What does concierge or direct primary care do for you? It gives you outstanding care at a reasonable cost. Your doctor cares for only about 500–800 patients instead of the typical 2500–3000 individuals. Instead of seeing 24+ patients per day for an average of 10–12 minutes of “face time,” you get same-day or next-day appointments for as long as necessary. You get intensive wellness advice through preventive medicine direction, immediate care of those episodic problems that arise every so often, and complete attention to complex chronic diseases (heart failure, diabetes with complications, etc.) with much less need to refer to specialists.

But when it is necessary for specialists to participate, the PCP plans and coordinates the care process. And most important, the PCP gets to know you as a person, part of a family and a community, developing a caring and trusting relationship. You will have fewer tests, X-rays, and specialist visits, fewer ER visits, and fewer hospitalizations. Some practices offer generic medications at cost and deeply discounted prices through arrangements for imaging and lab tests.

Here are four direct primary care practices to illustrate typical fees. For example, AtlasMD’s (Kansas City, MO) annual fee is $600 for a young adult and about $1200 for someone over age 65; Dr. Neuhofel’s (Lawrence, Kansas) is $708 (adult under age 70) to $948 (70 and older) annually for an individual and $1668 for a family of four.

Drs. Izbicki (Erie, PA) charge $1380 per year per individual 30 and above and $2340 for a family with any number of children under age 19. In Columbia, Maryland, Dr. Sarah Zahaar recently left a Johns Hopkins group practice and began a DPC practice called Oak Tree Primary Care. She charges $99 per month with a 15% discount for those who pay annually, just over $1000 per year. In addition, she has discounts for families and children. From her website, here is a link to a short video on DPC.

As Jon Izbicki told me, “Our monthly fee is less than what it costs to rent a parking space downtown for the month.” Even the more expensive retainer or concierge practices are still within reason for many. $2000 is about $5.50 per day. How many people spend that much per day at Starbucks? Or, consider the monthly/annual cost of internet, mobile phone, cable TV, and streaming.

As of 2021, the average expenditure per month (different organizations reach somewhat different conclusions, but the following is a good average) for internet, cable, and streaming services is $156 per month or $1768 per year. Add to that mobile phone service, and the total is well above $200 per month or $2400 per year. So, perhaps $1500 or $2000 — undoubtedly real money — is not such an onerous expense for comprehensive primary care when prioritizing healthcare expenses relative to other expenses.

Suppose you have a high deductible health insurance plan from your employer or from the exchanges with a health savings account (HSA). In that case, you can pay for the membership/retainer with tax-advantaged dollars and save considerably. And since the PCP will help you avoid digging into the deductible by preventing the need for expensive trips to the specialist, the emergency room, or the hospital, and for excessive laboratory or imaging tests, you will also save those dollars.

I predict that (absent a significant change in insurer behavior) direct primary care will likely be the future of primary care payment. It means that the patient will obtain genuine assistance to first prevent chronic illnesses from occurring; second, episodic care for those issues that pop up during the year; third, careful care of complex chronic diseases, and fourth, thorough coordination of the care of chronic illnesses, all at a reasonable cost which will be transparent.

Importantly, you have a PCP who has the time to listen — to listen deeply, resulting in a return to relationship medicine with mutual trust and respect.

Those who already have typically limited deductible insurance — commercial or Medicare — might argue that these various direct primary care models represent an added expense, not a savings. Yes and No. It is an added expense, but the potential savings can be substantial. For example, each of the three practices referred to above makes generic medications available at wholesale prices — considerable savings for many individuals.

Those with no insurance — for whatever reason — will find that they can obtain good quality primary care at a reasonable price from one of the direct pay or membership practices. It will cost much less than going to an urgent care center or an ER.

Perhaps Medicare and Medicaid will decide that it makes eminently good sense to pay the retainer for their enrollees and thus ensure their members get superior primary care at a reasonable cost. Meanwhile, save Medicare and Medicaid enormous total dollars. (In an earlier article, I reviewed what one company, AbsoluteCare, has done to reduce expenses while dramatically improving care for some of Medicaid’s most expensive patients.)

Some companies such as Erickson Senior Living that sponsor Medicare Part C (Medicare Advantage) plans have learned that by using DPC, although it costs more upfront for primary care, the total costs of care come way down, making the DPC investment a “no-brainer.” The image at the top suggests that older people can receive excellent care from a DPC/concierge physician resulting in better health and a longer life.

This concept could apply equally to commercial insurers, but they have largely avoided DPC, retainer, and concierge practices.

What about employers? The average cost per family, per the Kaiser Family Foundation, was about $22,463 in 2022, with the employee contributing $6106. Although KFF notes that the general annual deductible is $1763, many companies have very high deductibles, sometimes as high as $10,000 per family per year. For a family with members that have chronic illnesses, the costs of healthcare are thus substantial, indeed a level that makes one a medical pauper if you or a family member gets sick. In addition, employees will arguably feel their employer has walked away from them and saddled them with costs they cannot bear.

The company can partially offset the inherent anger this generates among its employees by paying the fee for direct primary care practice. It is especially valuable for individuals with multiple chronic illnesses since quality primary care can mean much better health, fewer tests, prescriptions, specialist referrals, and hospitalizations. In addition, since businesses are essentially self-insured using the “insurance company” as the administrator, their costs will decrease with this approach.

The bottom line, the company pays for the DPC doctor but reaps the benefit of lower total costs and a healthier employee who is more content and misses many fewer workdays due to sickness. More details are in my previous article, “Company paid concierge style primary care.”

Once companies recognize this advantage with its increased employee health yet reduced costs, employers will be the major reason for direct primary care membership/retainer-based practice growth in the coming years as they will essentially demand that level of service for their employees — and in so doing they will be reducing their company health care costs as a result of high-quality primary care.

The exact number of physicians in DPC practices is unclear, but an estimate by Concierge Medicine Today (CMT) in 2022 pegs the known number at about 10–25,000. CMT also notes that many combine insurance with membership fees, e.g., MDVIP; not exactly DPC anymore, but still an ability to limit the number of patients per doctor and give more attention to each.

