Here’s a Story of a Broken System (To Tune of Brady Bunch Theme)

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Yesterday I saw a long time patient who is on Medicaid due to disability. He is a great kid that is legitimately on aid due to mental illness. He has not had the best hand of cards dealt to him, but has a loving grandmother who has raised him as her own. She pays me directly because she knows I have his back and she values the relationship I have built with him. They trust me to always do the right thing for him and their loyalty to me is very much appreciated.

So yesterday he called first thing in the AM with a complaint of 4 days of abdominal pain with no appetite and low grade fever. Now this guy is very stoic and not a complainer so I always know that something isn’t right if he is complaining. We got him right in and evaluated him. He had some point tenderness right over McBurney’s point (where your appendix is) and had a low grade fever. He needed a CAT scan to rule out an appendicitis which Meghann, my LPN, scheduled for noon at our local hospital. For those who do not understand direct care, even though I do not take payment from Medicaid, the hospital would just bill Medicaid for the CAT scan and lab work etc etc. If he did indeed have appendicitis we would get him seen by surgery and all of his care would be billed to Medicaid- essentially the taxpayers in MA.

Well it took no less than a 20 minute phone call to get this scheduled, after which Meghann is told that Medicaid will not “approve/authorize” the CT scan because I am not a “Medicaid provider.” Now some readers may think I’m the jerk for not contracting with Medicaid and your entitled to your opinion, but this patient has paid me to work for him. (Maybe after you finish reading this you will understand why I dropped out.)¬†Now we have a¬†patient who is sick, a¬†doctor that is trying to treat him expeditiously based on years of training, and indirectly you the taxpayer all at the mercy of insane, bureaucratic nonsense. My only choice was to have him go to the ER and be evaluated….again….by another physician in order to get a CAT scan of his abdomen (with contrast an abdominal CT is about 600-800 per the Healthcare Bluebook). So instead of just paying this amount, as his CT was fortunately negative, your state bureaucracy decided it would be better to add on the cost of an ER evaluation and 5 hour stay as well to the taxpayers bill.

Does this make any sense to anyone? If it does than maybe you took a different economics course than I did. So there is a story of a broken system that just cost you a few extra grand because the doctor was regulated. Wonder how the system worked when the Brady Bunch was on? Did Marcia need a “Prior Authorization” from an “in-network doctor” to have her nose looked at after she got smacked in the face with a football?

Off to Kansas City to the DPC Summit today to try to fix this mess and get people the care they deserve.

Having ACA Insurance Often Means Being “Underinsured”

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Add a Direct Primary Care doctor to this image and you have true high-value health care.

This post is in response to two excellent articles in the Ideas section of¬†The Boston Globe today by Mark Pothier and Betsy Cliff¬†Out-of-pocket Costs Put Healthcare Out of Reach¬†and¬†How Health Plans With High Deductibles Became the New Normal, respectively. Even more poignant¬†are the comments that follow the online articles which I also suggest you read. It is published on the heels of the Supreme Court voting this week to maintain the subsidies to people who enrolled in the ACA through federal exchanges rather than state-based. (I will not express my opinion on this here). The overall consensus¬†from these comments is that people are struggling to afford out-of-pocket health care expenses and have no idea how to shop as a consumer for affordable care. And this¬†is not their fault, as they haven’t had to be a wise consumer with the cadillac insurance plans that “covered all.” Well these plans have gone by the wayside and with the Cadillac Tax from the ACA ¬†coming to employers soon enough, they will continue to disappear.

So how do you go from being a patient to a consumer of health care as well? You get help. You get an advocate. You find a Direct Primary Care doctor whose main job is to care for you and find the most affordable, high quality care possible. I would not try to buy stocks or mutual funds on my own because I do not have the knowledge base to do so. So I put my trust in an expert to guide me through the process and invest my money wisely. How do you shop for healthcare in the state of Massachusetts where it costs the most? You pay someone directly to help you and advise you. ¬†You do not brave it alone. You find a Direct Primary Care doctor you know and trust. Direct Primary Care doctors¬†are transparent, we are affordable, and we work¬†solely for you rather than third party interests. We are your doctor first and your healthcare agent/broker second. So go to¬†I Want Direct Care¬†and place a pin down. Write to your local congressmen and congresswomen ¬†to tell them about Direct Primary Care and its benefits to you, employers, and the system as a whole. And then, even more importantly, please remember that Health Insurance does not equate to “Healthcare”, ¬†especially the affordable kind.

