Monday, December 14, 2015

Direct Primary Care – Isn’t It Too Expensive?

A common criticism of direct primary care (membership/retainer/concierge practices) is the added expense – “isn’t it too expensive?” Ways to think about the cost are to prioritize expenditures and to consider potential savings that make it cost effective.

I gave examples of three direct primary care practices in an earlier post. Here is a recap of costs.
AtlasMD’s annual fee is $600 for a young adult and about $1400 for a family of four; Dr Neuhofel’s fee is $360-$600 annually for an individual and $1200 for a family of four and Drs Izbicki charge $780 per year per individual. All can be paid monthly.

As Jon Izbicki puts it, “Our monthly fee is less than what it costs to rent a parking space downtown for the month.” Even the more expensive retainer practices are still within reason for many.  $1500 is about $4 per day; $2000 is about $5.50. How many people spend that much per day at Starbucks? Or, consider the monthly/annual cost of a smart phone data contract with ATT or Verizon. According to the Wall Street Journal and quoting from a Department of Labor study, the average American family spends $2237 per year for internet, pay TV and telephone service. So, perhaps $1500 or $2000 - which is certainly real money - is not such an onerous expense when thinking in terms of prioritizing healthcare expenses relative to other expenses. Of course, it is an added expense if you already have typical insurance.

But if you have a high deductible plan with a health savings account (HSA), you can pay for the membership/retainer with tax advantaged dollars and save considerably. And since the PCP will likely help you avoid expensive trips to the specialist, you will save those dollars as well.

I predict that (absent a significant change in insurer behavior) direct primary care will likely be the future of primary care payment. In each of them, it means that the patient will obtain real 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 illnesses and fourth, thorough coordination of the care of chronic illnesses, all at a reasonable cost which will be transparent. Fifth and importantly, a PCP who has the time to listen – to listen deeply with a return to relationship medicine.

Those who already have typical limited deductible insurance – commercial or Medicare – might argue that these various direct primary care models represent an added expense, not a savings. Correct, although the potential savings can actually be quite substantial. For example, each of the three practices referred to above make generic medications available at wholesale prices; considerable savings for many individuals.

Those who have 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 a lot less than going to an urgent care center or an ER. Recall from my earlier post that Dr Neuhofel’s practice has more than two thirds with no insurance.

Perhaps Medicare and Medicaid will decide that it makes eminently good sense to pay the retainer for their enrollees and thus ensure that their members gets superior primary care at a reasonable cost and meantime save Medicare and Medicaid enormous total dollars.

This concept applies equally to commercial insurers who have largely avoided paying the retainer. Some are collaborating with the insurer paying the retainer out of its premium.

What about employers? Many are converting their health insurance policies to high deductible, often with a deductible as high as $10,000 per person or family per year. For a family with members that have chronic illnesses, the costs of healthcare will be very substantial indeed at this level. Employees will arguably feel that their employer has walked away from them and saddled them with costs that they simply cannot bear. The company can partially offset the inherent anger this generates among its employees by paying the fee for a direct primary care practice. It is especially valuable for the individual with multiple chronic illnesses since quality primary care can mean much better health, many fewer tests, prescriptions, specialist referrals and hospitalizations.

I suspect that 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 in early 2014 pegs the known number at about 4000 with about 8000 others doing so but without fanfare. CMT also notes that many combine insurance with membership fees; not exactly DPC anymore but still an ability to limit the number of patients and give more attention to each.

More doctors will convert once the general population understands the advantages and begins to ask for it. 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 savings despite the fee.

TAGS  Direct primary care, primary care, primary care physicians, health insurance, healthcare costs, relationship medicine, concierge medicine, retainer based medicine

Sunday, July 12, 2015

Concierge Medicine – For the Masses or the Elite?

Is concierge medicine (also known as direct primary care, retainer-based, membership) for everyone or is it just for the rich, the 1%? Most people assume it is for the elite and cannot be afforded by the common man, the masses. That is unfortunate because in many cases it can be quite affordable. Here are three examples.