More doctors will convert once the general population understands the advantages and begins to ask for them and demand them. There are many good reasons for an individual to connect with a direct primary care physician — better quality care, a return to relationship medicine, and often a significant cost saving despite the fee. Consider the copay and deductible savings if you spend less time in a specialist’s office and avoid visits to urgent care centers, the ER, and the hospital, including the copays for specialty testing, lab work, and imaging. Most importantly, you will have better health. That is priceless.

This is the 17th in a series on America’s dysfunctional healthcare delivery system. Here are links to the first and a recent article.

The post Are Direct Primary Care and Concierge Medicine Practices Too Expensive? appeared first on Medika Life.

Another variant, rather than establish their own primary care clinic, some companies have decided to purchase the retainer/membership for their employees in a direct primary care (DPC) practice. They choose one or more practices that offer the type of comprehensive primary care that has proven to be effective in both enhancing health and lowering total costs. Alternatively, they place a sum of money in the employee’s HSA or HRA which can be used pay the membership fee for the DPC physician of the employee’s choice.

Another example is a Catholic Health Initiatives (CHI) option for their employees. CHI’s Nebraska and southwest Iowa division with about 20,000 staff members established a DPC clinic and about 1100 employees opted for it in the first year, 2018. Total costs have and patient satisfaction improved.

Image from article explaining CHI program

Note, I use DPC here to refer to any of the variants of direct primary care, membership care or concierge care. In all cases, I refer to a physician who has a panel of about 400–800 patients rather than the usual 2500–3000, offers same or next day appointments for as long as necessary, responds to text and emails and makes their cell phone number available 24/7. They offer episodic care, full attention to complex chronic illnesses but when a specialist is needed, they coordinate the care and assist in making an expedited appointment. They are razor focused on wellness maintenance and disease prevention and may work with a health coach, nutritionist or others in a team manner. Some, but not all, offer reduced rates with local laboratories and radiology services and a few make available generic medications at cost. There is an annual or monthly fee for the physician’s services.

Image from Premier Health

Insurers have been slow to enter this field, preferring to let the employer purchase DPC rather than offering it as part of their policies. But it can work for the insurer. For example, the individual either directly or via the exchanges selects an insurer that partners with DPC physicians. Part of the payments to the insurer go to pay the DPC doctor, perhaps $100 -120 per month, and the remainder purchases a catastrophic policy with a reasonable but not excessively high deductible. To make the program even better, some insurers contract with a DPC group that also includes a health coach for each patient along with classes on health and wellness at no additional charge. The downside, of course, is the individual does not have full free choice of their preferred DPC physician.

A similar approach begins with a DPC physician group that offers self-insured employers a package of direct primary care along with insurance for specialty care and hospitalization. The employer pays the primary care physicians’ group which uses part of the premium to pay for the DPC physician care, including extensive preventive care and chronic disease management and, often, including common labs, radiology, generic meds, and vaccines. There are no co-pays nor deductibles. Specialty care and hospitalization is covered by the insurance component and may or may not include co-pays and deductibles as determined by the employer

Iora Health (a Boston-based company acquired a year ago by One Medical that in turn is being acquired by Amazon) also largely deals directly with employers or unions to purchase complete expanded primary care for their employees or members. An example is the Dartmouth clinic for its employees.

These are but a few of the new approaches being taken by employers and enterprising organizations to improve primary care and in the process improving the total health of company employees and their families. Do these represent the future? Only time will tell. But employers and insurers will recognize that high quality comprehensive primary care, although it costs more than typical primary care, will actually reduce their total costs while improving quality and satisfaction. Then I predict employers who appreciate the value of these arrangements will increasingly gravitate to DPC models.

Note: The companies listed are for illustrative purposes only; inclusion is not an endorsement. I have no financial arrangements with any of them.

The post Company-Paid Concierge-Style Primary Care appeared first on Medika Life.

The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality, and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls by government and commercial insurers and regulations, also by insurers, that reduce the trust and core interactions between doctor and patient. The doctor, not by choice, is the insurer’s client. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an Op-Ed that paying the doctor directly is better for all concerned.

Some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves. They have essentially said, “I won’t take it any longer; this is not good for my patients or for me.” They have also said it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system — direct primary care — rather than wait for others to fix it for them.

The concept of direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care, and it always means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principal payment systems.

One is for the patient to pay the doctor directly for each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list — transparency. This is sometimes called direct pay or “pay at the door,” unlike how it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of care for the year paid by the month or annually. This basic model comes with many variations and may be called direct primary care (DPC), membership, retainer, or concierge. Despite the various names, they all have certain characteristics in common, but there are many variations in how the practice functions.

All of these models offer a reduced patient-to-doctor ratio; instead of the typical 2500–3000+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or a high of about 800 for a panel with mostly low-risk patients. Some accept insurance and also charge a lesser retainer; most just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to offering same or next-day appointments lasting as long as necessary, a comprehensive annual examination, email and text communications, and an invitation to contact the PCP on their personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER, and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing, imaging, and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the monthly/annual subscription cost of direct primary care.

Many PCPs in these models only work with specialists who are willing to discount their fees for those of their patients who pay cash, have high deductible plans, or have no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact, DPC/membership/retainer/concierge practices can be of a quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes — “blue collar” concierge medicine.

Fees range from about $500 to $2000 or more per person per year. [I will ignore those doctors who charge a very high fee for “exclusive” services.] By some degree of common usage, those on the lower price end often refer to their practices as direct primary care or membership, whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or number seen per day, the extent of the annual evaluation, and added values such as following one’s patients in the hospital and in the ER.

For those with high deductible insurance policies from work or the exchanges, connecting with a direct primary care physician can offer significant savings. The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction — a return to “relationship medicine.”

With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration, more satisfaction for doctors and patients alike, and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down, way down. A triple win.

The post Saving Relationship Medicine with Direct Primary Care appeared first on Medika Life.

