Family Medicine: Odds and Ends December 2013

Various items from various readings and comments on medical sites by various physicians:
1.  Comment on Medscape Cardiology in response to the megavitamin study--Isn't it about time that we also gave up on the ridiculous practice of prescribing statins for elevated cholesterol?  Staitins (sic) have not been determined to prevent heart disease, heart attacks or strokes.  You can read that same sentence in every ad for any statin drug.  Yet, these "wonder-drugs" sell billions of dollars each year and do absolutely nothing to affect mortality or morbidity.  Once again, why we are 5% of the world's population, yet we take close to 70% of the world's prescription meds.  We are #1 in healthcare spending and #24 in overall health.

Please, quit acting like US Medicine has a corner on the market of science.  If it weren't for the placebo effect most drugs would not reach the threshold for clinically significant findings.  What about the CHADS II study - Relative Risk reduction of 43% - great!!!  Absolute Risk Reduction of .02% - abysmal!!  (Keep taking those incredibly effective blood thinners that can't stand up to a double-blinded, randomized, controlled trial).

2.  The OAFP received the following status update on retroactive payment of enhanced Medicaid primary care physician rates. The information from Medicaid was received on December 19, 2013.

Background

All enhanced payments from January 1, 2013, through the end of June 2013 were withheld due to a need for verification of attestation to ensure proper enrollment by physicians. Over the course of the summer, the Ohio Department of Medicaid and contractors took several steps to allow as many appropriate physicians and other providers as possible to receive the enhanced payment. By August, Medicaid had added several vaccine administration codes to the formula for calculating the 60% claims threshold; this allowed even more physicians to be eligible for the enhanced rates. August 16, 2013, was the final date for physicians to qualify for retroactive payments back to January 1, 2013. Any physicians who were approved for self-attestation after that will have the date of their self-attestation as an effective date for their enhanced payments. Through all of this, Medicaid has worked diligently to maintain a current list of approved providers, a complete list of which will be posted by the end of the calendar year (2013).

Payment of these enhanced rates will be distributed differently depending on whether the payment is from a managed care company or directly from Medicaid for fee-for-service. All payments were delayed due to the attestation issues and the retrospective payment methodology. Depending on the venue, payment is intended to occur as follows:

Managed Care Payments

The managed care plans—Americgroup, Buckeye, CareSource, Molina, Paramount, UnitedHealthcare, and WellCare, have received the primary care rate increase (PCRI) payment from Medicaid for the first and second quarters of 2013. Buckeye, CareSource, Molina, Paramount and UnitedHealthcare have also received their PCRI payment for the third quarter of 2013. Amerigroup and WellCare are no longer Ohio providers of Medicaid managed care as of June 30, 2013, and therefore will not receive any additional PCRI payments.

Eligible primary care physicians should expect to receive payments for at least services rendered in the first and second quarters of 2013 by the end of January 2014, depending on the plan. Medicaid will pay the plans for the first quarter (January-March) of calendar year 2014 in January 2014. For the remaining three quarters of 2014, the department will pay the plans the first month of the quarter. These are prospective payments for calendar year 2014. Plans must pay physicians, at minimum, quarterly.

Fee-For-Service

The fee-for-service payments will start going out to eligible primary care physicians after January 1, 2014. Thereafter, payments should occur timely and in synch with regular reimbursements.

SO, the incentive to help primary care physicians survive has been delayed a year so far due to bureaucratic inability to figure our how to do it (it's the law, by the way).  Not a surprise, though.

Family Medicine: Shedding Microbes and Spreading Germs

How long do people with respiratory infections spread microbes?  (Several days)

Family Physicians warn people about spreading infection every day.  A sneeze goes more than ten feet through the air, carrying microbes that may enter another person.  A great site to review how to avoid the spread of germs is www.HenrytheHand.com, where Henry the Hand teaches infection control:

The 4 Principles of Hand Awareness

1. Wash your hands when they are dirty and BEFORE eating
2. DO NOT cough into your hands
3. DO NOT sneeze into your hands
4. Above all, DO NOT put your fingers into your eyes, nose or mouth

Microbes from respiratory infections continue to spread via tiny droplets in the air or by an infected person touching someone after touching their "T Zone" on their face.  Germs are so tiny they might as well be invisible, so people accidentally spread them to others when they may wrongly assume themselves to no longer be contagious.

This time of the year is a difficult one for families who visit other family members, often while spreading infection by not washing their hands, touching their "T Zone" or not covering a cough or sneeze with an elbow.  If your Uncle Bill coughs on his hands then grabs a biscuit from the biscuit bowl, slightly touching several biscuits, he may be spreading infection.

