In this final blog post as part of this series, I feel the need to start with illustrating the difference between Direct Primary Care and Concierge Medicine. It is very important for my readers to understand the terms we are using in explaining how Direct Primary Care in combination with the Affordable Care Act (ACA) is the best solution for our healthcare system.
In addition, I refer to direct primary care as well as direct medical care in general. I strongly believe, as many specialists, surgical centers, and endoscopy suites do as well, direct pay for medical services is less expensive than billing to insurance companies.
So, in summary, Direct Primary Care:
In order to really understand the economics of health care spending on a national level, think about this: We spend about 25% of the national budget on four health insurance programs — Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and Affordable Care Act (ACA) marketplace subsidies. How efficient are we with our tax dollars? What is the return on our investment? We spend 17.2% of our GDP on healthcare; more than any other nation in the world. Take a look at the graph below. We spend 49% from public funds on health care. The reason for inefficiency all of a sudden becomes more clear.
What happens when direct care and health insurance programs work together?
It is estimated that about 80-90% of all health issues can be resolved or prevented in the primary care setting. Yes, you read that right, a significant majority of issues can be managed and prevented in the office. Urgent cares, stand alone ER, and now the new trend of small hospitals are feeding off the need for accessible care. Large health systems are trying to reach more patients with multiple "footprints" across the region to bring in more people into their system. People find comfort in that all their information is "in one place."
But, we tend to forget that when physicians are on medical staff or teach at various hospitals, we have access to the EMR and able to coordinate hospital care, like the "old" days. I would argue, when your patient panel is smaller (less than the traditional 6,000 patients) then it becomes easier to coordinate and provide hospital care.
Economics of direct medical care
A. Consumers save and decrease out of pocket expenses
By saving $0.40 on the dollar, practices are able to offer more services, use technology to make themselves available to their patients, while keeping the cost of their services low. The consumer's out of pocket expenses are drastically decreased as majority of direct primary care practices do not charge co-pays or any additional costs for in clinic procedures. In addition, the discounted imaging, labs, and medications are drastically lower than with insurance.
B. Health insurance premiums will decrease drastically
When we take insurance companies out of the outpatient world: all primary care practices, specialty office visits, imaging, laboratory, physical therapy, occupational therapy, speech therapy, and some outpatient procedures, then the insurance companies are purely covering inpatient care and catastrophic care. A large component of insurance premiums are to cover these services. So eliminating the outpatient services will significantly reduce these premiums.
The medical offices, imaging centers, laboratory facilities, and many procedural suites save big when they don't have to bill insurance by reducing their staffing, paperwork, and resubmitting of claims. Thus, the cost of their services will come down and the market is open to competition. Accounts receivables have minimal to zero balance; leaving liquid cash in the bank to offer more services.
Please note, many endoscopy suites, surgical centers (like Surgery Center of Oklahoma) specialty offices, imaging centers, laboratory facilities, and of course primary care offices are moving to a direct model because of these benefits.
C. Cost of hospital care and need for more services will decrease
With accessible and affordable primary care, studies have shown that not only do people visit with their primary care doctor more, but their risk for admission to a hospital is drastically lower (see diagram below from our friends at Qliance). Hospitals have an opportunity to embrace a direct model as seen around the world and surgical centers where there is no insurance billing. But, I fear this will take some more effort and health insurance lobbyists are quite powerful. So, I will push the envelope towards at least getting the outpatient world out of the grasps of health insurance.
D. Federal health spending and taxes (Federal and State) will decrease
Medicare and Medicaid are government sponsored health insurance programs that will also be focusing on inpatient and catastrophic care in this new model. Folks who are paying lower premiums can fund their Health Savings Accounts (HSA) or Flexible Spending Accounts (FSA) to pay for direct medical services. These are pre-tax dollars and funding them is more realistic as the consumer will be paying less out of pocket for their health insurance premiums.
Even the $50 monthly fee for direct primary care can become difficult for some Americans. This is where practices should be given a tax incentive to provide free charity care. The more they do, the more they save. Currently, tax laws place a cap on how much they can claim as charity care. Each practice can also be allowed to set up a charitable foundation and reduce the complexities of forming of 501(c)(3) organization. This will enrich a community feel of delivering health care and bring all Americans together in providing quality care for one another.
States can expand Medicaid without having to increase their state taxes as much. The IRS and the ACA must agree on terms, as they currently have different definitions for HSA and FSA as to what qualifies as a medical service. This will happen soon, but in aligning the definitions, this will incentivize more development of direct medical practices across the country.
So, what does it look like for the consumer purchasing medical services?
To answer this question, lets put ourselves into the shoes of a imaginary 40 year old man named Tommy.
