Posts from 2018

Charity and Concierge Medicine, Imagination the Only Limit

John T. Kihm, MD, Thomas LaGrelius, MD

The sky isn’t the limit for Concierge Medicine (CM) physicians and charity. Passionate about helping in and beyond their practices, CM doctors “give back” with amazing variety. They volunteer with boy scouts, fly airplanes to remote patients, teach and lead. They volunteer with gusto in local and worldwide communities. Unbridled from former volume-style practices, liberated from insurance constraints and free to think “outside the box,” CM physicians creatively share time, energy and financial resources to help and inspire—all while having fun!

Their chosen and hard-earned practice style, Concierge Medicine, engenders giving. Charitable opportunities abound on scales of adventure, time, and resource commitment. None is better than another, and the best is the one you love and have fun doing. Take the leap—try a new one on for size.

When up his ears in alligators, the traditional doctor thinks necessarily more about self-preservation than charity. Outside the insurance swamp, life is better. American College of Private Physician (ACPP) member, Donna Sue Dolle, MD, of Nassua Bay, TX, extolls, “Doing Concierge Medicine has allowed me to do much more in my community. I am very involved in Boy Scouts, which I was unable to do when I had a traditional practice.” Performing Community service, once unthinkable during traditional practice, becomes the norm in concierge. Shifting time formerly designated to doing insurance busy-work on family and community, is the starting point for giving. Perhaps lower on the adventure scale, but no less gratifying, family and local time found charity’s base.

Still local, homeless shelters abound in the US, as do homeless patients. One author, John Kihm, MD, regularly volunteers at Durham, NC’s Samaritan Health Center, a non-profit homeless shelter clinic. “I doubled my community service time since converting to CM,” he says. “This clinic is incredible fun, not only because it’s fun to give, but helping underserved ‘neighbors’ is rewarding. I love uncovering as-yet undiagnosed and interesting conditions in an incredibly appreciative and interesting population.” His CM practice also donates medicines, vaccines, and money to the clinic. For those who enjoy giving, charity work rewards beyond description. A notch up on the adventure scale, homeless medicine fits easily into a ½ day per month CM schedule.

CM physicians commonly give “scholarships” to needy patients within their practices. Most CM doctors forgo or discount membership fees to disadvantaged patients who value their doctor. ACPP board member, Sue Turner, MD, of Roswell, GA, figures that 8% of her patients are scholarship. CM doctors contract directly with patients, with health insurance secondary. So rather than donating unpaid or underpaid services to insurance companies, CM physicians donate directly to patients via scholarships. “Donating to patients rather than to health insurance companies is not only gratifying, it’s liberating,” says Dr. Kihm. As a side benefit, scholarship patients often refer fully-paying family and friends. Patients appreciate good will, and the good doctors reap what they sow.

Teaching, by sharing knowledge, skills and compassion appeals to physicians in CM. They donate time to shadow premed college students, train medical students, residents, nursing and physician assistant students. An informal survey of the ACPP indicates that nearly all teach in some fashion. In traditional medicine, teaching can be very stressful due to time constraints. In CM, teaching is a natural way to share in a less stressful setting.

Donating leadership-time through local, state, and national political work, Drs. Jeff Puglissi, of Greenwich, CT, and Tom LaGrelius, and Marcy Zwelling, of CA, ACPP board members, benefit not only the CM community, but have spoken strongly in the US Congress to represent all independent doctors. Having worked hard to create their dream practices, these very practices support the time and resources to help a myriad of physicians.

Adventure anyone? Robb Rowley, MD, of Las Vegas, led a group of medical students on a medical mission to Haiti this summer. International mission work involves a very high level of preparation and coordination, including travel plans, vaccinations, and documents, and coordinating with the destination mission regarding housing, travel, clinic facilities and supplies, scope of medical services, and personal safety. The financial outlay per unit time donated is also high. International mission work is adventurous and intense, creating lifelong memories. The palpable patient appreciation inherent with this work makes it all worthwhile.

