I am not writing about Covid-19 to make it a political issue (it’s not), to discuss what we should have and could have done better (hindsight is 20-20), nor am I writing about it to discuss all the fatalities and lives that have been adversely affected by it. It has been devastating for many people of all walks of life in so many ways- death, isolation, loss of income/jobs, loss of savings, etc etc. All these facts are known. The reason I am writing on Covid-19 is to try to see the hope in the devastation that it has caused. We as a society have a chance to better for ourselves and our children. We have seen the best and the worst of our society during the past few months. My hope is that we can be better to each other and for each other- learn how to meet in the middle on all issues, treat each other with respect, and have dialogue that may never end in an agreement, but that ends in mutually respectful disagreement with all parties learning something from one another. One of my favorite quotes is from Ayn Rand, who is admittedly a polarizing writer and thinker herself, but nails it with this one. “When I disagree with a rational man, I let reality be our final arbiter; if I am right, he will learn; if I am wrong, I will; one of us will win, but both will profit.”

With that being said, one thing I hope we can all agree on is that this pandemic has exposed the best of our healthcare system- the doctors, nurses, therapists, CNA’s, janitors, cafeteria workers, maintenance workers, etc that have kept hospitals/ERs operating like well-oiled machines so that people could be treated to the best of their ability, even while putting themselves and their families at risk by working every day with a lack of adequate PPE and support. Many have actually died themselves which I am pretty sure is not part of the Hippocratic Oath, yet they went to work because medicine is a calling not a job. Another aspect I hope we can all agree on is that the pandemic also exposed every aspect of our healthcare system that sucks. We are fragmented, the clinical staff of all ilks are underpaid and undervalued, we are overly expensive, and we are always reactive to everything rather than proactive. Ultimately, we don’t have a healthcare system, but rather sadly a “sick care” system. Being proactive, working to prevent chronic disease, and staying healthy are sadly not profitable nor “sexy”. Filling hospital beds, MRI machines, specialists offices, prescribing expensive drugs, and DOING more TO people rather than less are. Yet there is hope. We have an opportunity to rebuild a healthcare system that our children and grandchildren and generations following them deserve. We need this, but the question is do we want it badly enough? Do we really really want it? If you think we do then keep reading and ask yourself this- if given 5-10 million dollars to build a brand-spanking new ocean side mansion would you put it on top of a leaky, cracking, termite-ridden foundation?

My guess is that your response is a big fat NO. So now ask yourself why in gods name are we doing that in healthcare? Why have we devalued primary care to 7 cents of the dollar and a minute fraction of the spend from public payers like Medicaid and Medicare, from private insurers like BCBS etc, right down to the public itself that believes real primary care can be done well at a drive through clinic? In a ten minute visit? Costs nothing more than a 20-30 dollar copay? Can be done well by any Tom, Dick, Jane, or Harry with a white coat and initials after their name?! And these beliefs are mostly not the fault of you, the general public, as you have been brainwashed and trained over decades by the rulemakers- pharma, insurance lobby and bureaucrats- to believe them. If you do not believe this fact here is a reference: https://www.benefitspro.com/2019/07/26/u-s-spending-less-than-other-countries-on-primary-care/?slreturn=20200428161727 No wonder why our system is not affordable, easily accessible, and navigable?! Yet we- patients and doctors- can fix it. Let me restate that…it is UP TO US TO FIX IT!!!. From the bottom up, we can rebuild a system that works for us. We can be the rule makers. This is our chance for once and for all to stop relying on the wrong rule makers to fix it. As a dear friend and benefits advisor says “you can never win a game where the opposing coach and the referee are the same person. This is how we do it….

This article below was published in STAT news today and discussed how “Covid-19 has devastated independent primary care practices.” Well guess what? It isn’t Covid-19 that devastated it. It is the screwed up, inefficient, overly expensive way that we- or in most cases the way third parties like government, insurers, and self insured companies pay for it- and those dollars all come indirectly from working peoples pockets at hugely jacked up rates! It is what triggered me to write this post and urge people to help us rise like a phoenix from the ashes of this unfortunate nightmare that Covid -19 did nothing except shine a light on. https://www.statnews.com/2020/05/28/covid-19-battering-independent-physician-practices/?fbclid=IwAR17jbNkb02eHKZ0NKHh1Ue_3UiETM9PBsgfB87vSnE853nloCODjmKgk-k

