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Exclusively online practice?

  • 1.  Exclusively online practice?

    This message was posted by a user wishing to remain anonymous
    Posted 27 days ago
    This message was posted by a user wishing to remain anonymous

    Hi!
    I am wondering if it is possible to have a medical practice with focus on preventative medicine without actually seeing patients face to face?
    I am an IM physician licensed in New York and as far as I can tell from reading the regulatory documentation, there is nothing prohibiting this kind of practice.
    Putting up a website and using the doxy.me for visits should not be that hard. Getting patients is the difficult part, I was thinking about FB and Google ads. Overall, I am rather tech savvy, so setting up the site or the ads would not be a problem. But I know nothing about actually running a practice.
    Of cause, one could just do the telehealth for one of the big online urgent care companies, if online practice is desired. But I really don't want to turn into a Z-pack prescribing machine and I know preventative medicine is what I enjoy most. So trying to figure out a way to still practice preventative care without actually having face to face patient encounters.

    Also, if there are other states in which this practice set up is easier to run, I am willing to license elsewhere.


  • 2.  RE: Exclusively online practice?

    Posted 26 days ago
    why would anyone  want to do this? It is not good medicine
     the first rule  is take a good hx and the second do a good exam
    How you   gonna do those pap smears??

    ------------------------------
    Jean Antonucci
    ------------------------------



  • 3.  RE: Exclusively online practice?

    Posted 25 days ago

    Broadly speaking, yes I think a telemedicine practice could function (successfully) in lots of different ways.

     

    Knowing that you can't offer the same things that an office based practice can – you can make up for it in other ways that are valuable to patients.

     

    Telemedicine is great for:

    • Mental health where people are anxious about going to the doctor to discuss their anxiety
    • Addiction treatments where patients are too scared / proud / restricted to visit a local addiction treatment place
    • Offering help with wholesale labs (not available in NY but in nearly every other state)
    • Offering help with wholesale meds (not available in NY, but yes in 44 other states
    • Acute care
    • Second opinions etc
    • Specialty care on certain conditions (dementia, etc)
    • Weight loss counseling – again many patients too timid to regularly go to a public location

     

    Preventative health might be harder, b/c people don't always value that – so I wouldn't build the value proposition entirely around this, but make it one of many options.  Paint a very broad brush of value to attract the most consumers at the best price.

     

    Thoughts?

    Thanks

    Josh

    C 316.734.8096

    drjosh@atlas.md






  • 4.  RE: Exclusively online practice?

    Posted 25 days ago
    In Maine  the board requires a relationship with patients for tele medicine  Meaning you have to have seen  t hem
      I have done  evisits for 10+ yrs, worked for teledoc for awhile and  do suboxone x 3 yrs

     Telehealth has a role but exclusive care of patients  is not appropriate
     Certainly not drug addicts
    mental health yes but  you a re a PCP ? not a psychiatrist
    How will you know if their bps readings are accurate?
    How can  you do fobt cards eh?:)  refer for a colonoscopy?
     things to think about

    If you do not  want to  see actually human beings and oh there  are many  days I don;t :)   why did you go to med school- seriously what are your goals? do you need limited hrs   Exploring how far you can push telehealth?

    If they have insurance prev care is free why would they pay you to order and explain a lipid panel

     
    Check with your state requirements and decide what kind of doctor you want  to be
    edgy/ fluff  / guaranteed hrs etc
       if you do not do certain things then who else does the patietn have to have/ they will pay double for you ?ANd insurance?? I have only one payor who covers e visits though I admit I do not  grasp the new medicare rules But exclusive tele health  is for acute care, pschy counseling( this has been GREAT  here in rural  no wheresville) maybe a few other things  but  you cannot really be the patients' doctor And that means it is hard for the patietns and  to be blunt you dump on your colleagues- you take the low hanigng  fruit of uti's and I get the  complex stuff? 
    I just this week had to repair the damage form a patietn who called cigna- she has  to only pay 10.00-- and reports the  guy having his kids  yelling  in the background  and  she said one sentence  and he said you have BV ( egads he got it right but really WITH NO EXAM?? and he gave her flagyl with ho information She was sick as a dog for a week then came into see me  becasue she also had a uti and some other details
     let us know but tread carefully

    --



         Jean Antonucci MD
         115 Mt Blue Circle
         Farmington ME 04938
    ph 207 778 3313   fax 207 778 3544
    www.jeanantonucci.com





  • 5.  RE: Exclusively online practice?

