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.
The Primary Care Shortage: How Significant Can an Email Be?
We often read about the Primary Care shortage across the country continuing to grow, especially in states like Massachusetts that have a higher proportion of specialists. Some will argue that its exaggerated but numbers do not lie. Call a local doctors office and find out how long it takes to be seen as a new patient- provided they are even accepting new patients. Well here comes Direct Primary Care with smaller patient panels of 600-1000 patients versus the 2500-3000 of typical insurance based panel sizes, and along with it comes the critics. “You are worsening access,” we are told. Well the reason access to good primary care is poor is because the system is driving medical students- all with plenty of debt- into higher paying specialties. The system is forcing good docs to leave medicine early- whether it’s to retire early, move into administrative positions, or even go work for insurers! I argue that Direct Care can fix this by providing a professionally gratifying, financially rewarding experience so that more students like the ones I teach from Tufts will actually want to go into the field.
Take my current 3rd year Tufts medical student Ian Murphy who states: “I felt that a career in Primary Care would be rewarding but financially unsustainable and mentally draining. After being here for the past 3 weeks, I am now encouraged to look at and explore Primary Care more closely before making a career choice.”
And finally read this email from Salem resident Jennifer Kugel that I received a few months back (with her permission of course). She will be spending a day with me this week.
I am a perspective medical school student looking to gain insight and experience into the world of medicine. I have an undergraduate degree in Sports Movement Science from Salem State University, and am planning to take the MCAT’s next April and apply by June.
I heard about Dr. Gold’s Direct Care initiative while listening to NPR a few weeks back. I was thrilled to hear that someone locally (I live in Salem) is trying to change the way healthcare is being run. When I got home I looked up his website and read through all of the pages and anecdotal stories. I was quite taken aback to find a doctor who was still interested in doing house-calls and practicing preventative medicine rather then dealing with problems as they come.
As with many people who want to become a doctor, I have envisioned it since I was a toddler. As I have gotten older and taken alternate paths to get my degree, I have continually asked myself why I want to BE a doctor. The answer is still simple; I want to help people. With healthcare operating the way it does, patients are not getting the attention they need, and problems are not caught soon enough. Too many decisions are based off of what people can or cannot afford, and not what is best for their life and lifestyle. To see that an established doctor wants to go out of his way to make the system work better for everyone involved is quite inspiring.
I would greatly appreciate an opportunity to shadow Dr. Gold and gain experience from someone with a vision of a better healthcare system. I am hoping that by the time I finish my medical school experience, that I may be able to take the vision and apply it to my own patient care.
Thank you for the consideration, and I look forward to hopefully meeting Dr. Gold in person soon.
This…is how we actually fix the “access problem.”
Retail Clinics: Filling the Void
Todays issue of the Boston Globe had a great article in the Business Section on the Rise of Retail Clinics and how they are rising to meet the needs of patients. The article is below for those who wish to read it and please read the comments, as they are always fantastic when it comes to articles on our healthcare system.
The main question I ask in this blog entry is: Why are these clinics popping up everywhere and having success? It is actually a very simple answer- they are filling the void that our fractured, third-party based healthcare system has left in its path of destruction of the physician-patient relationship. They are the callus on the fracture, but they are not the cast that will keep it fixed for good!
Patients used to have access to their OWN doctor or nurse when and if they needed them, even if it were for a simple question. Now, because of a warped third party payment system and corporate run healthcare, patients feel as if they are nothing more than a number on a list. They would rather go see a doctor or NP that knows nothing about them at a pharmacy than their “in-network listed ‘PCP’ “. Why? Because they do not want to listen to a 5 minute list of menu options on a phone; they do not want to be on hold for ten; they do not want to wait to have their problem addressed for hours to days, especially when ill; they do not want to pay a copay or deductible for a rash that could be diagnosed with a picture; and most importantly they do not want to be rushed in and out in 10 minutes after waiting for 45! So do I begrudge companies like CVS for opening these clinics and do I begrudge patients for going to them? Absolutely not!