So it is time we s&*t or get off the pot. For five years myself and many other primary care doctors across the country have felt like we are moving a whole beach by ourselves. We need help. We need the public to grab a pail and start moving some sand along with us, because it’s the wet, dirty heavy sand of the Northeast, and not the light, fluffy white sand of the Caribbean. NEWS FLASH! No one else is going to do it for you and if we continue to try to do it on our own we will burn out and fade away (which is already happening at alarming rates). Sorry but thats the reality. A contractor friend of mine says that a foundation of an average home is about 15-20% of the spend. Imagine if we did that for primary care in the US? Imagine insurance premiums that do not cost a mortgage? Imagine transparent, affordable care delivered to you the way you want with a doctor of your choice? All for less than 3-4 dollars a day? One can only dream. We all want change, but we often resist the path to change. Why? Because its freaking hard! So here is my call to action: grab your pail(s), walk with your feet, speak with your words and your wallets (and if you truly can not afford an average of 70 dollars a month for unlimited primary care, discount labs, imaging, meds telehealth visits- yeah hey policymakers/insurers us DPC docs have been doing them all included for 5-10 years so welcome to the 21st century- call your elected officials and demand a health savings account funded with money based on need to use toward primary care with Medicare and medicaid to cover all that happens outside of it). Stop using insurance like a credit card for stuff that doesn’t cost as much as a sandwich. It makes no sense. Join a DPC practice, or at a minimum, use an independent primary care practice that is not owned by an unchained Goliath- aka major hospital system. If you do not like the beast and hate what it has done to you and your income, be a David. Help us starve it until it dies. Find something positive out of the Covid-19 pandemic and act on it. Do it for those we have lost and for our children and grandchildren who did nothing to inherit the ashes of the Goliath that now rest upon the beach we all want. Or please….DO NOT complain. Take the PATH less traveled: https://dpcalliance.org/dpc-path. You may enjoy the hike. If not, I’m sure the cartel of “rule makers” will be there waiting to pull you right back in. “Where’s the tylenol?”

I know it has been a while since I have written anything, but it has been a bit since I have seen something that has really driven me to write about. Yesterday I happened to see an article that was in the Boston Business Journal regarding health insurance options for our state employees that are on GIC plans- police, fire, DPW, teachers, etc. The following is a link to a free version by Martha Bebinger at WBUR Major Mass. Insurers Dropped From State Employee Health System. The three major players that are now out are Tufts, Harvard Pilgrim, and Fallon. What I find interesting about this change is that the GIC is quoted in the article are saying that “moving members to a more limited, less expensive number of insurance plans will save the state $20.8 million in the next fiscal year with little disruption.” I am very curious to see what these premiums will look like to our valued state employees. As a self-employed business owner I had to do my renewal by January 1st and by choosing Tufts Direct I was not only able to have great hospitals like Lahey and Tufts Medical Center in the network, but also saved $400 a month in premium compared to a similarly structured plan (i.e. same deductibles etc) with Neighborhood Health Plan that is owned by Partners. So again, I am curious to see where the costs savings will be? I highly doubt it will be to the employees.

See the issue here is that no one is actually addressing the cost of health”care” and only focusing on the cost of insuring it. The public has been led to believe that everything in “healthcare” is so expensive that we need a prepaid “insurance card”- one with a very large finance charge while we are at it-  so we don’t go broke. The irony is that it is the actual cost of insuring everything under the sun that is making people go broke. So employers- including the state government- have only two options to keep their spend under control: 1. transfer more cost to employees by raising out of pockets such as deductibles/copays/coinsurance and 2. limiting the network of hospitals/doctors employees can use with restrictive HMO-type plans. (As already mentioned, given that one of the options left here is NHP is quite strange given that Partners hospitals/practices are much more expensive but let us wait and see what the premiums are.) As a result of union leaders not wanting to see their employees carry huge out of pocket responsibilities such as deductibles and the like, what other options does the state have? When you expect a third party to cover 90-95% of your care this is what will happen. You lose money and the freedom to choose.

