Or is it? Help is possible for both you and your employer. Companies can change how they pay for healthcare coverage so they and you get a much better deal — happier, healthier staff with employees and companies spending less. It’s as simple as paying for you to get outstanding primary care with a direct primary care or concierge physician.

You will get what you need in care quality and satisfaction, and your employer will have reduced total care costs and a healthier and more engaged employee. Good for both parties.

What does company insurance cost today?

The Kaiser Family Foundation reported a new high of nearly $23,000 per year per family for employer-provided health coverage in 2022. This is more than double the cost in 2004 and 43% higher than a decade ago. The employee portion is also rising steadily to over 30% of the total.

Bringing down the costs and improving quality

Can these intolerable levels be brought down and, at the same time, improve care outcomes? The answer is a definite “Yes,” but not using the techniques politicians and policymakers recommend. Conservatives would say it is a matter of needing more competition between insurers. Progressives recommend universal health insurance (“Medicare for All.”)

These approaches begin with the insurance itself rather than the actual care. But the problem is with care delivery; this is where the money is spent. It starts with primary care. Little recognized by politicians or policy gurus is that primary care is broken. This aspect of our dysfunctional healthcare delivery system results in the rapid escalation of costs, especially the 75–85% of the dollars spent on managing complex chronic illnesses.

Whatever is done regarding insurance coverage, it is clear that individuals today are getting less than adequate care, and America’s per capita costs far exceed other developed countries. The real and relatively simple fix lies in a dynamic primary care system. But primary care physicians (PCPs) are trapped in a non-sustainable business model, forcing them to see too many patients daily, usually 24 or more, meaning only 10–12 minutes of “face time” per patient visit. That is not enough time for a complicated problem, for patients on multiple prescription medications, or with impairments of hearing, mobility, and maybe cognition, nor for aiding a patient with substantial anxiety. PCPs are also reeling under the constraints of government and insurer rules, regulations, and responsibilities that further take time away from the patient.

Not having enough time with each patient results in PCPs referring far too many patients to specialists when they could have dealt with the problem, including managing most chronic illnesses with more time. They prescribe drugs when lifestyle changes would suffice because working with a patient on lifestyle issues takes time. PCPs often order many tests when more time with the history and examination could give the answer. There is no time for developing a close, trusting relationship so critical to effective care. And there is no time to address anxiety which accompanies at least 40% of doctor visits. Visits to the ER are frequent, and many hospitalizations could be avoided.

The result is higher and higher expenditures yet diminished quality of care. More than 50% of PCPs show signs of burnout, and patients are less than satisfied. PCPs are retiring early or seeking other career options, and medical students no longer choose primary care as a career. Yet somehow, America tolerates this highly dysfunctional system of medical, not health, care.

Direct primary care to the rescue

There is another way. It is being done very successfully by individual primary care practitioners. It is not being mandated from above down but rather developing from the grassroots up. It is called direct primary care or DPC. Other terms used are membership, retainer-based practices, or concierge practices.

Although each of these has some differences, the essence is as follows: the primary care physician reduces the number of patients under care from the current 2,500 to 3,000 to a more manageable 400 to 800 and usually accepts no insurance. The patient pays a fixed amount directly by month, quarter, or year. The PCP commits to same-day or next-day visits, appointments for as long as necessary, 24/7 cell phone, text, and email access, and an extensive annual evaluation focusing on wellness maintenance and disease prevention.

Direct primary care costs are not reimbursed by insurance. You must pay out of pocket, but your health improves, satisfaction rises, and doctor frustration falls.

Many DPC physicians purchase generic drugs wholesale and pass them on at little or no markup. They may also arrange for markedly reduced-cost laboratory testing and radiology procedures. These can help substantially if you have a high deductible policy.

With the added time available for each patient, most issues, including the management of chronic illnesses, can be resolved by the PCP without the need for a referral to a specialist. But when one is needed, the PCP has the time to call the specialist directly, explain the issue and request a prompt appointment. More time with your primary care doctor results in fewer tests and prescriptions and more attention to lifestyle modifications. The costs of primary care do become your responsibility but the total costs of care decline markedly. With DPC or concierge primary care, the result is better health, the development of a trusting relationship, fewer specialist and ER visits, and fewer hospitalizations. A win-win for everybody.