Start a new family tradition this year by inviting relatives and friends to visit the Henry The Hand web site.  Have a whole family full of Champion Handwashers!

Family Medicine: Amish Girl Who was Taken Abroad to Avoid Chemotherapy

Some comments about the issues involved in the Ohio Amish family that left the country to seek alternative therapies for their daughter with a form of leukemia.  Family Physicians see patients like this and care deeply for the individuals and families who are involved.

On November 19, the 1851 Center announced its representation of the Hershbergers, maintaining:

• Section 21, Article I of the Ohio Constitution, the Ohio Healthcare Freedom Amendment passed by 67 percent of Ohio voters in 2011 prohibits the compulsion of any person “to participate in a health care system.”
• Even before Section 21, the Ohio Supreme Court held that the Ohio Constitution ensures “personal security, bodily integrity, and autonomy,” and therefore “[t]he right to refuse medical treatment” is amongst the “rights inherent in every individual.”
• The U.S Supreme Court has repeatedly confirmed the Fourteenth Amendment to the United States Constitution clearly provides protection to parents in the “care, custody, and control” of their children, including the right “to direct the upbringing . . . of children under their control.”
• The U.S. Supreme Court has also ruled that the “primary role of the parents in the upbringing of their children is now established beyond debate as an enduring American tradition,” and “[t]he statist notion that governmental power should supersede parental authority in all cases because some parents abuse and neglect children is repugnant to American tradition.”

The litigation began when the Hershbergers removed their daughter from Akron Children’s Hospital in July, in favor of a less invasive alternative treatment, after it appeared as though chemotherapy itself was a greater threat to her than her mild form of cancer. The Hospital then moved in court to take Sarah from the Hershbergers and force treatment in July.

The hospital’s move came only after county social services officials found the Hershbergers to be quality parents, and, and despite hospital demands, refused to take Sarah from the family. The Medina County probate court found that the Hershbergers were model parents, explaining “there is no evidence the parents are unfit or unstable,” and “there is not a scintilla of evidence showing the parents are unfit.”

However, the Appellate Court used an obscure Ohio statute intended to address child abuse and neglect to order Sara to be taken from the home and forced to undergo chemotherapy.

The Court made this ruling even though Sarah’s mild form of cancer is a type that can and is being treated without chemotherapy, and despite conceding that chemotherapy may well cause loss of hair, infections, infertility, cardiovascular disease, damage to internal organs, an increased risk of contracting other cancers, and even death.

The case remains pending on a jurisdictional motion before the Ohio Supreme Court and on appeal to the Ninth District; however those appeals are likely to be mooted by the Judge’s approval of the Resignation.

Media

November 28, 2013: Good Morning America: Amish Girl With Leukemia, Family Flees US to Avoid Chemotherapy
November 30, 2013: CNN Newsroom
December 3, 2013: Natural News Radio

###

Editors note: There is a comprehensive story about Sarah Hershberger’s ordeal on the Journal of Natural Food and Health website.  Donations for Sarah’s treatment which involve use of natural foods, nutritional supplements, natural medicines and treatments can be made at Sarah’s Amish Health Freedom Fund.

Click to Donate to Sarah’s Treatment FundPrint

Leave A Comment

United Health Care Drops Doctors

Today we learned that United Health Care has dropped the biggest gastroenterology group in the Dayton, Ohio area from their provider list.  During the last two weeks, we have read about thousands of physicians nationwide being dropped by United, which has a huge deal with AARP.  Who is next?

Should we anticipate the frustrations coming from our patients who are followed by that GI group somehow?  Should we assume that United will drop us, too?  Should we notify our patients that we are concerned about United Health Care?

The walls are starting to crumble.  Duck!

Fifty Years Later: Reflections on Assassination of JFK

The loud speaker in our Jefferson Township High School government classroom suddenly came on with the voice of Walter Cronkite announcing that the President had been shot in Dallas, Texas.  We left the classroom shortly thereafter when the bell rang.  I went to English class, where, shortly after about twenty of us seniors got another jolt when the continuing news feed from Walter Cronkite announced that the President was dead.

A couple minutes later, the radio on the speaker was turned off and we were jolted from our grief slightly when Miss True announced that we might as well go ahead and take our English test since we can't do much about the assassination of the President.

It was Friday, November 22, 1963.