Tommy is a car parts salesman and recently took over his fathers business. He is very energetic and overweight. He has diabetes, heart disease, and some kidney disease. He starts searching for a direct primary care doctor in his area. After spending time meeting the doctors and their staff at different practices, he settles on one. We can call it LiveActive Primary Care www.liveactivepc.com
He then looks for a health insurance product that has his hospital of choice in their network and co-incidentally his new direct primary care doctor also provides hospital care at that same hospital. What a find! His premiums are much lower and he gets a plan with a HSA account so he can fund his card with pre-tax dollars.
His first visit with his direct primary care doctor is 60 minutes where all his health issues are discussed and a plan of care is developed. He walks out with all his labs done for less than $35, medications that are significantly less, and plans to see his kidney specialist soon.
Since his kidney specialist does not bill insurance, they are able to see him same day or next day. All his doctors are a text message away. When he arrives at the kidney specialists office, his case has already been discussed by his primary care doctor and the specialist. This is a real possibility as both of these doctors have the time to discuss cases instead of seeing 30 patients a day with unnecessary paperwork. They discuss the case and he is on his way home with a plan.
When Tommy goes to the hospital, both of his physicians come to take care of him. The nurses and hospital staff are ready to take care of him upon his arrival.
How about the consumer with no health issues?
So for this part, we meet Elon. He researches a direct primary care practice just as Tommy did and signs up. His health insurance product is just as cheap as Tommy.
Elon is playing with electric cars and hurts his hand. He texts his direct primary care doctor with a picture of his swollen hand. His doctor takes a look at the picture and calls him to discuss his symptoms via video chat. After assessing his mobility, Elon is told to get a hand X-ray, which costs less than $40. Elon walks into the imaging center, gets his X-ray done, and within minutes his direct primary care doctor calls him to say that they saw the images and he needs a cast placed. Elon is told to come the office that same day and a cast is placed for $40. Elon goes back home to play with rockets.
How will hospitals save money in this health care system?
The ACA attempts to improve quality of care by penalizing re-admission rates, in hospital infections, and pushes for a medical home model. With the development of various direct care practices, the consumer is able to create their medical home: pick their direct primary care doctor, pick which specialist they like, and hospital. The hospitals should see less readmissions as the care in the outpatient setting is more accessible and affordable. There is a reduction in risk for hospital acquired infections with decrease length of stay.
The Emergency Rooms will not be overflowing as patients are able to be seen by their direct primary care doctor quickly or in their home as needed. If someone does have to go to the ER, then the process is much more efficient. The primary care doctor and the ER physician have already talked about the case so upon arrival of the patient, care is started immediately.
The ACA has more than 33,000 pages of regulations. Remember this famous photograph in the Washington Post:
But there are several benefits that should be continued:
Changes that need to be made to the ACA:
Now, this solution is a key ingredient in decreasing our national expenditures quickly. But, it is not complete on its own. We must make continued efforts in reducing pharmaceutical cost as well as medical devices. This will take some aggressive regulations and encouragement of free market. As the insurance companies remain involved in hospital care, long term care, and some other services under the model, there must be efforts to make billing more efficient and decrease the amount of waste we produce as discussed above.
Finally, as a country, each American must make a commitment to improving their health. We can open several doors for the American people, but as many direct primary care physicians will tell you, despite all these resources and at times FREE medical services, we still have trouble maintaining compliance in some of our patients. This must change.
It will take comprehensive effort to improve our national health care. President Obama, despite your opinion of his presidency, has ignited the push towards better health care for all of us. It is on us to keep pushing, improving, and supporting programs that have intentions of providing accessible and affordable care for all.
Dedicated to my beloved fellow Americans,
This is part 2/3 of My prescription for better health care for ALL Americans.
With the new president-elect nominated by the American electoral college, there are increasing worries about repealing the Affordable Care Act (ACA). Is it possible to repeal such significant legislation of our time? Will millions of Americans lose their insurance coverage?
Since its inception in 2010, an estimated 20 million of the estimated 47 million uninsured Americans gained health insurance coverage with surveys pointing towards many satisfied customers not only with their plan but also their chosen doctors. Studies, as cited by the Common Wealth Fund, also suggest an improvement in quality of care as a result of ACA implementation. In the last 6 years, there has been increasing interest in multi-payer initiatives to promote quality primary care by reimbursing physicians a set fee per member of their practice (sounds like the government likes direct care but won't admit it).
All this sounds great, right? So what is all the fuss about?
Well lets look at what this "coverage" means for the average ACA enrollee:
Think about this: When a person gets admitted, the hospital staff runs them through a myriad of exams and tests quickly to maximize their revenue (initial evaluation is highest paid with decreasing reimbursement for follow up visits), and then discharge them to the clinic setting where the wait times are long and the patient has little time with the doctor. The social workers and case managers will be the first to tell you there are several moments during a hospital discharge, we can predict someone will likely come back (called LACE score). To add to all this chaos, add the fact that the insurance companies will deny medications that at discharge might be needed or imaging that is needed for follow up. Hey, but I have coverage, right? Delay in care with prior authorization and denial of medications is what only the American who experiences this in some way truly understands.