    Posted 25 days ago

    Jean:

     

    1. You're in Maine, but the doc is asking about NY

                                                                   i.      https://imlcc.org/ telemedicine

    1. "telehealth is not appropriate for exclusive care" – that is just your opinion
      1. Other docs are welcome to their own opinions
    2. Most PCPs do a LOT of mental health
      1. And more affordable and/or more accessible mental health from a PCP (vs a Psychiatrist) is better than no mental health at all.
    3. Blood pressure readings – dozens of options for connecting directly with smart blood pressure cuffs, scales, glucometers etc.
    4. FOBT cards – you can mail patients FOBT kits and they can mail them back (very common)
      1. Referral for colonoscopy – is a fax

                                                                   i.      Or better yet, discuss Cologuard options with patients – and then send a fax

    1. It is not your position to question the physician's reasons for going to medical school just b/c you disagree with their QUESTION about telehealth
      1. their goals could be less burnout, more family time, helping patients that the system isn't currently helping, increasing access to care, decreasing costs to care – all valid goals
      2. nothing wrong with exploring the opportunities of telemedicine
    2. Lipids –
      1. not all patients have insurance,
      2. not all insurance makes preventative health easy
      3. the wholesale cost of a lipid panel is $4
    3. Check with your state
      1. Yep, no one is saying ignore state laws
    4. What kind of doctor they want to be is up to them – not up to you
      1. No one mentioned "edgy stuff"
      2. No one mentioned guaranteed hours – as if there would be something wrong with docs wanting a work/life balance
    5. Double pay – again, this is up to the patient and the physician
      1. Uninsured patients wouldn't be "double paying" and might really value a telemedicine option
      2. Insured patients might not be able to access their doc b/c of location / work / traffic etc
      3. Insured patients might have high out of pocket costs

                                                                   i.      A transparent fee for service might be desirable to them

                                                                 ii.      A transparent monthly membership fee might save more time/travel/hassle/copay

      1. Uninsured and Insured patients might highly value a doc that takes TIME with them
      2. Uninsured and Insured patients might value a doc that helps them find $$$ savings on meds/labs
      3. Uninsured and Insured patients might value a doc that they can keep regardless of job changes and ins changes
    1. "can not really be the patients doctor" or 'you'll take the low hanging fruit" or "dump on your colleagues"
      1. Again your opinion
      2. Don't be a bully
    2. Jean will get stuck with the complex stuff...?
      1. So you're worried that this docs freedom might hurt your practice?

     

    We can agree to disagree on some issues.  We can have fair and civil discussions.  But we shouldn't shame a doc for looking for solutions.  Which is probably why they felt the need to ask the question anonymously.






  • 6.  RE: Exclusively online practice?

    Posted 24 days ago
    Dear Anonymous
      I hope you see that when i write my opinion it is ,ah, my opinion :)lol
    ASKING people why they want to do something might engender an answer   "I was thinking  xyz ... I  like edgy stuff     I want  to  see if I can      I  need steady hrs"
    I get the part about being a zpak  prescriber   Having worked for teledoc  it was BAD if you did not prescribe Patients got angry alot   not all     I also saw people who desperately needed to be seen- listen to lungs asthma copd  folks. It was heartbreaking to  decide  how to help
    Something to think about.
     I have seen alot of people who do not know why they went to med school- I have watched them leave medicine or be unhappy so i ask because...  i was asking. if you think about that  it helps clarify  how you want to practice  but I bet you know that
    In medicine we call asking  motivational interviewing  Yeah sometimes email  comes off wrong/loses its nuance but you asked about  doing preventative medicine this way   Yes there are lots of techno  things to help you but why do you wan to do it    is still a good question?  Why?
      In Greece they called the questioning the Socratic method  Ah but he had to drink hemlock so I am hiring someone now  to taste my coffee
     And JOsh-  civil and fair  would not allow you to name call  "bully"
     Noone was shamed here except me.
    I see why one  would post anonymously Think I will try it

    Best of luck to  anonymous

    ------------------------------
    Jean Antonucci
    ------------------------------



  • 7.  RE: Exclusively online practice?

    Posted 24 days ago
    You questioned their quality as a physician and their motivations for patient care. It was rude and it was being a bully.

    I call them as I see them.







  • 8.  RE: Exclusively online practice?

    Posted 25 days ago
    I would not do it personally. How would you do a good cardio exam, feel for masses, get a good look at the skin, etc. Your exam would only be as good as a sensor, camera, or tool...or what your patient notices. I don't think biomedical engineers have anything as good as your own senses in a reasonable price point, if at all. If your exam is mostly conversational such as for psych it might work, but not the rest. I think that telemedicine is only good for follow ups where face-to-face isn't necessary or possible.

    --
    Andrea Freng, ARNP
    Pilchuck Primary Care, PLLC





  • 9.  RE: Exclusively online practice?

    Posted 25 days ago

    The idea isn't too be able to replace all of the physical things about medicine – the idea is to offer an alternative for when all of those things are necessarily required.

