Ever since I watched my grandfather and grandmother suffer from devastating diseases like diabetes and dementia, I have always been passionate about how we treat people at the end of their lives. With all of the technology, specialized medicine, and wonderful hospitals we have in this country we often never know when it’s time to stop using them. As physicians, we are so afraid of losing patients (i.e. failing), and death and dying in general, that we often lose sight of “life and living”. Sometimes the best medicine is to not only let people go, but more importantly to let them go on their own terms.
Yesterday, I lost of one my longtime patients and supporters- Mr. Wilbur Basset at the age of 89. (I am using his name and picture with permission from his family.) Wilbur and I met when I first moved to practice in Marblehead 8 years ago. What struck me about him was both how healthy he was for an older man, and even better how incredibly sarcastic and funny he was. I always enjoyed that he was for lack of better terms “a curmudgeon”. He never complained unless something was truly bothering him. It took 8 years, and me removing myself from the factory mill of modern day healthcare in order to move to the Direct Care model, for me to actually meet his family and spend time with them. I am so glad that they stuck with me and gave me the chance to show them what medicine can be like.
Unfortunately, over the past few months Wilburs illness and condition worsened. I saw him in the office with his daughter a few weeks ago and I could tell that he was declining. Given how stubborn he was, he always fought through stuff, but this time he just looked different. As I helped him in the car he said “I am so ‘blanking’ done with this.” I just knew he was ready. So after his daughter and I had a great chat about consulting with Hospice, he sadly ended up in the hospital before we could get the consultation scheduled. When I visited him there I could see how miserable he was. After a week or so, which of course included a few unnecessary consults, he rapidly worsened and was transferred to the Kaplan House where he peacefully passed away with family by his side after a day. Fortunately I got to say my goodbye to him yesterday.
As a system, we have to do better for patients like Wilbur and their families. We must do better. For me, I will always remember him the way he was a few weeks ago, and I will always be thankful to have had the opportunity to care for him and his family through his journey. I may not be a specialized surgeon or a cancer specialist, but I am so thankful that Wilbur and his family went Direct Care with me and granted me the most gratifying job in the world. I was his doctor.
Rest in peace Mr Bassett. You have earned it and did it on your terms.
Today, October 1st 2015, is a very critical day for the “disease management” system that we mistake for a healthcare system in the United States. Today is when the new coding system called ICD-10 goes live for a majority of American physicians and Nurse Practitioners. This is nothing more than another layer of bureaucratic red-tape that does nothing to enhance the quality or cost of your care, but rather furthers the disease process. All it does is waste more of your physicians and office staffs time- time that should be spent working towards your care. Instead it just feeds an already broken machine that is aimlessly running on fumes while blowing exhaust into the faces of the people whom matter most- the doctors and the patients.
Luckily for us and other brave practices and patients across the nation, we have nothing to do with this nonsense. We have decided to escape the mess and fix medicine from the ground up. Our focus is solely on working together towards a system that actually makes sense and works for our patients. This is what gratifies us most- being able to provide care the way we trained to do. So help us raise awareness about the Direct Primary Care model today- National Direct Primary Care Day! Check out the following link, share it, talk about it, and maybe even buy a t-shirt:
So I couldn’t not share this story about myself, MassHealth, and our completely dysfunctional healthcare system. After I left my old job to start my own Direct Care practice I needed to take on the more formidable task of finding my own health insurance that made sense for me and my family- we have two 5 year old twins. So I did what a lot of people did and went on the “Exchange” aka the “Connector” and entered all of our personal data including dates of birth, addresses, and of course estimated income. Now as I have always been an employed physician this was all new to me, but I felt that I would at least have some understanding and knowledge on how to shop for health insurance. Yet, after getting about 2/3 of the way through I put up my hands in surrender as I could not make heads or tails of anything. I can not even imagine what a lay person feels having to shop for something so convoluted and poorly organized. So I did the logical thing and called a local friend who sells other types of insurance and he connected me with a knowledgable professional that understands the health insurance market. He got me and my family what we needed at the best price possible. Then I just forgot about it….
Until yesterday September 14 2015, when I got home and checked the mail. In there was a letter from MassHealth and The Childrens Medical Security Plan that my son Cameron- not his twin sister, not my wife, not me, just Cam- had been approved for a MassHealth plan effective DECEMBER 11 2014!!! Actually a separate letter states that “MassHealth is changing my premium payment because of a change in your family’s circumstances.” Huh???? What status change? I didn’t even know I was approved and paying a premium to them in the first place! Also enclosed was his card (as you can see in the picture above) for both medical and dental plans at a cost of $64 per month with really cheap copays- well for me that is. You may also notice that in the body of the letter there are not one, but three different numbers for me to call if I have various questions. Well I actually only have one question with two parts….1a. why in Gods name am I even getting this?! and 1b. how am I or any member of my family even close to qualifying for government subsidies??! Somehow just one of my family members qualifies for subsidized medical and dental care from our state and federal government but the rest of us do not? Clearly this is huge mistake based on some information that I input into the Connector back in January of 2015 right?
So what should I do? Should I try to game the system and dump my more expensive, current insurance for my son and take this cheaper offering for him at the cost of the taxpayers of Massachusetts? Should I just wait and see all the administrative waste that will be used to figure this out and catch on to me and eventually correct the problem in another year or two? The answer to all of these questions for me is a resounding NO. Instead I will write a blog article about it that a few people will likely read and just chalk it up to another Dr. Gold rant on healthcare in the US. My deep hope, however, is that at some point more people will read this and actually think!