So my question to all GIC beneficiaries is do you really think your employer and the insurance carriers they are choosing are going to help address this cost equation for YOU? Are they providing the actual care you receive? No they are not , but they are determining where you can and can not get it from. So speak up! I lost a lot of you as valued patients when I stopped taking your “payment/insurance card” and instead wanted to be paid directly by you for all your primary care at a reasonable monthly fee that averages out to $75 a month. Sadly what you did not see is how on your side I was and continue to be.  Your choices of payment cards are now fewer and fewer and my educated guess is that it will cost you more to carry the card(s) offered to you and fewer places where you can actually use them. So why not grab your local DPC doctor as an ally so that we can fight this fight together and get more options for you-  like say a higher deductible plan that works like real insurance by covering major expensive medical care not the affordable part like primary care (lower premium) and combine it with a Direct Primary Care option. The only way we fix this system and the cost to you and the taxpayers of Massachusetts is to disrupt it from the ground up instead of letting policymakers do it for you from the top down. If you need more proof or evidence that it works look at what my colleague Dr. Rushika Fernandopulle has done at Iora Health in Boston for GIC members on Unicare: Iora Health and GIC Combine to Offer DPC to Unicare Enrollees. Why doesn’t NHP, Tufts, and HPHC offer the same? Hmmm. Also look at what Union County in North Carolina has saved offering DPC to their county employees! And this is with only 40% enrolled in the high decutible/DPC plan! Direct Care Helping North Carolina Public Sector Save Big On Health Care Claims. If you’re really bored but truly want to see how this worked in North Carolina watch this video. It includes my fellow DPC colleague and friend Dr Amy Walsh. It may be an hour but it is well worth it in my opinion.

I am willing to speak with any town administrator, union leader, state official you would like. Just ask them to schedule a meeting. You, that provide our communities with so much service, deserve much much more when it comes to your coverage and your care. Remember, they are usually not the same. Thanks for listening.

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.

When is the last time you went to a Blockbuster Video store on a Friday night to peruse the shelves for a rental? Yup, almost ten years ago. The key question is why is it extinct? There are many obvious reasons- inconvenience of having to go search the shelves, finding out the movie you want is out, and the most obvious is innovative disruption by companies like Netflix and Amazon (see article from Forbes below).

The key component of the decline of Blockbuster Video/On Demand and the rise of Netflix is what network scientists refer to as the “threshold model of collective behavior.” In other words, this is how innovation takes hold and finds success in society whereas other products/concepts fail and drift away because they do not keep up and change to meet the needs of the consumers of the service. Blockbuster tried to adapt but it was too late. It dropped its late fees- which was their key to profitability- and spent approximately 400 million dollars instead. All the while Netflix was charging an affordable monthly fee, could deliver DVD’s to your door, and figured out how to stream content. And even though their library was not as extensive, their affordability and no hassle service made them what they are today.

So what in gods name does this have to do with me? Well, I think it is pretty obvious. The Direct Primary Care model is the Netflix of Medicine. You pay less than a coffee a day, or less than an average cable/cell phone bill a month, so that you can receive primary medical care the way it was and should be delivered. It is easy, accessible, transparent, dependable, and personalized. We bring care to you not vice versa. There may be a month when you stream ten different TV shows or movies (not speaking for myself of course) or there may be a month when you watch none, but Netflix is always there. DPC is the same, and more importantly, there is a personal relationship and level of trust that is built to help you stay healthy, be accessible when you’re sick and need care, and more importantly help guide you through the tangled web of the US Healthcare/Insurance system.

The current system of insurance-based primary care requires in person visits for all care in order to bill your insurance – even for matters that could be handled remotely with a quick phone call, text message, or Skype session. This same in person care requires copays/deductibles for each visit, provides a maximum of 10-15 minutes with your doctor on a good day, and is inflexible to scheduling around your personal life. Also, with more and more people on high deductible health plans cost is being shifted onto patients. How do you shop for elective, outpatient care like labs and imaging studies in a system of zero transparency? How, in a country as developed and wealthy as ours, did it take this long to apply simple, affordable innovation to the most important, yet most costly, consumer-based product we have- our health and well-being. The current model of insurance-based primary care is Blockbuster video. Where do you want to be when it goes bankrupt?

Endnote: it is well worth an hour of your time to watch this incredible lecture by David Goldhill- CEO of the Game Show Network and author of “Catastrophic Care- How the American Healthcare System Killed My Father”- that I was fortunate enough to be present at this October in Dallas. His book is also worth the read. Besides a mortgage, healthcare is the largest expenditure we have so be informed and learn.