So whom do I have issue with? I have issue with a system that has been perpetuated for long enough to allow this fracture and pseudo-callus to form. The reason I call it a “pseudo-callus”- and this is in no way to be disparaging to the doctors and NPs who work at these clinics- is because they are not the patients OWN doctor. Are the “providers” at these clinics going to be there when that simple cough turns into a lung mass or emphysema? Are they going to be there when that simple UTI is actually a bladder cancer? No matter how excellent the quick care is, I ultimately believe that people still crave their OWN doctor. DPC not only fills this void, it is the cast that will allow this broken system to heal once and for all. And not only do you not have to “check with your insurer about coverage”, my monthly fee is cheaper than the visits to these clinics. See here: CVS Minute Clinic Prices
It is time doctors and patients look for the cast rather than the band-aid.
Boston Globe Article: Minute Clinics Rising
The Real Reason
Today, July 15, is a really important day to me- for both happy and sad reasons. This day in 1993 is when I physically lost my best friend. My grandmother, Bella, was and is a large part of who I am as a person. She taught me about hard work, determination, unconditional love, and empathy. She is also the main reason why I not only became a Family Physician, but also why I left the insurance-based system behind for this new endeavor of Direct Primary Care. I knew people deserved better because I knew she always deserved better.
My grandmother was stricken by early onset dementia at the age of 62 and rapidly declined over the course of my high school years until her death in the summer of 1993 following my graduation. Although her death was a finality, it was also a blessing. She never wanted to live her life the way she was at that time, nor did she want to be a burden on anyone. My family struggled to get her approved for Medicaid after she worked her entire life. As a result, we were unable to get her coverage for a nursing home. We cared for her at home until it was simply unsustainable. As awful as it was, it taught me what people deserve when they are ill. It taught me that we treat our animals better than we do our loved ones. The system was screwed up even back then. So she lived in the nursing home until her money ran out after which she died peacefully in her own home with me by her side.
I have always used this experience to guide me through college, medical school, residency, and now my career. I miss her guidance and love every single day, but I know that I am finally happy as a physician because of her. I will always look back at her and my relationship with her, but I will never look back at a system that prevents doctors and physicians from caring for each other and does nothing to secure the sanctity of the physician-patient relationship. Is that not what medicine was based on in the first place? Hopefully she is fully resting in peace knowing that her only grandchild is happily doing the right thing and being the doctor she knew I could be.
Here’s a Story of a Broken System (To Tune of Brady Bunch Theme)….The Sequel
Let me preface by saying that I can not and did not make this up. So after returning to work on Monday following the DPC Summit in KC this weekend, I went to check the mail and received this document from a Medicare Part D drug plan. (I did not include the image of the document here so as not to have the companies lawyers call me). This document is basically the 3rd party making sure that my patient is on the best drug regimen for his condition(s). Now on the surface this does not seem like a bad thing, but trust me when I say that what they are really looking for is a way to curb their costs.
So the comical part of this whole scenario is that they no longer have to worry about cost nor have they had to for the past 6 months. Why you may ask? Because that is how long this patient has sadly been deceased.
I would say that I’d be back next week at our regular scheduled time, but I am 99% sure something equally as asinine, if not more so, will come across my desk and/or mail in the next few days.
PS: I loved this patient and he would have had the exact same reaction. It would have been comical.
Here’s a Story of a Broken System (To Tune of Brady Bunch Theme)
Yesterday I saw a long time patient who is on Medicaid due to disability. He is a great kid that is legitimately on aid due to mental illness. He has not had the best hand of cards dealt to him, but has a loving grandmother who has raised him as her own. She pays me directly because she knows I have his back and she values the relationship I have built with him. They trust me to always do the right thing for him and their loyalty to me is very much appreciated.