AtlasMD in Kansas City and others like it think of themselves as “blue collar” concierge practices. According to AtlasMD physician Dr Doug Nunamaker “We realized that insurance paying for primary care is akin to using car insurance to try to pay for gasoline. ‘It’s something that’s otherwise fairly affordable until you try to pay for it with insurance: My premiums would be much higher because they wouldn’t know how much gas I would need, they would tell me where to get gas, and I’d have to preauthorize trips out of town.” AtlasMD physicians have 600 patients each. Monthly fees: 20 to 44 years - $50 a month, 45 to 64 - $75 a month, 65 and older - $100 a month, children to 19 years - $10 a month. Generic medicines are available at wholesale prices.

In Erie, a working class city in northwestern Pennsylvania, the Izbicki brothers also began such a “blue collar” membership practice. Just out of training in Family Medicine in 2005, they first worked for another practicing physician and then the local hospital, in each case being frustrated that they could not spend enough time with each patient.  They started their own practice using the typical insurance-based business model and soon had about 4000 patients between them. They were back to seeing too many patients for too short a time each. Dr. Jon Izbicki told me, “We were bitter, frustrated. We were in a failed profession. It was so bad that we really had to take a risk. We knew that what patients want more than anything else is uninterrupted time with their PCP and with that to build a level of confidence. They want relationship-centered care.”

They converted in June, 2013. They chose to call their practice direct primary care given the fiscal conservatism of Erie. Not all of their patients were pleased; less than 20% joined initially. But over time their practice numbers have climbed.

The Izbicki brothers charge $780 per year for unlimited primary care, payable as $65 monthly or annually with a discount. Visits are as long as needed and usually the same or the next day. They have developed contracts with clinical laboratories for highly discounted testing and radiology. They purchase generic drugs at wholesale prices and sell them to their patients at the same price. For many patients, especially those with multiple chronic illnesses who are taking 5-7 prescription medications, this can save as much or more than the annual membership fee. It is this latter factor that especially encourages Medicare enrollees to join.

Dr Jon Izbicki put it this way, “Perhaps the term ‘complex care physician’ would be better than primary care physician as it more closely relates the work of the doctor, especially with these patients with highly complex, serious illnesses.”

Not everyone has a sizable practice from which to convert. For younger physicians, with no base of patients to draw from, it can be a challenge to get started. In Lawrence, Kansas, Dr Ryan Neuhofel began a membership practice called NeuCare right out of his residency training in 2012. He had decided while in medical school and residency that he did not want to be in a typical insurance-based practice. He told me, “I saw that most PCPs did not have fulfilling careers; they spent enormous time in administrative tasks rather than actually working with their patients. I knew I wanted to do primary care but it had to be in a model that let me earn a decent living yet let me give real quality care in a compassionate manner.

“It was a real gamble to go straight into this. I had no patients and no reputation in Lawrence. My practice built slowly at first but is gaining momentum now.” The demographics of his locale are individuals with less than the national median income so his practice is “more like a safety net clinic.” About 70-80% are uninsured and a very large number have complex, chronic illnesses – “a lot more than I anticipated.” His monthly fee is $30 and $40 rising to $50 for those over age 60; he charges $100 for a family of four with $10 more for each extra child. He buys medications from wholesalers. He finds that the savings for some of his patients with multiple prescriptions can be literally hundreds of dollars per month for a family, far outweighing the monthly membership fee. Now a few employers have noticed and decided to offer his services as a benefit to their employees who take out a high deductible policy. “I see this as a real source of growth for my practice and the real long term growth for the whole direct primary care concept. It allows employers to initiate a high deductible policy yet give the employee access to quality primary care at no added cost. This is especially important for the person with lots of chronic illnesses personally or in the family.”

Asked about income once his practice is filled out, “I will be earning about average for a family practice physician in this area and that is just fine with me.”

These three practices demonstrate that direct primary care by whatever name can be affordable to most individuals and families and in many cases actually save money – not to mention a return to relationship-based medicine.

Tuesday, June 30, 2015

Saving Relationship Medicine with Direct Primary Care

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 and regulations that reduce the trust and core interactions between doctor and patient. 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.