Dr. Kihm, of Durham, NC has for 21 years combined his passion of aviation with medical mission by flying to Remote Area Medical (RAM.USA.org) clinics in the Appalachians, and has additionally flown over 220 missions to his house call practice on the remote Outer Banks, Ocracoke Island, NC (https://conciergemedicinetoday.org/2018/05/23/ep-169-docpreneur-podcast-meet-dr-john-kihm-mission-medicine-and-concierge-medicine-working-together/). Both RAM clinics and Ocracoke house calls serve the less well-off and medically isolated. Opting to combine the pleasure and fun of flying with helping patients is made possible by his CM practice. His hometown patients knowingly support his efforts, and often donate to his causes as well! It’s about the challenge, the fun, and “doing good.”

Finally, in addition to volunteer work, there are always money donations. For example, in disaster relief medicine, unless you are part of a highly organized and experienced group, it may be better to donate money to a reputable relief organization than to “show up to help.” Well-meaning physicians needing food, shelter and personal protection may actually hinder local relief efforts. Current disaster relief emphasizes paying for local help, rather than placing locals idly on the sidelines. Financial donations are extremely valuable and appreciated. Never underestimate your donation’s value.

Compared with traditional medicine, Concierge Medicine liberates physicians to do more for charity, while shedding insurance shackles. Imagination’s boundaries for giving blossom from Concierge Medicine’s hard-working doctors. Local, regional, national and international charity—take your pick--it’s all good. Anyone can give, and those who do will certainly reap far more than they sow.

Today Forum in Atlanta October 26-27, 2018

ACPP obtains Special Group Pricing rate for all ACPP Members for the upcoming Annual Concierge Medicine Today Forum in Atlanta October 26-27, 2018

South Carolina House Unanimously Passes Bill to Expand Healthcare Freedom

COLUMBIA, S.C. (Feb. 16, 2018) – On Wednesday, the South Carolina House unanimously approved a measure that would help facilitate healthcare freedom outside of government insurance regulatory schemes.

A bipartisan coalition of 12 representatives introduced House Bill 4643 (H4643) on Jan. 23. The legislation specifies that direct primary care agreements (sometimes called medical retainer agreements) do not constitute insurance, thereby freeing doctors and patients from the onerous requirements and regulations under the state insurance code.

The bill also includes provisions defining direct primary care agreements and establishing modest requirements.

On Tuesday, the House Labor, Commerce and Industry Committee passed H4643 with a favorable report. The very next day, the bill went to the House floor and passed 100-0.

According to Michigan Capitol Confidential, by removing a third party payer from the equation, medical retainer agreements help both physicians and patients minimize costs. Jack Spencer writes:

“Under medical retainer agreements, patients make monthly payments to a physician who in return agrees to provide a menu of routine services at no extra charge. Because no insurance company stands between patient and doctor, the hassles and expense of bureaucratic red tape are eliminated, which have resulted in dramatic cost reductions. Routine primary care services (and the bureaucracy required to reimburse them) are estimated to consume 40 cents out of every dollar spent on insurance policies, so lower premiums for a given amount of coverage are another potential benefit.”

This represents the kind of cost control Obamacare promised but failed to deliver. Last fall, Tom Woods interviewed a Kansas doctor who utilizes the direct primary care model. Dr. Josh Umbehr’s practice demonstrates the cost savings possible when doctors are unfettered from the bureaucratic health insurance system.

Under Obamacare, regulations define such programs as a primary care service and not a health insurance plan, and current IRS policy treats these monthly fee arrangements just like another health plan.

A FIRST STEP

At this point, it doesn’t look like Republicans will repeal or even reform Obamacare, and the changes to the ACA proposed by the GOP would have arguably made things worse. Even with the penalty for not buying health insurance repealed by the Republican tax plan, all other Obamacare rules and regulations remain in place. Regardless, state actions can help completely bring down the Affordable Care Act, or any national healthcare plan the Congress comes up with in the future.

Oftentimes, supporters of Obamacare criticize opponents for not having any alternative. Direct primary care offers one.

These direct patient/doctor agreements allow a system uncontrolled by government regulations to develop. It makes doctors responsive to patients, not insurance company bureaucrats or government rule-makers. Allowing patients to contract directly with doctors via medical retainer agreements opens the market. Under such agreements, market forces will set price for services based on demand instead of relying on central planners with a political agenda. The end result will be better care delivered at a lower cost.