Health care is a $3 trillion industry. Each change in policy means millions of dollars worth of changes in staffing and organizational structure for hospitals. Like any other business, these costs will need to be recovered in some way. Thus, the rising hospital bills, avoiding certain payers completely, and entertaining providing services in a cash basis without involving insurance; it's so much cheaper!
Health insurance adds about 5 staff members for each physician with denial of claims about 15-20%. Accounts receivables increase as the facilities await payment while continuing to pay for billing services to resubmit and submit new claims. This is the single largest cost and waste in our health system. From direct costs of paper, printing, software and hardware, billing services, to indirect costs of time wasted, prior authorizations, insurance denials and requests for more forms, less patients seen due to paperwork, and burn out. This is the foundation for the need to see 20-30 patients daily to capture a reasonable revenue stream to keep the business running. More on this in the final blog post.
Enter direct care.
The American Academy of Family Physicians (AAFP) proudly supports direct primary care and holds the single largest conference in Kansas City, MO every year. This single event has grown from a few 100 to over thousands of attendees, including physicians, medical students, medical residents, technology vendors, and others who are eager to partner with direct care practices across the nation.
Their tremendous support stems from the growing national shortage of primary care physicians, increasing prescription medication costs, poor access to care, and unaffordable medical care despite insurance coverage.
The American College of Physicians (ACP) has also written a white paper on practices contracting with their patients instead of insurance companies. This paper has increased the conversation differentiating direct primary care from concierge care. A social media storm was lead by yours truly. Sorry ACP, but I cannot tolerate poor research prior to writing a paper.
Here is the reality:
How would this new health system look like? I discuss this in my final blog post for this 3 part series.
Those of you who follow my blog know the foundation of my leadership philosophy. Empower your team with tools and resources they need to solve problems creatively; ultimately bringing success to the entire group. First step in solving any complex issue is to first understand the problem. And so, we start by looking at the problem in the economics of delivering care by understanding the cause for rising insurance premiums. I hope to raise your awareness in this 3 part series to illustrate the real issues with the Affordable Care Act and propose a solution which I think will propel us to being the most innovative and efficient health care system in the world.
If you are like most Americans, the open enrollment season is confusing, nerve-wrecking, frustrating, and quite honestly, an overwhelming time. How do you choose which insurance is right for you? All the language and terminology is so confusing that making sense of a single plan is a daunting task. Insurance brokers are there to help, but the industry is changing for individuals at least as the insurance companies are not paying these brokers commission for selling their product; leading to less brokers out there helping individuals and families.
Naturally, we wonder why the premiums are so high and why they keep rising? Here are the top reasons why insurance premiums are rising and will continue to rise until we finally agree to privatize primary care and other outpatient services; keeping health insurance out of these basic services.
Top 5 factors
How has the rise in insurance premiums compared to median household income or earnings?
So, to put this in perspective, workers are not earning enough to keep pace with rising insurance premiums. This leads to either the employer spending more on health care coverage, letting go of some employees in order to provide coverage for others, downsize the business, or stay less than 50 employees to prevent having to require health insurance. This de-incentivizes economic growth. How does this make any economic sense?
Higher premiums mean less out of pocket? Wrong!
Your analysis is correct: rising premiums and deductibles are outpacing inflation. This is why earnings are not keeping pace with premiums or deductibles, causing Americans to hold onto their wallets even tighter.
Rising Chronic Illness leading to higher costs of care
This is the reason why investing in primary care is so critical to keep costs down. More chronic illnesses does not necessarily mean more specialty care. Primary care is built, conditioned, and positioned to be fully capable of managing these illnesses at a low cost. The problem arises when the system does not allow primary care to do what it is capable of offering. Instead, the system encourages more specialty care.
Even with value based purchasing and the movement towards rewarding value rather than volume, the cost of doing business in health care favors larger health systems instead of small private practices. Ultimately, making no progress in making the delivery of health less complicated, more personal, accessible, and affordable.
Will the demand be met with a supply of primary care physicians?
The current health care market is ripe for future primary care physicians. Many may look at the current state of primary care and run away. But the informed and astute medical student will understand the industry and market trends illustrated in this blog and realize this is the best time to be a primary care physician. It is also a wonderful opportunity for investors and innovators to assimilate modern technology with quality primary care. No, not telemedicine by itself. The human touch and relationship must never be obliterated. Imagine the patient experience with modern technology and medicine that focuses on building strong, long lasting, relationships.
That is the future of primary care. That is the future of the United States Health Care System.
If you are a investor, innovator, or someone in the community who wants to support my vision, please support our growing practice. Health care will be much different and more efficient for the next generation.