Our Partnership With RubiconMD

logo-rubiconHave you ever been frustrated as a patient with the time it takes to see a specialist? ….The cost of seeing a specialist? Or maybe you are frustrated that your primary care doc refers out many of your medical issues without taking enough time to get to the root of them? Having worked in the insurance-based system for ten years, I can honestly tell you¬†that many of the referrals I made were medically unnecessary. Although I hate admitting this, it is a fact. Required to see 20-25 patients a day for 15 minutes at a time (if lucky), I did not have adequate time to think and/or treat even if it was an issue that was in my scope of care. This is one major reason I switched to a Direct Primary Care practice. I wanted more time with my patients to think, to treat, and as a result decrease the number of specialty referrals I make. And when you eliminate the restrictions of third-party payment many other great opportunities open up to you- both as a patient and a physician. One of the incredible services that I offer to my patients is called RubiconMD.

RubiconMD is a company built for Direct Primary Care practices, but¬†in my opinion it could also be used effectively by any primary care practice. They have created a network of specialists from all fields of medicine from some of the top hospitals in the nation. For a very affordable monthly fee that I pay them (with no extra cost to patients), I have access to online consults with any of these specialists. You have a rash that I can’t figure out? I can send pictures to them and get a response from a dermatologist in less than 24 hours. You have concerns about a complicated insulin regimen? I can email an endocrinologist for unbiased medical advice. All communications are secure, and all-in-all it is an amazing tool that saves time and money and facilitates much better medical care and patient satisfaction. It is one of the many great services we offer at our Direct Primary Care practice.

DPC and Hospitalists

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How does DPC help patients in the hospital? You can ask my patient quoted below or ask the Hospitalist who took care of him, but I would also like to comment on this.

There are many benefits to Hospital-based doctors (aka Hospitalists)- they are intelligent, well trained¬†doctors and NP/PA’s and they provide¬†24/7 coverage if something goes wrong when you are admitted. We as primary care doctors used to practice hospital medicine as well as outpatient/office medicine, but for many reasons which is beyond the scope of this blog post, most if not all primary care doctors solely see patients in the office setting now. And there are many negatives to this which most patients who have been admitted to the hospital at some point can attest to:

  1. As good and caring as these doctors and NP/PAs are, they don’t know¬†the patient like we do.
  2. Hospitalists often have a minimum of 10-12 patients on their census at a time some of whom may be very ill. That is a lot to manage.
  3. As a result of #2 and the amount of documentation and computerized order entry that goes along with it, hospitalists have very little time to call and/or email the Primary Care Physician with updates on their patients.
  4. This contributes to more fragmentation of care and increased costs to the system as a whole.
  5. Lastly, which is the worst in my opinion, is scared and confused patients.

So what does DPC do to help this? :

  1. We can actually come visit our patients periodically to check in and see how the hospital stay is going. The patient- like the one quoted below- gets to see their own doctor and be reassured that we are “in the loop.”
  2. We have more time to communicate with the Hospitalists regarding our patients histories, medication lists, social situations etc. This allows us to work in a collaborative way to ensure the patient gets the best care possible. 
  3. I believe Hospitalists would appreciate this involvement rather than look at ¬†as us “stepping on toes.” We can provide information that the patient may not be capable of communicating¬†or that they may not think is vital to their hospitalization.¬†
  4. The end result is what healthcare should be about- BETTER OVERALL PATIENT CARE.

 

So here is my patients quote/review:¬†“If U haven’t yet signed up with Gold Direct Medical Services, U R surely walking in the wrong direction! I recently had a several day hospitalization and was actually visited by Dr. Jeff Gold, and was also privy to a conference between him and the hospital doctor, to say nothing of the several daily direct calls to me in my hospital room from him. WHEN WAS THE LAST TIME YOUR DOCTOR VISITED U IN THE HOSPITAL?”

 

Some date on hospital medicine:

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WBUR Interview with Martha Bebinger

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Thank you Katie Couric for the photobomb

 

Thank you to Martha Bebinger from WBUR for interviewing me and publishing this great piece today on Gold Direct Care and how Direct Primary Care in general can work to improve the healthcare system as a whole. Also thank you to Mr. Bird who agreed to be interviewed that day while he was here. To reinforce why I feel the arguments against Direct Primary Care presented in the article today are weak at best:

 

1. DPC worsens the primary care shortage:

I ask these questions in response. What is the current system doing to fix it? Bogging down primary care doctors with more paperwork and more patients to see a day? “Value-base payments” that are based on how complex a physician “codes” their patient and visits rather than how complex the patient actually is as a human being?

By making primary care attractive to medical students from a professional and financial standpoint- including the ones I teach from Tufts Medical School- we can further supply this system with high quality, passionate students that want to do primary care for the right reason which is caring for patients. Most medical students graduate with around 150,000-250,000 dollars worth of debt. It is very challenging to offer them primary care as it currently is and currently pays. So lets fix that with Direct Primary Care.

