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Cash-only Physician?

A Virginia family physician has established a cash-only practice model based largely on electronic patient interactions.

By Mike Norbut, AMNews staff. Oct. 20, 2003.

Unlike the typical physician starting a new practice, Alan Dappen, MD, likes to see an empty waiting room and only a few appointments on his schedule. As long as his telephone keeps ringing, the family physician is happy.

Dr. Dappen has created a practice model based almost entirely on telephone and e-mail contact, and he touts it as the future of health care. After scheduling an initial office visit with new patients, he runs his practice like he's perpetually on call, stressing to patients the convenience of a phone call as an alternative to a potentially long wait for a routine exam.

It may sound like a revolutionary idea, but Dr. Dappen, based in Vienna, Va., near Washington, D.C., calls it "the standard of care that's been around forever." The practice developed not only out of his frustration with managed care, but also his feeling that the need to physically examine each patient is quickly becoming an anomaly.

"The notion that you have to see every cough that walks in the door because it may be pulmonary edema or tuberculosis -- give me a break," Dr. Dappen said.

Dr. Dappen's practice also puts the spotlight on a notion that is gaining momentum in organized medicine: paying physicians for health-related communication, either over the phone or Internet. AMA policy states physicians should be compensated for telephone and e-mail services provided to established patients, and it calls on the Centers for Medicare & Medicaid Services and other payers to recognize this communication as a separate billable service.

The American College of Physicians recently published policy papers also recommending physicians should be reimbursed for their time spent communicating in these ways. The American Academy of Family Physicians has assembled a task force to tackle this issue, with an initial meeting scheduled for this month.

Questions about how far to take the idea still linger, however, especially when it pertains to prescribing medication based on a fairly unknown patient's description.

"There has to be a knowledge of the doctor-patient relationship to pull something like this off, and it has to come from multiple interactions," said Jim Martin, MD, a family physician in San Antonio and board chair of the AAFP. "It concerns me to push in that direction because patients don't always pick up on what's wrong with them."

AMA policy requires physicians to have an initial face-to-face encounter with a patient before caring for them at a distance, said Michael S. Goldrich, MD, chair of the AMA Council on Ethical and Judicial Affairs. There are other guidelines depending on the specialty and the type of encounter, but they largely rely on a physician's judgment, he said.

"Some things can be delivered at a distance," Dr. Goldrich said.

Dr. Dappen said his practice is no different from what he did for years as part of a large group, when he would cover night and weekend calls for his partners and treat patients whom he had never met over the phone. Even his liability insurance premium is about what it was when he was with his former practice, he said.

Patient interactions

His practice, Doctokr (pronounced "Doc Talker") Family Medicine is an example of boutique medicine meeting telemedicine meeting a cash-only practice. Patients who call can often get right through to him, regardless of the time, and he touts his model as offering convenience and efficiency at a fraction of the price of a typical office visit.

When patients call, Dr. Dappen can access their medical records electronically from his desk, and he calls in prescriptions or schedules lab work and x-rays as needed. If there are issues he's not comfortable working through over the phone, he will suggest the patient visit his office. He also makes house calls, if necessary.

Dr. Dappen charges $20 for a five-minute block spent on the phone and $25 if that time is spent in the office. However, he reduces his fees -- $15 for a five-minute phone visit, $22 in person -- if the patient sets up a prepaid account that allows Dr. Dappen to withdraw funds as services are provided. He said he doesn't charge for time spent doing the "back-end work," like faxing information or ordering a test after the conversation is completed.

Dr. Dappen does not accept insurance, but he does provide out-of-network forms for PPO patients, which they can use to apply for reimbursement on their own.

He estimates he needs to converse with or see eight or nine patients a day to break even and about 20 to "make a good living." He currently has about 300 registered patients, and each day receives five or six calls and sees a patient or two.

"I'm a full-service practice," he said. "I'm not like MyDoc.com."

MyDoc, the Roche-owned online consultation company, ran into regulatory troubles in Illinois for examining and treating patients without face-to-face contact.