I introduced Henry in an earlier article; here is his story in more detail. Henry is a 69-year-old widower living alone in a small town about 60 miles from the nearest metropolitan area. He has a small pension and healthcare coverage via Medicare, a Medigap policy, and a Medicare Part D drug policy. He was recently hospitalized in the ICU with a serious urinary tract infection that spread to his kidneys [pyelonephritis] and to his bloodstream [septicemia], and then his lungs [acute respiratory distress syndrome.] This was a recipe for rapid demise, but the needed intensive acute care is where American medicine excels. It was the full court press to save his life, and it was successful.

A week later, he called me and asked for some advice. He was discharged from the hospital to take his former medications plus a few more. He was now to take twenty-three — yes, 23 — different prescription drugs, some once, some twice, and some three times per day, along with one by shot monthly. He was not sure why many of them had been prescribed and asked if I thought he needed them all.

I responded that, at 400 miles distant, I could not be his doctor, but I would review the list and offer some questions he might ask his physician. He sent me the list, and I reordered it by category: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate (it was felt in the hospital that an enlarged prostate had been a predisposition to his urinary tract infection), one for depression, an antibiotic to finish up the treatment of his kidney infection and a few others.

I asked him who his primary care physician was and learned he did not have one but went to four different doctors, each of whom treated different issues, and none of whom shared all of his information with each other. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage of one or more.

He told me that it was always normal when he went to the local drug store and checked his blood pressure. I told him it might well be that he had “white coat hypertension,” meaning it was only high in the doctor’s office. Perhaps if he took these regular readings to his doctor, the physician would get him off one or more of the blood pressure meds. Besides, two of the three had a known side effect of impotence. Finally, I noted that he was on one drug to shrink his prostate, yet the testosterone might well be causing some of his prostate enlargement.

Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension, and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues.

The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, he was given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result, he developed an infection that almost killed him. The hospital doctors had added a drug to shrink his prostate but left the testosterone in place. And all these drugs were expensive for him and his Medicare Part D insurance plan.

Heart failure and diabetes together consume more than 50% of our healthcare dollars. Here is a person whose care is not being adequately monitored; instead, he is getting one drug after another without attention to what else is happening. This lack of care coordination is a prime reason why the costs are so high yet the quality so low. The problem is less that drug companies charge too much for many drugs (they do) but rather that too many drugs are prescribed unnecessarily or inappropriately.

It is also instructive that Medicare pays without question for intensive hospital care – tens of thousands of dollars in Henry’s case, yet pays primary care physicians minimally – even though with time to listen, think and consider, a PCP could have, with limited costs, prevented the hospitalization.

My first suggestion was that Henry needed a primary care physician, one to call his own. He learned that a young doctor he had met at a nearby hospital would be setting up private practice near his town, so he became one of the first patients. Since the PCP did not have many patients yet, he gave Henry the time needed. A few months later, he called and told me that he was now taking just seven medicines, felt better, and was saving a lot of money.

But during our initial discussion, I also asked him what he weighed. I have known him for over forty years but had not seen him for more than twenty. I recalled a stocky, muscular man with perhaps a bit of a beer belly, so I was surprised when he said he weighed 285 pounds. His wife of more than 50 years had died a few years before and he found himself lonely and isolated. He rarely went out and told me he did not exercise; it was just too difficult. He fixed his own meals, mainly from prepared foods.

I asked him what he planned for lunch and was told soup and a sandwich. The soup was a canned one, so I asked him to read the sodium content to me. It was 320mg, or 35% of the daily recommended amount. The can had “two servings,” but he planned to eat the whole thing or 70% of his daily salt requirement (assuming he was not on a restricted salt intake because of his high blood pressure and heart failure) in the soup alone! The sandwich was salami on white bread with some lettuce and mayonnaise.

That sounded great for his high cholesterol problem. Together we figured out that he ate about 2000 calories per day, which he thought was about right based on the soup can label. I suggested that 2000 calories was about right when he was 22 and in the Army, but now, since he did not exercise and needed to lose weight, this was way too much.

My next suggestion was that he needed to get out, interact with people again, carefully consider his diet and begin a modest exercise program, perhaps just a short walk each day. When he called later, he told me that a friend had gotten him to start going with him to the local senior center, where he had made some new friends. Eventually, he agreed to go to evening dances, where he met a widow whose company he enjoyed. His depression seemed to have lifted; he was exercising and enjoying dancing again. I could hear the smile in his voice.

Henry still has four serious chronic conditions. But with a single physician serving as his primary care physician who was aware of all of his medical, emotional, family, and financial issues, his care became much more effective. And when he did need a specialist, which was now rare, the primary care physician became the orchestrator, not just the referrer. As a result, Henry now has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap, and Medicare Part D’s money. In short, it is a win-win for all concerned.

The key to improving Henry’s care was to find a PCP who would and could spend the time with Henry necessary to offer such comprehensive care. Today, because of high overhead costs and low insurance payments per visit, most PCPs need to see about three patients per hour. They just do not have the amount of time a person like Henry requires. But those that do provide such time offer much better care. Yes, more time per patient means fewer patient visits per day, so someone has to pay for the difference. Insurance rarely does, which is unfortunate. The patient will have to pay the PCP directly, “Direct Primary Care” or DPC. But as we will see in later articles, the total cost of care comes way down, quality goes up, and patient and doctor become less frustrated. Henry is a great example of how totally dysfunctional care can, quite simply and a very low cost, be converted to excellent, cost-effective care.

The post More Time With a Primary Care Provider Means – Better Care, Lower Costs and Less Frustration – A Win, Win, Win appeared first on Medika Life.

The power of the painting is the gaze of the doctor on his patient. Now is the place, the time, the person – he has no other thoughts or concerns except to assist her back to health if he possibly can. We do not know the medical problem, but we can infer it is serious. And we do not know the outcome, although there may be a clue because through the window comes a faint ray of light.