I felt empty.  The next week, I took the SAT's for college application purposes.  The Army- Navy Game was delayed for a week and ended with Army confusion on the two yard line -and Navy headed for the Cotton Bowl to play Texas was played while I took the test.  I wanted to see that game on TV since I wanted to go to West Point.  But, my SAT score helped me get a nomination from Congressman Robert Taft to the Academy.  I saw the 1964 Army- Navy Game in Philadelphia wearing Cadet Gray.

I was glued to the TV for the next 3 or 4 days during Thanksgiving Week after the assassination, watching news with the tragedy and the mystery unfolding before the eyes of the nation.  We saw Lee Harvey Oswald in custody for the murder, then murdered himself on live TV by Jack Ruby.

We saw the funeral of the President.  Jackie, the widow and the two, now fatherless, children faced every TV camera in the nation, it seemed.  The nation mourned together. Thanksgiving week provided a buffer for processing the shock and grief a bit more before returning to daily routines.

The Class of 1964 is now planning its 50th reunion.  How the time flies.  Our high school was bulldozed into rubble last summer.  We have our grandchildren, retirement (or delayed retirement with the present economy), declining health, medical expenses, painful parts, etc. to focus on.

What did it all mean?  What did we learn?

Dreams can be shattered.  And rebuilt while the wounds heal.  Loss and grief happen - again and again.  They are never "resolved".  They are reconciled.  They settle into who we are.  Our shared identity includes our shared grief as a nation.  In our modern era, 9/11 sits in our hearts and brains like an anvil of loss and grief.  But we remember Miss True's lesson as much as the rest of the events of November 22, 1963.

Move on to the next test.

75,000 Views: Thank You Readers!

Thanks, Folks for reading my posts.  I hit the 75,000 views milestone today.  I'll keep blogging, now that I'm warmed up.  I love Family Medicine and learning about how to help patients in a neighborly, affordable way.  It's not always easy in today's changing health care (non) system.  Writing about it makes it clearer and more meaningful.

We need more Family Physicians.  Currently there's no way we're getting many more, so American creativity is called on to make solutions.

Churches should get into health care locally as one strategy.  Cable TV has to be used in the care of some chronic/ stable diseases, too.  Phone apps, texting, patient controlled medical records, etc are other ideas to stir the pot of better health at lower costs.

We will have to crank up our mutual problem solving strategies to "Bend the cost curve" in the short and long term.  Otherwise, "The Beast", delivers more bankruptcies to our communities and the hole gets deeper.

Being a Family Doctor is still fun, challenging and rewarding.  I love it and I enjoy writing about many aspects of the doing and teaching of it.

I'll be writing more about Direct Primary Care as one of the solutions to the health care financial mess.  Likewise, I'll write more about the power of the human spirit that I see in patients, their families and health care workers every day.

Humans were given a sense of the sacred and a quest for meaning that helps Family Doctors a lot.  As we quest together to understand our humanity and our Creator, let's remember to be neighborly and show our care for each other and our appreciation for God's mysteries.  Onward, together, we can get through the transformation of healthcare.  Humans in teams and tribes can help each other.

Veteran's Day Reflections-- 2013

When I hear someone mention Veteran's Day, November 11, 1918 comes to mind quickly, followed in a micro-second by thoughts of Vietnam and the United States Army.  Then West Point and the Hudson River Valley looking up the river from Trophy Point-Beauty, Peace, Order.

 Duty, Honor, Country.

The Wall.  Twenty names engraved in it from the West Point Class of 1968.  Taps.

The Flag of the United States of America.  The National Anthem.  "The land of the free and the home of the brave".  America.

Serenity.  Reconciliation.  Somber moments honoring those who lost their lives in service to this great nation and those who still serve and protect us.

We served as ordered.  We did our jobs.  We grew.  Thank You, America, for being the best nation in which to be a military veteran. We've learned together- since Vietnam when you were confused about who should answer and who should honor those who served in the "wrong" war.

America.  America.  God shed his grace on thee.

Thanks to all you military veterans who served and all you folks who continue to serve and protect us.

Peace

Family Medicine: One Hundred Eighteen Patients Today

I finished with various responses to the pile of papers, forms, reports and letters from various insurance companies.  It looked big.  So... I counted.  NINETY-TWO PATIENTS were represented by this pile.  I was surprised.  I was also discouraged.  There is no end in sight to the ridiculous waste and harassment by various entities in The Beast (Medical Industrial Complex).

AFTER, finishing with the last patient, I attacked the pile.

