Another message from Dr. Lawrence Afrin:
Thursday, July 20, 2017
“It has been brought to my attention that there has been much misinterpretation of my July 11 announcement. There are several issues and misperceptions I would like to address.
(1) My #1 goal my entire professional life has been to provide my patients the best care possible. Mast cell disease is inherently a complex multisystem disease. Such patients inescapably come to need the services of a wide array of specialties. Mast cell activation syndrome (MCAS), in particular, is a newly recognized disease, and thus it’s quite understandable that most health care professionals across the range of specialties remain unaware of its existence, let alone its prevalence or significance. As I have previously stated, the University of Minnesota is a fine institution which obviously has world-class expertise in a number of areas, but I have come to realize that delivery of “the best care possible” for my many MCAS patients requires an alternative setting, staffed with multiple professionals experienced with the disease and providing more flexibility. I am confident I can better achieve my #1 goal in such a setting.
(2) As many reading this message can personally attest, it is quite an understatement to say that finding professionals experienced with mast cell disease is challenging. Even just a few years ago, the institute I now seek to participate in developing could not have been formed. Over time, though, more professionals have been coming to understand what I myself first began coming to understand only a decade ago, and though such professionals still remain few and far between, there now are enough to make it feasible to form an institute where better care – and research and education – in this area can be provided and conducted.
(3) In developing this transition I am now undertaking, I considered a number of settings, each with unique advantages, and I considered a number of collaborators, all familiar with mast cell disease and all outstanding physicians with whom I will continue to collaborate. My reasons are many, both professional and personal, for choosing to collaborate with Dr. Dempsey in developing an independent institute addressing mast cell and other multisystem diseases. One important reason is that Dr. Dempsey has always been an internist par excellence, and it is a huge credit to her that when she founded her practice, she specifically took on the great challenge of primarily helping patients with ill-defined chronic illness. Few physicians, of course, head down such a road, and Dr. Dempsey should be congratulated for her patient-centered dedication. Furthermore, a physician should engage in life-long learning and adaptation, and just as my approach to challenging patients has evolved over time, so has Dr. Dempsey’s. It is another huge credit to Dr. Dempsey that soon after she first became aware of MCAS, she was able to see the significance and prevalence of the disease in her own patient population. In magnetics, opposites attract, but in human relationships, like attracts like, and Dr. Dempsey’s “pivot” in a short time to a full embrace of MCAS – together with her distinguishing willingness to take on the disease’s challenges, plus her demonstrated rigor in assessing such patients to be sure nothing else was being missed – was obviously similar to my own professional course and approach. This professional attraction was natural and mutual, and we now are greatly looking forward to working with one another to better achieve our shared #1 goal of providing our patients the best care possible while at the same time advancing this arcane but important field through research and education.
(4) Because they are easily accountable factors, the current health insurance system compensates professionals for the number of patients they see and the number of procedures they perform; the system gives little consideration to what benefit is gained by the patient from the encounter, let alone the time spent by physicians. There are only so many hours in each day, and the more time that is spent with one patient, the fewer patients the physician can see and the fewer procedures the physician can perform. Most physicians choose to see many patients and/or perform many procedures, and that is fine. Other physicians choose to see fewer patients and to spend the time needed to consider their full complexity – but the time this minority of physicians spends seeing fewer patients is no less valuable than the time the majority of physicians spends attending to greater numbers of patients. Therefore, since the present insurance system by and large does not compensate for a physician’s time, physicians who spend more time with fewer, more complex patients simply cannot operate within that system. Dempsey astutely recognized this fact of physician life when she opened her practice. I, on the other hand, have spent my career to date at institutions which participate in the insurance system and which thus obligated me to similarly participate. As such, for a decade now I have been spending extraordinary amounts of unreimbursed time taking care of extraordinarily complex MCAS patients who have come to comprise more than 90% of my patient population (a similar percentage as Dr. Dempsey now recognizes in her population). While it may be possible for a large institution, desirous of a broad range of expertise and with many income sources available, to accommodate an occasional physician in this type of time-based practice and still compensate that physician comparably to its other physicians, it’s a fundamentally untenable situation in a small organization. A physician’s time should always be appropriately compensated, and in a small organization, if insurance cannot provide that compensation, then the patient is the only other – and certainly the most appropriate – source. It is worth noting, too, that the fees which will be charged for my time in the future will be similar to what the University of Minnesota has charged for my time in the past. The University of Minnesota, however, has consistently been reimbursed by insurers far less than how the institution has actually valued my time (as reflected in its charges), a situation which, again, is untenable in a small organization.