I believe that 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 that 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 with 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 always it means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principle 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,” not unlike the way 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 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 to a high of about 800 for a panel that has mostly low risk patients. Some accept insurance and also charge the retainer; others 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 communications, and an invitation to contact the PCP on his or her 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 only work with specialists who are willing to discount their fees for those of their patients who pay cash and have high deductible plans or no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact membership/retainer/concierge practices can be of 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 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 who have high deductible insurance policies from work or from the exchanges, connecting with a direct primary care physician can offer a 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 and more satisfaction for doctor and patient 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. A triple win.

Next post – more on the costs of direct primary care

Tuesday, June 16, 2015

Solving the Crisis in Healthcare Requires Solving the Crisis in Primary Care

There is a crisis in the provision of primary care in the United States. If you are a patient, a primary care doctor, an insurer, an employer or a policy maker, this crisis is exceptionally important to you. The crisis means that Americans do not get the level or quality of healthcare that they deserve and need. This crisis is the major reason that healthcare in total is so expensive and why costs keep rising. This crisis needs to be fixed and fixed as quickly as possible. Fortunately, a solution exists that is within reach. It will be a disruptive and transformative change so it will not come easily to a profession that is “conservative” by nature. My new book Fixing The Primary Care Crisis, addresses all of these issues in easy to read language.

Contrary to what many assume, PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and especially the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. To appreciate this is to begin to understand why the current system just does not and cannot work and why it needs to change.

The fundamental problem is that primary care doctors (PCPs) care for too many patients with too many short visits per day, and as a result do not have the time they need to provide high level care. They need time to listen, time to think, time to give quality preventive care and time to offer care of complex chronic illnesses and to coordinate care for those actually do need a specialist referral. They also need to be able to build a trusting relationship with the patient and to offer true healing, something that also takes time. In other words, they need time to practice their profession, something they currently are unable to do fully or effectively.

This crisis has led to a culture of highly frustrated doctors who feel they are on a never ending treadmill, and are leaving private practice or retiring early. It means that patients are equally frustrated at the long waits, short visits, high costs and no sense of being listened to, of not receiving empathy, of not being actually cared for. The crisis means that there are currently not enough primary care doctors, and it will only get worse because students in medical school see the impact of this crisis and choose not to enter primary care as a result.  It’s a downward spiral that needs to be reversed.

The crisis began a few decades ago when insurers, beginning with Medicare, held reimbursement rates low (cost control through price fixing). At the same time, doctors’ office costs were rising. In order to meet basic overhead expenses while maintaining their incomes, PCPs began to see more and more patients per day. The average PCP’s income in 1970 was slightly more than today (in inflated dollars) but the PCP was seeing only one half the number of patients as today. Now, with about 25 or more patients per day, a visit is often only 15 to 20 minutes: actual “face time” with the doctor is just 8-12 minutes. If you’ve been a patient recently, I’m sure you’ve experienced this. While this amount of time is long enough for a simple problem, it is much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescriptions. And it is not nearly long enough for an elderly person with impaired vision, hearing or cognition. There is no time for compassion, to build trust or to be a healer. Since there is too little time, the tendency is to send a patient off for tests or to a specialist when a bit more time with their history would provide the answer. There is not enough time to discuss lifestyle changes, meaning it is easier to just write a prescription and hope for the best. It is these steps that are the major cause of higher and higher medical care costs in the United States: unnecessary referrals, unnecessary tests, unnecessary X-rays and unnecessary prescriptions. And with it has come the loss of the close and trusting doctor-patient relationship and the lack of true healing.

When PCPs do have time, they can develop a trusting relationship and then give superb preventive care. This type of care will reduce serious chronic illnesses in the future, the diseases that today account for 75-85% of all medical costs. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing. When PCPs do have time, they can coordinate the care of those patients that truly do need to be referred, ensuring high levels of quality at a reasonable cost. When PCPs do have the time, they can appreciate the underlying stress and anxieties that propel so many illnesses and trips to the doctor. When PCPs do have time, they can give truly proactive preventive care – population health - by reaching out now rather than waiting for the patient to arrive with a problem.