I did not fully appreciate the implications of this work of art when I first received it, but I came to understand that this physician was a healer. He had listened; he was nonjudgmental; he had earned trust. He has done his best but understood that he alone would not be her cause of cure should a cure ensue. He understands that he is but a humble person entrusted with the most important of all missions – to assist others in finding health. He has done his best and, in doing so, exemplifies the characteristics of a healer.

My maternal grandfather, Leonard McClintock, MD., was a general practitioner in New York state. He graduated from Albany Medical School in 1898. He set up his practice in what was then a small town on the Hudson River, Beacon, N.Y. He built a room on the side of their home to serve as his office and used the large wraparound front porch as the waiting room. There were no appointments; you came and sat on the porch until it was your turn. Office hours lasted until the last patient had been seen. 

Initially, there was no hospital, and he cared for all patients in the office or at home, although later in his career, he helped to establish a hospital directly across the street. In his day, a physician had relatively few tools to treat someone, so the skill was to make a diagnosis and inform the patient and the family what the situation was and what the course of that illness would probably be. Yes, he could do some things, including treating pain with morphine, removing an inflamed appendix, sewing up lacerations, and delivering babies much more safely than could have been done without the assistance of a trained clinician. 

But during the course of his practice, which ended with his death in 1936, medicine began to change toward a much more scientific basis. To a large degree, this was propelled by the influence of Johns Hopkins University School of Medicine and Hospital in Baltimore, MD. Founded in the late 1800s, it instituted the concept that medicine was and should be a science. Therefore, Johns Hopkins would teach a science-based medical practice during four years of medical school. In addition, Hopkins established what we know today as the standard residency training program following medical school. 

This was a dramatic change in medical education and training and, as a result, dramatically changed the way physicians thought about medicine and patient care. During my grandfather’s practice, he began to see the beginnings of those changes. For example, insulin was discovered in the 1920s, and the first antibiotics in the 1930s. After his death and the completion of World War II, the National Institutes of Health began to develop, grow and place large sums of money across the country in various medical schools and within its own walls to conduct basic biomedical research. 

The result is that today our ability to repair, restore to function or replace an organ, tissue, or cell has moved ahead at a dramatic pace and will do so even more quickly in the coming years. Concurrently, the pharmaceutical industry also became scientific, resulting in a continual outpouring of new drugs that can relieve suffering, reverse harm and cure many diseases while extending our life span. In addition, with the advent of the science of genomics, it is increasingly possible to predict the onset of illness before it occurs and thereby create a preventive approach for the individual patient.

Soon we will have immediate access any time, any place to our medical records, which will be fully digitized, and the safety and quality of medical care will dramatically improve. All of this is because of the science base of medicine, which was introduced over 100 years ago.

Something else has happened, but it has not been appreciated. In the past, illnesses tended to be “acute,” meaning that they occurred, were treated, and got better, or the individual died. For example, if your child developed “strep throat,” the pediatrician gave an antibiotic, and it got better. If it was an inflamed gall bladder, then you were referred to a surgeon who operated, threw away the gallbladder, and you were cured. But today, most illness is chronic and complex as well. For example, if a person survives a heart attack, he may still have some damaged heart muscle and so develops heart failure. This will be with him for life and will need multiple treatments, many medications, probably multiple hospitalizations with an ICU stay or more, and might even get to the point of a heart transplant.

Now that is chronic, and that is complex! So it is also with diabetes, rheumatoid arthritis, many cancers, chronic lung disease, kidney failure, and many other diseases are frequently seen today.

This is a major shift and enormously impacts how we should [but mostly do not] organize the treatment of the patient and their disease, how we should [but mostly do not] organize the payment system for that care, how we should [but mostly do not] use technologies wisely for maintenance, and how we should [but mainly do not] assure quality and safety in patient care.

This is a profound change, but most of the “healthcare reform” approaches do not address the implications of this change to chronic, complex lifelong illnesses. Although aware of the change toward more and more chronic diseases, physicians also tend to want to preserve their current practice patterns developed over the years to handle acute illnesses, even though the current chronic, complex diseases require a different approach.

But in that same time frame of scientific advancement and the rising frequency of chronic illnesses, we also began to lose something in medicine. That loss is the genuine “connection” between the physician and the patient. Most of us feel we do not have enough time with our physician; the physician seems busy and distracted, often by the computer, and not able or willing to listen to our story in full. 

From the physician’s perspective, they feel that there is not enough time to spend with an individual patient; not enough time to learn about the family and the environment in which that patient lives, and therefore in which the patient’s disease has occurred; that there is not enough time to focus on preventive instructions or to even talk thoroughly about the plan for the care of a specific illness or problem. But all too much time is spent following mandates, filling out forms, often repeatedly, and then being paid by the insurer well under what the time and effort were worth. Physician burnout has reached epidemic proportions.

Today we need to preserve our newfound skills and techniques, drugs, and devices but also remember that patients are human and need empathy, caring, and attention, not just technology. Equally, providers need the ability (time) to give the care they were trained to provide, the care most wanted to give when they first decided on medicine as a career.

Unfortunately, rather than a true healthcare system, we currently have a dysfunctional American medical care delivery system. We need a healthcare system, but the cards are stacked against it. That said, it can be changed. Probably not by Congress, nor by the insurance companies but only by the unique interaction of doctors and patients demanding what is and could be the very best. Concurrently, one of the best ways to change the system is for companies to realize that they can secure better medical care for their employees while augmenting health and wellness, which will dramatically reduce the company’s and their employees’ costs. That is a win-win all around.

In later articles, I will outline further what patient and their doctors can do to improve care and what employers can do to create true healthcare for their employees.

The post Healthcare and Medical Care Are Not the Same – The Difference is Very Important appeared first on Medika Life.

Henry was fortunate to find a primary care doctor who would devote the time needed to fully understand his many problems, including his social/psychological issues. With an attentive PCP, he had much less need for various specialists, but as the need arose, the PCP was there to coordinate his care.