What are other people doing with these healthcare mistakes and oversights that our government is making with your hard-earned dollars and taxes you pay? How much money is wasted if this mistake happens to 3,000 people that actually pretend they deserve the subsidy and use it? Is this what you want your money spent on? Waste? Is this really how you want your care to be delivered? Would you tolerate it if you paid an 800 dollar a month or higher premium for your families health insurance and found out that a friend paid 64 dollars a month due to a clerical error? Now do not get me wrong, I am for all people of all walks having good access to high quality, affordable healthcare, and there are ways that the government could help do this the right way. I will not get into all the gory details here, but one possible solution is working with Direct Care doctors like me and Iora Health to spend your tax dollars on something of worth- actual healthcare instead of bureaucratic, administrative waste. Now, I think I’ll go shred my sons new MassHealth card and save the state some money. I would rather stay true to the Oath I took and hope that it is spent on care for people whom actually need the assistance instead. Doubtful, but a doctor can hope right?
So after battling with the state of Massachusetts since February, we finally got the okay to supply State Vaccines. The vaccines which we can supply are:
DTaP (Helps children develop immunity to three deadly diseases caused by bacteria: diphtheria, tetanus, and whooping cough aka pertussis.)
Hep A (Used for prevention of liver disease caused by the hepatitis A virus.)
Hep B (Used for prevention of liver disease caused by the hepatitis B virus.)
HIB (Used for prevention of invasive disease caused by Haemophilus influenzae type b bacteria.)
IPV (Used to combat poliomyelitis aka Polio.)
PCV13 (Used to protect infants and toddlers from pneumococcal disease.)
RV (Oral Dosage- Used to prevent Rotavirus which is a contagious virus that can cause gastroenteritis.)
These vaccines can be supplied to anyone under the age of 19. However, we will not be supplying HPV or Menactra(Meningococcal Meningitis Vaccine). We do have places we can send our patients to receive these vaccines at a cash price, or by using their insurance.
We will be implementing a $20 inoculation fee to help pay for the needles and syringes. This is just a one time fee per visit, NOT per vaccination.
If you have any questions, or would like to set up an appointment, please call our office at 781-842-3961.
If you would like to know more about the vaccines, or what schedule your child should be on, you can visit the CDC website here.
Todays issue of the Boston Globe had a great article in the Business Section on the Rise of Retail Clinics and how they are rising to meet the needs of patients. The article is below for those who wish to read it and please read the comments, as they are always fantastic when it comes to articles on our healthcare system.
The main question I ask in this blog entry is: Why are these clinics popping up everywhere and having success? It is actually a very simple answer- they are filling the void that our fractured, third-party based healthcare system has left in its path of destruction of the physician-patient relationship. They are the callus on the fracture, but they are not the cast that will keep it fixed for good!
Patients used to have access to their OWN doctor or nurse when and if they needed them, even if it were for a simple question. Now, because of a warped third party payment system and corporate run healthcare, patients feel as if they are nothing more than a number on a list. They would rather go see a doctor or NP that knows nothing about them at a pharmacy than their “in-network listed ‘PCP’ “. Why? Because they do not want to listen to a 5 minute list of menu options on a phone; they do not want to be on hold for ten; they do not want to wait to have their problem addressed for hours to days, especially when ill; they do not want to pay a copay or deductible for a rash that could be diagnosed with a picture; and most importantly they do not want to be rushed in and out in 10 minutes after waiting for 45! So do I begrudge companies like CVS for opening these clinics and do I begrudge patients for going to them? Absolutely not!
So whom do I have issue with? I have issue with a system that has been perpetuated for long enough to allow this fracture and pseudo-callus to form. The reason I call it a “pseudo-callus”- and this is in no way to be disparaging to the doctors and NPs who work at these clinics- is because they are not the patients OWN doctor. Are the “providers” at these clinics going to be there when that simple cough turns into a lung mass or emphysema? Are they going to be there when that simple UTI is actually a bladder cancer? No matter how excellent the quick care is, I ultimately believe that people still crave their OWN doctor. DPC not only fills this void, it is the cast that will allow this broken system to heal once and for all. And not only do you not have to “check with your insurer about coverage”, my monthly fee is cheaper than the visits to these clinics. See here: CVS Minute Clinic Prices
It is time doctors and patients look for the cast rather than the band-aid.
Let me preface by saying that I can not and did not make this up. So after returning to work on Monday following the DPC Summit in KC this weekend, I went to check the mail and received this document from a Medicare Part D drug plan. (I did not include the image of the document here so as not to have the companies lawyers call me). This document is basically the 3rd party making sure that my patient is on the best drug regimen for his condition(s). Now on the surface this does not seem like a bad thing, but trust me when I say that what they are really looking for is a way to curb their costs.
So the comical part of this whole scenario is that they no longer have to worry about cost nor have they had to for the past 6 months. Why you may ask? Because that is how long this patient has sadly been deceased.
I would say that I’d be back next week at our regular scheduled time, but I am 99% sure something equally as asinine, if not more so, will come across my desk and/or mail in the next few days.
PS: I loved this patient and he would have had the exact same reaction. It would have been comical.
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.