BEFORE the pile, twenty patients had presented themselves for various aspects of our neighborly Family Medicine practice yielding various diagnoses such as:  Well child exams, HTN, asthma, COPD, GERD, FMLA form, Health Maintenance-immunizations, mammogram ordering, colonoscopy discussion and referral, deferred immunization options for under-immunized, physical examination.  Contact dermatitis, multiple benign nevi, insulin resistance, snoring, sinusitis, allergic rhinitis, overuse syndrome-legs, venous insufficiency with edema of lower extremities, degenerative osteoarthritis of knee with effusion, acute situational reaction to custody hearings, acute situational reaction to relationship stress, GAD, ADHD, Depression, Insomnia, OA C-Spine, Degenerative Disc Disease C-Spine, Med Management opiates, Ureterolithiasis with hydronephrosis, nephrolithiasis, abdominal pain, acute viral bronchitis, Calf pain, family hx early coronary disease, uncontrolled type II DM, noncompliance with medical therapy, lumbar disc disease, trochanteric bursitis, fatigue, macrocytosis, hyperhomocystenemia, micro-albuminuria, family hx colon cancer, hematuria, menopausal symptoms.

Yes, there are many more than twenty diagnoses. There were more than I've noted above, even, due to the vastness of my scope of practice, which patients realize, appreciate and sometimes misuse (but we love them, so we're vulnerable when they ask for help and pile on three or four extra problems)

AFTER these many and several diagnoses/assessments in the twenty patients, six medical questions presented from patients calling in.  These were dispatched with a recommendation for clarification, office visits or urgent refill for one (when pt was in for acute, unrelated symptoms, "forgot" to get chronic disease med refilled and has one pill left- I succumb to one 30 day refill if pt agrees to make appointment to deal with chronic disease mgmt before we call it in-yes, it's coercion- or the practice of medicine).

We collected two hundred dollars today from insurance and patients.  I sense a bit of a problem, Folks.
This may not be a sustainable model of practice.  It's interesting and challenging.

What do you think?

Direct Family Medicine: Beavercreek, OH Update

Family Health Connections, Inc.   Beavercreek  (937) 427-7540

New Patients:  No Insurance Needed

Now offering Direct Family Medicine to New Patients

Neighborly Family Medical Care:  Dr Rebecca Cherry, Dr A. Patrick Jonas

            Respecting our Patients and Protecting them from Avoidable Care

            Acute Problems, Chronic Diseases, Prevention, Physicals

            Traditional After Hours On Call Physician Coverage

  

Families ONLY (entire households)

NOT INSURANCE

Family Fees:

Enrollment                Monthly        Visit

1 Adult           $80                             60                  20      

2 Adults         $150                           120                 20

1 A, 1 Child   $140                           100                 20

1 A, 2 C          $190                          140                 20

2 A, 1 C          $205                          160                 20

2 A, 2 C          $250                          200                 20

2 A, 3 C          $295                          240                 20

2 A, 4 C          $340                          280                 20

Infant (Child less than 2)- add $20 to family w/child enrollment, $10 to monthly

For Example:  2A, 1 Infant equals $215, $130, $20 for enrollment, monthly and visit fees

Labs, X-Rays, Office Surgeries, Immunizations extra

Patients are advised to have catastrophic medical insurance in addition to Direct Primary Care

Dr Synonymous BTR Show Reflects on the Direct Primary Care National Summit

Here are my reflections about the Direct Primary Care National Summit in St. Louis October 11-12. 2013.  Listen in for my perspectives about the Summit and DPC.

Dr Synonymous Show: Reflections on DPC Summit

I review the entire program, vendors and sponsors.  I also review Tweets from the #DPCSummit Twitter site referring to speakers and other aspects of the meeting.

The energy was impressive.  The ideas were rampant.  DPC is moving right along.  A follow up to the summit will be in April, May or June in Washington, DC.

Onward.

Direct Primary Care National Summit: WOW!

What a great group of people gathered in St Louis for the Direct Primary Care (DPC) National Summit, October 11-12.  A vast array of perspective and experience was represented in an effort to focus some of the energy of this movement and share information.  It felt pretty successful.

While DPC is way more vast than this meeting of 170 people, the energy of DPC seemed present.  The variety of DPC practice models could only be superficially represented in such a meeting, but the attendees got a flavor for many of them.  They also heard about the challenging history of DPC through legal, professional and political battles since 2000.  Many of the "founders" of the DPC movement were present and more were not, but the stories were great from Garrison Bliss, MD, who was founding president of a few organizations that sought to define and protect DPC.

Creativity was overflowing in every session and even during the breaks from those doing or preparing or thinking of doing DPC.  Medical students from PA and NC were present to get in the "DPC" pipeline.  Residents were also in attendance, applauding the program and the movement.  Physician Assistants and Nurse Practitioners added their voice to the meeting with timely comments about teamwork.