Unfortunately, most primary care physicians do not have enough time for careful listening and contemplation nor for delving into anxiety and family issues that may precipitate an exacerbation of heart failure. For example, concern about a sick adult child might be underlying the heart failure flare. Some physician recommended changes in medications will help but what is really needed is attention to his deepest concerns.

Adequate time between patient and doctor, especially the patient with one or more chronic diseases and the primary care physician (PCP), is essential. Developing a population that values healthy lifestyles and government actions designed to assist in prevention is equally crucial. Unfortunately, we have none of these three in today. PCPs are too busy; we don’t take care of our health and wellness; and government is AWOL.

Since most chronic illnesses are preventable with simple lifestyle modifications (I know, easier said than done), we need aggressive attention to preventive approaches and maintaining and augmenting wellness. Physicians (and other members of the healthcare team) and patients working together can make significant inroads here. This would reduce the burden of disease over time and greatly reduce the rising cost of care.

But that is not enough. Government, in its many forms, needs to assist. Addressing lifestyle needs as done over the past few decades with tobacco is critically important. But, unfortunately, the American government places far too few resources into wellness and preventive care, whether regarding school lunches, employer wellness programs, insurance rebates for healthy living, or many other possibilities. And as the pandemic clearly demonstrated, there has been decades of inadequate public health funding, from the Centers for Disease Control (CDC) to state and local health departments.

Individuals all too often and for many reasons do not follow basic approaches to general wellness, including the top five: sound diet, adequate exercise, stress management, enhanced sleep, and no tobacco/ moderate alcohol.

Living in “food deserts,” unsafe neighborhoods that prohibit effective exercise and augment stress while tempting illicit drug use all conspire toward less wellness and poor health with later chronic illnesses. Marketing tobacco products in these same neighborhoods has often left islands of continued smoking.

All of us are bombarded daily with marketing that touts ultra-processed foods high in fats, refined white flour, salt, and sugar. Think of most sodas with their high levels of sugar; fruit yogurts that always add sugar; those packaged snacks loaded with all the wrong ingredients plus others you never heard of; those buns in the mall that smell so good from their cinnamon and butter but are mostly sugar and white flour.

Think also of most breakfast cereals. Even the ones you might assume are healthy often have substantial sugar added, and most only use refined white flour, which is almost equivalent to eating sugar. Unfortunately, government, unlike tobacco, puts little or no restraints on such marketing of blatantly unhealthy foods.

We all love French fries, hot dogs, fried chicken, and high-fat content hamburgers. Fast food outlets know what we like and do their best to not only attract us but seduce us to buy more. “Get a double for only half price.” One of my favorite stories relates to iced tea. We stopped at a fast-food place to take a break from traveling and get a drink. My wife got a black coffee; I ordered an iced tea. “Large or small?” I said small but she looked at me skeptically and said that the large was only a few cents more. I didn’t want to tell her that a large would run right through and we would have to stop again sooner than planned, so I just reiterated “small.”

“Sweetened or unsweetened?” “Unsweetened, please.” “You should get the sweetened; it is $1, and the unsweetened is $2.” I insisted on unsweetened, and she looked at me as though I was the stupidest customer she had ever encountered. She gave me a small cup, and I went over to the other counter where you could take from the sweetened or the unsweetened containers. I could have said “Sweetened,” paid less, and taken the unsweetened. Later, in the car, I looked at the receipt. She charged $1 me for a “sweetened iced tea.” So kindly toward this foolish old man.

But why should sweetened cost less than unsweetened. Because once the sweet taste is in your mouth, you will want more – either at this stop or the next. The company knows it and so lures you back with a “reduced” price. It is a “nudge” but in the wrong direction. Another example of good marketing but lousy policy.

Assuring medical insurance for all Americans is an important goal, but it is far from sufficient to ensure we all get the best or even adequate care. For example, what good is an insurance card in your pocket if you cannot access a PCP in your neighborhood, one that has the time needed to give you the care you need. So instead, you go to the local emergency room, which, although well intended, is no substitute for a personal physician or nurse practitioner.

America needs a new vision for healthcare delivery:

It must become a health care, not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness, and it must do so prospectively from the perspective of the population, not just an individual who appears in the doctor’s office. The keys are straightforward – good diet, adequate exercise, reduced chronic stress, enhanced sleep, no tobacco, moderate alcohol, good dental hygiene, and careful driving. Add to these – blood pressure control, cholesterol management, cancer screening, and combined, these will prevent most chronic illnesses.

For those who do develop chronic disease(s), the PCP needs the time to attend to the complexity of care and, when necessary, there needs to be excellent specialist coordination by the PCP. This will improve the quality of care and dramatically reduce the costs of care.

Because the PCP does not have enough time, the patient who already has a chronic illness is often sent for extra tests, imaging, or to see one or more specialists. As a result, the expenditures go up exponentially, yet the quality does not rise commensurately. Indeed, quality often falls. Again, Henry’s story is a good example.

Henry’s story points to another problem – clearly, America has a medical care system, not a health care system. American medical care focuses on a disease once it has occurred but focuses relatively little on maintaining health and wellness.

Healthcare must be redesigned so that the patient is the customer. Today the insurer controls. That makes no sense, including no financial sense, no quality of care sense, and certainly no patient or doctor satisfaction sense.

Very critically, America needs many more primary care physicians (and other primary care providers such as nurse practitioners) – the backbone of the healthcare system – who can offer outstanding preventive care, care for most illnesses, and care coordination for chronic illnesses when necessary. Unlike today’s insurance system, they need to be reimbursed for their efforts in a manner that allows for adequate time for each patient and their total healthcare needs. It must be satisfying to doctor and patient alike, with true healing in addition to expert medical care.

All of this requires a change in the conceptual approach to insurance coverage; to what PCPs believe their function is or could be, to your understanding of what excellent primary care can be, and to everyone’s understanding of the importance and effectiveness of preventive care to maintain health and wellness. These are major changes in how we think and act about healthcare. It will not come easily or quickly but desperately needs to begin the change process now.

It also requires government to change its approach to healthcare, to see it not just as an insurance problem but as an opportunity to improve the health and wellness of all citizens.