But Dr. Dappen said he has established relationships and limits his practice to local patients.

His idea for the model dates back to his days as a partner with his former practice, where he said he started to consider the inefficiency of bringing HMO patients into the office. During a two-week informal study of his own interactions with patients, he discovered the longest extended physical examination he performed was five minutes, while some conversations ran 30 or 40 minutes in length.

"He always liked to use the phone and e-mail with his patients," said Jim Jenkins, MD, a partner with Vienna Family Medicine, Dr. Dappen's old practice. "Alan's always been a little adventuresome."

Dr. Jenkins said his colleague's idea generated interest to a point, and it also contributed to the practice developing a Web site and providing e-mail access to patients. Unlike at Doctokr, however, e-mails sent to Vienna Family Medicine do not go directly to a physician.

Evolution of telemedicine

Technology is certainly enhancing the physician-patient relationship, but telemedicine is not an all-or-nothing phenomenon, said Joseph C. Kvedar, MD, director of telemedicine for Partners HealthCare System in Boston, vice chair of the dermatology department at Harvard University Medical School, Boston, and president elect of the Washington, D.C.-based American Telemedicine Assn.

The sicker a patient is, the more likely he or she will want face-to-face contact with a physician, he said. On the other hand, as technology improves and home monitoring becomes more of a reality, the physical exam won't be as necessary, and a typical algorithmic approach to diagnosing will be effective regardless of the location, he said.

"The doctor doing this has to be comfortable knowing what he doesn't know," Dr. Kvedar said. "[But] for describing what a sore throat feels like, I'd be hard pressed to see why you need to do that in the office."

While Dr. Dappen believes his idea may help solve the current crisis in health care, the fact insurance companies won't cover the services may make it difficult for the idea to gain mainstream acceptance, physicians and consultants said.

The practice is a variation of the boutique medicine idea, in that it serves a small population willing to spend a little extra for more convenience, said Fran LaVallette, president of Healthcare Facilitators, a consulting firm based in Ocoee, Fla.

"It's a novel idea in the way he's approaching it," LaVallette said. "But I think it's a niche. For people with chronic issues, it doesn't play real well."

Dr. Dappen admits he has not heard from other physicians interested in copying his model, and he is still trying to discern what patient group is most receptive to his marketing efforts. Building his own practice is one thing; however, spreading his model is another.

"This model will not grow unless I can show doctors they can make a living at it," he said.


How the practice works

Doctokr Family Medicine is Alan Dappen, MD, and a nurse. When Dr. Dappen receives a call from a new patient, he first schedules an office visit to establish a relationship. Subsequently, patients either call or send e-mail. Most problems are resolved that way, but if Dr. Dappen isn't sure what the patient is describing, he schedules an office visit. He also makes referrals and schedules lab tests or x-rays as needed.

The fee breakdown:


Plan A
(prepaid account)  

Plan B
(pay as you go)

Phone calls and e-consults
   (per 5-minute increments)



Office visits (per 5 minutes)



New patient office visit



Medication refills (up to 5 meds)



Source: Doctokr Family Medicine

Growing trend

The idea of physicians being reimbursed for telephone and e-mail communication with patients is gaining momentum in organized medicine.

  • AMA policy states physicians should be compensated for services provided to established patients with whom they have had face-to-face contact "whether the current consultation service is rendered by telephone, fax, electronic mail or other form of communication." The policy also calls on the Centers for Medicare & Medicaid Services and other payers to recognize this communication as a separate billable service.
  • The American College of Physicians recently published policy papers recommending physicians receive reimbursement for telephone and e-mail communication and that insurers work with the physician community "to develop guidelines on reimbursement of health-related communications, consultations, and other appropriate services" via telephone and Internet.
  • The American Academy of Family Physicians has assembled a task force of physicians, insurers, and large employers to examine reimbursing physicians for this type of communication.


Copyright 2003 American Medical Association. All rights reserved.

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