By incentivizing creative healthcare solutions, the market will naturally provide better options, such as the Surgery Center of Oklahoma, This facility operates completely outside of the insurance system, providing a low-cost alternative for many surgical procedures.

A more open healthcare marketplace within a state will help spur de facto nullification the federal program by providing an affordable alternative. As patients flock to these arrangements and others spurred by ingenuity and market forces, the old system will begin to crumble.

Passage of H4643 would take the first step toward healthcare freedom in South Carolina and would create a stepping stone to further action to nullify the onerous Affordable Care act. Once in place, South Carolinians could take further steps to fully extricate themselves from Obamacare for good.

For more information on a plan to nullify the PPACA, click HERE.

WHAT’S NEXT

H4643 now moves to the Senate for further consideration. It was assigned to the Senate Committee on Banking and Finance where it must pass by a majority vote before moving forward in the legislative process.

 

How Amazon & Co. Could Fix Health Care

The first step would be to go completely outside the existing U.S. health care system.

by Leonid Bershidsky January 31, 2018, 7:02 PM GMT+5:30

Could this be the future of care for some U.S. employees? Photographer: Chris Ratcliffe/Bloomberg

Amazon, Berkshire Hathaway and JPMorgan haven't said much about what their new joint venture will do to "provide U.S. employees and their families with simplified, high quality and transparent healthcare at a reasonable cost." It's not hard to imagine, however, how the three companies could set up a large, closed system that could serve as a blueprint for the only disruptor with the ability to fix the entrenched, inefficient U.S. health care system -- the U.S. government.

The worst thing the joint venture could do is try to use its bargaining power to bring down costs within the existing system. It's not really big enough for that. The three partners have a combined 1 million employees; the health care industry is the biggest employer in the U.S., and even if you add in the family members of Amazon, Berkshire and JPMorgan employees, that won't be enough to go head to head with the medical juggernaut on doctors' and nurses' pay and the cost of pharmaceuticals. The partners need to start from scratch.

It's well-known that the U.S. leads the world in health care spending but not in life expectancy. But the U.S. health care system is inferior to those of other rich countries on a number of technical parameters, too: For example, it has more hospital admissions for preventable diseases and more medical and lab errors than comparable countries. It ranks 30th in the world on "basic physical and mental health, health infrastructure and preventative care" according to last year's Legatum Prosperity Index.

U.S. health care achieves similar or worse results compared with other Organization for Economic Cooperation and Development nations with a higher ratio of nurses per physician than any of them except Finland, Japan Ireland and Denmark -- 4.3. France does fine, and has a higher life expectancy than the U.S., with 2.8 nurses per doctor. Doctors in the U.S. are massively overpaid compared with most of their OECD peers. A primary care physician makes $217,000 a year, almost five times the U.S. average wage; according to OECD data, the average general practitioner's pay is higher than the average wage by a factor of four in Germany, three in France and two in Israel.

It's interesting to imagine how three large companies could build a better system for themselves. Start with the doctors and medical professionals. According to the OECD, 25 percent of doctors and some 6 percent of nurses working in the U.S. are foreign-trained. Other OECD countries -- especially Mexico, Canada and the U.K. -- are already the biggest source of foreign-trained doctors for the U.S.; India is close behind, followed by the Philippines and Pakistan. This implies there's already a functioning pipeline for getting the qualifications of doctors from these countries recognized. Amazon, Berkshire Hathaway and JPMorgan, with their combined administrative might, could turn this pipeline into a factory, bringing in enough foreign doctors exclusively to serve their combined workforce at more reasonable pay to average wage ratios.

Lower pay than in the rest of the U.S. health care economy would be justified by having to do zero insurance paperwork -- something that forces U.S. doctors to hire extra staff and waste precious time. The companies would merely set pay levels based on tasks performed -- something that, in much of Europe, falls to health care providers' unions to negotiate with the government or with payer pools. That's the system the joint venture would ultimately end up with. Amazon's tech could help track the tasks in real time.

