our first point of contact, we also need help understanding exactly how to navigate a system composed of a hodgepodge of health-care services and specialists. Given the cost of medical care, a mistake in how to best spend your money can be financially catastrophic

Insurance companies have already tried to offer patients medical guidance by providing nurse phone lines, and video visits with doctors have also recently attempted to increase access to health care. But both of these strategies are reserved for very simple issues. For more complex problems, we need an online, integrated service made up of doctors and nurses who can help Americans make sense of a system of specialists and coordinate treatments and care. Such a project would be an ambitious undertaking–but it could go a long way toward fixing the problems with our current health-care system.
It’s a wonderful thing to have a trusted relationship with a primary-care doctor. But as our society changes, we must adapt. It’s time to admit that our system isn’t set up to allow a PCP for everyone, and demand something better for American patients.

Starting today, any adult in America can sign up for Sherpaa.

In addition to companies, individuals can now become Sherpaa members because everyone needs:

  • Accessible doctors who solve problems and communicate anytime and anywhere. That’s just how life is done nowadays.
  • Help spending healthcare dollars because a mistake in spending your money is increasingly becoming financially catastrophic

For the last 5 years, Sherpaa has been working exclusively with amazing companies to make healthcare easy for their employees. Our mission with Sherpaa has always been to make healthcare accessible, appropriate, and affordable. And when you make healthcare accessible, it becomes appropriately delivered. When it becomes appropriately delivered, it becomes affordable.

Sherpaa pioneered delivering care online and created the world’s only exclusively online medical practice. After you become a member, you get unlimited Sherpaa access and care and we don’t bill your insurance for any of the things we diagnose and treat. We use messaging, photos, blood tests, imaging, phone, and video to manage everything from simple acute issues to ongoing chronic illnesses that evolve over the course of years. We’ve found over the last 5 years that 70% of healthcare issues can be diagnosed and managed virtually without using your insurance. Not having to use your insurance 70% of the time and deal with the headache of going to the doctor is a gamechanger. But for the other 30% of the time, you need guidance and arranged care with the exact person or place best suited to solve your problem. But no matter what, Sherpaa doctors are communicating with you and involved throughout because we know that’s the safest and highest quality care that can be delivered. It’s real life problem solving. It’s not a transaction where all communication has to be done in 10 minute office visit increments. 

Individuals can think of Sherpaa as a professional filter that ensures they use their insurance only when they need in-person care, which is ~30% of the time. In the last 5 years, individuals have seen massive increases in the deductibles they are required to pay prior to their insurance kicking in. Out-of-pocket limits in 2016 for all Obamacare plans are capped at $6,850 for individuals and $13,700 for families. However, when you’re sick or injured and you seek help from traditional doctors, your wallet is at their mercy. A $5,000 ER visit is quickly becoming normal and it’s chock full of tests used to cover their ass without considering actual value to you and your personal spend. There are very few people in America who can unexpectedly cover that kind of expense, especially when 65% of ER visits were non-emergencies that could be handled by accessible doctors.

And the $5,000 spent on an unnecessary ER visit could pay for over 10 years of access to Sherpaa.

As healthcare gets more and more expensive, it’s not only about having high quality doctors you trust, it’s also about working with them to ensure you’re spending your money wisely. Sherpaa started before Obamacare. And I respect Obamacare. Like everything, it’s not perfect. Giving the American people an option to protect themselves from financial ruin due to medical expenses is the ethical thing to do. But, it doesn’t go far enough. Healthcare involves real money and real expenses. And I think it’s wrong to only make Sherpaa available through companies. Individuals need help.

Some people compare us to on-demand video visits. On the contrary, instead of uber, Sherpaa is your own private driver. To take you home after a night of drinking with friends, you’ll accept the commodity of any old uber driver. But when it’s your life and your health and things are getting real, you don’t want some random stranger junior doctor staring at you as you scramble to find some privacy in the stairwell at the office for a weird video visit. You want a doctor who can work with you throughout your situation, order tests, communicate with specialists on your behalf, and be your inside connection to get things done for you. You want an experienced doctor who knows you, who communicates normally like we all do nowadays, who’s accessible anytime and anywhere, and who’s been a part of your life. You need a doctor you know and trust.

And I’m proud to say most everyone can have that for themselves and sign up today.

I had a pediatrician when I was a kid. Dr. Keefe. He was my mom’s go to. He was in a solo practice in St. Charles, MO where I spent the first 22 years of my life. Then I moved to Pennsylvania to go to med school. Ever since, I’ve never had a “relationship” with a primary care doctor. Granted, I’m a doctor. I can prescribe my own meds or go see my doctor friends. But, in talking with friends and family, I occasionally stumble across someone who uses the term “my doctor.” It’s like they’ve somehow seen and befriended a mythical creature.

If you do a literature search for “how many people in America have a relationship with a primary care doctor” you get zero results. First of all, nobody would benefit financially from the results of the study, so nobody would spend time and money on this issue. We know what people are. We know what primary care doctors are. But we don’t know what “relationship” means.

So what the hell is this mythical thing?

First and foremost, a relationship is loyalty to someone you respect, trust, and jives with your personality. In order to find that one person, just as you find a spouse, you’ve got to shop around and experiment to find the one that actually personally fits with you. This is a rare find.

Second, we’re a mobile society, both doctors and patients.