Please note, too, that charges for a new patient’s first two encounters at our practice focusing on complex multisystem diseases must be substantially greater than for follow-up encounters because of the substantially greater amounts of time spent in those first two encounters in thoroughly reviewing records (sometimes amounting to hundreds or even literally thousands of pages), taking a comprehensive history, performing a full physical examination, discussing complex diagnostic issues at the first visit and complex therapeutic issues at the second visit, and writing comprehensive diagnostic and therapeutic reports and engaging in other communication as needed. Those who choose to question the propriety of the charges should consider carefully that the total amount of the physician’s time typically spent on each of these first two encounters, including time spent face-to-face with the patient as well as time spent before and after the face-to-face time, is 4-6 hours (and sometimes even much more than that), and the total amount of the physician’s time typically spent on each follow-up encounter is 1.5-3 hours. This is the investment of time which Dr. Dempsey and I have learned is required to provide optimal care for the diseases we address. If one does the math, one will quickly realize the propriety of the charges. Support staff time invested before, during, and after each encounter often is significant, too. The money to cover all of this expert physician and support staff time has to come from somewhere – and it’s clear that the current insurance system is not that “somewhere.”
A final point of clarification on charging issues: patients who have already seen me will continue to be considered follow-up patients, i.e., their initial encounter with me in the new practice setting will not be considered a “new patient” encounter.
(5) It goes without saying that no physician is capable of seeing, let alone is obligated to see, every patient who may want to consult with that physician. It is a fact of life encountered by everyone at some point that, for a variety of reasons, we can see some physicians and not see others. There have long been many patients who have not been able to see me for various reasons, and that will continue to be the case. However, I feel I should note that included in the huge extent of uncompensated time I have provided MCAS patients over the last decade is a very large block of time I have spent dialoguing with other physicians to help them better understand the disease and thus better serve their own patients. I have always provided such service as a professional courtesy and have never asked for a dime of compensation – many patients even can attest I have refused their offers of compensation for my time spent in dialogue with their physicians – and I will continue acting in this manner for the rest of my career. (I should note here that Dr. Dempsey, too, has always provided similar professional courtesy.) As such, patients with suspected or proven MCAS who cannot see me for one reason or another, but who have found local physicians who are willing to try to help but are unsure how to proceed, are welcome to encourage those physicians to contact me (or Dr. Dempsey!), and I (we!) will remain delighted to engage in those contacts. Like all other physicians, Dr. Dempsey and I won’t be able to see every patient who wants to see us, but Dr. Dempsey and I will be happy to try to help, via direct physician-to-physician dialogue, every patient who wants our help.
(6) Finally, with regard to the grossly incorrect inferences some have made about Dr. Dempsey’s current practice based on information at her practice’s original website, armonkmed.com, I will note again that the website of the institute – where Dr. Dempsey and I will take our practice – is being built. Meanwhile, the technology at the seven-year-old armonkmed.com website is such that the site’s content cannot be significantly updated (such as to describe Dr. Dempsey’s current practice), and this is why I specifically noted in my July 11 announcement that (A) the armonkmed.com website is serving for office contact information only while the new institute’s website is being built and (B) current information about Dr. Dempsey’s practice is available at drtaniadempsey.com and facebook.com/taniadempseymd. Again, other than office contact information, armonkmed.com contains no information about Dr. Dempsey’s current practice. Anybody wanting to know how Dr. Dempsey was best trying to serve her complex patients seven years ago when armonkmed.com was initially built can look at that site – and then can look at drtaniadempsey.com and congratulate Dr. Dempsey on achieving insights I have seen come to few physicians. I regret any confusion created by the obsolete information about Dr. Dempsey’s practice on armonkmed.com, but I did take care to note in my July 11 announcement that the site is now providing office contact information only while the institute’s website is being constructed. This confusion will naturally resolve, of course, when the institute and its website open and armonkmed.com is removed from service altogether.
I can only hope it is obvious that it is always a very difficult decision for any physician to leave any practice, if for no other reason than the physician’s regret for the challenges created for the physician’s existing and pending patients. It was a difficult decision for me to leave MUSC, and it is at least as difficult a decision for me to leave UMN, yet leave I must if I want to achieve the most I can in this area – the best care I can provide, the best research I can conduct, the best education I can provide – before my working days are over. There are different pluses and minuses to each imaginable setting for doing this work, but Dr. Dempsey and I believe the independent Institute we will create will provide the most pluses and fewest minuses possible. (As just one example, the insurance-based compensation system has long precluded my offering the telemedicine services much requested of me, and release of those handcuffs is one of the points of flexibility I will gain as a result of this transition. Dr. Dempsey, never handcuffed in this fashion in the first place, has long provided such services, and I am happy to finally be able to follow in her pioneering footsteps – but please do not call yet for telemedicine appointments with me. There are many details which must be worked out first, and more information will be made available at the appropriate times.)
In closing, I want to again emphasize that we may not be able to see every patient who wants to see us, but we remain as committed as we always have been to trying to help, in the manners possible, every patient who wants our help, and we expect that our efforts at education and research will result in the best overall gains possible in care and health for all patients. To the best of our knowledge, an Institute of the sort Dr. Dempsey and I seek to build has never been built before. There is no example for us to copy or learn from. Along the way there may be missteps, which we will do our best to recognize and correct as quickly and effectively as possible. (Suggestions which are thoughtful, polite, and constructive will always be welcome.) Whatever course the road ahead takes, though, we thank you for your ongoing respect of our ongoing efforts to do our best on behalf of all patients, and we thank you very much for your understanding and your patience as we work through this complex transition.”