It is doable, but it means rethinking how we perceive health, wellness, healthcare, and how our delivery system is structured.

In the following articles, I will address the How’s to achieve real healthcare.

The post Preserving Health and Wellness and Preventing Chronic Diseases – America Does It Very Poorly appeared first on Medika Life.

My friend Susan in the first article of this series was a good example. Presenting to her PCP with a somewhat unusual symptom, she was sent from specialist to specialist without ever learning what was causing her symptom, much less resolve it. It was a true waist of time, money and her emotions when the answer was there if only a doctor spent some time to listen to her.

To further exacerbate the problem, the doctor and patient no longer have a “contract;”. The patient and doctor are bystanders to the decision-makers. Frustration by doctors and patients is high, and physician burnout has become rampant.

 Add to this is a significant change in the common serious diseases – complex, chronic illnesses, mostly preventable, for which American medical care has not established suitable methods of prevention or adequate methods of care. In addition, what should be the role of the primary care physician has been compromised by the insurance industry (both commercial and government-sponsored) that puts the incentives in the wrong places. The result is a sicker population, episodic care, and expenses that are far greater than necessary.

Our current delivery system was designed early in the past century with the expectation that the patient would pay the doctor a reasonable fee for the effort, skill, and time involved.

Insurance developed during the past 70 years initially to pay for unexpected, highly expensive care, such as surgery or hospitalization. But over time, insurance transitioned into what is essentially prepaid medical care and along the way eliminated the financial “contract” between you and your primary care physician (PCP or Nurse Practitioner.) The contract today for both you  and the doctor is with the insurer The patient and doctor are bystanders to the decision-makers. Frustration by doctors and patients is high, and physician burnout has become rampant.

Worse yet, insurance pays primary care providers a pittance, driving them to “make it up in volume” by seeing too many patients per day, often 24 or more. Of course, this means short visits, perhaps three per hour, which translates into about 10-12 minutes of actual face time with you.

The delivery system was developed to deal with acute medical problems, where it is reasonably effective. For example, consider the pneumonia that a single internist can treat with antibiotics, an appendicitis that can be cured by the surgeon, or the fractured arm that the orthopedist can cast. But our medical care system works poorly for most chronic medical illnesses and costs far too much. Chronic illnesses include diseases like diabetes with complications, cancer, heart failure, chronic lung and kidney disease, and Alzheimer’s.

These chronic illnesses are increasing in frequency at a rapid rate and consume the bulk of health care expenditures. They are largely (although not entirely) preventable.

A century ago, the most common causes of adult death were infections – pneumonia, typhoid, and tuberculosis. Today these are uncommon and treatable. Now the most frequent causes of death are chronic illnesses – heart, cancer, and stroke, with Alzheimer’s and diabetes just behind. Other than some cancer, most others are not curable.

Most chronic diseases are related to lifestyles and are preventable. A myriad of social, environmental, financial, and personal reasons has led to non-nutritious diets, lack of exercise, chronic stress, inadequate sleep, smoking, and excess alcohol. Obesity is now a true epidemic, with one-third of Americans overweight and one-third obese. The combined result is high blood pressure, high cholesterol, and elevated blood glucose, which, combined with the long-term effects of the above behaviors, leads to diabetes, heart disease, stroke, chronic lung problems, kidney disease, and cancer.

No one pays for prevention, for maintaining health and wellness. Insurance is for disease care. Government does little (except with tobacco) to assist. As a result, as a country, we do not attend to actual healthcare and maintaining wellness, which in turn means greater pressure on the medical care delivery system. We don’t have a health care system, it is a medical care system that focuses on disease, its diagnosis, and treatment. Wellness and prevention are largely ignored. That is unfortunate because most of today’s chronic diseases could be prevented. Attention to prevention is the logical method to maintain and improve health and is much less expensive than treating a disease once it occurs.

When any of these chronic diseases develop, except for some cancers, it usually persists for life. These are complex diseases to manage and are often very expensive to treat – an expense that continues for the rest of the person’s life. Preventing them is equally complex but a lot less expensive.

Although not adequately appreciated, primary care physicians can handle most of today’s chronic illness care. They have the knowledge, experience, and skill level to do so. But this does not happen with short visits. All too frequently, the patient is referred to one or multiple  specialists when the PCP could have dealt with the problem had they had enough time. That extra time would not have cost much, but the referral, of course, means an increase in the costs of care, often substantial.

Some patients with chronic illnesses will need a team of caregivers, but the various specialists and the PCP are not a true team working in a unified manner. For example, consider a patient with lung cancer who may need a surgeon, radiation oncologist, medical oncologist, pulmonologist, pain specialist, palliative care team, nurse practitioner, and many others. Primary care physicians generally do not have the time needed to coordinate the care by the specialists. This is very unfortunate because coordination is absolutely essential to ensure good quality at a reasonable cost. You might think that one of the specialists might take on that role but that rarely occurs. More often the patient starts with a surgeon who refers him on to a radiation oncologist who then refers to a medical oncologist who then may or may not call-in others as needed. 

Any team needs a quarterback, and in general, that person is or should be the primary care physician. The PCP needs to be the orchestrator of the various specialists when needed in these complex patients. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute disease in which one physician can usually suffice. A team quarterback dramatically reduces the total costs of care if only because it means continuity and organization of care, keeping the patient’s welfare upper most in mind.

This shift to a population that has an increasing frequency of chronic illnesses mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need. This is no way to run a railroad.

Join me with the following articles as I address more of the Whys and Hows and What to Do.

The post Complex, Chronic Diseases Are Rampant Today appeared first on Medika Life.

In a comment related to the patient’s story, it was suggested that the American medical delivery system is truly dysfunctional. I agree. This has prompted me to write this series of articles to define, address and offer opportunities for improvement – improvements that will make medical care better, will reduce patient frustration and anxiety, and greatly improve physician well-being, the latter now being at rock bottom.

