A dozen hospitals in New Jersey have begun an experiment to see whether paying doctors differently can lead to better, more efficient care. If the "gainsharing" experiment with Medicare patients works, doctors and hospitals will share the financial rewards. Hospitals contend the current system's incentives are "misaligned" so that hospitals are rewarded for lowering costs, while doctors are not.

With prospects fading that the Senate will include a government-run insurance option in healthcare reform legislation, congressional Democrats and Republicans are sparring over a series of private regional cooperatives that advocates say could achieve the goals of a public plan without the potential for government interference. The key negotiators in the Senate are scheduled to meet by teleconference to discuss prospects for keeping a bipartisan health plan alive, which could hinge on the acceptability of co-ops to both sides.

With the debate over President Barack Obama's healthcare reform bill raging on Capitol Hill, some physicians are carving out their own path to reform that involves eliminating barriers to care and improving the doctor-patient relationship through the use of technology.

"The health system has been moving in the wrong direction," says Sean Khozin, MD, MPH. "People talk about healthcare reform, but no one is talking about what happens between a doctor and a patient. We have to pay much closer attention to the way that doctors and patients interact and transact and enhance that process because that's where care is delivered."

Khozin's futuristic Brooklyn, NY-based practice is unlike any other. It is powered by Hello Health, a secure, Web-based platform that includes a practice management system, an electronic medical records system, and a social networking tool that allows physicians to communicate with patients both online and face-to-face. Another Hello Health practice is scheduled to open in the West Village. Both practices serve as the beta testing grounds for the product, which was developed in collaboration with a Quebec-based technology company called Myca.

Creating improved access to care
According to Khozin, ER overcrowding doesn't happen because of the uninsured. It happens because patients can't access their primary care doctors when they need medical attention.

"Despite the fact that you have to wait at the emergency room for five hours, at least you get seen the same day," he says. "In my practice, you get an appointment the same day or within 48 hours."

After a patient establishes a relationship with a Hello Health doctor, he or she can use e-mail, video chat, instant messaging, or phone to reach their physician to ask questions, obtain test results, and to conduct other matters which would typically require an appointment in the office.

"We establish a relationship with a patient and we do a lot of the follow ups and care coordination online," says Khozin. "We cut down on the number of unnecessary visits while giving patients different channels of communication with their doctor."

Patients still have the option of scheduling an appointment if they have a problem that requires attention, but he has found that most of the time he can conduct patient follow up visits remotely.

While not all patients feel comfortable using technology to communicate with their physicians, Khozin says they learn over time and with his encouragement. He expects that more and more people will begin relying on technology to communicate with healthcare professionals.

While video-chatting with your physician may sound out of the ordinary now, Khozin predicts that it a few years it will be commonplace for a large segment of the population. In fact, today's young generation will more than likely expect this type of communication in the future because of the way that they have embraced technology and integrated it into their lives.

For example, the company is conscious of how popular smart phones have become. According to an April report by Manhattan Research, the number of physicians using smart phones more than doubled to 64% over the past year. In response to this growing trend, the company is in the process of developing applications for use on the Apple iPhone to address the needs of patients and physicians who want to communicate using smart phones.

"A smart, health IT company builds products for devices that people already have."

Khozin currently uses his iPhone to e-prescribe, review test results, e-mail, and graph and trend disease information for patients while they are in the office.

He says that with diabetes and heart disease on the rise, physicians need to engage patients and pull them into the process of care by allowing them to use online tools to better track their health and communicate information remotely.

For example, patients with diabetes would be able to submit their glucose levels online to Hello Health and have their physician monitor their results and respond to them if necessary—all without an office appointment.

"We can't rely on office visits alone anymore," he says. "Even if you have a chronic disease and you see your doctor four times a year, the rest of the time you're on your own. By connecting a doctor virtually with a patient, you can ensure continuity of care."

Building a Hello Health "ecosystem"
When physicians conduct an in-office or remote transaction with a patient, it automatically becomes part of that patient's electronic medical record in the Hello Health platform. The patient can view their medical record at any time. In addition, other physicians in the practice who see the patient and have access to the system can also view the same information.

