News & Updates

Retail Clinics: Filling the Void

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.

Boston Globe Article: Minute Clinics Rising

The Real Reason

Today, July 15, is a really important day to me- for both happy and sad reasons. This day in 1993 is when I physically lost my best friend. My grandmother, Bella, was and is a large part of who I am as a person. She taught me about hard work, determination, unconditional love, and empathy. She is also the main reason why I not only became a Family Physician, but also why I left the insurance-based system behind for this new endeavor of Direct Primary Care. I knew people deserved better because I knew she always deserved better.

My grandmother was stricken by early onset dementia at the age of 62 and rapidly declined over the course of my high school years until her death in the summer of 1993 following my graduation. Although her death was a finality, it was also a blessing. She never wanted to live her life the way she was at that time, nor did she want to be a burden on anyone. My family struggled to get her approved for Medicaid after she worked her entire life. As a result, we were unable to get her coverage for a nursing home. We cared for her at home until it was simply unsustainable. As awful as it was, it taught me what people deserve when they are ill. It taught me that we treat our animals better than we do our loved ones. The system was screwed up even back then. So she lived in the nursing home until her money ran out after which she died peacefully in her own home with me by her side.

I have always used this experience to guide me through college, medical school, residency, and now my career. I miss her guidance and love every single day, but I know that I am finally happy as a physician because of her. I will always look back at her and my relationship with her, but I will never look back at a system that prevents doctors and physicians from caring for each other and does nothing to secure the sanctity of the physician-patient relationship. Is that not what medicine was based on in the first place? Hopefully she is fully resting in peace knowing that her only grandchild is happily doing the right thing and being the doctor she knew I could be.

Here’s a Story of a Broken System (To Tune of Brady Bunch Theme)….The Sequel

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.

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

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”

Diagram-PiggyBank — 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

Have 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

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?”

Some date on hospital medicine:

WBUR Interview with Martha Bebinger

0519_direct-primary-care01-620x465 — 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

illustration-societe-satisfactionEn

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

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.