Vendors seemed busy talking with all the participants who wanted to do DPC better.

It seemed to answer the needs of attendees as evidenced by their numerous comments during the Town Hall session at the end of the meeting.  They shared gladly, in general, but Dave Chase had to remind a few about how big the market is on the ground floor of DPC where we don't need vigorous competition...yet.
Listen to my review of the entire program as well as listing sponsors and  vendors.

Dr Synonymous Internet Radio Show: DPC Summit Reflections

More later.  Onward with Direct Primary Care.

Dr Synonymous Show October 8,2013: Direct Primary Care Transitional Practice Becomes Hybrid

Direct Primary Care:  Transitional Practice Becomes Hybrid

A.Patrick Jonas, MD, ABFM

—Beavercreek, OH

—Family Health Connections, Inc.

—Families Only

—1.6 FTE Family Physicians

—1-2 half days/week FNP

—Next Door New 75 bed gen hosp

—Suburban, Mall across street

—Suddenly:  A Dynamic Dysequilibrium
—Recession

—EMR, Meaningless use,  Quality initiatives

—Financial Losses

—Intrusive “Administrivia”

—Disruption

—STRESS

—Philosophy of Care- Before DPC

—Deliver Continuous , Comprehensive Care

—To Individuals and Families

—From Birth to Death

—Philosophy of Care -With DPC

—Be a Neighborly Family Practice

—In a Human Centered Way

—A Human Centered Health Home (HCHH) is Neighborly

—Respect

—Protect

—Connect

—Detect

—Correct

—Reflect

—Scope of Practice

Families Only

Persons of all ages & stages- includes Hospice

Well, Ill or Injured

Acute, Chronic, Prevention

Integrative Practices aligned w/NCCAM

Ext Relationships w/ Drs, Labs, Imaging, Hosp

—Marketing

—Families w/Individuals & Current Patients

—Small Businesses via Chamber of Commerce

—Physician Offices and PHA

—Churches

—Health Food Stores

—Holistic Practitioners

—Contracts

—Retain Commercial, Medicare, Medicaid

—No new patients in any of them

—Retain Hospital relationship w/privileges

—Seek vendor relationships for DPC & Network

—Challenges of Hybrid Practice

—Office Staff Belief/Support

—Patient Understanding & Motivation

—We seek limited number of patients

—Align with philosophy and scope

—Avoiding “The Beast”

—Guilt

—Direct Primary Care:  Transitional/ Hybrid Practice

—Questions?

—

Family Medicine Celebration

OK, Family Medicine Nation,  Let's Celebrate...Something of our own choosing... a well child exam... an "old child" visit with a 93 year old in their home.

That's more like it.

Peace to all

Affordable Care Act Preliminary Insurance Information for Ohio

This is from  WebMD 9/25/13: Ohio Plans, Benefits, and Costs

Companies can offer four levels of plans: bronze, silver, gold and platinum. These “metal level” plans all cover the same benefits in your state. What differs is how much they pay on average toward the costs of the services the plan covers. Here’s how it works:

• Bronze Plan: You pay 40% and the plan pays 60%.
• Silver Plan: You pay 30% and the plan pays 70%.
• Gold Plan: You pay 20% and the plan pays 80%.
• Platinum Plan: You pay 10% and the plan pays 90%.

Catastrophic plans may be available, especially for people who are under 30 and healthy. These plans cost less up front, but they don't give you as much coverage. They generally require you to pay more out-of-pocket costs. 

You must have at least a bronze-level plan to meet minimum requirements under the Affordable Care Act and avoid the penalty for not having health insurance.  

Costs: Here are the average monthly premiums across Ohio for all age groups released by the Department of Health and Human Services. Specific premiums will vary from these averages based on the region within the state, the specific insurance plan selected, and age. 

• Lowest cost bronze: $263
• Lowest cost silver: $304

Tobacco Surcharge: Ohio allows insurance companies to charge tobacco users 50% more than non-tobacco users. 

Who Is Selling Insurance in the Ohio Marketplace?  Ohio is waiting for insurance companies to submit rates and plans. The state needs to give this information to the federal government by July 31.