Here is what your employer can do for you

It is essential to understand that employers are generally self-insured. They use an “insurance company” to manage the costs. The “insurer” calculates the approximate costs for your company for the year ahead based on the previous year’s activity plus an inflation allotment. This almost always results in an increase in the premiums for the upcoming year. The employer decides how much to pass along to the employee to pay, and the employer also sets the yearly deductible with the assistance of the “insurer.” In the following year, the company’s costs will decline. Should the company’s staff have better health and hence use fewer medical resources, the company will see a reduction in premiums in the following year; this rarely, if ever, happens today. But it could.

Employers can embrace this approach by reimbursing the cost of DPC. Paying for DPC may seem like an added expense to your employer. Still, the result is improved employee health, reduced absenteeism, and sick leave while bolstering employee satisfaction and decreasing the total care costs for both employer and employee.

Here is how to make it happen

DPC’s time has come. It is time for employers to embrace it, but it won’t happen unless they are “nudged” into action. Here is my advice to you. Go to your employer and advocate for direct primary care/concierge care paid for by the company. Let them know why it is to their definite benefit. And get your co-workers to do the same. It is definitely to your advantage to advocate.

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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.

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In this article, the third in a series, I will focus on cognitive and mental health disorders that frequently appear well after a Covid infection has cleared.

Many people during and after infection refer to “brain fog,” an inability to think as clearly and rapidly as pre infection. Often it clears spontaneously but for some it persists and for others it occurs much later, weeks or months later. Now there is evidence that the brain is damaged even in individuals with mild Covid-19.

A large ongoing study at Oxford University indicates from MRI brain scans that individuals post Covid-19 may have gray matter loss and brain size shrinkage when compared to those who did not get infected during the same time period.

In the UK Biobank of over 500 million volunteers, many have had MRI scans of the brain done between 2014 and the onset of the pandemic. The study investigators invited those aged 51 to 81 to have a repeat scan in early 2021. There were 401 volunteers that had Covid-19. The great majority had “mild” Covid with only 15 hospitalized. They were re-scanned, on average, 4.5 months after infection. As controls, 384 volunteers were selected to match the infected group for age, sex, and a variety of risk factors such as obesity and diabetes.

They found, on average, that the infected individuals had reduced gray matter especially in the areas related to smell, evidence of tissue damage in the same areas, and cognitive decline as measured by standard tests with anatomic correlation of shrinkage of brain tissue in areas known to be important for cognitive abilities.

It is still unclear if these changes will or can be reversed.

An investigation from Wuhan, China that studied 3233 Covid-19 survivors over the age of 60 hospitalized during the early months of the pandemic and evaluated for cognitive function 6 and 12 months after infection and compared them to uninfected spouses. Those with severe disease had a higher risk compared to the controls of early onset cognitive decline, late-onset decline and progressive decline. Importantly, it was found that those with non-severe infection had a higher risk than controls of early progressive cognitive decline.

These and other studies make clear that cognitive decline post Covid-19 is real, not uncommon and can be persistent. It is also becoming clear that various neuropsychiatric symptoms also occur after Covid-19 infection. My prior article reviewed a Veterans Affairs study that assessed Long Covid cardiovascular syndromes.

The same group of epidemiologists did a concurrent study of neuropsychiatric issues such as anxiety, depression, cognitive decline, brain fog, sleep disorders, stress and adjustment disorders, and substance abuse post Covid-19. The ~154,000 veterans who visited a VA health facility who tested positive for Covid-19 during the first 10 ½ months of the pandemic and who were still alive 30 days later were studied over the next 12 months and compared to the over 5 million veterans seen at the VA health centers who never had a positive test.

There were many that developed one or more neuropsychiatric symptoms in both groups. The larger group served as the baseline control yielding the expected number of veterans during that time frame who would develop one or more mental health syndromes. The Covid-19 positive patients neuropsychiatric syndrome frequency was compared to the control group.

