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

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!