     

    Dermatologists do their board exams on pictures alone (not real patients).  A doc that is available to help a patient determine what is low / middle / high risk is still helpful.  Telemedicine may not be able to do the biopsy, but then again, a number of clinics would refer to derm for the biopsy.  

     

    PVCs are rarely caught on physical exam alone, but technology like https://ekohealth.com/ or https://alivecor.com/ open up interesting options for patients that don't have insurance or who have needs not being met by busy clinics.

     

    So then the doctor could design the model to take advantage of technology's strengths while identifying the weaknesses.

     

     

     






  • 10.  RE: Exclusively online practice?

    Posted 24 days ago
    There is a popular call in medical show on the radio in Albany and Hudson valley of NY.   Callers and listeners find it valuable.   I presume similar shows exist elsewhere.   So not sure why a doctor who wants to avoid insurance game, and have very set hours, could not do telemedicine consults.

    A few examples that could be done would be Preventative medicine, second opinions, interpreting lab tests, diabetic counseling, giving opinions on symptoms.

    I am not sure of the malpractice risk, state rules, if one has not established a more traditional doc-patient relationship with an initial F2F visit.  Nor would I swear it is financially viable.

    I think (to avoid the zpack issue, refill of prescriptions, etc) make it clear you are not prescribing meds, not replacing a primary MD, offering advise only.  Always advising they see their doctor to confirm your impression.

    It is not for me as an exclusive model of practice, but apart from the malpractice and legality issues, I dont see a down side and start up cost will be negligible except for marketing.

    BUT....
    why not add this to our traditional practices? (An epiphany moment?)  Maybe I should start offering telephone hours to my patients daily from 8-9am making it clear it is a non-covered service.  Then advise they need to come in if I feel it is warranted or they need a prescription that should not be offered on the phone.

    My gut tells me there may be a significant number of my patients who would pay $75 - 125 (depending on length / complexity) for telephone advise to not miss work or change other obligations.   Ater all, some copays are upto $50 and they have high deductibles, etc.  SInce I know my patients, my malpractice risk would be minimal.

    A local mega group charges $99, and they do give the zpak.

    Curious what others think about this.  (Not the Zpak)  This is why I love and support IMP.

    ------------------------------
    Michael S. MD
    ------------------------------



  • 11.  RE: Exclusively online practice?

    Posted 24 days ago
    I am aware that at least U. of Wis Health System offers these phone consults (with prescriptions) to established patients for $35, utilizing physician assistants at Urgent Care (where I used to work x 6 years - it was starting just as I was leaving).  They do have EPIC EMR so there is review of chart available.   If the phone conversation triggers concern the patient needs to be seen, the $35 is deducted from their Urgent Care or ED co-pay/bill.   

    Insurance Agencies now often these services with in-house providers (?not sure what level) for a similar fee level for their insured - basically becoming providers of medicine rather than just an insurance service.   I suspect this will increase as patients are "carrot and stick"-ed to just stop seeing their doctors and work with insurance providers directly. . . . and that brings up a whole other kettle of fish . . . 

    I'm old enough now to know that change is inevitable, and that there's probably good and bad in most every change, and could probably make an argument each way for this evolution . . . (some might say devolution).  Traditional medical school teaches 80% of diagnosis can be made on H&P, but that was long ago, and not sure the breakdown on H vs P but phone/computer visits can offer history, but not physical (though I have found smart phone pictures of rashes very helpful and possibly this will be available in such visits).

    I do know that sense of smell I find helpful on many urgent care diagnoses/vulnerabilities (Strep, BV, wounds, general wellbeing/grooming, substance abuse) and that is definitely lacking over V-tel, phone visits, e-consults, etc. . . . 

    Deborah Lathrop, MD







  • 12.  RE: Exclusively online practice?

    Posted 24 days ago
    Hi everybody. I am the original author of the post, and am using a guest account because the registration feature does not work for me for some reason, but anyway...

    First of all, thank you for all your opinions.

    It is absolutely reasonable to question what I want to accomplish with this model of practice, as this could, potentially change the advice you give me.
    So, here is a bit of a backstory. I am an IMG, but I did not practice in my country (didn't even do residency there), moved to US straight after med school, did IM residency and then practiced here for several years.

    I do mostly enjoy my current practice, although my favorite time was when I just started with the group I am with now, my patient volume was low and I was able to spend an hour with each patient going over their diet, fingerstick log, sleep hygiene, etc. Now I can't do it as much anymore, because the next patient is always waiting, but I try to do it as much as I can. That being said, I have not done a pap-smear since out of med school, I just refer to GYN for that. And all the other IM docs I know don't do them either. I rarely send FOBT, because it's either colonoscopy or cologuard most times. The accurate BP reading is a problem, but when I ask my patients to monitor their BP at home and get something unexpected, I ask them to bring their machine to the office or to the pharmacy to be verified.