The company plans to develop regional "ecosystems" on the Hello Health platform that will consist of a group of primary care doctors and specialists who can communicate with the patient and with one another in a patient-centered environment. Khozin says that specialists are beginning to participate in the Hello Health platform in New York and he expects similar ecosystems to be launched throughout the country.

"There's a lot of ways this technology can be implemented in terms of coordinating the care of complex patients, such as cancer patients," he says. "It's so difficult to really take care of these patients because of lack of access to the right information when you need it."

An elegant platform to replace Frankenstein systems
L. Gordon Moore, MD, a family medicine physician, has been waiting for a product like Hello Health to come along for quite some time. He is credited with pioneering the Ideal Medical Practice (IMP) philosophy. Physicians who subscribe to IMP concepts operate low-overhead, high-technology practices that provide patient-centered care that is efficient, effective, and accessible.

To run these types of practices, physicians often piece together many different pieces of technology to build a grassroots version of what Hello Health now offers. They pull together billing systems, appointment schedulers, and bare bones EMR applications to come up with a complete, albeit imperfect, package.

"Other docs have picked up this Frankenstein system, and it's hard," he says. "They're pouring money into IT to finesse this Holy Grail of interoperability, which is almost an illusion."

By comparison, Moore describes Hello Health as an "elegant platform." "It manages relationships like nothing I've ever seen," he says. "It's really the best IT solution that I've seen out there so far."

Moore is in the process of developing Hello Health University for the company. It will educate physicians who are about to launch their own practices using the platform. The tool will provide the physicians with assistance on everything creating a business, deciding whether to hire staff, and purchasing office space.

Cash-based practices
The company will offer the platform to physicians free of charge and collect a fee for each transaction.

"If physicians aren't seeing patients on the platform, they're not paying for anything," says Khozin. "If they see a patient and a transaction occurs, then a percentage of that goes to Myca/Hello Health."

The Brooklyn Hello Health office is operating a cash-based, concierge practice, since most insurers do not pay physicians for the phone, e-mail, video chat, or instant messaging services that they offer. A concierge practice allows patients to pay for this service themselves, and many patients are more than happy to do so for the added convenience of being able to access their healthcare provider. The Brooklyn practice does not accept insurance, but they will provide paperwork for patients who want to submit claims for reimbursement.

Moore says that Hello Health is one of the few venues where practices are able to completely cut loose of all the rules and impediments, allowing them to perform e-care when it makes sense because they don't need to worry about receiving reimbursement from an insurer.

Initially, Moore expressed concern that some patients may skimp on vaccines, tests, and the like if they participated in a cash-only practice. "There are a lot of people who think that if you care about healthcare, then you'll get out your wallet and pay for it," he says. "I don't think that applies to everyone."

His concern was assuaged when he learned that the platform allows physicians to determine their own price structure and payment policies. Even physicians who cater to vulnerable populations such as the uninsured, unemployed, or underserved can opt to charge as little as $25 per transaction.

"There are wonderful programs that are cash-based and accessible to a huge slot of the population," says Moore. "What I was initially interpreting as concierge, breaks open to a pretty full practice model. Those who can afford it can be a very large slot of the population depending on how you set up the pricing."

According to Moore, the company has plans to incorporate back-end billing into the platform in the future so that practices can use the platform to bill insurance companies.

A practice platform for physician "entrepreneurs"
According to Khozin, many physicians from across the country have contacted Hello Health to express an interest in using the platform for their practices. It has selected approximately 20 physicians to become part of their beta test.

"We're starting a process to educate and empower other doctors to start using the platform so they can lower their overhead and start practicing medicine in a more meaningful way," he says. "Right now, not only are patients unhappy, but a lot of doctors are unhappy. Their overhead is so high, they have to see 30 to 40 patients a day to stay afloat."

Khozin says if physicians can lower their overhead, cut down on the number of unnecessary visits, and conduct virtual visits instead, then they can have more meaningful interactions with patients and, as a result, operate a sustainable medical practice.

"They can lower their overhead, better communicate with patients, and generate more revenue," he says.