What's covered: All approved plans in the state must cover the same package of benefits, called essential health benefits. In Ohio, the benefits include:

1. Outpatient services, such as doctor visits or tests done outside a hospital
2. Emergency services
3. Hospital stays
4. Pregnancy and baby care
5. Mental health and substance abuse services, including behavioral health treatment
6. Prescription drugs, including  generic and certain brand-name drugs
7. Rehab and habilitative services, those that help people recover from an accident or injury and those that help with developmental issues. In Ohio, this includes physical rehabilitation, speech and language therapy, applied behavioral analysis, and mental health services for children with a diagnosis of autism spectrum disorder.
8. Lab tests
9. Preventive and wellness services, along with those that help people manage chronic conditions. This includes biofeedback and chiropractic care.
10. Children's care including dental and eye care

Family Medicine: We Take Care of People

I love doing Family Medicine (FM).  The people are amazing.  Their biologic variation is phenomenal.  The opportunity for helping others to have their life is quite satisfying.  That's what I call quality.  They define it, often with our help, and together, we deliver it.  What a team.  Wow!

Secret:  Later, they all die.  Oops, we do, too.  Even if we don't smoke, or drink or swear.  Even if we had a great set of labs every year.  Even if we had our shingles shot, colonoscopy, flu shot, pneumonia shot and Adacel.  What kind of quality is it if we all die?  Who decides?

The Medical Director of Wholeness may be the one to decide.  If we die whole, that's quality.

I remember an elderly patient I was caring for who arrived at a terminal state while in the hospital with pneumonia.  He improved enough to get comfortable enough to die.  Alone.  His wife said he didn't die alone.  He was with God all along the way, and he didn't need people for his departure.  She declared that he died whole, with God.  She was pleased.

Another opportunity to redefine quality arises with the expansion of Direct Primary Care.  My mode of  practice is a hybrid of "traditional" FM and a version of DPC that I call  Direct Family Medicine (DFM).  In DFM, I have more time to work with patients to define their goals after learning about their values and dreams than many Family Physicians who are getting caught on the "medical hamster wheel".  Dream building helps to define quality goals in a personalized way.  That's the fun of  both traditional FM and DFM.  Personalized care via dreaming.  What is their dream?  How can we use our skills to better align them with it?  How do we celebrate accomplishing the dream?

Once we identify the dream, we assess motivation and belief.  Do they believe they can do it?  Much of Family Medicine is about these steps, especially helping them to know that they matter and we believe in them.  We look out for our people.

As they succeed over time,  we recognize the quality and celebrate with them.  We take care of people.  It's special.  It's Family Medicine.

Let's protect it like we do our people.  Let's adjust our business models so we can still dream for our patients and for ourselves.  Let's respect it, our patients and ourselves.  We all matter.

45th Reunion West Point Class of 1968: "OLD Souls" in "Old Bodies"

I was deeply touched by our 45th class reunion at the Marriott in Tarreytown, NY with daily outings to West Point.  In 1964 we started the adventure.  700 + graduated on June 5, 1968.  Now 39 are deceased, 20 of them in Vietnam.  Many alums and/or spouses have ailing bodies with arthritis, cancer, heart disease, kidney disease, prostate disease, etc.

BUT, we still are instilled with the "Old Souls" put into our once young bodies as cadets.  Our "old bodies" match the souls now.  The hearts are big, as are many of our understandings about life and the meaning of our West Point experiences.  The music of the sixties goads us on through CD's provided by Dick Steiner to tell the stories.  The Sugar Bowl story and the Stealing of the Navy Goat story stimulate the telling of many other stories of life in another era.  It was good, once we graduated.  Then we missed part of West Point.

Which part?  The reliable part?  The honorable part?  The friendship part?

Here they are- friends, brothers.  They understand part of us that no one else can.  Every five years or so we refresh that feeling of being understood and get a sense of West Point Wholeness.  Through the relationships and the connections to each other.

A glimpse of The Plain, A Cadet Parade, The Cadet Chapel, Trophy Point, The Hudson River, Thayer Monument, The Hotel Thayer, The Park Restaurant (I love it), Constitution Island, etc. may last for five to ten years as an anchor test.  Yes, I graduated from West Point in 1968.  That is very satisfying.  BUT, much less meaningful without the friends and brothers.

Thank you, Brothers.  Of the Class of 1968.  NO TASK TOO GREAT!

I reviewed our 45th Reunion Weekend on my Dr Synonymous Show:  Click Here

Erika Bliss, MD "Changing the System" with Direct Primary Care- Interview

The President and CEO of Qliance, a Direct Primary Care network in Washington state, Erika Bliss, MD tells the story of Qliance and her desire to "change the system".  "We work for our patients" has been a key factor in health care delivery by Qliance physicians since founder, Garrison Bliss, MD started the first practice.

