Opiates: A Painful Topic For Everyone
Todays Boston Globe has an article regarding physician prescribing of opiates to patients that have already experienced an overdose Opiate Prescribing to Patients With OD History. Between the documentary that HBO aired last night regarding the opiate crisis on Cape Cod and this article from today, I felt that as a primary care physician and as a resident of a seemingly “white-picket fence” suburb of Boston that has experienced its own opiate epidemic with the loss of too many good people- many of them kids-to this illness, it was worth commenting on. Many of these kids and young adults I knew and even played street hockey with as a kid. Others I did not know at all, but I can feel the loss when something like this happens.
I am not an Addiction Specialist or a Psychiatrist but as a Family Physician we do often deal with these issues and are usually the front door to the healthcare system. I have treated many patients that struggle with the disease of addiction and it is an extremely complex disease that is extremely difficult to cure and it usually coexists with other mental health diagnoses whether it be ADHD, major depression, anxiety disorders, bipolar disorder etc etc that add to the challenge. The hardest part of the disease to address initially is the denial. As a key cog in the wheels of this disease, denial is the toughest nut to crack. Just like any other chronic disease we treat, patients have to come to some degree of acceptance to move forward, and with addiction denial prevents this from happening easily. Sadly, we have no idea when that bridge of denial will be crossed and what the outlook on the other side looks like, but it needs to be crossed nonetheless.
I may be an idealist at heart and obviously have my biases, but I think one key solution to this epidemic is better primary care. People that struggle with the disease of addiction obviously need a multidisciplinary approach- one that includes doctors, nurses, social workers, counselors, addiction specialists etc- but they also need a primary care doctor that can help them navigate this messed up system, be the teams quarterback, and most importantly know them and treat them as a human being rather than just a “disease”. We need to ask the hard questions such as “with all the stories and news out there on this issue, what drove you to take that pill that started it all? what support system if any do you have? how can WE help YOU get healed? How do we as a community band together to educate and support our kids in a nonjudgmental supportive way? What are WE as a community doing wrong?” It isn’t all about the actual drug or the patient and the choices they have made. Its an US issue because it could be any of our friends, family members, or children that can succumb to this disease. And I don’t know about you but aren’t you tired of reading these obituaries week after week?
Our primary care system and mental health system need an overhaul for many reasons, but this epidemic is a big one. All patients of all socioeconomic backgrounds that struggle with this awful illness deserve better than 15 minute visits. They deserve better than more pills thrown at them. They deserve a relationship that is based on trust, care, and respect. What if the doctors that were studied in the aforementioned article had time to research records and databases during these visits? What if they actually had time to call other members of the patients care team? What if they had time to discuss the risks, benefits, and alternative options for pain management with their patients with appropriate, close followup and communication? I can personally attest to the fact working in the Direct Primary Care model has allowed me to treat patients with addiction 100% better. I have the time to listen, call other resources if needed, and followup frequently by phone or email. I am by no means perfect and do not always have success sadly. Yet there is one thing that DPC has allowed me to show the patient who struggles with addiction that all the Continuing Medical Education and seminars in the world do not even touch on and that is……that I too am an imperfect human being, that I do care, and that there is hope. I know this idealistic view will not solve the whole crisis, but maybe infusing some humanity towards these patients is a good start towards helping them heal and live a healthy life? What we are doing certainly is not enough and to me that is unacceptable.
Happy Thanksgiving- A Honest and Heartfelt Thank You Note
It amazes me to think that at this time last year, though Gold Direct Care was so close to becoming a reality, it was still in many ways a figment of my imagination. So it is in a state of disbelief and gratitude that I’m writing this post, focusing on what I am thankful for this holiday.
I chose to leave the “established healthcare system” after 10 years of practicing in it, because I knew there had to be a better way to give and receive care. The two key groups of people who actually make the healthcare system breathe- the doctors and the patients- deserved so much more and so much better. I realized the only way I could possibly make a positive change and deliver care in a better way was to leave the existing, broken system and hope that others would follow. I hoped the level of care and the relationships I had nurtured with my patients would trump the admittedly steep curve of subscribing to a new model. As I well know, change can be hard even when it is a positive one. Despite huge opportunities for cost savings ( read post by Dr Patrick Rohal from Lancaster PA here: Why In the World Would I Pay TWICE for Healthcare), I worried it might be difficult for my patients to feel comfortable paying out-of-pocket for some services. Then again, I also figured so many people would be thrilled to regain control of their health care and health care dollars that they would jump at the chance to improve on our existing, personal doctor-patient relationship. People seemed to crave “old-school” medicine. I heard all around me patients talking about the value of “good” health care – this made sense.