Full disclosure: This topic has been discussed many times and the best article I have read on this question by far is by our fellow direct primary care doctors at CovenantMD. Please feel free to read their full article by clicking the link.
The most common question of all questions I get is "Why would I pay a monthly membership when I already pay for health insurance premiums?" The first thing I do is remind people that most people with insurance already pay twice for health care. Once for your premiums and then the second time for prescriptions medications, labs, imaging, and anything else outside of the premiums. So, direct primary care aims to decrease the amount you pay the second time you pay for health care, while adding significant value to your investment.
Most people will save on insurance premiums by selecting a high deductible plan, use the direct primary care practice to save money on 80-90% of medical needs, which includes discounted medications, laboratory, and imaging. They reserve their health insurance for expensive items like surgery or procedures.
It is difficult to place a quantitative value on medical services that would be prevented with good direct primary care. This is the whole idea behind this model. Be accessible and affordable to prevent catastrophic complications, unnecessary testing, and reduce hospitalizations. The lay public has no idea how a small open wound, a few high blood pressure readings, few high blood sugar readings, ignored leg swelling or other symptoms, can lead to horrible complications if not diagnosed and managed early in its course.
Regardless of how much I educate and teach about the importance of primary care and prevention, people want to see savings in dollars or don't bother thinking about it until they experience a health crisis. So here it goes:
These figures are estimates and certainly can fluctuate on a case by case basis. But, overall, the savings increase as we age simply because you might require more office visits, which are FREE in our direct primary care practice. Most in-clinic procedures like breathing treatments, skin biopsy, joint injection, etc are also FREE. These visits are not 10-15 minutes, instead the 30-60 minute visits might allow us to avoid unnecessary testing and specialty consultation. If specialists are involved, then a direct model allows better communication between the specialist and the patient. It truly is rewarding to see patients become more empowered, more enthused about the physiology at play and learn how they can make an impact in their health with a few steps; ultimately, they feel more in control of their health.
What about those who are very complicated and have a lot of health issues with multiple specialists?
You mean like someone with multi organ failure with a large abscess that needs to be drained, liver failure, kidney failure, malnutrition, high blood pressure, and progressing malnutrition...complicated like that? Yeah, we have that case and in fact we are celebrating his recent hospital discharge and every organ that was injured is now healed. More importantly, his hospital stay on average would have been 7-10 days and we were able to get everything tuned up in 3 days. Direct care allows the primary care doctor to organize an effective team and arrange procedures that have to be done efficiently for that patient. Again, saving 5 days of a hospital stay is very significant, not mentioning the peace of mind of having your leader who you see in the clinic take charge in the hospital as well with smooth communication throughout your stay.
Did you say massive stomach bleed, severe anemia where all the diagnostic procedures can't find a source of bleeding, or the rash that no specialist would take her case because she has no insurance and ultimately needed a strong medication that at times is used for chemotherapy from our office to treat it....and now the rash has cleared...cases like that? Yup, we take care of them too!
By all means, the point of all this is not to brag, but to illustrate a very important point. Primary care is extremely effective if there is time, no 3rd party influence dictating care, and the patient and physician have a strong relationship. Primary care is not just treating common colds, joint aches and pains, and other minor issues. Good primary care takes charge of multiple issues and focuses on preventing chaos. The more complicated the case, the more value you get!
What about Medicare?
Our Medicare patients who have additional supplemental insurance will say that the accessibility and leadership of their care is what attracts them to our practice. The cost of care is still cheaper with a direct practice as illustrated above. Specialist visits likely will be reduced and the focus is to reduce the number of hospitalizations by preventing medical illness. House calls are a known benefit which save people time and money.
Stop by, ask questions, and see how we can help you stay healthy or help manage any health trouble you might be experiencing. Monthly membership too much for you? Then, consider pay per visit rather than monthly membership plan.
We are here to help and have a model to serve everyone. Cost should not be a barrier to join if one really understands this model of primary care. We will be honored to serve you and help you to live a happy and an enriched quality of life.
Tis the season for the most popular sport in America, FOOTBALL! But, what is astonishing is that it is not just football where concussions occur. Sports like soccer, wrestling, basketball, ice hockey, lacrosse, volleyball, gymnastics, cheerleading, baseball/softball, and of course skiing and snow boarding.
What is even more interesting is that girls report concussions more than males. Part of this might be the "macho" effect, but there is more to this than under reporting from males. It also tells us that there is more to concussions than the fact that athletes are getting bigger, stronger, and faster.
Check out the study published in Clinical Sports Medicine 2011, January issue, volume 1, pages 1-17. Here is the link if you have access to this article CLICK HERE.
It is also no surprise to anyone that athletic participation across genders has increased when we compare 1982-1983 to 2007-2008. But, it will blow your mind at how drastic this increase has been.