Dr Bliss expounds on some aspects of "The System" that may be corrected by Direct Primary Care.  She reviews the vision of Qliance from founding to the present.  To grow the movement, Qliance hopes to network with other practices and networks to keep it expanding to serve the whole nation.

Listen as she speaks of individual and population based care via the DPC business model and practice strategies.  From caring to measuring outcomes and responding to patient and employer needs, she sees DPC as having a workable, (flexible) answer.

Interview w/ Dr Bliss 9/17/13 by Dr Synonymous

Dr Bliss interview starts at 14:30 on the show.  Skip ahead to that spot and get some great information.

She will be a presenter at Direct Primary Care National Summit

Direct Primary Care: Interview with Erika Bliss, MD President Qliance

The Dr Synonymous Show 9/17/2013  The interview starts at 14:30 into the show.

Listen on September 17 at 9 PM ET on blog talk Radio (internet) as Dr Synonymous interviews Erika Bliss, MD about her experience with Direct Primary Care as a Family Physician and as President of Qliance in the Seattle area. Qliance

Questions will include:

How did you get into Direct Primary Care?
What do you like about it?
Where is it headed as a movement in Washington and nationally?

Tell us about your career in Family Medicine?

How about your relationship with Qliance?  Then let's look at the home page for Qliance and chat a bit about it.  (click on Qliance link above)

Why was it started?  By Whom?

What are the benefits of having a network of several practices?  Drawbacks?

Who can be a Qliance physician?

What is the policy scene doing with DPC?  How does it relate to the Affordable Care Act?

Who are friends of DPC?  Enemies?

What else is important about DPC?

What do you expect from the DPC National Summit in St Louis October 11-12?
Direct Primary Care National Summit

Direct Primary Care: Expanding the Conversation From NC to DC and Beyond

DPC PIONEER:  Dr Brian Forrest discussed his history with and approach to DPC, including the training of physicians in multiple specialties in Direct Pay practice on my BTR Dr Synonymous Show.  His heart for open access for all showed through in this 50 minute interview with Dr Synonymous (aka, A. Patrick Jonas, MD) on Blog Talk Radio.  Listen as he describes his mission, passion and success with DPC in Apex, NC and beyond.

DPC Interview w/Dr Brian Forrest on Dr Synonymous Show 9/10/2013

Dr Forrest (and Dr Synonymous/Jonas) will be presenting information about DPC at:

Direct Primary Care National Summit


How about DPC and the poor?  Read the two part guest post on Common Sense Family Doctor written by Dr MargueriteDuane.

Common Sense Family Doctor Guest Post Part One on DPC by Marguerite Duane, MD

DPC for the Poor- Part Two by Dr Duane

Direct Primary Care is jumping, folks.  It isn't for everyone, but it's an important model for the present and future.  What do you think?

The Dr Synonymous Show: Interview with Brian Forrest, MD about Direct Primary Care

Dr Brian Forrest, Medical Director and Founder of Access Healthcare (and current Board Chair or the North Carolina AFP), is the special guest of Dr Jonas (aka, Dr Synonymous) tonight speaking about Direct Primary Care.

Access Healthcare

The general questions we'll cover in the interview include:                  

                     What is Direct Primary Care?  How did you get into it?

                      What do you like about it?

                      How many ways can it be done?  How about rural settings?

                       How does a "pure" DPC practice differ from a hybrid?

                       What about the poor?  Do they use DPC, too?

                         What about the rich?  Do they have access, too?

                       What kind of physicians practice DPC?
                                 
                        How does your practice work in North Carolina?

                         How do you train other physicians to do DPC?
                       
                         What kind of demand is there for  DPC?

                          Is this just a way to make more money?
                         
                          Does every state allow DPC?

                          Are DPC companies competing to buy up practices?
                           How does DPC affect the course of the healthcare transformation?

                            What about the DPC Summit in St Louis on October 11-12?

Direct Primary Care National Summit

Join us for another episode of Dr Synonymous live from 9-10 PM on Blog Talk Radio    The Dr Synonymous Show September 10, 2013 

Direct Primary Care: It's Not Just the Money

When we didn't receive Medicare payments for five of seven months between October 2012 and April, it hit my practice hard financially.  We were close to a disaster (like closing) until the OSMA (Ohio state Medical Association) helped us get connected with a human who could get our claims paid.

The non-payment was caused by new computer registrations we had to make for the Affordable Care Act (ObamaCare, aka, RomneyCare).  They made data entry errors in all three of the major changes, not easily detectable by the first four representatives we spoke with as the problem worsened from December through April.  After we had assurances in May that it would be fixed, we heard nothing at all for 30 days.