It was never out of egotism, rather out of the work and care that I had given to my patients that made me believe a significant number would follow me. I had 2,500 patients or so on my “panel” and knew that I would need around 700-800 to make a Direct Primary Care practice sustainable. So, in the first couple of months, when only a hundred or so patients moved to the new practice with me, I wondered if I had been wrong. Had I deluded myself into thinking I was more valued by my patients than I actually was? Did people truly want a better relationship and more access to me as their physician, or is that just trendy to say? Were people honest when they talked about how important excellent care was to them? Had I misread everything?
I had invested so much into my patients and tried my best to develop real relationships with them, albeit in rushed 15-to-20 minute “traditional healthcare model” intervals, that I believed the same was felt on their part. See, what I always valued most was not my salary, but the privilege to take care of people. Yes, I like money just as much as the next person but let me tell you, med students do not choose a career in Primary Care for money. They choose it for the relationships with people. That’s why I chose Primary Care. I wanted to develop real, longitudinal relationships with my patients and truly care for them…providing that real value that they were saying they wanted and that everyone deserves.
But at the end of the day, value is determined by how much we are willing to spend on something. And so from January through about April of this year, I felt quite devalued as many of my patients elected not to pay out of pocket to keep me as their doctor. I share this, not to make anyone feel bad for making that choice. People have a variety of reasons for the choices they make- especially in a scary and complex industry such as Healthcare- but it was quite hard not to take this choice personally. I mean, medicine, particularly primary care, is personal after all. So please understand that I share this solely as an honest description about what I felt and how I viewed things at the time. I have looked at this from all perspectives as I too am a patient after all.
When pricing for my services, I tried to be as reasonable as possible without selling myself too short. I wanted to be accessible to my patients while developing a sustainable business model that supports state-of-the-art facilities and equipment, an unbelievably convenient location and – most importantly – time. If I was to be the change in the broken system, I needed to make sure the new model was set up to allow me and a growing team the time to nurture patient relationships and provide real primary care. The end result was that I settled on a maximum of 125/month, which is less than most monthly cable bills and a coffee a day if you look at it from a dollar perspective. Surely people who had been crying out for better care, better access, better Doctor relationships, less wait times, less frustration, less – well – crap would consider this a huge value. So to put it bluntly and honestly, I often felt heartbroken during those months.
After those few months of feeling sorry for myself, focusing my energy on why I now had a huge population of “former patients”, and continuously asking myself , “did I make the right choice here?” I realized it was time to move on. It was time to focus on my mission of promoting the Direct Care model, and working to introduce my practice to new patients. Even more importantly, it was time to spend all of my energy on the 100 or so people that chose to come with me. They deserved what I promised them; it was this core group of people that would determine the success of my practice.
There was never one specific moment or incident that occurred to help me turn that corner and refocus. It was a gradual process of becoming a business owner for the first time in my life and really just growing up. I focused on the positives of the change- such as new patients excited to come on board, seeing more of my old patients trickling back to me, and enjoying my ability to actually doctor in the manner I always wanted.
So here I sit, writing a long thank you note on Thanksgiving Eve to those 100 or so patients that stuck with me right from the start. I hope you read this so you can truly know and understand how thankful I am for you seeing the value in keeping me as your doctor and in my lofty endeavor of fixing a truly archaic and dysfunctional system. It is because of early adopters like you that my practice is growing and thriving. It is due to your willingness to go against the grain that we now have Dr. Mancini with us. It is certain people who dropped a Medicare HMO plan to switch to regular Medicare so that they could keep me as their doctor that helped heal a broken heart and revive my belief in the value I provide as a Primary Care physician. I am so thankful to you and the rest of the Gold Direct Care patients for believing in me and for taking the first step towards a better quality, more humanistic, and ultimately a more affordable healthcare system.
Thank You. Thank You. Thank You.
And finally…a big thank you to my nurse Meghann Dunn who was there from the beginning because she believed in my mission. Our patients and I are very lucky to have her.
Now feel free to go stuff your face with turkey and loads of carbs. Happy Thanksgiving to you and your families!
Dr. Carmela Mancini Joins Gold Direct Care
Hello, I am Dr. Carmela Mancini and I have recently joined Gold Direct Care. I am so excited to be a part of the Direct Primary Care movement! Like many physicians in today’s healthcare environment, I realized that my idea of being a doctor was not possible in the current system. I wasn’t able to spend the necessary, quality time with patients; decisions were often based on what insurance dictated and not what I thought was medically appropriate; there was disintegration of the doctor-patient relationship. This is when I discovered Direct Primary Care and I have not looked back.