 

2. DPC is “insurance”:

Without getting into legalities, the Affordable Care Act states in Section 1301 (a) (3) that Direct Primary Care combined with a catastrophic or high deductible insurance plan qualifies a patient as meeting the ACA standards of full¬†“insurance”. ¬†However, having DPC alone would result in the patient paying the Obamacare fine. Therefore, it seems clear that DPC alone is not “insurance” or an “insurance-type product”. ¬†If you are interested in reading about this further please read this article by Dave Chase from Forbes. Mr. Chase is a great¬†proponent of Direct Primary Care and very knowledgable on the topic.

Forbes Article on DPC Regulation by Dave Chase

Value and Perspective

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So the main question we get asked a lot by former and prospective patients regarding ¬†DPC is “why should I pay you when I already pay insurance”? ¬†This is a very good question and I think I have a very good response- what value¬†does insurance give you? Insurance value should be that you pay as little as possible upfront (the premium) in the hope that you never have to use it. That way, ¬†you get to keep more of your hard-earned dollars in your pocket rather than in the hands of an insurer. You then have the money in your bank account if– god forbid- something catastrophic happens. Yes, you may have to pay a deductible but this is again a “what if. ” Insurance is supposed to protect you when the big unexpected stuff happens not the everyday stuff. Think of it this way: do you pay your contractors, plumbers, landscapers, etc with your home insurance?? Do you pay for gas, oil changes, mechanical issues, tire rotations, etc with car insurance?? The easy answer is no! So my question is why are we paying for affordable, routine primary care with 3rd party insurance? Instead, why not:

1. pay a Direct Primary care doctor an affordable monthly fee to cover all of your primary care needs (no copays, no deductibles, no hidden fees).  Even better we have negotiated cash pricing on routine labs, imaging studies, and most common medications (our cholesterol panel cost $4.00)

2. Carry a lower premium high deductible plan with an HSA account (tax free savings in your bank!) and be protected against the big stuff if and when it happens- i.e. hospital, surgery, cancer, heart attack, accidents, etc

3. Have your own personal primary care physician available to 24/7 through any form of technology- text, cell, Skype, even twitter! We work for you- not insurers or the government. And I include visits to the hospital and do home visits for 30-50 dollars. 

So there is the value now lets look at the perspective. Our maximum monthly rate is $125 for age 65 and over. Here are some examples of “value/perspective” to ponder:

1. This year the average household cable TV bill in the USA is $123 per month

2. Average cell phone bill $73.00 per month

3. Dinner at Uno’s for four averages $60 without tip

4. Going to a movie averages out to a minimum of $60 including tickets and food for a family of four

5. A filet at Abe and Louis is $48

and here are the final two- which¬†people have daily- that amazes me….

6. A regular size latte at Starbucks is 3-4 dollars. 

7. A medium hot coffee with bagel and cream cheese combo at Dunkin Donuts is $3.69

I will leave the math to you the readers. Hopefully, my analogies and the value that we provide for people are clear. What is more important than your health?

If you wish to read further about what a typical family of four pays out of pocket in the USA for their “employer-based” insurance premiums, copays, deductibles, coinsurance, etc please read the following link below. Or I can save you the time and tell you: $23,215.00. I think we provide high value, transparent, affordable care to our patients. So I leave you with a final question: Does your insurance provide this?

Milliman Medical Index 2014

The Home Visit: Bringing It Back

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Yesterday I did a home visit for one of my long time patients that recently got discharged from a Skilled Nursing facility. She has a very complex medical history and has been in and out of hospitals and rehab facilities over the past few years. She is frail and elderly and getting to her dialysis sessions three times a week takes a lot of energy out of her. So why is it necessary for her to expend a lot of energy and experience pain to physically come in for a visit to see me? The answer is it’s not anymore.

See… in the current medical system doctors and nurse practitioners only get reimbursed by 3rd party payers if the patient physically comes in and meets with the doctor face to face. The doctor sees a complex patient like mine for 10-15 minutes if lucky (or if longer end up an hour behind), and then spends a majority of time documenting and coding the visit in order to get paid. Sounds great for the patient and doctor huh? Not exactly. It doesn’t work and it makes no sense.