If you want to learn more in depth details about the decline of Blockbuster, please read this great article from Forbes A Look at Why Blockbuster Failed

Yesterday Dr. Edmond Weisbart wrote this article for Family Practice Management (http://www.aafp.org/fpm/2016/0900/p10.html#commenting) which we posted on our Facebook page last night. He basically gives reasons why he feels DPC is not a solution to our healthcare crisis. I took the liberty of writing the below rebuttal which I have since emailed to their editorial staff for publication as well as a medical blog called www.KevinMD.com. I truly hope you will read this, and if you agree with my arguments, help us DPC doctors across the country that are trying to fight for you, our patients, and speak up to everyone. Send letters to your congressmen and congresswomen. Send it to our governor. Share it on social media. WE- patients and doctors- need to fix this as people are paying more for healthcare than their mortgages and getting less and less in return.

September 14, 2016

I am writing this letter on behalf of my fellow DPC colleagues in response to the Opinion piece by Edmond S. Weisbart, MD, CPE, FAAFP from your September-October issue titled “Is Direct Primary Care the Solution to Our Health Care Crisis?” I will be so bold as to answer Dr. Weisbarts questions with an affirmative “yes” and will try to respond to each of his bullet points.  For further reading that is excellently done and supported by fact please refer to Dr. Phil Eskews piece “In Defense of Primary Care.” (http://www.aafp.org/fpm/2016/0900/p12.html)

1. DPCs exacerbate the growing physician shortage: No Dr. Weisbart, plain and simply our current system is exacerbating the shortage of physicians. People who choose to go into a primary care field want to care for patients and not be burdened with an excess amount of bureaucracy that prevents them from following their oath to provide said care. One could argue that many physicians taking administrative jobs, such as a CMO of a pharmacy company, could also be contributing to the “care” shortage and access problem. Maybe we should stop doing that? And having a panel size of 2,300 patient is a good thing? If our system continues down its current path our primary care will be nothing more than an Urgent Care clinic.
2. DPC’s are essentially unregulated insurance, capitating physicians and removing vital protections: Where do i begin with this one? Insurance by definition is to protect people against major financial loss for major unexpected events i.e. life insurance, car insurance, home insurance etc. Primary care is not an insurable event, as everyone needs it and should have it. Primary care is actually highly affordable, but has been made expensive BECAUSE we insure it. And the difference between captivated plans from an HMO and DPC is that there is NO THIRD PARTY determining the capitated value for the primary care services. The sole value determinant is the actual patient. What a novel concept that we have completely failed to see since third party payers have stepped into primary care. You know? To help weed out those greedy PCP’s- compared to the affordable premiums people (many with chronic disease) are paying to to carry, only to have 3,000-6000 deductibles and zero transparency on pricing for outpatient services in the third party system. Plus, if providing your technical skills and knowledge for a set monthly fee is unethical or illegal, then why can lawyers, accountants, etc do this everyday? And as far as your HIPAA concern, in true DPC guess who has access to the patients file? me and the patient!. Thats it. No one else unless its the patients choice. Can’t get more private than that can you?  If I do sell patients info to vendors I am pretty sure my state BORIM and the exodus of my patients will regulate me sufficiently thank you very much. No other third party or acronym needed for that.
3. DPC relies on an erosion of medical benefits:  Lets look at your first sentence. The under-utilization due to HDHPs is actually due to the fact that people have no access to transparent care due to this third party payment cartel we have abided by for decades.  Secondly, the current system is THE “hardship to patients” because it is an over regulated Gordian knot. DPC is accessible, affordable, and transparent with discounted pricing on imaging, labs, and meds in most states- i.e. those that allow dispensing. We actually help patients navigate this nebulous system, save them money, and yes, get them to specialists when needed with less fragmentation of care through better communication with said specialists. The only thing that makes specialty referrals difficult is the insane red tape that already exists (ie HMO patients needing an “in-network PCP” as their gatekeeper. So much for being “locked in” to something right?) We also use services (at no extra cost to patient I may add) like RubiconMD that reduce a lot of unnecessary speciality referrals that the 8 minute visits in our current system exacerbate. Also, many specialists will also see patients for a cash price if uninsured or underinsured. Thirdly, as far as employer plans go, the employers allow their employees to choose their own physician. DPC is offered as an option, not a mandate. They still have insurance, albeit with copays and deductibles, if they choose to have a PCP in the 3rd party system. So that statement is completely erroneous.
4. DPCs exacerbate disparities in care: I will simply ask this in rebuttal- instead of citing studies. Have you actually visited a DPC practice and spoken to the patients that are members? Yes, the wealthy can afford anything. But what about all of those people you mentioned in paragraph 2 of section 3? A 90 dollar lipid panel at a hospital based lab is better for a blue-collar patient/family than a 75-95 dollar a month primary care medical home with no copays/deductibles and a 6 dollar lipid panel? Do the math. And as far as your inference to “cherry picking” patients with chronic diseases such as diabetes- that is just completely false and presumptuous. If anything, myself and my colleagues have many patients whom the current system has completely failed. But again, maybe you should actually speak with some DPC patients? Many of us actually have Medicaid patients. Being “insured” does not equate to actually receiving “care.” I will even provide charity care for those truly in need. Maybe policymakers and Medicaid administrators would actually work with us to make the model more accessible to Medicaid patients? Maybe the government could give those patients a voucher card for DPC no different than they do for food stamps etc?