I am board certified in Internal Medicine and have spent the last several years as a hospitalist. Prior to medical school I received a Masters degree in Public Health and spent 5 years as a public health advocate and epidemiologist. I subsequently went to medical school at Nova Southeastern University and eared a degree in Osteopathic Medicine. I completed my residency in Internal Medicine at Baystate Medical Center in Springfield, MA.
I am very excited to be accepting new patients. Please contact the office at 781-842-3961 or email me at firstname.lastname@example.org to schedule a free consultation.
For those of you interested in learning more about Direct Primary Care please attend one of our information sessions at the Salem Waterfront Hotel (225 Derby Street Salem, MA 01970) on November 9 (1-3 or 7-9) or November 17 (1-3 or 7-9). Go to http://findnsave.wickedlocal.com/Local-Ads/a-634135/Gold-Direct-Care for complete details or call 781-780-2461 to RSVP.
End of Life Care: We Can Do So Much Better (Dedicated to Wilbur)
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.
Reasons # 2 and 3: Happy Birthday
I want to dedicate this entry to my now 6 year old twins- Cameron and Isabella. It is amazing to me that time is going by so quickly and that you two are already 6 years old! It seems like just yesterday we were learning how to give you your first baths, and now you are in Kindergarten learning how to write and count. You are now talking back instead of just screaming….although often there is still some screaming. Your are playing soccer, learning how to skate, tumbling, building legos, and all of these other amazing things that are so enjoyable to watch. Yet, most importantly, you are constantly inspiring me to be a better person.
You are a significant part of the reason why I left a well-paying job as an employed physician to put us in debt and start this practice. I know its often hard when I am working many hours trying to take care of patients or working to grow this business, but I want you to know that you are why. I love when when you both ask questions like “how was your patient?, are they ok?, did you get any new patients today?” It shows me that we have taught you to care! In the crazy world we live in we are often bombarded with ugliness and what people are doing wrong. I want you to have a dad who shows you what is right. I want you to see that doing the right thing is not always easy and that people may act like you’re crazy, but to keep doing it. Do not give in to naysayers and fight for what you know and believe to be right. If you do these things you will never fail. You may have to “regroup” and find other solutions sometimes, but you will never fail.
As one of my boyhood idols Wayne Gretzky once said: “You miss 100% of the shots you never take.”
So always take the shot- or at least pass it to someone who has a better scoring chance. And thank you for driving me to be the type of doctor, father, and person that I want to be. As much as I love medicine, I will always love you guys more. I hope you always know that. So Happy Birthday and enjoy the gifts that you will play with for 5 minutes and then never touch again 🙂
ICD-10: It’s Nice Not Knowing You
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:
And finally, here’s to being part of the solution rather than adding to the problem. We thank you for your support and for being willing to do one of the hardest things for anyone- change.
Our Lab Prices
Because DPC is known for it’s price transparency, this is a list of our most common labs and their prices. If you don’t see a test on here which you would like to know the price of, don’t hesitate to send Meghann an email at Meghann@golddirectcare.com.
Harvard Medical School Meets Gold Direct Care
I am writing this as a sincere thank you to the Research Team and Incite Health at the Center for Primary Care at Harvard Medical School for taking the time to visit us this summer to see and hear what Direct Primary Care is all about (Here is link to story: Harvard Medical School Team Visits Gold Direct Care). If an institution of Harvard Medical Schools caliber can get behind this model of care, the potential for growth and implementation is boundless. Hopefully, we showed their team that the simplistic model of Direct Primary Care in combination with an appropriate high deductible/Health Savings Account insurance plan accomplishes everything that the Quadruple Aim is about:
- Lower costs….even for insurers
- Better health outcomes
- Happier Doctors
- All of which lead to the most important goal….HAPPIER PATIENTS!
Hopefully our relationship with their group- as well as other medical schools- will continue to grow as we continue our efforts to get more patients, doctors, employers, insurers, and legislators to buy into an old but new model of care that actually makes sense for all. The top down approach is not working so why not ground up?
Me, My Son, and MassHealth
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 this is a quick and short post, but I just wanted to write something today and dedicate it to all of the people and families who lost loved ones on 9/11. The first responders that day- the police, firefighters, EMTs, doctors, nurses- and really everyone that helped others out that day, showed the good side of people in this country. They showed the side that cares for others and that risks their own wellbeing to help others in the face of tragedy. Too often all we see in the media is the bad side of people, but there is a really good side that sadly often gets overshadowed.
So my hope is that we find ways to “Never Forget” every day- not just 9/11. Remember what you felt like that day and try to nourish the kindness and good you witnessed on a DAILY basis -not just when tragedy strikes. That is what I hope we are doing with this type of medicine- bringing back the humanity. We need more in medicine and we need more in our daily lives. Thanks for reading and never forget.