To begin, consider this true story. The patient’s name and some characteristics have been altered to protect anonymity. It is adapted from my book Fixing The Primary Care Crisis which was a sequel to The Future of Healthcare Delivery.

Susan is 56, married, insured, a successful professional and is in generally good health. She began to have a strange sensation in her right chest, which she described as a shooting sensation almost electrical or vibrational in nature which stretches from high up in her right chest down as a narrow line over her rib cage and onto her abdomen. It seems to be immediately under the skin, starts intermittently and ends at no set time. She visited her primary care physician (PCP) and gave this description, adding that she was concerned that it might be her heart. The doctor asked additional questions and did an exam and electrocardiogram. All were normal except for the description of the sensation Susan was feeling.

Her PCP was now running out of time for this fifteen-minute visit. Here was a fork in the road with two paths. One path was to say that it was a real sensation but nevertheless he could reassure her that there was no evidence of disease.  But given that Susan indicated a concern about her heart, the PCP chose the path to send her to a cardiologist for further evaluation. The cardiologist did a history and exam related to her heart and found nothing abnormal but suggested a stress test and an echocardiogram. Both were normal. The cardiologist said it was not Susan’s heart causing the problem, but since the sensation crossed over to the upper abdomen, maybe it would be a good idea to see a gastroenterologist.

The GI doctor also did a history and exam and found nothing. Nevertheless, among many other tests, he ordered a CT scan of the abdomen. All was normal except for a small cyst in her uterus. The radiologist read it as a benign cyst but – feeling the need to be cautious – recommended Susan visit a gynecologist, “just to be sure.”

The gynecologist also said it looked benign, but “ just to be on the safe side,” she could remove it laproscopically. Susan would be “out of the hospital the same day and feeling fine in a day or so.” The cyst was just that, a benign cyst.

Susan still had the strange sensation in her chest and no one had found an answer for her. But given that it seemed to have an electrical feeling, the gynecologist suggested that it could be a nerve issue. So, she visited a neurologist who found nothing, commenting that nerves run around the chest, not up and down. She still had the strange sensation,

Susan’s story illustrates the problem so common today in primary care. The primary care physician should be the backbone of the American healthcare system. But primary care is in crisis – a very serious crisis. In this story, the PCP did not truly listen to his patient. He did not stop and think the issue out carefully. The fundamental problem was not his disinterest. It was that he had no time to delve into what might actually cause Susan’s pain since there was a waiting room full of patients and he needed to see about 25 that day. So instead, he took the easier path and referred the patient to a cardiologist since this seemed like a logical choice.

Had he followed the other side of the fork in the road, listened long enough and then thought about it, he would have concluded that Susan was hypersensitive to minor – albeit real – sensations. He would have offered reassurance that it did not represent a life-threatening ailment. He would have said that it was real but of no concern. He might have offered a few weeks of a low-dose anti-anxiety medication such as alprazolam (Xanax), offered further reassurance and told her to return in two weeks for a follow-up. At the follow-up, he might have explored the issues producing anxiety or stress in her life – finances, marital relationship, a disruptive child, or an overbearing in-law.

After hearing about this patient’s saga, I asked a highly-regarded PCP to comment on how he would have cared for this patient. I told him only about the initial visit. He smiled and said, “I bet she got sent for a big workup.” He first said that if she were his patient then he would know her well, her family situation, and would be aware of her health status including blood pressure over the years, cholesterol levels and other factors that might predispose to heart disease.  From there he offered his approach to her visit, which I have reiterated above.

Unknown to the original PCP, Susan had some very stressful events occurring in her family, a situation that was having a major impact on her and her husband’s lives. What Susan really needed was assistance to overcome her stress, not months of specialist hopping, which was unnecessary, very expensive and only increased her stress.

Anxiety and stress are often components associated with a physical symptom, and these can only be addressed with more time to carefully listen and respond with suggestions. But Susan was shipped from doctor to doctor, test to test, and even had an operation with no one really listening enough to figure out her problem. All each specialist could do was say it was not in his or her “organ system” and leave her without a sense of closure. Each said it was not the heart, the stomach or the nerves. And the surgery “went fine,” but she still had the unpleasant sensation. All of this resulted in far less than adequate medical care and cost a king’s ransom. That is what happens today. All that was needed was for the PCP to spend some more time – time to listen, then to think and then to counsel. That’s not expensive at all.

These events point to at least three significant issues that help to define why American medical car is dysfunctional. The first was the PCP not spending the time to truly understand Susan’s issues. If he had done so, there would have been no needed to refer her to the cardiologist. That referral was essentially a copout. But perhaps, we should blame the PCP but at the same time understand his circumstances. He was stressed for time as a result of the perversity of the insurance system. No excuse but perhaps understandable. Unfortunately, this lapse resulted in the patient undergoing months of useless strain and lots of anxiety.

The specialists continued the referral process, one to the other, again without much attention to what the underlying causes of her problem might be. It was simply easier to send her to another specialist than to spend any time thinking more broadly, silo based rather than holistically based care.

Finally, the specialists were totally disconnected. If indeed specialty care was indicated, it should be the PCP that is in the driver’s seat, coordinating the referrals, personally contacting the specialist and explaining why the referral was pertinent and requesting an early appointment. As best Susan knew, none of the specialists even consulted with the PCP as to next steps before referring her on to the next specialist. None called ahead and all left it to her to arrange for an appointment, meaning that it often took weeks or more to see the next specialist on this ever-lengthening list. Another copout for sure but in some ways explainable since it is easier to refer than it is to connect back in a useful manner – telephone discussion with joint planning on next steps.

Susan’s story and her travails with the medical system illustrate how deep the problem goes. Her journey highlights many of the issues I will address in the coming articles. Multiple other patient vignettes will underscore the reality of the crisis – and its impact on all of us. In the process, I will explain how you, as a patient, can receive excellent care at limited expense.

The post America’s Health Care Delivery System is Dysfunctional – Here is Why appeared first on Medika Life.