To address this crisis, both patients and PCPs will need to take charge and change the paradigm of primary care. Government will not do it. Insurers will be slow at best to do it although there are some examples to the contrary that we’ll explore in this book. A few enlightened employers are beginning step up as we shall also explore. But if there is to be real change—change that works—it will take PCPs and patients to force the issue. Patients need to demand the time they deserve. PCPs need to be able to give them the necessary time. This means fewer patients per PCP. Patients will need to migrate toward doctors that have 800 or less patients (compared to today’s standard of 2500 or more) and can therefore give them more time as needed.  The actual number per doctor should depend on the demographics of the doctor’s patient panel (the doctor’s patient load)—for example, a panel of mostly older individuals with chronic illnesses means fewer patients. Fewer patients means more time for each patient and much better access to the PCP. We’ll take a look at what some innovative physicians, insurers, and employers are doing—separately—to transform primary care and bring it back to being “relationship medicine” with a heavy emphasis on health and wellness and the care of complex chronic illnesses in addition to typical episodic primary care: true comprehensive primary care. One of many innovations is to not accept insurance and charge a reasonable amount per visit according to a posted price list. Another is using some form of “direct primary care” (DPC).  DPC comes in many variations and is known as membership, retainer or concierge medicine, but in essence it means charging a flat rate by the month or year for all primary care services, reducing the number of patients under care to about 500 and offering same or next day appointments for as long as necessary and access to the PCP via his or her cell phone twenty four hours per day and via email. It means comprehensive primary care not just episodic care: attention to health and wellness, reduction of risk factors, preventive actions, intense management of chronic illness and coordination of specialist care when needed and a return to relationship medicine with trust and healing. The latter is essential if we want to move from a reactive to proactive approach to healthcare. That means much improved care quality and satisfaction, and lessened frustrations for patients and doctors alike. Often it means generic medications at wholesale prices and laboratory and radiology at deeply discounted rates. Despite a widespread belief to the contrary, DPC is not just for the elite, the rich or the 1%. In fact, it can be quite reasonable – “blue collar” –  and, when DPC is combined with a high deductible health insurance policy (which is much less expensive than typical policies,) the savings for patients are substantial and the total costs of all care decline quite dramatically.

Among other options is capitation, as in some Medicare Advantage plans, but where the payment to the PCP is sufficient per patient that he or she can afford to have a reasonable total number of patients. Another is for insurers to create incentives for reducing patient numbers. Yet another is for employers to create their own primary care clinics with a low employee to physician ratio or to offer a payment into a health savings account (HSA) to purchase the membership in a direct primary care practice. One additional example is to place extensive primary care resources for the management of the “sickest of the sick,” often the socioeconomically disadvantaged with insurance via Medicaid – a team of PCP, nurse practitioner, nutritionist, mental health therapist, etc. We will explore each of these and other options.      

In all of the examples cited in the last two paragraphs where the PCP to patient ratio is reduced to a manageable level, the care quality goes up and the total costs of care come down very substantially. Throughout Fixing The Primary Care Crisis, we’ll look at the details of how that can be.

Fixing The Primary Care Crisis explains the crisis and its origins. It details what outstanding primary care can be for patients and society as a whole. It explains how and why illness has changed from the acute infectious diseases of the past (e.g., typhoid, pneumonia) to complex chronic illnesses (e.g., heart failure, diabetes with complications, kidney and lung disease) of today and why chronic illnesses now constitute 75-85% of all healthcare costs. It reviews how healthcare insurance went from covering unexpected expensive medical care (“major medical” and the catastrophic) to now include primary care; how employers have adjusted their assistance by expecting employees to pay a larger and larger portion of premium plus co-pays and deductibles. It then delves into some of the approaches referenced above that are being taken to return primary care to true relationship-based medicine.

Finally the book ends with a chapter that gives explicit recommendations to patients, doctors, insurers, employers and academic medical center leaders to effectively transform primary care to achieve the outcome of the very best care in a cost effective manner that improves quality yet reduces the total costs of care.

Together, this crisis can be solved with much better care, much improved satisfaction, much less frustration by patient and doctor alike, much less total money spent and with many more students selecting to become primary care physicians thus resolving the PCP shortage. It will be a win for everyone. But the change will only occur if and when patients become educated and then advocate for the new paradigm.  Fixing The Primary Care Crisis provides the information needed to make that transformation happen.