Those of us who follow athletics know about the growing participation, competition, and support of high school athletics. High school athletes are also getting bigger, stronger, and faster with aspirations for professional athletics. Therefore, it is not surprising when researchers and doctors see a rise in concussions and other serious injuries in high school athletes.
Understand the terminology:
Concussion is a mild Traumatic Brain Injury (TBI). It is a trauma-induced alteration in mental status that may or may not involve loss of consciousness.
TBI happens with head injury due to contact with acceleration/deceleration forces.
Check this out:
1. Seek medical attention if either the parent or athlete notice these signs or symptoms:
Rest from physical and mental activities. This means that television, computers, and music should be limited. That is right, NO VIDEO GAMES! These activities might make symptoms worse. Eating well balanced meals with adequate hydration are key to recovery.
Play by the rules and practice good form when it comes to tackling, wrestling, etc. Identify if there are any trouble spots on the field that may increase risk for an abnormal fall. Make sure you are using the right sports equipment.
Bottom line: practice good technique and focus on strengthening and conditioning. This is most important.
Too many athletes focus on getting "big" or "ripped". But a good looking physique does not guarantee prevention of injury. Workout with purpose and intention. Think about the muscles your are working out. Know your anatomy. This is what makes working out fun. Take your time and take your workouts and nutrition seriously. Surround yourself with people who care about your health instead of pushing products. Being in private practice and becoming involved in my community, I meet a lot of people and small businesses. I must say, there are products out there, exercises, diets, and ideas that are just NOT SAFE. Please consult with your doctor before doing or taking anything.
4. Never ignore a head injury. When in doubt, sit the athlete out.
Have you ever wondered how this prescription drug abuse epidemic spiraled out of control? How did we let this happen? Who are the major stackholders? These powerful drugs were developed with a real noble purpose, but soon cycled out of control. Was it our own doing? Similar to cigarette companies, pharmaceutical executives have become significantly rich at the expense of bringing incredible harm to all of us. This is our terrible reality across all industries - greed always results in harming everyone involved. Physicians have been screaming about the dangers of these medications, but lawmakers continued to ignore them Why do we do this? Ignore the scientific community for the mighty dollar. Whether it be the approaching epidemic, rise of harmful medications or technologies, or gun control - the concern for financial profits always win.
The commercial manufacturer of morphine started out in Germany in 1827. In fact, morphine was the painkiller of choice during the American Civil War. Interestingly, the doctor who invented Coca Cola formula had developed a morphine addiction during the Civil War and in their attempts to solve this issue, cocaine was sought. The new drink had cocaine mixed into it and sold to a pharmacy in Atlanta. During that time, this was perfectly legal.
Heroin was created by Bayer Company in Germany in 1898. It's sole purpose was to be a remedy to the morphine addiction. Legislation, like The Pure Food and Drug Act of 1906 and Harrison Narcotic Tax Act in 1914, brought these addictive substances under the control of physicians; preventing casual distribution of these products.
The current problem:
Factors that contributed to such growth:
The number of prescriptions has increased from 76 million in 1991 to nearly 207 million in 2013. The United States is the biggest consumer globally.
What does it mean for the pharmaceutical companies?
It means more than $35 billion in sales since releasing medications like OxyContin. Annual revenues are about $3 billion for pharmaceutical companies selling prescription drugs.
So, what does all this mean?
Well, let's see...
A medication or family of medications whose sole purpose was to help the soldiers during war starts to be sold unregulated to people around the world. Then as addiction starts to develop and people take notice, regulations are made to help control its spread, but either inadvertently or not, products like cocaine and heroin are used to "remedy" the situation. This leads to more addiction.
Meanwhile, the US health system was undergoing major changes. In attempts to control costs in the 1960s-1990s major developments in public and private health plans were developed. Not too surprisingly, as the managed care organizations were attempting to control costs, US health expenditures started to rise, while reimbursement started to fall. Pharmaceutical companies started to market heavily and capitalized on a health care system that was reducing clinic visit times to an average 7-10 minutes, which led to more written prescriptions.
Sound familiar? Our country has a HUGE antibiotic resistance problem where antibiotics are prescribed unnecessarily. The American public doesn't see the "super bugs" which claim many American lives where these bugs are resistant to ALL available antibiotics.
Pharmaceutical companies do not invest in making more antibiotics as there is more money to be made in drugs that are taken for a long time, instead of the 5-7 days regimens that are usually prescribed for antibiotics.
But, we digress.
So what does the US government do to fight this epidemic? Spend more money where it doesn't matter! The President signed legislation that authorizes $181 million a year for new programs to train emergency personnel in administering drugs to reverse opiod overdoses and help communities purchase those drugs, as well as develop treatment and overdose programs.