Bottom line- those with a positive test for Covid-19 had more syndromes develop than did those who never tested positive.

Among the ~154,000 veterans who were Covid-19 test positive were those who were asymptomatic or had “mild” Covid and were never hospitalized (~133,000) and those who required hospitalization (~21,000.)

Perhaps not surprisingly, those who had been hospitalized and those treated in the ICU had a much higher frequency of post Covid mental health syndromes than the control group. They also had a higher incidence than those who were not hospitalized.

This difference can be easily observed on the graphic below. The upper dotted line represents the mental health issues when first diagnosed among the control group. The solid line plots the first diagnosis for those with Covid who were not hospitalized. Finally, the lower line indicates that those hospitalized developed neuropsychiatric syndromes at a much higher rate than the control or the mild Covid patients.

Look again at the line representing the non-hospitalized patients with Covid-19. It may not appear to be that much different than the control group, but it is. The risk for any mental health syndrome developing after Covid-19 for these non-hospitalized individuals was greater than the controls by 32 per thousand. Multiplying just within this group of 133,000 veterans yields about 4250 more cases than expected among these veterans.

Consider for a moment the implications of these numbers. About 80 million Americans have had Covid; most have been mild. Will the healthcare system be overwhelmed with Long Covid patients, even just those with neuropsychiatric syndromes? Most likely.

The cause or causes are not understood although there are many possibilities including the social impact of the infection with isolation, loss of normal employment, family impacts, etc. Among the proposed biologic causes are direct damage to the brain by the virus, immune cells traveling to the brain and causing damage, brain cell inflammation from some other mechanism, and an overall immune system dysfunction that also impacts the brain. But even if one or more of these are correct, it leaves open the question as to why some develop mental health issues after mild Covid-19 and others do not.

Without a unifying causation concept, treatment will be symptomatic rather than attacking the specific cause or causes.

This much is certain. The development of cognitive decline and mental health syndromes after mild Covid is one more reason, if one is still needed, to discount the idea that getting infected can be useful.

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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.

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In my earlier posts in this series, I have written primarily from the perspective of what primary care physicians can do to improve their patients’ health and reduce total costs of care. Concurrently, they can reclaim their right to practice in a non-frustrating environment with a limited number of daily patient visits. Torinus approaches improving health care from the perspective of a business leader faced with rising health care costs. Here I will quote and paraphrase from Torinus’ book and, since I basically agree with his recommendations, will amplify with some of my own thoughts.

He argues that company CEOs must make health care a strategic priority since it is one of the top three costs for any company. In addition, healthcare costs can make the company noncompetitive if not managed aggressively. However, strategic priority to him also means it is essential for the company to attend proactively to the health and wellness of its employees, not just be the provider of an insurance plan.

CEOs need to consider the long term for their companies and employees. The company and the employee together spend about $16,000 per year for a family for insurance as of his 2014 book publication, obviously much greater than that today! Using his $16,000 estimate, an employee who works for a company for 25–40 years represents an insurance expenditure over a lifetime career that could be as much as $400,000 to $640,000 in 2014 dollars. This drives home the point that it only makes sense to have a long-term view of employee health, beginning with an aggressive approach to maintain wellness, actively reduce risk factors and manage disease as it occurs.

Some repetition here is worthwhile. Don’t just focus on treating disease but prevent disease and maintain wellness. Of course, that will cost some money now, but the end result will be a substantial decrease in total costs over the years. And, don’t just cover disease care but arrange for each employee and family member to have outstanding primary care to avoid unnecessary excessive specialty care.

He observes that the current health care system focuses on specialty care, whereas it needs to focus on the care recipient with high-quality primary care — the patient/consumer/employee. But to be effective, the patient/consumer/employee needs to be engaged. Instead, the current healthcare system disengages the patient — it removes responsibility because the patient is not the doctor’s customer.

In his company, expenses were rising to double digits by 2003, but with their new plan in place, it dropped to 2% or less per year.