Monday, June 1, 2015

Most Medical Decisions Are Not Risk Free

Interpreting Your Benefits and Risks of Medical Decisions

Patients and doctors need to be a team in making important health care decisions. Good decision making requires solid, appropriate information but all too often it is either not available or presented in a format that is not of great value. Well grounded decision making is critical because every action has not only the hoped for outcome but also the risk of an adverse outcome. No medicine is devoid of side effects. A diagnostic test may produce a false positive or a false negative. A procedure may or may not cure. For example, choosing statins may lower cholesterol but may also cause muscle damage. A decision to have a mammogram may lead to a suspicion of cancer leading to a biopsy which turns out to be negative – a false positive. Choosing to have a stress test that turns out negative may lead to a sigh of relief and yet the patient dies of a heart attack the next week. A false negative.

These and others like them are high stakes decisions so doctor and patient need good data in order to reach a well informed decision. The information needs to be presented in a manner that is easy to grasp and to visualize in one’s mind’s eye.

Eric Rifkin, PhD and Andy Lazris, MD address these in Interpreting Health Benefits and Risks– A Practical Guide to Facilitate Doctor-Patient Communication. For each of twenty commonly encountered decision points they offered well informed information. Should I get a mammogram at my age? How likely is a stress test to clarify if I have coronary artery disease? What are the risks/benefits of taking a statin? Do I need an annual examination with my primary care physician, and if so what should it include? If I have atrial fibrillation should I take a blood thinner?

To each of these and sixteen others they give a concise overview of the data available, pointing out where it is strong or weak. They also include a patient vignette from Dr. Lazris’ internal medicine practice, thus giving each decision issue a compelling connection to real life situations. They then add a third and critical layer, a visual representation that adds clarity to the complex issues.

The visual is called Benefit Risk Characterization Theater (BRCT). It uses the floor plan for a thousand seat theater. Each seat represents a person. So for example, if a person smokes regularly, the question might be what is the risk of death at 25 years of doing so? The theater shows a thousand seats with 198 of them blackened out. This of course means that compared to 1,000 non-smokers, this group of smokers will experience 198 extra deaths compared to the other group. Seeing the blackened seats is a strong statement of risk – more compelling than just indicating  a percentage. As the authors state, “the graphic should do the math for the patient.”


Implicit throughout the book is the understanding that great controversy exists within the medical community about the risks and benefits of many screening tests, diagnostic procedures and therapeutic approaches. The BRCT allows the patient to become a co-equal with the doctor regarding the data and thus a real contributor to the decision making process.

For the purpose of shared decision making, the combination of factual data, a patient’s story and especially the visual BRCT allows patient and doctor to approach the question at hand with substantial assurance that whatever decision is made, it was done so in the context of real knowledge.

I have only one criticism of the book and it is leveled squarely at the publisher (Springer), not the authors. It is a paperback priced at $89.99, apparently assuming it will be of interest to a limited number of academics. In fact, it should be in the consultation room of every primary care physician and available to all patients who want to participate in their health care decision making. My recommendation: It is too expense for the average person to buy so ask your library to get some copies and then avail yourself. You may be surprised at what you learn. You will certainly be better equipped to talk with your doctor.

Monday, April 27, 2015

As A Physician Do You Have Adequate Financial Expertise?

Book Review – Physicians (and dentists, nurses, nurse practitioners, and other health care providers) need to understand money but most have limited financial expertise. No wonder and it’s not your fault. Four years of college, four more of medical school and three or more of residency left little time for personal financial education. But you still need that education and now is the best time to start.
The financial playing field is definitely not level and so you need to do what you can to level it. You are probably encouraged regularly to invest in various money making schemes that sound too good to be true. Making good financial decisions over time means the benefits can compound over long time periods – to your definite advantage.
Unfortunately, medical school and residency programs have essentially no time devoted for personal financial education and little if any time for learning the financial implications of starting a medical practice. You are on your own. Your natural mentors – professors, senior residents or senior colleagues in your practice – are probably no better equipped than you. Some medical students are obtaining combined MD/MBA degrees but this is overkill for just your own personal financial educational needs.
I was encouraged by consultants at Sage Growth Partners to meet Dr. Yuval Bar-Or. Dr. Bar-Or comes from a medical family (father and brother are physicians) but he entered the finance field, obtaining a PhD in finance from the University of Pennsylvania’s Wharton School. He is now a faculty member at the Johns Hopkins Carey Business School. His own family’s circumstances led him to realize that medical families need access to clear, objective, expert financial knowledge. He has written a set of two books, called Pillars of Wealth I and II, to address this need.
The books are straight forward, easy to read, thorough, yet not mired in financial jargon. In short, you can learn and do so easily. He begins with what he calls three axioms (reminds me of high school math!) 1) Your most valuable asset is earning capacity (not lucrative sounding investments); 2) Your most precious resource is time (saving now will pay off handsomely in retirement); 3) Your greatest enemy is procrastination. From there he reviews the basics of stocks, bonds, real estate, business ownership, insurance, annuities, 529 college savings plans, etc. He puts an emphasis on getting out of, and not entering into, debt (except a mortgage for a reasonably priced home.) This is followed by a discussion of risk and risk anticipation as a front line of financial defense. This leads to insurance – what you need and what you can avoid in terms of life, disability, liability and of course malpractice insurance.
It is an important principle that sound financial decisions early in your career have a big impact down the road – and so too do suboptimal decisions. You are probably bombarded by sales people that assume you have money to spend; some will have good ideas and products and many will not. Should you have a personal financial advisor? Or can you learn enough to make sound decisions yourself – for your own financial well-being, for your family and for your career?
A personal financial advisor would be worthwhile but you need to find the most appropriate person whom you can trust to offer sound meaningful advice and who charges appropriately. Pillars of Wealth gives suggestions on making this choice.
Bar-Or is articulate and passionate to meet. He thinks of himself as a financial risk management “physician”, i.e. to keep your finances healthy and functional while you help your patients stay healthy.
Your practice priorities are always uppermost but for some limited time and on a regular basis you deserve to consider your own financial health. Pillars of Wealth might be a good place to start. A chapter every few days will put you in a much better position over time to benefit financially from your education and training. These books are very well written and thoughtful. I will go so far as to say they should be must reading for all medical students and residents.
Note – Dr. Bar-Or and I met for lunch; we each paid our share. I bought his books before we met. I have no financial relation with him or his book sales.

Thursday, April 2, 2015

A Humble Opinion

Book Review - Readers of my posts know that I am a strong advocate for primary care and especially a primary care physician (PCP) that provides each patient with sufficient time. Time for the PCP to listen, to think, to treat and to prevent. This allows the patient and doctor to reclaim relationship medicine, a standard tenet of care in the past but now largely lost in our financially driven medical care system.
Dr Jordan Grumet is a primary care physician in Ohio who tries to assure his patients of a strong relationship, one in which they can build trust. Recently he has reduced his practice to about 600 patients and become “concierge.” Now he has more time for his patients and even some time for his family. For years he has written a blog entitled “In My Humble Opinion” in which he records his thoughts of events in his practice, in his home life and in his wide ranging mind. His posts are thoughtful, thought provoking, engaging, emotional and educational. Recently he published book curated from his posts and arranged into meaningful sections such as “The Grateful Death” or “In Sickness or in Sorrow.”
Dr Grumet’s book is a must read for anyone who cares – cares about their health, cares what they or their family receive from medical professionals, cares about what the doctor or nurse offers to  their patients. I have read Dr Grumet’s blog intermittently for the past few years. Always it leaves me with the sense that here is a real human being doing what he does best – caring for patients, one at a time and in the process trying to care for himself and his family. His book title - “I Am Your Doctor” - implies not a fact but a responsibility that he accepts when you come to him. The cover picture is equally powerful – a hand holding another’s, a clear and compelling symbol that this is a physician who wants to have a real relationship with you, his patient. Relationship medicine has largely been lost to today’s business and economic imperatives but doctors like Grumet are trying their best to retain it in their everyday practice. Dr Grumet brings us back to the true calling of what it is to be a physician and in his humble manner but compelling writing style reminds us that physicians are human with of the frailties and foibles as everyone else – the longings, the joys and the sorrows. But especially they want to be there with you as you experience those joys and sorrows, those exhilarations and frustrations that come with life, living and eventually dying. Here are two excerpts:
“Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrancy. He’ll stare deeply into my eyes and I'll detect a hint of mirth. "We're all dying, my friend." He will draw in a deep breath and put his hand on my shoulder. "The trick is learning how to live!" 

“It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second 45-minute trip to the hospital on an otherwise busy Saturday afternoon. For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, calmly listened to the patient and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time? I guess it starts with one simple fact. I blame myself for every heart attack, stroke or new diagnosis of advanced cancer. As disturbing as that sounds, how could I not?”
Read this book and you will want him to be your doctor. Or at least you will want to find a primary care physician like him who practices real relationship medicine the way he does and who assures you that you will have his or her  undivided attention

Friday, March 27, 2015

Curing Medicare

Book Review.This might seem like a curious title for a blog post but it reflects a very serious national need. Medicare is the central method for financing medical care for those over 65. It brings major value but it has serious deficiencies. We are frequently reminded that the Medicare Trust Fund will shortly run low of money. Enter Dr Andy Lazris a gerontologist with over 25 years of experience caring for the elderly. In his book – Curing Medicare – he lays out the issues that truly need to be addressed if America’s seniors are to “Age Gracefully.”
Dr Lazris and I live in the same community but had never met nor knew of each other. A retirement community executive, knowing I was writing a book about primary care, urged me to meet him. Before our meeting the next week, I ran into an acupuncturist I have known for some time. He also spontaneously suggested I meet Dr Lazris and so did the CEO of a major nursing home chain. Each said Lazris was a terrific doctor, a humanist, a real “gem” and an all-around nice guy. With such a buildup it would have been easy to be disappointed. But I certainly was not.
Although he sees any adult patient, his practice is largely composed of elderly individuals living in retirement communities, assisted living or nursing facilities. He limits his practice to about 600 patients so each can get the time needed and deserved. He is at once humorous and wise, light hearted and dead serious. He clearly understands the needs of the elderly and likewise understands how Medicare works – including how it impedes care and encourages aggressive care when a more benign or palliative approach would be better medicine and certainly more humane. As he puts it, “sometimes less is more.”
Curing Medicare should be a must read by anyone who is over 65 and anyone who has loved ones that are growing older, in other words it is important for most of us to understand what he teaches us. Medicare has been a major medical and financial boon to most elderly individuals but it has some serious deficiencies and it behooves us to understand them. Dr Lazris writes from his personal experience and gives many patient vignettes to back up his observations. A major point is that it is often best to not diagnose and treat aggressively (or “thoroughly” as he puts it) but to use a more palliative approach. But Medicare in both its payment systems and its regulatory approach essentially dictates aggressive medicine, indicated or not. Whether in the home, an assisted living facility, a nursing home or the hospital, the pressures are for being “thorough”, often to the patients’ detriment if not outright harm. And such aggressive diagnosis and therapy are what make costs go sky-high. These and other problems are fully presented and discussed in a way that we can all understand and appreciate along with his commonsense recommendations for reforming Medicare.
Recently, Health and Human Services secretary Silvia Burwell announced that Medicare will shift from the current fee for service reimbursement methodology to one that rewards value, i.e., reduced costs yet improved quality. On the surface that appears like a responsible direction. But is it? In an Op-Ed in the Baltimore Sun, Dr Lazris lays out some critical issues that lead one to question the HHS rationale. He uses points and concepts discussed in detail in his book so a quick read at this link will be of interest to many potential book readers.
Overall, Dr Lazris presents us with an elegant approach to the care of the elderly, one that he personally uses as best he can despite the restrictions imposed by Medicare’s payment and regulatory dictums. He offers us commonsense suggestions on how Medicare could be vastly improved, offering patients much better quality of care yet at the same time offering Medicare (and our tax dollars) enormous savings. I recommend his book highly.
Next Time - Another book review - I Am Your Doctor by Jordan Grummet

Monday, March 23, 2015

Aging Gracefully Part 4 Comprehensive Primary Care For The Elderly

Comprehensive primary care is essential to good health, wellness and needed medical care during our elder years. It is critical to Aging Gracefully.

