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!

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.

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.

So the main question we get asked a lot by former and prospective patients regarding  DPC is “why should I pay you when I already pay insurance”?  This is a very good question and I think I have a very good response- what value does insurance give you? Insurance value should be that you pay as little as possible upfront (the premium) in the hope that you never have to use it. That way,  you get to keep more of your hard-earned dollars in your pocket rather than in the hands of an insurer. You then have the money in your bank account if– god forbid- something catastrophic happens. Yes, you may have to pay a deductible but this is again a “what if. ” Insurance is supposed to protect you when the big unexpected stuff happens not the everyday stuff. Think of it this way: do you pay your contractors, plumbers, landscapers, etc with your home insurance?? Do you pay for gas, oil changes, mechanical issues, tire rotations, etc with car insurance?? The easy answer is no! So my question is why are we paying for affordable, routine primary care with 3rd party insurance? Instead, why not:

1. pay a Direct Primary care doctor an affordable monthly fee to cover all of your primary care needs (no copays, no deductibles, no hidden fees).  Even better we have negotiated cash pricing on routine labs, imaging studies, and most common medications (our cholesterol panel cost $4.00)

2. Carry a lower premium high deductible plan with an HSA account (tax free savings in your bank!) and be protected against the big stuff if and when it happens- i.e. hospital, surgery, cancer, heart attack, accidents, etc

3. Have your own personal primary care physician available to 24/7 through any form of technology- text, cell, Skype, even twitter! We work for you- not insurers or the government. And I include visits to the hospital and do home visits for 30-50 dollars. 

So there is the value now lets look at the perspective. Our maximum monthly rate is $125 for age 65 and over. Here are some examples of “value/perspective” to ponder:

1. This year the average household cable TV bill in the USA is $123 per month

2. Average cell phone bill $73.00 per month

3. Dinner at Uno’s for four averages $60 without tip

4. Going to a movie averages out to a minimum of $60 including tickets and food for a family of four

5. A filet at Abe and Louis is $48

and here are the final two- which people have daily- that amazes me….

6. A regular size latte at Starbucks is 3-4 dollars. 

7. A medium hot coffee with bagel and cream cheese combo at Dunkin Donuts is $3.69

I will leave the math to you the readers. Hopefully, my analogies and the value that we provide for people are clear. What is more important than your health?

If you wish to read further about what a typical family of four pays out of pocket in the USA for their “employer-based” insurance premiums, copays, deductibles, coinsurance, etc please read the following link below. Or I can save you the time and tell you: $23,215.00. I think we provide high value, transparent, affordable care to our patients. So I leave you with a final question: Does your insurance provide this?

Milliman Medical Index 2014