The bottom line Dr. Weisbart is that nothing we have done or continue to do with this top down approach to fix our broken healthcare system is working. We have many administrators, policymakers, and CEOs telling us how to fix this and plugging fingers in the dyke that is ready to collapse as people pay more for insurance than they do their mortgage! So why don’t we try listening to the doctors and patients that have become the blips in the matrix on how to fix this mess for a change? The best solution to a complex problem is often the simplest. Remember Occams razor?

Sincerely yours,

Jeffrey S Gold MD

Owner/CEO Gold Direct Care PC

123 Pleasant St Suite 105

Marblehead MA 01945

DPC Coalition Steering Committee Member

We all should know by now that we have a major obesity epidemic in this country.  The best way to reverse this epidemic by controlling our weight and reducing our risk of diabetes, high blood pressure, and vascular disease is by eating real, unprocessed food. Doctors, nutritionists, and other healthcare providers often advise patients to shop the periphery when in a grocery store. Why? Because that is where the real food is. That’s where the produce, the real dairy products, fish, chicken, and meats are. Now, not all of these are truly healthy products which is beyond the scope of this post, but you catch my drift. If you shop the aisles and try to read the nutrition facts you will see my point. For example here is the nutrition info for Cheerios with Protein:

This may seem healthy on the front but look on the back and see that there are 41 grams of total carbohydrates and 17 grams of sugar! Even more interesting to point out is why is sugar one of the few items that does not have a daily percentage value next to it? Hmmmm…..Obscure. And look at the number of ingredients listed- most of which can not even be pronounced. All in all….not good and certainly not healthy. Real food is always the better option.

It is also recommended to try to cook and eat as home a much as possible to help you get or stay healthy. I am by no means a master chef but based on my experience whenever I have tried to make some complex recipe with a lengthy list of ingredients it has turned into a complete inedible mess. Ask my wife about the spice-rubbed pork tenderloin from Epicurious I tried to make a few years back…god awful. Yet, every time we use a recipe from Cooking Light it comes out great. There are fewer ingredients and fewer steps for one to screw up. It is simple, healthy and usually quite delicious. I’ll leave the complex recipes and dishes to the master chefs.

Hopefully by now you can see how this is going to tie in to our Healthcare Epidemic. Our system has become so bloated and complex with way too many needless ingredients and cooks in the kitchen that we can’t get out of our own way. See the proof here as our own state of MA spends 40% of the budget on Healthcare at the expense of other important needs:

While we keep adding layers of red tape and bureaucracy, as well as continuing to allow third parties (government and insurers) to set quality measures, create networks (i.e. doctors and hospitals whom you can and can’t use), and set nontransparent prices, the doctor/patient relationship- you know… where the actual care and medicine takes place- will continue to suffer. You will have less access, longer wait times, less time with your doctor, and more visits to an Urgent Care clinic. Is that really what people want for their healthcare?