In the last few posts I wrote that Aging Gracefully physically requires attention to lifestyle/behaviors to assure good nutrition, plenty of exercise, reduced stress, no tobacco and – for preserving cognitive function – intellectual challenge and social engagement. That is what each of us needs to attend to but we also need a good primary care physician (PCP) to assist us on our journey. That PCP needs to have adequate time to listen and listen fully.
The Erickson Living retirement communities have developed an approach that appears to work well for its residents. Let me use it as an example. The fundamental concept is to assure that everyone has comprehensive primary care. The Erickson leadership learned that healthcare was of paramount importance to their residents. A strong program would be good unto itself but also a strong marketing attraction. After substantial study and trial and error they set the resident/patient number per doctor at a remarkably low 400 for their in-house salaried PCPs. They found that this 400:1 ratio was the ideal number of elderly geriatric residents per doctor in order to assure the quality, humanistic and integrative approach to care desired. (For comparison, the usual patient to PCP ratio is about 3000:1.) They have clearly demonstrated that this approach to primary care with a low number of patients per doctor (and a team that functions akin to a medical home) not only gives superior care but that it results in much reduced total costs of health care overall. 
According to the medical director, Matthew Narrett, MD, residents can have same or next day appointments for as long as needed, they are offered extensive preventive care (“It is never too late to prevent,”)    the PCPs are well versed in gerontology issues  and there is a strong commitment to listening. Some of the results of this approach: Chronic illnesses can be managed usually quite successfully without the need for referral to specialists but, when needed, specialists are readily available (many conduct office hours on site on a rotating basis eliminating the need to travel to a distant office). Hospital admissions are down absolutely and markedly so in comparison to equivalent groups of elderly individuals. The length of stay in the hospital for those who must be admitted is lower and the 30 day unanticipated readmission rate has consistently been below 11% (the national rate is about 20%plus) despite the average age of their residents being about 82, i.e., one would expect their average rate to be higher than the national rate for Medicare-covered individuals overall. Dr Narrett reported that resident satisfaction was very high. I confirmed that when I was at the Charlestown community to give a talk organized by residents. With no staff present, I asked the 90 or so attendees their impression of the healthcare program. I received only positive accolades.
At the Charlestown and Riderwood communities where I have toured (and other locations) the onsite clinic includes not only the PCPs, but one or more nurse practitioners, a podiatrist, and a suite for a visiting dentist, for an optometrist and for an audiologist. The podiatrist is full time (at the larger communities) but the others are there commensurate with the need. Various outside medical and surgical specialists (e.g., cardiology, gastroenterology, dermatology, orthopedics, etc.) offer office hours on site on a scheduled basis. The clinic has an on-site nurse to coordinate special needs such as preparing for surgery, returning to the community from the hospital, transferring to assisted living, arranging in-home special needs care, etc.
A Medicare Advantage Plan is also offered by Erickson Living to residents of their group of 18 continuing care retirement communities. In the Erickson plans (administered through United Healthcare) one can choose the on-site PCPs or continue with one’s own PCP, can access a wide range of specialists when necessary, can use most any hospital, can be driven to most off-site doctors’ offices at no cost, etc. Unlike Traditional Medicare where one must spend three days in the hospital in order to be eligible for Medicare to pay for the first 100 days of residential skilled nursing care,  this Advantage plan waives the required three day stay. In other words, if the resident would benefit, the doctor can make the decision and can arrange immediate referral to their on campus site. This of course eliminates a very costly and potentially hazardous hospitalization. There is also an on-site benefits specialist to assist residents with their questions. The most common plan costs substantially less than one might pay for both Medigap and Part D policies yet it includes greater benefits (e.g., basic dental) with few co-pays and no deductibles. 
Older individuals perhaps even more than others need comprehensive primary care. It is a critical aspect of Aging Gracefully. Unfortunately, most older people do not have the benefit of a PCP who can spend the time they need.
My takeaway from the Erickson model is that when the PCPs are allotted the needed time and can listen and think, the care is excellent, satisfaction is strong and the total costs come down substantially. It also means that the PCP can get back to relationship medicine where trust builds and healing is possible.
I am not advocating for Erickson Living or that you move to a retirement community but my recommendation is definitely that you seek out a PCP who can and will offer the time you need to assure good healthcare so that you can Age Gracefully.
Disclaimer – I have no financial relationship with Erickson Living. It is used solely as an example to demonstrate the utility and value of a PCP (along with a well-functioning team) who can offer each patient the time necessary for comprehensive primary care.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).