So that brings me to yesterday. ¬†Since I no¬†longer¬†have to see 20-25 patients a day like a machine, I now have¬†control over how I practice medicine and the type of care I provide. By contracting solely with the patient,¬†I can drive¬†2 minutes to my patient and see her at her home. I spent 70 minutes with her and her children. We reviewed her discharge paperwork, her multiple medications (trying to taper¬†her off a few), and discussed any current issues or concerns they had. I then wrote a brief note documenting the plan and emailed the specialists involved with her care to update them as well. The focus was and is solely on THE PATIENT. All of her and her families questions were answered and we have a solid plan in place to prevent her from ending up back in the hospital- a place she dreads and I don’t blame her. Now we can work as a team to be proactive rather than reactive. We can work towards solid pain management, reduce unnecessary medications and testing, and keep her home where she is safer and more comfortable. Her quality of life is significantly better because her care is better.

And what did I receive in return? A great deal more than $30 or her monthly fee of $125. ¬†After 8 years of caring for this woman I got to see her in her ideal setting- her home. I got to learn about the little toy animals she keeps as her hobby. I saw her family in action taking car of her and making her quality of life the best possible. Carpets have been removed so she doesn’t trip with her walker. She has a bell so she can ring in the middle of the night if she is in pain or needs something. And now she has her physician capable of coming to her and spending over an hour with her to make sure she is heard and cared for with dignity. So I got a lot more….I got to be a doctor. Not a bad value proposition for the two core people that make medicine tick- the patient and their doctor.

What We Strive For With DPC

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One of the main reasons I decided to make this huge career change into a Direct Primary Care practice was to give patients what they deserve from their doctor….time. One of my patients that followed me from my old practice has allowed me to post this wonderful testimonial she wrote on Facebook on Friday. Many thanks to her for doing so. This is an example of what true patient and doctor satisfaction are about:

 

“Today I had my first official appointment with Dr. Jeffrey Gold at Gold Direct Care. It was a phenomenal experience. His new office space is beautifully decorated and comfortable. Dr. Gold spent quite awhile with me, answering numerous questions and making me feel, as he always does, at ease. Has anyone ever gone to their primary care doctor and been greeted with: “Would you like some coffee or tea?” My visit was an experience- not rushed, not pressured to hurry up. If you want a primary care doctor who sincerely cares about you and your family and is in the practice of medicine to do just that, then you have to meet with Dr. Gold and see what Direct Primary Care is all about.”

Open Enrollment: What To Do Next

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For all of you who are in the enrollment period for employer-based insurance, including town employees, we can help answer your many questions. We offer free one hour consultations to help look over your insurance benefits.  We also show you how Gold Direct Care can complement your insurance in a way which accomplishes two main goals:

1) Provide you with better access to primary care (AKA better quality care) with a doctor that is available to you when you need them. Appointments guaranteed within 24 hours and no insurance hassles.

2) Lower your cost. By combining our aged-based monthly fee with a lower premium/higher deductible plan we can get you to either break even for better value or, best case scenario, we can save you money all the while keeping you protected medically and financially.



 

We understand how complex insurance options can be. We are here to help you become a better consumer and navigate these complexities, so you and your family are protected; all the while getting the best value for their dollar.  Please contact us for any inquires and to set up a time to talk at info@golddirectcare.com or 781-842-3961.

We also have knowledgeable insurance consultants as well whom we can direct you to if needed.

Here is an article with great examples if you would like to learn more: What Really Happens When You Cut The Red Tape

Tufts Family Medicine

So today I spent an hour speaking about Direct Primary Care to 1st and 2nd year medical students at Tufts University that are interested in Family Medicine or Primary Care in general. It was a great experience to see students engaged and interested in pursuing a field of medicine that desperately needs young, bright, and energetic minds. They asked intelligent questions and hopefully learned that there is hope on the horizon for primary care. There is a currently a shortage of good primary care physicians across the country, but especially here in Massachusetts. We need to fix this and the only way to do so is to make Family Medicine palatable, financially rewarding, and most importantly gratifying by focusing on patient care. Read this article from 2013 for more information: http://www.beckershospitalreview.com/hospital-physician-relationships/primary-care-shortage-dire-in-massachusetts.html

Direct Primary Care, in my opinion, is a way to build off the positives of our healthcare system and simultaneously remove the bureaucracy and red tape of insurance that does nothing to help patients or control costs. We have a solid foundation to work off of, but we have to modify it without scrapping the whole construct. DPC does this. It allows insurance to be used the way it was intended to be used- for catastrophic, high cost events or illnesses.

In my hour with them today, I hope I was able to show the students that if we keep fighting the good fight and do the right thing, maybe someday DPC will become the norm rather than the exception. I hope the more than 200 patients we have enrolled already can attest to the value and quality of this old, yet new, model of primary care.

As Albert Einstein once said the definition of insanity is doing the same thing over and over again and expecting a different result.