This means that pharmaceutical companies have more buyers for medications like Narcan and other products. Which leads to more profits! These treatment centers will be overwhelmed with the large demand as the public now has available "quick reversal" agents. This sends the wrong message and does NOT get to the root of the problem. Those of us who have taken care of overdose patients know that the problem does not cost so much money, development of more "reversal" agents, nor does it require capital investment to create "treatment facilities." The solution is simple: Establish a human connection involving time to talk, engage, motivate, build strong relationships, and bring people together.
What does this solution look like more specifically?
All physicians, including specialists, are demanding better primary care. Longer visits allow for conversation and developing a plan that may include various pain control options outside of prescription medications.
The primary care setting is the place where opioid management should take place. Why not? The primary care physician is the leader of their care; the quarterback who is most likely or should be managing multiple health issues. They are the ones who spend time with the family, loved ones, might even have done a few house calls, knows what barriers exist to better health, and is the one making referrals or partnerships to bring more solutions to their delivery of care.
This is what true primary care looks like. Not a place to get a referral to a pain specialist or some methadone clinic. Why do we accept such nonsense? Let the primary care doctor to what they are trained to do. The health system must support and allow this interaction to happen because this small investment will prevent huge costs in the future. Psychologists, counselors, psychiatrists, social work, and others might need to be involved. More importantly, there cannot be a delay in seeing each of these specialists and there needs to be total - 24/7 - contact between physician and patient to prevent "loss to follow up."
This solution is cheaper, preserves human dignity, and most importantly it gets to the root of the issue - whether it be economic stress, poor family interactions or challenges, depression or other mental illness, or poor medical management of pain.
I am optimistic that the American people will speak out and share their personal experiences with a direct primary care practice. Soon, the current momentum that is already motivating public and private insurance companies offering "total health " plans that has a direct care flavor or large health systems offering more ways for patients to connect with them, will lead to national support for direct care. The challenge will be for physicians to prevent corporate greed getting in the way of our patient care.
To a healthier America,
February 1, 2015 was the day I broke free from the insurance run health care system. After several years of being a staff physician at a large health system, medical directorship, running research studies, writing articles, being a pharmaceutical consultant for 2 large companies, I realized I cannot change this system from within. Corporate greed was too great for a young physician to fight.
Each year I practiced medicine, I met another hard working American who waived his/her plastic insurance card, yet could not receive accessible or affordable primary care. I have met many other hard working Americans who couldn't get coverage regardless of the Affordable Care Act (ACA).
The final story I could tolerate came when I met a 35 year old female who suffered a massive stroke and had to have her skull drilled to relieve the growing pressure from a massive brain hemorrhage.
I took over her care after she had been moved from the ICU to the floor. My job was to figure out why she had the stroke, prevent the next stroke, and aggressively pursue rehab. I had triaged her as one of my last patients to see as she was reportedly stable.
I knocked on the door and found a young brown haired caucasian female laying quietly in a dark room, alone. Her hair was disheveled as she had staples on one side of her scalp with part of her head shaved, allowing exposure to her staples. She looked exhausted. Unlike the other rooms, there were no flowers, no cards, no "Get Well" balloons. It was just her, a beeping IV pump, and a computer next to her bed. The guest couch and chairs sat empty in the corner of the room. The 42 inch TV was turned off. The large window provided some light as it penetrated the dark window and the window shade. Upon my entrance, she turned to look at me with sad eyes and managed to smile half way.
I pulled up a chair next to her bed to listen to her story as I did with every patient. She readjusted herself, which was challenging as her entire right side was still weak.
You see, she was a young 35 year old single mom who was working 3 part-time jobs, because her employers did not want to offer a full time job as that would require them to offer her health insurance under the current laws. So, she did not have insurance because of this. Her story began with a visit to an urgent care center where she was told she had high blood pressure and she was given a medication to help control her blood pressure. She didn't understand what high blood pressure would mean if it is not controlled. After taking the medication for a few days, she simply stopped taking it because to her it was all numbers and certainly didn't make her feel any "better." Besides, she was a young 35 year old and so how bad could it be?
In reviewing her records, it seems she had presented to the ER with a blood pressure of 220/120. Likely, her blood pressure was the reason for her stroke and head bleed. The medication she was on for high blood pressure is $4. Needless to say, I can get this medication for my patients now for $0.87 for a month supply.
As her story continued to unravel, I started to stoop lower and lower in my chair. My mind started to race with anger. How can she be so abandoned? Why did no one tell her about the importance of blood pressure? Where was the follow up visit? How is this fair? She is a contributing American citizen to our economy, yet we abandon her?
To put all this in perspective, here she is as an uninsured patient with an ICU stay of 5 days, surgical drainage of blood, multiple imaging studies and labs, she couldn't move her entire right side and so will need 6-8 weeks of rehab. One of her jobs was being a waitress. There is no way she could return to this line of work. In essence, we have effectively bankrupted a young, sweet, innocent, 35 year old single mom.