Doctors move neighborhoods. Doctors move jobs. And doctors move health insurances they take. Doctors are increasingly no longer solo entities. They’re now part of group practices that have been bought up by local large hospital networks. Doctors are becoming employees, not entrepreneurs. They’re abandoning the personal responsibility felt when you’re emotionally, professionally, and financially beholden to the group of patients you’ve been building relationships with for years.

And people move neighborhoods. People move jobs. People move health insurance companies. If they move too far away from “their” doctor, they have to find a new one. And when their doctor takes a job at a large group practice, the group has to provide a better experience and benefits than the solo doctor. If not, the patient will likely lose loyalty. They’re often forced to lose loyalty because the average person changes jobs every two to three years. And when they change jobs, they are almost guaranteed to change health insurance plans. Even when they stay in their job, companies change health insurance plans every few years because health insurance has become a race-to-the-bottom commodity. And every time you change your plan, there’s a good chance “your” doctor won’t take your new plan.

Compounding all these logistical issues, the way different age groups consume healthcare has more to do with the demise of the old-fashioned doctor-patient relationship than anything. As children, we get sick and hurt all the time precipitating many acute visits. We also have a very set schedule for why and when we’re supposed to visit the pediatrician to keep everything all up to date. Then, blam, high school and college happens. Then our 20’s. We don’t need much healthcare in our 20’s and 30’s except for the same kinds of issues we had when we were kids- acute sickness and injuries. But we’re too old for our pediatricians and we also feel out of place sitting in waiting rooms with 90 year olds. For the most part, 40’s and 50’s are the same, except some of us start having an early onset of old people diseases. Then our 60’s happen and the diseases we get tend to mimic more of a 90 year old than a 10 year old. And that’s when we again start looking for the old-fashioned close relationship with an internist similar to the one we used to have with our pediatrician.

All relationships, both personally and professionally, are built over time with consistency and mutual dedication. Does it qualify as a relationship if you’ve seen a doctor 3 times over 3 years? How about if when you make an appointment at your doctor’s practice and her colleague sees you because your doctor had to leave early that day? How long must the loyalty and consistency exist before we can call it a relationship? One year? Two? Ten? How many visits? And does it matter what those visits were for?

Kids need a consistent pediatrician. The elderly need a consistent internist. The chronically ill, no matter the age, need a consistent team and place to receive care. But for the rest of us (around 75% of the population) the likelihood of wading through today’s nearly impossible logistics of maintaining consistency and mutual dedication makes this old-fashioned thing called a “doctor-patient relationship” unrealistic in today’s society. And honestly, how much of a relationship can you build with a doctor when the interaction is a harried 8 minute conversation in which your doctor is constantly interrupting to focus your answers to her questions. Not only is it unrealistic, it’s of questionable value. I’ve heard it said that the value of longitudinal healthcare data, which is what a relationship is supposed to maintain, is less valuable the older the data. Data that’s 5 years old is less valuable than data that’s 5 weeks old. Since from your 20’s and into your 60’s most people need more transactional fixes than ongoing routine management of issues, the value of the data and the emotional connection you have with your doctor simply isn’t there.

Going forward, we need to update the definition of the doctor-patient relationship. We need to view it as a tool meant to solve a certain constellation of problems for a certain kind of person. But as we all know, there is no one tool  to solve every problem. And we also need to stop assuming that everyone has a relationship with a primary care doctor. Our data here at Sherpaa suggests that only 10% of the working age population does. And we also need to stop saying that everyone needs a relationship with a primary care doctor. Not everybody does. Anything that’s threatening to the concept of the old-fashioned doctor-patient relationship doesn’t need to be feared. A relationship with a singular doctor is a wonderful tool to solve a certain subset of health problems for a certain type of person. Not everyone has that subset of problems. Marcus Welby was a wonderful invention for a certain time when things were less complicated and less mobile. Times have changed and he’s no longer the perfect tool for every single healthcare problem.

Another reason for the medical community’s initial resistance to anesthesia was that it threatened to upset what had always been considered “normal” surgical procedures. Surgery was traditionally performed on a conscious patient, one who was able to communicate and express pain to his or her surgeon. Surgeons and doctors would use their patients’ reactions—either by asking them questions or listening carefully to their wails and cries—to help guide their surgeries. Removing this element from the act of surgery seemed strange and unnatural to some—like removing one of their senses.

Mütter was dismayed that something he considered a gift from God could be seen as an evil by his peers and contemporaries. The strong feelings against the use of anesthesia went much deeper than just a gentleman’s disagreement about its use. Institutions began to take public stances against it. The board of Philadelphia’s Pennsylvania Hospital—the main hospital with which Jefferson Medical College had a working relationship—successfully voted to ban all use of the surgical anesthesia for seven years. Even worse for Mütter, one of anesthesia’s most outspoken critics would emerge among his own faculty: Charles D. Meigs.

Change is glacial in healthcare. Anything new always, always meets resistance. To learn more about this, please read the biography of Thomas Mütter, Dr. Mutter’s Medical Marvels, which includes that passage. It’s one of my favorite books of all time. Mütter was one of the fathers of modern medicine. Simply a fascinating man, mostly for his desire to push the profession forward while being known as one of the great medical lecturers of all time. 

I’ve seen this resistance firsthand multiple times. Since 2007, I’ve been doing everything I can to update how doctors and patients communicate. I spoke about this many years ago in this TED talk. In 2016 the resistance has lightened, but it surely hasn’t stopped. Persistence and rational, vocal arguments builds coalitions. But it takes time. Hang in there everyone. While slow, we’re building something far better. Please don’t forget that.