So yesterday he called first thing in the AM with a complaint of 4 days of abdominal pain with no appetite and low grade fever. Now this guy is very stoic and not a complainer so I always know that something isn’t right if he is complaining. We got him right in and evaluated him. He had some point tenderness right over McBurney’s point (where your appendix is) and had a low grade fever. He needed a CAT scan to rule out an appendicitis which Meghann, my LPN, scheduled for noon at our local hospital. For those who do not understand direct care, even though I do not take payment from Medicaid, the hospital would just bill Medicaid for the CAT scan and lab work etc etc. If he did indeed have appendicitis we would get him seen by surgery and all of his care would be billed to Medicaid- essentially the taxpayers in MA.
Well it took no less than a 20 minute phone call to get this scheduled, after which Meghann is told that Medicaid will not “approve/authorize” the CT scan because I am not a “Medicaid provider.” Now some readers may think I’m the jerk for not contracting with Medicaid and your entitled to your opinion, but this patient has paid me to work for him. (Maybe after you finish reading this you will understand why I dropped out.) Now we have a patient who is sick, a doctor that is trying to treat him expeditiously based on years of training, and indirectly you the taxpayer all at the mercy of insane, bureaucratic nonsense. My only choice was to have him go to the ER and be evaluated….again….by another physician in order to get a CAT scan of his abdomen (with contrast an abdominal CT is about 600-800 per the Healthcare Bluebook). So instead of just paying this amount, as his CT was fortunately negative, your state bureaucracy decided it would be better to add on the cost of an ER evaluation and 5 hour stay as well to the taxpayers bill.
Does this make any sense to anyone? If it does than maybe you took a different economics course than I did. So there is a story of a broken system that just cost you a few extra grand because the doctor was regulated. Wonder how the system worked when the Brady Bunch was on? Did Marcia need a “Prior Authorization” from an “in-network doctor” to have her nose looked at after she got smacked in the face with a football?
Off to Kansas City to the DPC Summit today to try to fix this mess and get people the care they deserve.
Having ACA Insurance Often Means Being “Underinsured”
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.
DPC and Hospitalists
How does DPC help patients in the hospital? You can ask my patient quoted below or ask the Hospitalist who took care of him, but I would also like to comment on this.
There are many benefits to Hospital-based doctors (aka Hospitalists)- they are intelligent, well trained doctors and NP/PA’s and they provide 24/7 coverage if something goes wrong when you are admitted. We as primary care doctors used to practice hospital medicine as well as outpatient/office medicine, but for many reasons which is beyond the scope of this blog post, most if not all primary care doctors solely see patients in the office setting now. And there are many negatives to this which most patients who have been admitted to the hospital at some point can attest to:
- As good and caring as these doctors and NP/PAs are, they don’t know the patient like we do.
- Hospitalists often have a minimum of 10-12 patients on their census at a time some of whom may be very ill. That is a lot to manage.
- As a result of #2 and the amount of documentation and computerized order entry that goes along with it, hospitalists have very little time to call and/or email the Primary Care Physician with updates on their patients.
- This contributes to more fragmentation of care and increased costs to the system as a whole.
- Lastly, which is the worst in my opinion, is scared and confused patients.
So what does DPC do to help this? :
- We can actually come visit our patients periodically to check in and see how the hospital stay is going. The patient- like the one quoted below- gets to see their own doctor and be reassured that we are “in the loop.”
- We have more time to communicate with the Hospitalists regarding our patients histories, medication lists, social situations etc. This allows us to work in a collaborative way to ensure the patient gets the best care possible.
- I believe Hospitalists would appreciate this involvement rather than look at as us “stepping on toes.” We can provide information that the patient may not be capable of communicating or that they may not think is vital to their hospitalization.
- The end result is what healthcare should be about- BETTER OVERALL PATIENT CARE.
So here is my patients quote/review: “If U haven’t yet signed up with Gold Direct Medical Services, U R surely walking in the wrong direction! I recently had a several day hospitalization and was actually visited by Dr. Jeff Gold, and was also privy to a conference between him and the hospital doctor, to say nothing of the several daily direct calls to me in my hospital room from him. WHEN WAS THE LAST TIME YOUR DOCTOR VISITED U IN THE HOSPITAL?”
Some date on hospital medicine: