Thank you to Dr. Allison Edwards from KC DPC for her work on a majority of this information.

Good Afternoon,

We are reaching out because we know this is a confusing and anxiety provoking time for many people. As you are likely aware, Massachusetts residents have tested positive for COVID-19 (the illness caused by the novel Coronavirus) and we expect more cases to be identified as testing availability expands over the coming days to weeks. As of earlier today there are a total of 95 presumptive and confirmed cases of coronavirus in the state. Most of the these patients will do very well and will not require hospital level of care.  

As your physicians, we are committed to staying up to date on developments and changes, so that we can provide you with the most accurate and timely information possible.  We are routinely reviewing updates from the Massachusetts Department of Public Health (https://www.mass.gov/orgs/department-of-public-health) and the CDC (www.CDC.gov). If you have questions or concerns, we strongly urge you to visit and utilize these resources. We do not recommend you get your information from social media.  

This is not a time to panic, but we do all need to institute some changes in our day to day lives to try to slow the spread of the virus. Yes, it may be inconvenient, but it is necessary. We may not be able to prevent a large portion of the population from getting this infection, and the majority of people who are infected will do just fine. However, it is very important that we slow the spread so that huge numbers of people are not infected at the same time, which would overwhelm our hospitals’ ability to care for the segment of people who need hospital level care due to severe illness. We ask that everyone practice “social-distancing” and avoid non-essential large gatherings or unnecessary travel, wash your hands frequently, avoid touching your face and stay home if you have a fever or cough. This is the best way for us to ensure that there will be adequate health care resources for folks who do get very ill from the virus.

At Gold Direct Care we are fully committed to caring for our patients in the most evidence-based, safest capacity possible. We want to make sure that you know how we plan to serve you as COVID-19 spreads through our community, so we’ve put together the following information to explain what you can expect from us over the next few weeks to months.

As of today, March 12, we are asking those with respiratory symptoms (cough, shortness of breath, wheezing) and/or fever to first call the office (781-842-3961) or text message your physician.  DO NOT walk-in to the office without first calling. If you walk-in you are potentially putting our staff and other patients at risk unnecessarily.  We will reach out to you for more information and determine the best way and place to evaluate you.  If you have a regularly scheduled visit for a routine, non-urgent issue and you want to cancel in light of current events, please call the office and Lauren will reschedule you. Many issues can be handled over the phone, so we can always arrange a phone-visit between you and your doctor. In addition, no patients will be given an appointment without providing a brief reason for the visit. This helps us from being surprised by someone’s symptoms. Please do not “back-door” us and say you are coming in for a benign reason when really you have respiratory symptoms that should be handled as stated above. When in doubt, call the office and we will triage you appropriately.

The key points of the triage system we have put in place to keep everyone safe are as follows:

    •    If you have mild, isolated, upper respiratory symptoms (runny nose, nasal congestion, post-nasal drip, sore throat), but NO fever or cough, and have NOTbeen in close contact (within 6ft for at least 15 minutes) with someone diagnosed with COVID-19, nor recently returned from travel to a high transmission country (China, Iran, Italy, South Korea and Japan) or the Northwest US, we will recommend home care and that you not come in for an in-person visit.  You are always welcome to schedule a phone visit with Dr. Mancini or Dr. Gold to talk through things.  

    •    If you have lower respiratory symptoms (deep cough or shortness of breath) and/or fever your physician will recommend a telephone visit to ascertain if an in-person visit is warranted.

    •    If we determine that you need an in-person visit, the visit will occur in your vehicle in the parking lot of our clinic so as to prevent potential spread and exposure to others in the office. While this is not how we usually do things, it’s the most effective way to prevent the spread in the clinic.

    •    If you have severe symptoms, we will likely refer you directly to a hospital.  

    •    Currently, we do not have the COVID-19 test kits in our office.  All testing as of today is still being done through the Mass Department of Health. We are working with our lab vendor to confirm the exact specifics of when commercial testing will be available. When testing becomes more readily available we will continue to work with the Mass Department of Health and the CDC to determine who needs testing.  We will not be recommending testing for just anyone with symptoms of respiratory infection; we will make this decision on a case-by-case basis using sound medical evidence and our clinical judgement. 

I cannot be more explicit than this: if our staff comes into contact with someone who is symptomatic and positive for COVID-19, we may be required to be in quarantine for 14 days. As we are a small office, this may lead to a situation where we will have to close for all in-person interactions for up to (and potentially longer than) a 14-day period.  If this were to occur, we would attempt to still offer telephone triage and telemedicine visits.

We are taking an abundance of caution by putting these guidelines in place to prevent the spread of this illness to the most vulnerable around us.  We appreciate your understanding, patience, and effort to keep everyone in the community healthy as we all see our routines upended a bit by this virus.

Don’t hesitate to ask questions or reach out.

Carmela Mancini, DO and Jeffrey Gold, MD

For additional information please visit:

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.mass.gov/resource/information-on-the-outbreak-of-coronavirus-disease-2019-covid-19

Updated Testing Guidelines for More Information

https://www.mass.gov/doc/covid-19-pui-criteria/download

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

Depending on your age and income, and whether or not you are shopping for a car or a place to live, the answer to this question may vary. If you enjoy getting a new car every few years then leasing is clearly the way to go, but if you really like your car then buying would be the better choice. You will likely take better care of the car because you actually own it and have zero interest in having to make new car payments once it is fully paid. Same goes for renting an apartment versus buying a home. When you rent you are just simply handing over money to a landlord to live there. There are benefits to it such as maintenance and landscaping being covered, and if you only plan on being there a short time then renting is a great idea. However, if you are looking to have a long term or permanent place to live then buying is the way to go. You are investing in the roof over your head, your yard, and the upkeep of your property. In the long run it is a much better investment.