Telehealth services remain distant dreams to others. The digital divide further expands the wedge between the haves and have-nots, people with broadband, and others in rural America. Survival — whether to schedule a vaccine or doctor’s appointment — rests on being tech-literate. Good intent alone cannot resolve access-to-care problems.

The words of Howard University’s President, Dr. Wayne A.I. Frederick, who is also a professor of surgery at Howard University School of Medicine, reached the New York Times in an opinion piece and should find its way into the hands of every health-sector leader and elected official:

Expanding primary and preventive care efforts is urgent and long overdue. We should train more health care professionals who have regular contact with patients to conduct primary care services. Imagine going to the dentist or the pharmacy and getting a mammogram or a diabetes screening, in addition to having your teeth cleaned or picking up a prescription. With more trained professionals looking out for patients, we can prevent emerging problems from becoming emergencies.

Access to Care is Survival

Convenience of care is essential to people’s well-being. We read each day of too many seniors and rural Americans struggling to access this nation’s health system. We see the wise moves of public health officials to ensure the continuation of telehealth services and recognize that hybrid care is a step toward integrating in-person with on-screen medical professional relationships. Convenience supports access to care. Access to care is survival.

One of the nation’s more pressing public health threats is now gathering momentum when our front-line medical defense force — primary care — is in retreat. Slowly driven underground by the coding maze, mysterious reimbursement hurdles, physician burnout, and consumer desire for on-demand appointments, primary care is morphing before our eyes into a pharmacy-store service add-on. That change may be the straw that breaks the camel’s back when it comes to the growing threat of prediabetes and other non-communicable illnesses that progress step-by-step from sickness to death. 

Consider the work needed to apply what we have learned during these many months of confronting COVID. It’s evident that people with non-communicable diseases (NCDs) such as cancer, diabetes, heart conditions, obesity and respiratory illnesses — amplified by COVID-19 – are at heightened risk for morbidity and mortality. While we look to tackle inflation and address supply chain challenges, we must revisit and reinvigorate our public health prevention and primary medicine network to engage and intervene around NCDs.

The Prediabetes Epidemic is the Perfect Public Health Storm

The scale of the problem is immense. Approximately 84 million adults — more than 1 in 3 Americans — have prediabetes. According to the Centers for Disease Control (CDC), 90% of people with prediabetes do not know they have it — nor that, left unchecked, it leads to Type 2 diabetes.

Though its symptoms are subtle, prediabetes is not benign. Like elevated blood pressure and high cholesterol, the unseen becomes the deadly.

Further complicating our ability to address this growing threat may be how we define the term “prediabetes.” For most people, prediabetes means, “Whew! I don’t have diabetes.” But prediabetes requires the toughest treatment — a real pledge on the part of the patient to change their behavior. Without a consistent commitment to healthy diet and exercise patterns, they will join an ever-growing community of people with Type 2 diabetes. If a routine medical test raised a red flag that something was precancerous, we would jump into action; a diagnosis of prediabetes can be treated no less seriously.

The Last Part of the Problem is Primary Care Access

Medical school debt — the need to see more patients in a day to make ends meet — has shifted physicians toward higher-paying medical specialties. Physician assistants and nurse practitioners have filled the gaps in front-line patient-care roles. Plus, the Amazon-era “I want it now” consumer mindset is transforming expectations for primary care. The ability to walk into a CVS MinuteClinic, Walgreen DR Walk-In, or Walmart Care Clinic for primary care is a win for patient access. But will ongoing, comprehensive medical needs — a plan for self-care instead of sick care — be tackled?

Today, fewer and fewer people have a long-term family physician who tracks their needs and feels responsible for their longevity. At the same time, the single-practitioner office — like pharma companies and hospitals — is now being “rolled-up” into larger practice groups and private practices are vanishing. At this pace, the discipline will become practically extinct. Yet, without the primary diagnostic oversight provided by a trusted health care provider, we are missing an important strand in the medical safety net between urgent and specialty care — between prevention and illness — between prediabetes and diabetes.

A Perfect Storm

It is a perfect storm. Poorer diet, higher sugar intake, and increasingly sedentary lifestyle are leading to prediabetes, which isn’t straightforward to diagnose and is often not taken seriously by patients. The most important player in defense against the condition — the primary care physician — is beginning to phase out.

Considering how the care market and medical ecosystem are shifting, we have our work cut out for us in getting ahead of this epidemic. We must take on more responsibilities ourselves as patients, armed with the knowledge that one-in-three has prediabetes. We must continue to foster good relationships with healthcare professionals, increasingly with specialists, to fill the role that primary care doctors are leaving vacant. Plus, communication between physician and patient around prediabetes must dial-up, with physicians combining tough love with access to behavioral insights to better understand how to motivate their patients. Both must find a conversational bridge that connects how a stitch in time saves eyesight, peripheral nerves, kidney function, and quality of life.

People with Health Needs are Calling Out Urgently

Dr. Fredrick, as an educator, public health advocate and physician maps out a commonsense and compassionate approach to preventing needless suffering and death — engage! His words must be read again and again by everyone allied to the cause of preventing illness:

The health care industry should also invest more in-patient outreach, communication, and education. Patients should not be required to fully understand their health risks and navigate complicated systems to receive the care they need. Nor should they have to travel far for it. We must create more convenient opportunities for patients to receive health care, especially for those who can’t take time off work or afford transportation. We should expand telemedicine efforts, which are still inaccessible for many minority communities that lack consistent access to the internet. We should also bring mobile health care services into low-income communities, just as we have set up coronavirus testing and vaccination sites across our cities.

A learned medical advisor — whether an in-person physician advocate or one powered by smart technology — who knows our name and knows what’s happening with us over time. It is the best defense we have against prediabetes and other chronic conditions. Even in the changing medical landscape (still struggling to overcome COVID-19 and the unresolved challenges of racism that result in illness), there must always be a place for that relationship. Otherwise, the ticking time bomb of 84 million prediabetic Americans will morph into the next overwhelming public health crisis.

The post America’s Front-line Disease Defense System has Broken Down appeared first on Medika Life.