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.
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.
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:
As good and caring as these doctors and NP/PAs are, they don’t know the patient like we do.
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.
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.
This contributes to more fragmentation of care and increased costs to the system as a whole.
Lastly, which is the worst in my opinion, is scared and confused patients.
So what does DPC do to help this? :
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.”
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.
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.
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?”
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.
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.
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 firstname.lastname@example.org or 781-842-3961.
We also have knowledgeable insurance consultants as well whom we can direct you to if needed.
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.
One of the key differences between a conventional insurance-based primary care practice and a Direct Primary Care practice is the overall structure of the office space. (see the latest update on new location)
When you first walk in, you’ll immediately notice a difference:
Instead of a large waiting area, we will have a cozy “lounge” area. I do not call it a waiting room because patients will not actually WAIT to see me or my nurse Meghann.
There will not be a crowded waiting room with contagious patients. There will be no front desk staff of 5-10 employees. Instead, patients who enter the door will be greeted by Meghann at the reception desk, checked in without the need to verify “insurance”, and brought back into an exam room.
The exam rooms are different, too:
The exam room as well as the rest of the space will be a warm, homey environ with lots of soft colors and natural light so patients feel relaxed.
The space will be sterile and immaculate without feeling like a a cold and impersonal conventional office.
Your visit with me will be thorough and personalized:
Instead of visits that last 15 minute or less, patients will be in the exam room or my office for no less than 30 minutes (or even more if needed).
There are no rushed visits with patients being filed in and out of exam rooms.
There will be no computers or kiosks in the exam room. Attention will be given to the conversation being had with the patient. Laptops may be brought in on occasion to demonstrate medical education or show anatomical pictures, but never at the expense of patient-physician interaction.
The whole focus of a DPC office is to make our patients feel relaxed and comfortable, whether they are there for a routine checkup or a sick visit.
We want our office to feel like our patients’ true medical home!
It has been an honor to practice primary care in the community in which I grew up and where I now live with my wife and our 5 year old twins. When I made the decision to become a Family Practice Doctor, I had a vision of what I thought my practice would be like…it would be in a community similar to where I grew up; I would have personal relationships with all of my patients; I would be accessible to my patients when they need me; I would be able to spend as much time as I want with my patients; and the list goes on and on.
Over the course of the past couple of years, due to many factors, it became very clear to me that my vision for how I wanted to practice medicine was not coming to fruition; at least not in the dysfunction of the current healthcare system. I started to read about a movement in the world of primary care medicine called Direct Primary Care (DPC). DPC was quickly gaining notoriety and attention, not only in the medical community, but in the business world as well. Slowly but surely news outlets such as MSNBC, FOX NEWS, and CNN started to interview doctors who opened DPC practices across the country. The Wall Street Journal, The New York Times, Forbes, and other major news outlets started publishing articles about the DPC movement and the attention that it is getting in the medical community. The more I read and the more research I did, it became obvious to me that the vision that I had for how I wanted to practice medicine- as well as the vision that I had for how my patients deserve to have me practice medicine- could be achieved by opening my own DPC practice. I truly believe that Direct Primary Care is a large part of the solution to the healthcare crisis in this country.
After two years of doing research, attending DPC conferences, having numerous conversations with doctors who are already operating successful DPC practices, and lengthy discussions with people in the business world, I am proud to introduce you to Gold Direct Care. I am the first doctor in the state of Massachusetts to open such a practice, and I know it is the right thing to do for me, but most importantly for my patients.
Please peruse GoldDirectCare.com to learn more about Direct Primary Care. I look forward to growing my practice with you, my patients, by my side. And I thank you for allowing me the privilege of being your doctor.