Importing the entire workforce sounds like a mammoth task, but then the U.S., according to the OECD, only has 2.6 practicing doctors per 1,000 population. At this rate, some 7,800 doctors would be needed to serve 3 million employees and their kin. If the German level of 4.1 doctors per 1,000 residents were the goal, some 12,300 doctors would be needed. That's some 8 percent of the number of medical graduates OECD economies produce every year -- not an impossible number to bring in. Add in telemedicine opportunities -- whole clinics could be set up overseas on local budgets to do much of the necessary work -- and U.S.-resident doctors who'll accept a pay cut just to practice medicine and never deal with an insurance company again, and the task appears even more feasible.

Besides, the joint venture could consider offshoring some of the hospital care. The average cost of a hospital day in the U.S. was $5,220 in 2015, compared with $424 in Spain -- a country with a higher average life expectancy than the U.S. One could fly business class from New York to Madrid every day to spend a night at a local hospital and it would still cost less than comparable U.S. care. Even Swiss hospitals are, on average, cheaper than U.S. ones. In quite a few cases, it would make sense to relocate an employee or family member to save on the hospital costs. Of course, the new venture would need to help employees get passports, too.

Moreover, relocation could even work for people with chronic conditions requiring pricey pharmaceuticals. A recent IHS Markit study found that a basket of 30 innovative pharmaceuticals cost about a third as much in Germany, U.K., Spain and Italy as in the U.S. The U.S. protects its pharma market, making it difficult to import cheaper medicines than those produced by local companies -- but it can't ban companies with large overseas operations from exporting patients.

In other words, it's possible for a pool of big, multinational U.S. employers with a relatively sophisticated workforce to go almost entirely outside the existing U.S. system and shake off the layers of useless regulation and bad practice that make it up. The cost savings would probably be considerable.

Such a system, however, wouldn't be scalable beyond the biggest companies with mobile workforces: It would be hard to expand the doctor immigration pipeline or a massive medical relocation operation. It would still be worth building a separate health care system for big company employees, though, just to show the U.S. government how it could be done. Maybe someday there will be politicians courageous enough to start rebuilding U.S. health care from scratch, with less bureaucracy, fewer intermediaries, less protectionism, more efficiency and fairer prices.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

President’s Report - February

Warren Buffett of Berkshire Hathaway, Jeff Bezos of Amazon and J. P. Morgan the nation’s biggest bank just announced plans to bypass the American health insurance system and independently organize healthcare for 3 million employees and their families.

https://www.bloomberg.com/view/articles/2018-01-31/how-amazon-co-could-fix-health-care

Anything that bypasses the health insurance industry and creates direct relationships between doctors and patients deserves our applause.

Throughout its history the health insurance industry has paid lip service to controlling costs while actually driving them higher. It profits from higher costs because it can charge higher premiums getting it’s ten percent profit regardless. This will continue as long as payers put up with it. Perhaps our tolerance has reached its limit.

Primary care practice disruptive innovations have been around for two decades in response to insurance industry failings. These innovations can help business leaders drain the insurance industry swamp, control cost and improve quality.

What Americans really need are a few hundred thousand independent, personal, private primary care physicians that work ONLY for their patients, not for the insurance industry. Berkshire Hathaway, Amazon and J.P.M. need only 6,000 such physicians to manage their three million patients and family member’s primary care. It would be a good start and a beacon for the rest of the nation.

Thirteen years ago I launched one of the early direct practices at a time when only a few hundred existed nationally. There are now tens of thousands of doctors, caring for millions of patients, who have made conscious decisions to get out from under the insurance system’s control and work directly for patients. The terms Direct Primary Care (DPC) and Concierge Medicine are both parts of this movement. Let me explain why private primary care physicians should be part of the package that these business leaders create.

First, we limit our practices to hundreds rather than thousands of patients, thus allowing us to spend much more time with each patient and still be fresh and rested when delivering care. Primary care doctors in conventional insurance-dependent practices are often failing to take good care of patient panels that number 2,000 to 3,000 patients per doctor. These huge panel sizes have been forced on them by the insurance industry’s relentless withdrawal of support for primary care over many decades. Great primary care is the backbone of any effective, affordable health care system, and the health insurance industry has all but destroyed it. Direct practice is recreating it.

Second, to allow our small patient panels, we finance our practices with membership fees directly from our patients. These fees vary with the practice and are usually age adjusted. Most practices charge fees between $50 and $300 per month, an affordable price for many, but a barrier for others.

