Flashback in Medical Economics

25 years ago: March, 1976

"My patients take their medical records with them." Under that matter-of-fact headline, Hugh Schade described an eyebrow-lifting innovation at his San Jose, CA, clinic.

The family practitioner made each patient custodian of his or her complete chart. It was up to the patient to bring the records for appointments with Schade, take them along for visits to consultants or emergency rooms, and assure their safekeeping at all times. In his office files, Schade maintained only a streamlined, problem-oriented record for each patient.

Schade acknowledged most physicians' resistance to his approach. "If you think like I used to," he wrote, "you'd never give a patient his medical record to keep. After all, what if he loses it? What if something in it frightens him unnecessarily? Or what if an entry proves so disturbing that it triggers a malpractice claim? Well, I tackled those 'what ifs' head-on, and believe me, they're exaggerated."

The benefits of his system far outweighed the risks, he insisted. "The patient becomes more aware of his medical needs, and more conscientious about following treatment orders, taking medication, and keeping appointments for follow-up care." Among the specific advantages he claimed:

• Records were immediately available in emergencies. Schade recommended carrying the chart, packed in a sturdy case, in the patient's car trunk.

• When the patient visited a consultant, that doctor could check the record and see exactly what test or treatment was appropriate.

• Patients became better informed. "Though most people want the details about their medical problems," Schade noted, "they often get the feeling doctors don't want to tell them. But my patients can find out by reading their own records."

• Giving the patient the chart actually reduced malpractice risk, Schade contended. "Suppose a patient does think about suing me," he explained. "The attorney will say, 'Let's subpoena the medical record.' Then the patient will say, 'We don't have to—Dr. Schade gave it to me.' I think that news is going to shake the lawyer; he'll know I have nothing to hide."

Schade presented a strong case for his unorthodox system. But persuading fellow physicians and others was a tough task. "Keeping a double entry of financial records takes enough time," one skeptical practitioner commented after reading an advance draft of the article. "But Dr. Schade calls for a double entry of medical records. He will either fall behind or make inadequate entries."

A malpractice defense attorney challenged the idea that letting patients keep their records would discourage liability claims. "If a reputable lawyer thinks a patient's complaint is valid, he's not going to be deterred because the doctor demonstrated he had nothing to hide by giving the patient his medical record."

Schade stuck to his guns, though. "One day, I'm convinced the government is going to require that all medical records be readily transferable among doctors," he noted. "Until the Big Computer comes along, the best way to transmit medical information will be through our patients' own hands."

50 years ago: March, 1951

The doctors of Walnut Creek, CA, had a communications problem: Their offices, and their patients, were scattered throughout a rural area. And telephones were few and far between there. All too often, a doctor who was needed in one location was on the way to another, and out of touch for a long period.

Two-way car radios seemed an obvious solution. But it was an expensive one, as well. Besides the unit in the car, a transmitter would cost each doctor the better part of a thousand dollars. Then one of the physicians had a flash: Why not pool their money to buy a transmitter they could all use?

Each one shelled out $400 for a radio, and $70 for a share of the transmitter. Upkeep of the transmitter—$3 to $5 per month apiece—was the only other outlay. The answering service they all used said it would run the transmitter for free.

The system paid off promptly, for all concerned. The answering service operator no longer had to make four or five calls to track down a doctor visiting patients in the countryside. One call on the radio usually did the trick. If the doctor didn't respond, and the message didn't involve an emergency, the operator simply waited for the roving physician to check in.

But the real advantage came when an emergency did occur. The operator put out a call for help, and the traveling doctor nearest the scene, or the one best qualified to handle the situation, responded immediately. If the doc got lost, the radio could bring directions. Or if the patient needed an ambulance, one could be paged quickly. And not a few of the physicians were able to have a tow truck dispatched when their cars broke down on lonely roads.

Within months, the car-radio network was such a success that 30 more of the Walnut Creek physicians signed on. They knew a great idea when they saw it in action.

75 years ago: March, 1926

Writer Dirk P. DeYoung stationed himself in a hallway at a New York City convention hotel where doctors were getting the latest word on various medical concerns. As the physicians moved between sessions on clinical topics, De Young buttonholed 33 of them at random, and asked a nonclinical question: "How do you get your patients to pay their bills?"

Twenty-four relied simply on regular statements in the mail, but admitted that sometimes those bills were ignored for months—or even permanently. The nine doctors who'd given up on the US Mail as their lone collection tool reported success with more active approaches. One had gone so far as to discount his fees by 2 percent for patients who settled with him promptly.

He'd made the move reluctantly, fearing that some patients might find it unprofessional and go elsewhere for care. "[Offering a discount] didn't seem quite dignified," the doctor confessed. "On the other hand, I told myself it was just as dignified as to have to go to the bank and get a loan to tide me over until someone made up his mind that it was time to pay me."

He needn't have worried. The markdown loosed a flood of income where before there'd been a trickle. Bills went out the first of the month, with the discount offer included. "By the tenth of the month, I average an 85 percent collection, sometimes more," the doctor reported.

Five others interviewed by DeYoung were city practitioners who'd learned the folly of extending any credit to individuals they treated for the first time. "Except with patients whom I personally know," said a Manhattan physician, "I get my fee on the spot. If it is a hospital case, my bill is paid before the patient leaves, just as the hospital bill must be."

Two other physicians had taken themselves out of the collection loop entirely; they relied on their secretaries to get payment before the patient left the office. It worked—most of the time.

"It remained for a quiet, grayhaired surgeon from South Carolina to set forth the most astounding method," DeYoung wrote. "He makes collections on a gratitude basis."

When the doctor had rendered his care and the patient asked the cost, the surgeon would reply: "What do you think my services were worth to you?"

"You'd be surprised what comes of that," the doctor continued. "I'm not worth a great deal to some, and to others it is far more than I ever had any notion of."

In a business sense, the good doctor's method was questionable at best, DeYoung concluded. "Yet perhaps he is the shrewdest of all. It is likely that this quiet surgeon from the South is ahead of the game financially."

Well . . . maybe.

James D. Hendricks
Executive Editor

 

James Hendricks. Flashback in Medical Economics. Medical Economics 2001;6:131.