After she had completed her story, teary eyed, and by now I was almost laying in my chair, I straightened myself and leaned forward towards her. I said,"ma'am, I am so sorry for all this. We have failed you. I as a representative of the American health care system have failed you. For that, I am sorry."
I went on to explain how important blood pressure is to control and how we can prevent another stroke. I left that room with only one thought in mind...NEVER AGAIN.
Never again would I allow myself to be in that chair hearing a story like that from any of my patients. My mind was made up to offer the best primary care I can, regardless of insurance status.
Many people do not hear the stories that we as physicians hear. Yes, you pay for insurance premiums, but for primary care, that insurance card likely is not getting you the best care. Think about it. Some pay $25 to over $100 in copay per visit for what? A 10-15 minute visit that feels rushed or is not comprehensive. Or be sent to a specialist, procedure, imaging study, or be prescribed pills when in reality you probably didn't need it. These decisions are made simply because there is no time to get to the root of the problem.
The follow up is the most important component of primary care. Start a gameplan and then you need to follow up maybe in a week or 2 weeks. But eliminate the copays that people have to pay to make the follow up more feasible. This is where direct care makes sense and saves money.
The young and healthy individuals also save money and gain value in a direct care model. Simply put, casting, medications, EKG, suturing is FREE or at a minimal cost in a direct care practice. Time and money is saved. But, think about the value. That young and healthy individual is probably going through some emotional roller coasters. What are their aspirations? How strong is their social network and who are they? Who do they spend time with and how are they dealing with any stressors they may have? Are they exercising and eating healthy? If they do exercise, then are they doing it safely? Do they practice safe sex? Where are they planning to travel? Are they overweight? Do they have family history of diabetes or heart disease that predisposes them to these conditions?
These questions are so important that essentially a life can be saved by simply talking to them. These young adults are connected to their physician by a simple text or video chat under a direct care model. How neat is that?
This is the value of direct care with or without health insurance. Take the time to understand what you are paying for when purchasing a health insurance plan. Our patients with Medicare and supplement insurance will say the value of access, coordination of care, and availability overwhelms the minimal monthly cost.
Health insurance and direct care together make a phenomenal resource for all Americans to live well. Quality of life will be enhanced. Our health expenditures will go down. Taxes will be reduced and employers will be able to retain their talented workforce. Increase in direct care practices will solve the primary care shortage, lead to more young physicians embracing private practice to revive the practice of medicine, technology will be used to bring accessible health care into the home, and the American people will be empowered to navigate the health care system with more confidence. Together, we will achieve a healthier America.
Give a direct primary care practice some consideration. Visit iwantdirectcare.com to learn where the nearest direct care practice is for you.
Welcome to the new US Health Care System!
Scoliosis, as many of you know, means lateral curvature of the spine. It is a structural alteration that can progress as the person grows, leading to significant deformity. Adolescent idiopathic scoliosis (AIS) is typically defined as curvature greater than 10 degrees. Curvatures that are less than 10 degrees have no long term clinical significance.
The 3 subcategories include:
- Infantile (0-3 years)
- Juvenile (4-9 years)
- Adolescent (>10 years)
So how common is AIS?
The prevalence of AIS is approximately 3% and only 10% of those adolescents require treatment. Males and females are affected equally. However, the risk for curve progression is 10 times higher in females than males. The degree of curvature is measured by Cobb angle. When considering prevalence, think about this:
So if a family member or friend has scoliosis, first appreciate their strength and uniqueness, and then ask about their angle if they wish to share. Knowing that piece, one can greatly appreciate the prevalence of their condition.
It may surprise you, but your primary care doctor can screen for scoliosis, diagnose, order the X-ray, and even start brace treatment if needed. If surgery is indicated, your primary care doctor can coordinate efficiently with an orthopedist. Point is, don't run to an orthopedist the minute you hear about scoliosis. This diagnosis, like any other diagnosis, requires a conversation.
What does having scoliosis mean? Do I have to have surgery? What are the post surgical challenges I may encounter as I am recovering? Even after treatment, what should I worry about? What about pregnancy? What about sports or even contact sports? Is this genetically linked that I need to have my kids screened? What about working out - any precautions I should take?
So, what does all this mean in adulthood?
Regardless of getting treatment or not, there definitely are clinically significant concerns one may face as they enter adulthood. Even when the spine is corrected to midline with surgery, individuals must be cautious when weight training, aerobic activity, and may have chronic back pain. The muscles that support the spine have to adjust and may be prone to strain. Rotation is largely limited in the surgically treated spine, so one may not be able to participate in some activities.
Mental health studies have yielded conflicting results based on surveys. My opinion is that this only reminds us that diagnoses are perceived differently by each one of us. I argue that your perception of your diagnosis, whatever it may be, is facilitated by your team of doctors. As physicians, we have a duty to treat illness, but also to be a coach, a friend, and most importantly a partner in any journey that requires chronic management. Positive thinking and supportive behavior has shown study after study to improve outcomes - that is the job of the physician. Be a true advocate and partner.