In conclusion, healthcare- especially primary care- does not have to be so expensive and complex if we just get rid of the wasteful ingredients. Let the patient, the actual consumer of the service/care, determine value and not a third party whose goal is profit and profit only. Let insurers be true insurers. Let government provide financial aid to those whom truly need it, but stop practicing medicine. Let the doctors practice medicine without layers of regulation and trust me, the bad ones will show themselves. In healthcare, just like with nutrition, the saying “less is more” could not be more appropriate. Just look at these these diagrams to see how DPC changes the recipe. *mic drop*

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

Last Wednesday, January 6 2016, was a day I will not forget any time soon. It was a day that showed me the worst of our healthcare system but also the best. The week prior, a new patient enrolled with us online. His name was not one that was familiar to me. We scheduled him for a full checkup the next week. Patient X  is a 29 year old male chef that found me online because he had no health insurance and was looking for an affordable entryway into our healthcare system. He had applied for Medicaid but was waiting on confirmation. He is a hard working, honest guy that could not afford to purchase any of the “affordable Obamacare plans” on the exchange. Luckily, he did qualify for subsidies to get MassHealth but he was not confirmed at the time of our visit. For this, I will thank Obamacare. It is not bad in every way.

After my nurse put him in the exam room and got some information on him she came back to my office to tell me about the multitude of symptoms he had been having for the past 4-6 months. These symptoms had worsened over the past few weeks and finally prevented him from working. These symptoms included left sided headache with blurred vision in his left eye, bilateral hip pain, back pain, some weight loss, and an enlarging lump in his testicle which he attributed to an enlarging benign cyst that was diagnosed by another physician years prior. Clearly he was anxious and you know what? So was I.

As I entered the exam room I was greeted by a tall, slender and very personable young guy. We walked through the details of his symptoms and the time course. I encouraged him to relax and take his time since with Direct Care there is happily no more rushing through the mill. Needless to say his story was very concerning to me and it was amazing to me that this guy was able to perform labor up until two weeks prior, especially since the pain was keeping him up at night. After his history, I conducted a thorough head to toe exam. He only had minimal neurologic findings. When he was lying down so I could examine his abdomen I could see a large left sided mass in his groin under his shorts. Sadly, all the worst-case scenarios that were running through my head were now close to being confirmed. As he stood up and lowered his shorts I was presented with the culprit- a large left sided testicular mass with swollen nodes in his groin- i.e. it had already spread and now I was concerned that all his other symptoms were manifestations of the same. This was not an easy conversation to have but I sat with him and relayed my concerns.

So the first worst part of the day was seeing this guy suffer with awful symptoms for so long without engaging our system. Was it fear of illness that kept him away? Fear of cost? Denial? Truthfully it was probably a combination of all of the above. The hard part for me was seeing the regret on his face. I tried to reassure him that what is done is done and we can not go back in time, but that we need to deal with the here and now and move forward.  And so we did.

So now for the best part of the day. Within 20 minutes our wonderful insurance broker, George Claassen, came over to the office to meet with Patient X and get his insurance confirmed, as I knew he would be heading for extensive and expensive treatment- the stuff for which insurance should be used. While he met with George, I was on the phone with a great local urologist who agreed to see the patient that afternoon and was willing to do a cash price for him if needed. Following his visit the patient called me and told me it was advised that he would need CAT scans the next day prior to urgent surgery that was scheduled for Friday AM. Thank god we got him on insurance right?

That is until he told me that his new Medicaid plan would not cover the CAT scans- CAT scans ordered by a specialist with years of experience that is CONTRACTED with MassHealth!- the second worst part of the day. He was told by the schedulers at the hospital that the order needed to come from a MassHealth PCP! What planet am I on? A specialist nor an MD who diagnosed his condition can’t order an outpatient scan because of what?… Bureaucracy of course. I will not bore you with more details as the situation ended up working out and he got his scans the next day- which sadly showed spread of disease to bone, brain, nodes etc- and he had surgery last Friday. He is now in the hospital with a long arduous road ahead while he awaits chemotherapy. His pain is under better control and all we can do now is hope that his strong constitution and will to get better will guide him to being fully cured. But did he really need the two hours of aggravation after being told he had bad disease?

So like I said…it was the best of days and the worst of days all wrapped into one. It glaringly showed the positives and negatives of our system in the USA. All I hope for is the “best of days” when I can say that Direct Primary Care- for 50$ a month- saved the life of a really nice, polite, hardworking, appreciative, 29 year old year guy. It is an honor to be his doctor.

Disclaimer: this was written with the patients consent and he approved its content prior to posting.

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.

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.