Third, because we work directly for and are paid directly by our patients, we give incredible service. If we didn’t do so we would lose their loyalty, and they would move on. My partner Dr. Nicole Lawrence and I see and manage our patient’s care the same day they call, during and outside office hours. All our patients have our home and cell phone numbers and are encouraged to call for even minor issues. Our patients can reach us immediately 24/7/365 with one five second dial or text. We do home visits and manage their hospital care personally. In other words, we do what most doctors used to do before the health insurance industry took over and changed the rules.

We eliminate between 50 and 80% of costly emergency room visits and urgent hospitalizations. There are several published studies proving that. One of the best was published in 2012 in the American Journal of Managed Care:

http://www.ajmc.com/journals/issue/2012/2012-12-vol18-n12/personalized-preventive-careleads- to-significant-reductions-in-hospital-utilization

Since ER and hospital care is such a huge part of the excess cost, we know placing employees in this kind of direct private primary care practice is key to solving the cost problems. However, direct practice saves money and improves care in dozens of other ways. Those who have carefully studied these practices understand why they work so well and why the insurance industry version of primary care works so badly.

Direct Primary Care and Concierge Medicine have not yet expanded to the general population, though attempts have been made, such as Qliance in Seattle. So far they have largely failed. Funding is the issue. It is hard to convince financially stressed employees to invest their own limited funds in a novel healthcare design they don’t fully understand while continuing to pay sky high insurance premiums. Enlightened employers could be part of the solution to that problem.

Like the cell phone and other disruptive innovations direct practice innovations are first adopted by astute consumers with disposable income. When it becomes clear that the benefits are huge for everyone, eventually such innovation are adopted by wider groups of people. Assistance can come from employers. Perhaps that will happen with Direct Private Primary Care. Employers could help to fund it with HSAs and vouchers for an aggregated list of vetted DPC/Concierge practices which would not handcuff the participating physicians as the insurance industry does. Physicians running such practices must remain in control of their practices, fees and decision making. The opposite path has already been tried and failed. Let’s try something that will work this time, since we’ve tried about everything else.

Urgent Message Regarding High Census

The hospitals are currently swamped with flu victims and have no beds or ER space. See below note from Torrance Memorial to Medical Staff.

You and I at least are not contributing to the problem. You and I have managed dozens of young and elderly flu victims recently without trips to the ER. I directly hospitalized only one, a 95 year old with flu A. He was in for just 48 hours for fluids and you had one also briefly too, both over a week ago. Both got Tamiflu within 24 hours of onset.

As is typical for us in this concierge practice, today, Saturday, I just met a patient at the office with 12 hours of mild symptoms, as yet still not too ill, and performed an office flu test which was 4+ positive for flu A. I found Tamiflu for her and her husband (who is not yet sick but would be soon otherwise) at a distant Walgreens after three phone calls and THEY won’t be at the ER.

Few people, even doctors, know as we do that Tamiflu (works on both A & B) and Amantadine (Only works on A) given within 24 hours of Sx onset actually stop the illness cold in many cases, but almost nobody gets it that fast, except our patients. If you wait past 48 hours it simply does not work. One has to attack during the viral replication phase, which is brief.

Almost ALL our patients had flu shots, 95% plus, which was quite effective agains B and blunting of A. The ones that refused the shots, and in fact all our patients, have had the lecture about calling quick when sick or hurt with ANYTHING. They can get us in seconds, and today we have NOBODY in the hospital for anything, let alone flu. And as you know we usually have a census of 3-4 patients.

Somehow in the midst of our two flu drugs becoming “Unobtanium”, we have found it somewhere for all of them, so far. Proof of concept I must say.

And of course this concept applies to hundreds of less dramatic illnesses and injuries too.

Joining a concierge practice is a no brainer, unless you want to sit surrounded by coughing masked flu victims in a packed ER unable to treat you with antivirals anyway. The hospitals are using Tamiflu only on patients so sick they are in the ICU. And in most of those cases they need not have bothered. They got their first dose long long long after the effectiveness window had closed. They should save it for the ones ill less than two days when it actually works!

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