See chart from Trulia.com here for a visualization of how buying saves in the long run:

So I ask this question: why would anyone not want to do this for their healthcare, especially primary care which is the heart of medical care? This is nothing against the many great physicians that are employed and contracted with 3rd party payors, but when your primary care physician is being paid by a third party you are technically renting/leasing them. Maybe they will drop or be dropped by that third party? Maybe they will burn out and fade away which is happening all across the country? Maybe you will get lucky and just like the old days they will stay in one place and be contracted with your third party payor for years to come? Yes they took an oath to care for you which they do to the utmost of their abilities, but technically, given that they are being paid by their employer through your insurer they aren’t technically working for you

So what if you could own the relationship with your primary care physician and have them work only for you rather than leasing it? What if you- the patient/consumer- were the only party determining the worth and value of your doctor and the care that he/she provides instead of a third party that knows zilch about you as a person? What if you could have a mutually beneficial relationship with your personal physician based on respect and trust that exists in sickness and health? And what if you could have all of this investment for less than a coffee a day? After all isn’t your health, peace of mind, and wallet worth the investment? If the answers are yes then Direct Primary Care is here and here to stay. Lets take primary care and medicine back one doctor and patient at a time. You can rent DPC for a year and if you really like it- just like Chevy Chases’ rubber gloves in Fletch- it comes with an option to buy 🙂

When was the last time your PCP accompanied you to a specialist visit? Never? Same here. That’s actually not entirely surprising in today’s healthcare environment, given the demands placed on healthcare providers and primary care physicians in particular. But last week, I had the opportunity to be a part of such a visit.

I’m a medical student on my family medicine clerkship with Dr. Gold, and on his schedule this day was a cardiology visit for one of our 78 year-old patients. In the afternoon, we drove to meet her at the cardiologist’s office. She had recently had an episode of atrial fibrillation picked up by her pacemaker, and at this appointment, we would discuss the possibility of starting her on blood thinners. The cardiologist thoroughly explained the algorithms that guide decision-making for the treatment of new a-fib, along with the risks and benefits of blood thinners. He concluded by saying that, while he slightly favored starting the medication, he would leave the decision to our patient. As she took a moment to take in this information, her eyes began to well up. Amidst her tears, she explained that having to add yet another medication to her regimen or the thought of a stroke or going into a-fib again or bleeding from a fall was all too overwhelming to process.

The situation was complicated further by our patient’s chronic pain, which she experiences as a burning sensation across her lower chest. It has been treated with varying success for many years, and she was soon visiting a pain clinic for further assessment. So how was she to decide given these circumstances? The cardiologist offered expertise focused on giving her the best possible care for her cardiovascular health and went on to reassure her that the pain was not cardiac in origin. The presence of her primary care physician in addition, however, proved essential in helping her feel comfortable with her options. Primary care physicians are charged with taking care of the whole patient, a-fib, pain, tears and all. So when it became Dr. Gold’s turn to offer his input, he took a step back and considered her quality of life and her priorities. He helped her to sort through the risk calculators, EKG results and medication side effects to reveal what was really causing her the most distress each day and keeping her up at night. It was not her cardiac issues. It was her pain. Perhaps, he advised, we should address this issue first and then reconsider starting blood thinners in the future.

I would argue that any primary care physician would want this opportunity, the chance to sit down with his or her patient and another member of the healthcare team for one hour and determine what is really best for the patient at a given point in time. The problem is finding that hour amidst the multitude of patient visits, phone calls, notes, prior authorizations and EMR notifications. This time is what Dr. Gold offers his patients, and I believe that this single visit demonstrates how essential that time can be.

Tufts 3rd Year Medical Student

Not surprisingly, recent studies have shown a broad value proposition that links workplace health and well-being to favorable business performance. So why don’t more employers invest in programs that promote healthy employees? Expense is one glaring reason! Employers, both large and small, are being crushed by the rising cost of providing insurance benefits to their employees. Most employers address this growing cost by shifting it to their employees in the way of increased premiums, higher deductibles or higher co-pays. There is a cost effective solution and this solution is Direct Primary Care.

With Direct Primary Care, employers pay a fixed amount for all primary care services. This removes the guessing game on how much money will be spent on claims filed by employees. Direct Primary Care can be inserted into the overall health insurance plan offered to employees and ultimately control downstream costs. DPC, combined with an appropriate supplemental catastrophic plan, can save employers up to 40% on healthcare costs! This is all in accordance with the Affordable Care Act, so employers won’t get fined for non-compliance.

If saving money wasn’t enough to convince you, other perks for the employer include: decreased absenteeism, decreased workman’s comp claims, utilization of telemedicine to evaluate employees so they don’t leave early for doctors’ appointments or miss work altogether. Employees benefit too, as they receive same day appointments, a personal relationship with their physician, telemedicine/virtual visits, decreased out-of-pocket expenses, no more visits to urgent care centers.

Direct Primary Care physicians can be an employer’s most valuable ally as they search for ways to control healthcare costs, while simultaneously offering their employees the highest quality of care. Check out this article http://www.directdoctors.org/blog/direct-primary-care-a-solution-for-small-businesses to learn more.

If you are a business owner or know a business owner call us at 781-842-3961 to start saving money!

 

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

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.

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!

 

 

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