Torinus’ “prescription” for all companies (and what his company initiated beginning in 2004) follows:

First, every company, including small companies, should self-insure with an added stop-loss catastrophic policy.

Second, employees should be offered only a consumer-directed healthcare policy (CDHP), in essence, a moderately high deductible plan (often about $2500) with either an associated health savings account (HSA) or a health-related account (HRA.) The company should prefund the account with an amount (often about $1500 or more) that the individual can use for any health care needs with the assumption that since it is now the individual’s money, he or she will spend it more wisely — employee/patient engagement.

Third, the company should insist that each provider have price transparency. Since that’s often difficult to obtain, Serigraph uses various companies like Alithias Inc to provide that for them so that they can compare one provider to another. For example, they determine the price of the all-inclusive (gastroenterologist, anesthesiologist, and facility fee) along with quality data of colonoscopies at the nearest five centers and then rank them. The employee or family member who needs the colonoscopy is told that, for example, the company sees it as appropriate preventive care and so will cover the cost, in this case up to $1,500. [His book appeared before the ACA became law, so the insurance component would cover colonoscopy now, but the principle is still valid.] This is an amount that will pay for, say, four of the five local centers, but if he or she selects a provider that charges more, they are on the hook for the remainder.

Fourth, if the company is large enough, it should provide an on-site primary care clinic at no cost to the individual. For example, at Serigraph, the clinic includes a concierge-type physician (meaning that the physician is salaried, has a low number of patients under care, and gives ample time and energy to each employee/family member patient, consistent with some of my previous posts) plus a nurse practitioner, a health coach, a dietician, and a chiropractor. On the other hand, if the company is too small to justify a full-fledged clinic, then the company can pay the retainer for a nearby direct primary care/membership/concierge physician who works with others, such as a health coach.

Fifth, the clinic, with particular attention by the health coach, gives all employees a health risk assessment annually and then works one-on-one with each employee (and family member) at no cost to maintain wellness and health, including the use of behavioral change programs around diet, nutrition, exercise, stress management, and smoking cessation.

Sixth, the clinic staff gives very intense management of chronic diseases and coordination of specialist visits when needed. (See my earlier article on care coordination by the PCP)

Seventh, Serigraph uses what Torinus calls Centers of Value for procedures beyond those that the primary care physician does. These are doctors/institutions that have outstanding quality records yet a competitive price for, say, a knee replacement. Serigraph gives their employees $2,000 toward the deductible or covers the deductible for the surgery when they use these Centers of Value.

Seventh, his company gives (and he recommends others do likewise) generic drugs for free, and all of the above prevention and wellness programs are supplied free of charge. Finally, the company makes free counseling available for developing advanced directives, and if an individual requires end-of-life care, hospice is available free of charge.

I notice that his company spends considerably on extensive/comprehensive primary care, including wellness maintenance, proactive prevention, behavioral health, and chronic care management. In return, the company is rewarded in return with lower total costs and healthier workers.

Given that healthcare has become a company strategic priority, then it needs to be managed, and that requires data. Hence, he urges all companies to develop health-related management dashboards, including both a financial dashboard (how much is the company spending) and a health dashboard (how many individuals in the company have uncontrolled blood pressure, uncontrolled asthma, uncontrolled cholesterol, have not had appropriate mammography or colonoscopy, etc. — all information collected from the clinic in an unidentified manner to protect individual privacy).

These approaches are based on fundamental principles, including individual responsibility; marketplace discipline — installing consumerism, steering business to the best quality and price (“do good work and you get our business”); proactive care — maintaining employees’ health and wellness and give extensive care to those with chronic illnesses; and sound management — putting those who pay, i.e., the employer and the employee, in charge.

Torinus suggests that there are multiple rewards for following this basic approach (I added number 2 since he implied but did not write it.)

1) The reward for business is a healthier workforce and more affordable healthcare expenditures.

2) The reward for individuals is more health and wellness, less illness, and fewer dollars spent.

3) The reward for high-value providers is more business.