    Now, to why I am looking to change my practice - in the past 3 months my family situation has changed significantly and I am expecting to have to move back to my country in the near future. I am not licensed to practice medicine there and the doctor's income there is so low that I am not sure it even makes sense to get licensed. I could be doing some non-clinical peri-medical remote work for US customers for income and, in case I get licensed, seeing patients in my country for enjoyment. But that is not an ideal situation in terms of time requirements.

    That is where an idea of preventative health telemedicine comes in. I would be happy to spend an hour or more of time with a patient going over their bloodwork results, diet, meds, etc. With labs available, I think I would be comfortable prescribing meds like Metformin or Synthroid. Not sure about BP meds and Chantix, etc, probably situational. As far as the steroids and antibiotics, I make a great effort not to write those that often in my everyday practice anyway. I mean, I obviously write them when needed, but when someone shows up with a cough from postnasal drip, I take the time to do my exam and reassure them and not give a Z-pack. And definitely no controlled substance prescribing online.

    Also, Josh, could you please elaborate on the wholesale labs/meds issue. I have never practiced anywhere but NY and have no idea how that works, but am willing to get licensed in other states if the situation requires.

    Once again, thank you all for your input!

    ------------------------------
    IMP Guest
    ------------------------------



  • 13.  RE: Exclusively online practice?

    Posted 24 days ago

    Hi Doc,

     

    Thanks for the additional information – all very interesting.

     

    I've always been curious how docs could do telemedicine to other countries – with the long wait lines in Canada, the UK, and the poor access in other countries, it seems like there are opportunities to help patients in new ways.

     

    Providing telemedicine to the US from another country seems very doable – the beauty of tech is that its not location dependent.

     

    If you did the telemedicine compact, you could be licensed in dozens of states so that you could serve a much wider audience which would help with growth and with finding market fit.

     

    Yes, I think there's lots of patients that don't enough time with their docs and could be interested in some dedicated time/answers/guidance (maybe one time, fee for service) but if they like that, they may also like a membership.  People have busy lives and the hassle of getting to the doctors office can actually make their conditions worse.

     

    Home blood pressure monitoring is supported by EBM - https://www.uptodate.com/contents/ambulatory-and-home-blood-pressure-monitoring-and-white-coat-hypertension-in-adults#H16 but you could always ask the patient to go to a fire station for a free blood pressure check to confirm their machines accuracy.

     

    I think most non-abuseable medicines are reasonable to prescribe as long as you have good access to them (email, call, text, video chat) and continuity.  I wouldn't start an SSRI on a pt I'm never going to see again, but if they have a membership for monthly access to me, then that's more access than most patients get from their doctors office.

     

    Easy to set boundaries before or at before enrollment about no controlled medicines and an evidence based antibiotic protocol.  I actually find most patients are pretty reasonable about antibiotics for colds if you give them time and help with their symptoms.

     

    Wholesale meds: https://www.dpcfrontier.com/dispensing-medications most states allow docs to purchase medications direct from the wholesalers just like pharmacies, and dispense them to their patients.  Some docs have seen this before as "3rd party packers" where the cost is grossly inflated.  But we can get 100 lisinopril 20mg for $1.99 or 1000 pills for $15.23.

     

    Here's a video: https://recordit.co/kY4WbAR7tX

     

    Wholesale labs: aka "client bill" pricing, you set up a contract with the lab company (quest, labcorp etc) for direct payment w/o no paperwork/approval/denial etc – in exchange for great pricing.  Locally a cbc is $1.50

     

    Here's a link to our wholesale med/labs/imaging prices - http://bit.ly/2JoVyJi Yep, getting licensed in other states would make it much easier.

     

    Thoughts?

    Josh

    C 316.734.8096

     






  • 14.  RE: Exclusively online practice?

    Posted 24 days ago
    Jay Parkinson MD, MPH - pioneer of using tech for the single doc hanging out a shingle. Please check out his Sherpaa website and online videos about an online-only primary care practice. I am working on organizing an online-only practice for myself and plan to go live at the first of the year. My husband's job is not local, so having a practice that is mobile would allow me to work from anywhere and to spend more time with him. I would love to hear from anyone else who is considering this option.

    ------------------------------
    Kathleen Summers
    Jacksonville IL
    480-238-2324
    ------------------------------



  • 15.  RE: Exclusively online practice?

    Posted 24 days ago

    Great example!

     

    Sherpaa actually was acquired by an employer clinic company, crossover health.  But the point still stands.

     

    We've helped over 500 docs start ins free practices.  Happy to help answer any questions.