Published in the Boston Business Journal April 7, 2017:

The longer Republicans debate and dissect the Affordable Care Act, the more people are turning to Direct Primary Care (DPC) physicians. Unlike the recently proposed American Health Care Act — and the Affordable Care Act it is seeking to replace — direct primary care is both affordable and easy to understand.

The rising popularity of DPC practices in Massachusetts and in more than half the states where it is being practiced is in stark contrast to the utter confusion and fear that has ensued since Congress and White House set out to repeal Obamacare. A health care system once focused on prevention has given way to expensive intervention and specialty care. Experts disagree on how to fix our health care system, but it is well understood that what has been driving up the cost of health care are prescription drugs, overutilization of our hospital emergency rooms for non-emergency primary care, escalating prices for medical procedures, and unnecessary diagnostic tests. What patients — and doctors — need from our health care system is simplicity. Think of how we use car insurance to protect us from personal injury and car damage — not for the replacement of tires or windshield-wiper blades. We shouldn’t use health insurance for routine primary care.

Rebuilding the primary care foundation of our health care system won’t fix all of what is ailing health care, but it would reset a system that now largely benefits the insurance industry and pharmaceutical companies. A study by the health policy journal Health Affairs found that a direct primary care practice they studied was nearly half the cost to the patient when they purchased a lower-premium, higher-deductible insurance plan. A 53-year-old man who would have paid $11,068 for a one-year $1,000 deductible plan instead bought a higher-deductible plan and cut his health care costs by more than $4,000 annually — and he actually spent more time with his physician.

During the course of an appointment that is typically an hour or longer, DPC physicians can figure out why a patient hasn’t been sleeping rather than just writing them a prescription and dashing off to the next 12- minute appointment. We get to know our patients, their diet, whether they are exercising. That consultative relationship is critical to prevention of future and expensive illnesses such as heart disease, cancer and diabetes. Direct primary care physicians aren’t necessarily better doctors — we just spend the time that it takes to be a good doctor and actually listen to our patients. But you can’t fix what you don’t have the time to see or hear.

The Boston Globe published an article on March 23, 2016  titled Even With Insurance, Mass Residents Often Can’t Afford Healthcare and I can’t even begin to explain how true this is. They really hit the nail on the head with this topic!  Being a young adult, I can completely relate to what it’s like to not be able to afford health insurance. Not until last year did I really begin to understand how expensive health insurance really is. I started working for a big company which offered “the best” health insurance (no need to mention names).  I was so excited to think I had this ‘top of the line’ health insurance.  It was all great until of course, I made my first visit to the ER. With a very expensive co-pay, high deductible, and multiple bills later, I realized how unaffordable healthcare truly is. Just as this article states, having health insurance doesn’t necessarily mean you can afford care. I immediately noticed- yes, I finally have “great” health insurance, but does it even matter when I can’t afford to go to the doctor? With the statistics from the survey BCBS conducted, clearly I’m not the only one in the same boat. As mentioned in the article “43% of people said in 2015 health care and costs had caused problems for them and their families, including 19% who went without needed care as a result.” How crazy is it that almost 50% of the people surveyed have issues with health care costs?!  That’s a huge percentage, which includes me, and possibly you too. We already have so many bills to pay and stress about, healthcare really shouldn’t be one of them. Another thing I noticed from the article are the comments being posted.  So many people are complaining about this issue, yet they don’t want to do a single thing about it or, perhaps, they don’t know of other options out there. I think it’s time we start doing our research as healthcare consumers and see what other options we have out there!

This article really struck a chord with me, especially now knowing about Direct Primary Care and really understanding what it is. I wish I would have known about DPC earlier, or even know DPC was an option. Of course we do still need health insurance, but why not choose DPC for our primary care needs? This way we don’t have to deal with co-pays or high deductibles from our health insurance, not to mention getting more personalized care, appointments in a reasonable amount of time and honestly, a real connection with your doctor. Why wouldn’t you want a real connection with your doctor?!  They are the ones who are dealing with a big part of your life; your health. The article from the Boston Globe should really relate to many of us, and also be an eye opener. With the results from the survey by BCBS, we can’t deny health insurance is way too expensive and we just aren’t receiving the best care for the amount we are paying. Instead, we end up with a huge headache because of very high bills and often poor to mediocre healthcare.

Written by Jessica Leon, Administrative Assistant; Gold Direct Care

Direct Primary Care is written into the Affordable Care Act as an approved method of receiving primary care as long as it is combined with a catastrophic insurance plan. (Isn’t that how insurance is supposed to work? But I digress.) The ACA clearly defines that DPC is not “insurance” and purchasing a DPC membership alone does not meet the standards of being “insured.” It is required to purchase at least a high deductible insurance plan along with it to be qualified under the ACA. See great article on this here: DPC Clause in the Affordable Care Act

However, on the State level, many legislators, policy makers, and Department of Insurance commissioners want to claim that DPC is the “business of insurance” and should have to pay licensing and regulatory fees. In other words, paying a reasonable monthly fee for all your primary care needs should be regulated no different than Blue Cross Blue Shield, Harvard Pilgrim, etc etc. Having to pay fees of this magnitude would clearly put a small DPC practice like us out of business. We are not “insurance”. We are a primary care medical practice that chooses to work solely for our patients- not third parties- and therefore be compensated by our patients for what we believe is a reasonable monthly fee. About 15 states in the US have now passed legislation stating this as law. Massachusetts is not one of them and has yet to introduce a bill that by stating such protects us and our patients who choose us. We, along with three new DPC practices in MA, are tirelessly working on getting our legislators to listen to us and sponsor a bill.

As the first DPC practice in MA we were contacted by the Massachusetts Department of Insurance when we first opened in January 2015. With our legal counsel we have met with them and corresponded with them on this issue. It has been months of waiting and practicing medicine in an unclear regulatory environment. This weekend, much to my delight, I was contacted by my attorney with a letter from the DOI that has given us the green light to continue practicing medicine without 3rd party interference. (The letter is attached below a sit is a public document.) We are very thankful to Commissioner Daniel Judson and Deputy Commissioner Kevin Beagan for their understanding that what we are trying to do is solely for the benefit of the people of Massachusetts and the primary care doctors who want to care for them in a manner that echoes the “olden days of medicine.” Hopefully there are better days ahead for healthcare in Massachusetts.  (more…)

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?

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.