4) The reward for entrepreneurs comes if they innovate with better care provided at a lower cost

5) There could be a reward for taxpayers — if governments (federal, state, and local) were to utilize these approaches.

Sound advice? I certainly think so.

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“It is all about vigilance and caring. We aim to put the caring back into healthcare, and we are serious about that. Our standards are not how many patients you saw today but how much quality you dispensed today,” Dr. Greg Foti told me about the comprehensive care center, AbsoluteCare, where he works in downtown Baltimore, MD.

Individuals with multiple chronic illnesses compounded by socioeconomic issues are perhaps the most difficult to treat, and the annual expenses can be exceptionally high. Success with these patients would be a story worth telling. Here it is.

Individual doctors and doctor groups have embraced the direct primary care approach with either a fee per visit (direct pay) or a fee per month or year (membership, retainer, and concierge). Mostly, they convert an ongoing practice of 2500–3000+ plus patients to a new model that encompasses about 500 patients. Their patient group usually spans a wide range of ages and the spectrum of some with serious chronic illnesses to those who are basically healthy. I wrote earlier in this series about the advantage of an all- gerontology practice that maintains a patient panel per PCP of about 400.

But what about a panel of patients that all have serious illnesses, who are socio-economically disadvantaged and cannot afford to pay a membership? A number of companies are addressing this need with a focus on the medically most needy; here is an example.

An infectious disease practice in Atlanta initially dedicated to HIV patients later expanded to a broad primary care program for those with multiple serious chronic illnesses — just those who are among the 5% of individuals for whom 40% to almost 50% of all medical dollars are expended. The company, AbsoluteCare, opened a second program in Baltimore — a 17,000-square-foot primary care office in a new building to manage the care of “the sickest of the sick,” whose average annual claims approach $40,000 per year.

Their model has one PCP or NP per only 300 patients working with a team of case manager, medical assistant, and nurse. Other on-site professionals include a mental health therapist, psychiatrist, and social interventions. They also deploy a community-based team that cares for patients in their neighborhoods and homes. In addition to medical care, they address social issues that may impact health status, such as food, clothing, housing, and transportation. For example, they will pick up the patient, bring them to the office, and return afterward.

In essence, the center staff is providing dramatically enhanced primary care at a substantial additional cost over typical primary care but with the aim to improve health and thus lower total costs. Most of the initial patients were on Medicaid or in a Medicare Advantage plan and lived in economically stressed areas. AbsoluteCare now also has contracts with both local and national health plans and has operations in 6 cities, and continues to grow.

It is important to be repetitive here. This type of primary care costs much more than traditional primary care but the result, besides for much-improved patient health and wellness, is a major reduction in total health care costs. That’s why health plans representing Medicare and Medicaid are willing to be supportive. Good for them to have opted to give it a try, and it is working in multiple cities.

The Baltimore office, which I have visited twice, is notable for its ambiance, cleanliness, exceptionally courteous staff, the sense of fun yet seriousness, and the clear message that everyone really cares about the patients and is determined to develop a trusting healing relationship with each. Not exactly what one might expect in an inner city medical office that caters to the socially-economically disadvantaged.

A major focus is on the family and social situation — are they living alone, having transportation, or are they having difficulties with rent, phone, and heating bills?

Same-day visits are the norm; basic blood tests are done on-site, and IV therapies are available, as is an in-house pharmacy. General radiology is transmitted to a nearby tele-radiologist. In addition, the center has a cadre of specialists they tend to call upon for referrals — chosen not only for their expertise but also for their willingness to work in close coordination with the care team.

As Chief Medical Officer Dr. Greg Foti told me: “It is all about vigilance and caring. We must call the hospitalist if the patient is admitted. We must follow up with skilled nursing if needed. We must transport them here to ensure they get the care they need. We want to fully wrap our arms around all the factors that affect their health. We don’t have any magic bullets, but we can give true love and care to our ‘members.’ That will make the difference in both quality and costs.”