After surgical correction, pulmonary function improves, but skeletal alignment may still have long lasting joint pains.
In those patients where surgical correction is not done, the curvature can progress and cause more pain with pulmonary issues. As our bones get weaker with age, the spine may slump even more leading to alteration of your gait.
Surgical correction at times requires repeat operations, scar healing, and hospitalizations can be prolonged. Thus, the sooner we can screen and treat, the better outcomes we get. Self-image might be an issue in adolescents. Wearing a brace or having visible scars after surgery may leave keloids that challenge an adolescents self image.
Scoliosis is a condition that must be identified early, have a management plan, and must be included in long term management. This is not, like any other diagnosis, something that is "repaired" and forgotten.
Build a relationship with your primary care physician to be at your side as you enjoy the many blessings life has given you. Nothing is impossible. We just have to make some adjustments with the challenges that are thrown our way.
Please help me raise awareness about scoliosis and I hope I taught you something new about this condition that you may not have known before.
To your health and our community,
Memorial Day was originally established to celebrate Civil War heroes in a single unified day, instead of separate days celebrated by the Union and Confederate states. Around the 19th century, Memorial Day expanded to celebrate all veterans who fought as American forces.
As physicians, we learn from one another and are united in our thirst for knowledge to better serve humanity . War, in all its ugliness and chaos, demands innovation in science and technology. Thus, it is not surprising that modern medicine seems to have strong roots during times of war. The ancient philosophers and scientists created a foundation for physicians during the Civil War to innovate to meet the demands of its wounded soldiers, but also to create standards of care that we practice even today. Here are 5 innovations that were developed during the Civil War:
1. LIFE SAVING AMPUTATION
- The old practice of saving limbs with wound cleaning using rats and maggots was replaced with cutting off infected limbs to prevent the spread of infection. In fact, Union soldiers were known for amputations, had less mortality from their procedures, and took no more than 6 minutes to perform. The technique not to cut through joints and to cut far away from the heart as possible became the standard of care.
2. THE ANESTHESIA INHALER
- Stonewall Jackson's surgeon recommended the removal of his left arm after it was injured during friendly fire. When a chloroform-soaked cloth was placed over his nose, General Jackson muttered, "What an infinite blessing," before going limp. The cloth was inefficient as the liquid evaporated quickly, so Dr. Julian John Chisolm invented a 2.5 inch inhaler. Chloroform was dripped through a perforated circle on the side onto a sponge in the interior - the patient inhaled through tubes and the vapors mixed with air. This new method required less liquid; thus, allowing the physicians to treat more soldiers and using less supplies.
3. CLOSING CHEST WOUNDS
- Benjamin Howard, an assistant surgeon, was told to do busy work while his superiors performed the surgeries. He started to experiment and realized that if he closed the chest with staples and linen, the lungs did not collapse as they did when the chest cavity is opened from negative pressure; thus, there was no suffocation. Survival rates quadrupled with this new technique. This technique became the standard treatment.
4. FASCIAL RECONSTRUCTION
Dr. Gurdon Buck, father of modern plastic surgery, looked onto a young 20 year old private named Carleton Burgan of Maryland. This private had battled pneumonia and now the mercury pills had led to gangrene that was moving from his mouth to his eyes. His right cheekbone had to be removed and the young man was willing to try anything to stop the infection. Dr. Buck was the first to photograph his progress of his repairs and use tiny sutures to minimize scarring.
5. THE AMBULANCE-TO-ER SYSTEM
- The Union went into the First Battle of Bull Run on July 21, 1861 not expecting a true battle. As approximately 1,011 Union soldiers lay wounded, the ambulances remained empty, leading to high numbers of mortality. The civilian drivers at the time were, according to some, described as "cowards" or "drunkards."
Jonathon Letterman, the medical director of the Army of the Potomac, created a model of triage that we all know today. He established caravans of 50 ambulances, each with a driver and 2 stretcher bearers. He hired private wagons to carry medical supplies. The ambulances had spring suspensions and a lock box to prevent soldiers from stealing protein, bedsacks, and morphine that was reserved for the injured.
Every war brings innovation and the medical community must not forget the sacrifices made by soldiers, scientists, physicians, and several other professionals who made modern day medicine what it is today.
In this reflection, we must ask the question, have we been effective in preserving that fundamental drive that our predecessors had to innovate to help a large number of people without regard to creating any complex systems that may interfere in allowing the injured to access the innovation?
Memorial Day should make all of us pause and reflect on the many lessons learned across all professions during our times of war. What is even more fascinating is that those lessons continue to teach us today; regardless of how advanced we think we are as a society.
In loving memory of all fallen soldiers,
"He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."