Physicians interested in the platform generally have an entrepreneurial spirit, says Khozin. The platform appeals to physicians who want to build stronger relationships with their patients to deliver effective care—something most physicians want but find difficult to achieve due to the administrative work they must complete to receive reimbursement from third parties.

"This allows a viable way of actually running a practice and making a living," says Khozin. "The traditional way has become very abrasive."

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Cynthia Johnson is the editor of Medicine On The 'Net, a monthly newsletter from HealthLeaders Media.

Is anyone else having trouble understanding why so many people seem so angry or at least nervous about "advance directives" provisions in the Energy and Commerce Committee's health reform proposal?

I read all 11 pages in section 1233 of "America's Affordable Health Choices Act," as well as all four pages of the amendment by Rep. Mike Ross of Arkansas.

Nowhere did I see anything about "killing Grandma," "euthanasia seeking death squads" or any mention of governments forcing beneficiaries to specify how they want to die. Nothing even comes close.

What is Sarah Palin talking about?

In fact, there it is in black and white: just the opposite. A qualified health benefit plan shall present "the option to establish advance directives and physician's orders for life sustaining treatment according to the laws of the State in which the individual resides."

It "shall not promote suicide, assisted suicide or the active hastening of death." Nor shall it "presume the withdrawal of treatment and shall include end-of-life planning information that includes options to maintain all or most medical interventions."

The language says in several different places that the advance directive process is entirely voluntary.

What I read was a reasonable effort to carve a way to encourage discussions about the end of life, so patients and their loved ones can have a cogent, calm conversation. In this way, they can express their wishes, fears and expectations, and do so long before the incapacities and indignities of the death process take that opportunity away.

The proposal would pay physicians a designated fee to launch these conversations, something that they don't get now. When they give such counsel or facilitate such discussions between family members and loved ones, they now do it for free, and therefore taking the necessary time may not be something that's high on their list of priorities. This would make it easier.

So I don't understand why so many Americans are so angry. Or why 50,000 to 60,000 AARP seniors angrily cancelled their memberships in AARP in the mistaken belief that the association favors a health reform bill that includes such death squads.

AARP spokesman Jordan McNerney acknowledged the extent of the outcry and what he called a disappointing number of resignations, and blamed it on "scare tactics on the part of opponents of health reform and people with a financial stake in keeping the system broken." The AARP is doing its best to dispel the myths with an ad campaign circulating in local media across the country, he says. And he thinks people will start seeing the truth.

But until they do, it seems to me that seniors especially would want to have a system in which their doctors are incentivized to help them have a frank conversation with their families and loved ones about their end of life care.

I certainly want my wishes known about how aggressively I would want to be treated if I could no longer walk, talk, think clearly or feed myself. Would I want to be kept alive if the choices were between being kept in a drug-induced delirium or having out-of-control pain? Absolutely not.

So I called Laurel Herbst, MD, an internist who has supervised the dying wishes and death processes for thousands of patients for the last 31 years. What does she think is going on? Why are so many people so upset about advance directives?

"It's superstition," she quickly replies. "Some people believe that if you talk about death, that will make it happen faster."

Herbst, vice president of the Institute for Palliative Medicine at San Diego Hospice, says that for the most part, families and spouses "don't like to talk about values. About what's most important to them. They don't communicate very well at all."

That's why this legislation is so important. It would establish a provision in law that sets up a process to nudge these conversations between caregivers, families and patients, conversations that aren't, for the most part, happening today.

Herbst surprised me by saying that today, because of a basic lack of communication, even advance directives that do exist don't work that well because they're often old, forgotten, lost, ignored or disputed.

"We don't believe that signing an advance directive works very well today, even for people who have them. Because people don't know about them, or the families don't agree with what the patient wanted," she says.

Sometimes, they're even ignored by the caregivers who want to keep treating the patients, because they don't want to be perceived as failing to save the patient.

What is important, she says, is for patients to have those conversations with loved ones and caregivers so everyone is on the same page about how aggressively providers should be to safeguard quality in those oh so very precious last moments of life. "They need to express what's important to them," whether it's to not be connected to machines, or to die at home.

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