The Baltimore office is focused on ensuring that they provide quality care as measured by some standard parameters. “Before AbsoluteCare intervention, our traditional member population scores in the lower 30th percentile with most quality- and value-based purchasing outcomes. After Absolute Care intervention, our members have increased their quality- and value-based purchasing outcomes [such as blood pressure control, HbA1c control, etc.] into the 75thth-95th percentile. Our culture demands that success be tied to quality- and value-based purchasing performance.”

For the payor, these numbers are impressive: a sharp reduction in hospitalizations (down 50%), ER visits (down 34%), reduction in specialists visits (24%), and total costs of care by perhaps a third, a remarkable decrease for these very challenging patients.

But most important, patients have, probably for the first time, found compassionate, thorough, comprehensive, meaningful care that has had a positive impact on their health and their lives.

Many pressures are driving the need for alternative approaches to providing primary care. Enterprising physician entrepreneurs are often the drivers of paradigm change. The fundamental concept of this center and others like it is to offer expanded primary care with heavy use of resources to improve health and lower total costs. As Dr. Foti noted, “We cannot always cure these individuals of their chronic diseases, but we can make a big difference in each person’s health, in their ability to enjoy life and be productive.”

The patient gets extensive primary care not just with a doctor or nurse practitioner but also with a team including attention to social needs as well as medical and mental health requirements. The result is that the patient becomes much healthier and will be using fewer medical system resources, especially those that are exceptionally expensive, like ER visits, procedures, imaging, specialist visits, and hospitalizations.

It is time for insurers to recognize and support this type of care. It changes the payment model but will lower their total care costs.

The post Primary Care for the Sickest of the Sick 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.

Until now, you just sort of accept medical caregivers to be what it is, even if it frustrates you. But the time is rapidly approaching when you will expect an adequate period of time with your caregiver, that the caregiver will know you as a person and indeed know you as a person that is part of a family, a community, and a society. You will not tolerate any longer being treated as a “number,” a “case,” or as a “problem.” If you don’t receive the care as described, you will seek out care elsewhere.

An example of this is a friend, Rebecca, a physician’s wife, who developed breast cancer. She was seen immediately by a topnotch surgeon who did her biopsy and then lumpectomy in a very timely manner with plenty of discussion and “hand holding,” She then went to a highly regarded medical oncologist with the expectation that she would receive her drug therapy and radiation therapy at that individual’s hospital. She knew that the oncologist was well trained and very competent. However, the physician seemed pleasant enough but not engaging and not really focused on my friend as a person.

It seemed as though she went through a “checklist” of information in a “rote-like” manner. Rebecca felt like she was just “one more” breast cancer patient rather than an individual with a particular problem. She felt that perhaps the physician was just having a tough day or that she, the patient, was being seen at the end of a long line of other patients that day. But no matter, this was the physician who was to be her primary caregiver concerning an issue of utmost importance to her. The result: My friend went elsewhere for her medical oncology and radiation therapy care. The basic message, of course, is that patients now want and expect not only competency but also personal and professional care and will both pay for it and demand it. A bit of empathy doesn’t hurt either.

Compare that story to this one. A couple, Bob and Ruth, went to a small Caribbean island for a two-week vacation. On the last day of their vacation, the husband had a heart attack. Bob was taken to the island’s small 25-bed hospital. He and Ruth, who works at a major hospital in a patient care/advocacy profession, were immediately concerned that the level of care would not be up to the standards that they would have expected in their large U.S. city. However, what they found, to their obvious pleasure, was a highly skilled physician who was also highly interactive with the two of them. He did the appropriate diagnostic tests to demonstrate that it was a heart attack and then began the proper medical therapy. Concurrently he arranged for Bob’s air transport to a major Florida hospital.

Meanwhile, others at this small hospital helped Ruth cope with her concerns and deal with some practical issues of getting checked out of the hotel, returning the rental car, arranging medical evacuation flight and all the other details that needed to be done. In short, they looked after her as well as her husband. Ruth cannot speak highly enough of the care that her husband received.

Both of these patients were “connected” to the healthcare professions. So, if you think compassionate, attentive care always comes to such individuals, think again. Years ago, doctors offered their colleagues and families “professional courtesy.” No more. That will not change, but whether the doctor or family member is a patient or not, they will expect compassionate, attentive care just like everyone else. They may be the ones to push the system the hardest and, at the same time, “look in the mirror” at their own practice patterns and initiate change. Change will occur but never as soon as desired.

Both of these stories also illustrate the issue of complex, chronic disease. These diseases do not go away; they can often be cured, but the possibility of a subsequent problem [heart failure] or recurrence [cancer] is real. Many chronic illnesses will be with the patient for life. They require many different practitioners with differing skills to help care for them, which all need coordination.

But in America today, care for these complex, chronic illnesses, which consume more than 70% of all medical care expenditures, are definitely not addressed in a coordinated manner except in a few centers and practices. This means that the care is not up to the quality levels it could be given our knowledge base and our excellent practitioners, and it also means that the costs are much too high. We need to find a way to change our delivery system so that it delivers coordinated, compassionate, and safe care to individuals with these complex, chronic diseases.

Here is a “problem” which everyone needs to understand. If you are on Medicare, Medicare sets the payment for the doctor. He or she cannot bill you more than what Medicare allows. So, if you say to your doctor, “Look, I’d like to spend some more time to fully have you understand my situation or so that I can better understand your advice,” the doctor can say “OK” but Medicare will not pay any more for that extra time and the physician, by law, cannot bill you for the extra time spent. If you were doing a new will and wanted to spend more time understanding what the lawyer was recommending, the lawyer would say “OK,” but both of you would know that you would be billed for the added time. With Medicare, you don’t have that option.

Consider Renee. A few years ago, she asked me for the name of a physician who would give her the time needed for her situation as an older single lady with multiple chronic problems not being fully addressed by her all too many doctors. I suggested Gary Milles, MD MPH, who has a “concierge” practice. He charges a flat fee of $1850 per year and, in return, is available by cell phone 24/7, text, and email. He has only about 490 patients, unlike his original practice with 2700. So, he can offer same or next-day appointments lasting as long as needed.

Each year he does a very comprehensive evaluation lasting two hours, including multiple blood tests, a vision, hearing, and pulmonary analysis at no added charge. Importantly, if a specialist is needed, he will call that doctor directly, explain why he is referring you, and ask for a prompt appointment. That means you will be seen much sooner than if you called that doctor’s office and the doctor will understand why you are there when you come for your appointment. This all makes a big difference in care.

“You aced it when you referred me to Dr. Gary Milles! He has been terrific for me. First, he found out why I’ve had very high BP for four years, e.g., 250/160. Then, instead of all those blood pressure pills, he stopped them and put me on something less powerful and with less side effects and stopped some supplements recommended by a different doctor, adjusted my diet, and gave me some suggestions on stress management. As a result, blood pressure is now OK. So far, so good….we had to make only one adjustment after several months!

“But now I need to see a pulmonologist. The one he recommended did not work out. Great background and experience, but when I had my first visit, things started out poorly (very impatient and rude with me) and quickly spiraled downhill. He definitely is not for me. I will ask for another option.” Dr Milles was thankful that she reported the poor caring and sent her to another pulmonologist who had the appropriate medical but also personal skills. The first pulmonologist will not be getting referrals in the future.

This change to “patient first” is occurring slowly, beginning with primary care physicians, using the direct primary care or concierge models, regaining the time needed to give adequate, expert attention, and, when necessary, coordinating multiple specialists. This means much better quality of care, coordination when needed, all tied into genuine compassion and caring. In that way, it will be a return to my physician grandfather’s time when treatment options were limited. Empathy and caring will be uppermost while still preserving the incredible advances modern science has brought forth. It will mean better care, less patient frustration, less doctor frustration and burnout, and a huge reduction in total costs as an added, very important bonus.

It is a contract between the doctor and patient; no insurer is involved. But of course, if the patient does not feel well treated, the contract is voided, and they will move on to someone else.

The post Consumerism in Healthcare appeared first on Medika Life.