That experience was an eye opener.  Our survival as a practice is threatened by the massive system changes.We have no assurances that we'll have any patients after January 1, 2014.  We're small and vulnerable.  How do we continue?

I love being a Family Physician.  There is a sacred aspect to each of us that should be honored in our human endeavors.  As a Family Physician, I get to witness and experience that sacredness in my patients and myself.  The patient-physician relationship is the sacred core of the practice of medicine that I believe to still be worthy of honoring and protecting.  The relationship is a human connection that gives each patient and physician glimpses of the sacred nature of the other.  People are amazing and I'm blessed to get to help them with their health, illness and, eventually, their demise.  But, OUR demise as a practice is a surprising possibility.  How do we stabilize and increase our chance for survival?  We need to find an Island of Hope in the Heart of Darkness.

I'm starting to see that Direct Primary Care (DPC) might be that island.  It's a business model that gets us away from insurance companies, misaligned quality initiatives, and the quicksand of the Affordable Care Act.  (The ACA has some strengths and weaknesses, one of which is that we may disappear or drown in a sea of well-intended initiatives).

My practice has started Direct Family Medicine (DFM), the practice part of the DPC business model.  All new patients to the practice can only enter via DPC into our DFM.  I've posted about it before.  A good introduction to the concept can be found at www.dpcare.org.  It's not just about the money.  It's also about serving others as a Family Physician as well as I am able.

I'm a member of the planning committee for the Direct Primary Care National Summit in St Louis October 11-12 at the Airport Marriott.  It will be an exciting opportunity to explore the "Island of Hope" and get some great information about how to proceed with Direct Primary Care.  Physicians and practices from pure DPC, hybrid (traditional/ DPC practices) and transitioning practices will all be represented as well as a few networks of DPC practices.  Click on the link below for more information.  More conferences of a similar nature will start to pop up as thousands of physicians seek to leave The Heart of Darkness and continue to practice.

Direct Primary Care National Summit

In Search of A Principled Heart in Health Care

"A Principled Heart, that's what we needed.  Just someone with a principled heart."  I could hear the anger through clenched teeth as someone described a dehumanizing experience in a hospital with a dying relative in severe pain as they reflect on "the cartel that used to call itself a hospital."

A FAMILY PHYSICIAN in the best sense is called to have a principled heart.  We care.  We serve.  We'll protect our patients from unnecessary suffering.  We'll preserve their humanity when they crawl through the muck of sickness and ill health and impending demise.

Or will we?  Are we there?  Or are we communicating in real time with the admitting hospitalist, cardiologist, intensivist, oncologist, etc. if we're no longer admitting to hospitals?  Would they let us know if our patient is stuck and in need of a translator or decision maker who is a broad based generalist, able to dance across the confusion of our non-system of health care?  (Like us).

I know we have principled hearts.  BUT, are they connected where they are needed?

What do you think?

Direct Primary Care: Niche Marketing for a Small Practice

OK, you read about my listing with the Physician Hospital Alliance that we are taking patients without insurance (or are willing not to use their insurance in our practice).  We got about six calls in three weeks, half of which were insured and wanted to use it in our practice.  DPC is sometimes hard for people to understand when they're used to the traditional medical insurance that includes family physicians.

Remember, we have about two hundred total patient slots to use for enrolling DPC families.  We're a two physician, independent practice.

Next we'll market to a health food store where a lot of their customers are less prone to go to physicians for minor problems.  The clerk at the cash register understood DPC instantly.  "I just have medical insurance for hospitalization and disasters requiring emergency care," she noted.  "Your membership practice sounds like a great idea.  Can you give us some of your cards?"

It's nice to be understood.  We have the only practice in our city accepting uninsured patients, and they're not pouring in.  Because they don't know.  Yet.

We'll also market to the local urgent care, owned by the hospital system that we relate to.  Then we'll see where the callers learned of us.

Our strength/limitation is that we only take families (households) so we get 2 to 4 new patients per enrollment.  Costs for our subscription practice are $80 to enroll, $60 at the end of each month, and $20 per visit for adults.  Children pay less, seniors 65 and older pay more.  Patients also pay for labs that are sent out of the office and imaging.

After the health food store and the urgent care center, we'll market to one or two religious groups.  They may have uninsured or underinsured persons in need of medical care.

More later.

The Dr Synonymous Show Aug 27th, 2013

The Dr Synonymous Show August 28, 2013 on Blog Talk Radio.

In my weekly blog, tweet, medical literature review I mentioned and commented on the following:

JAMA Aug 28 edition, Vol. 310, Number 8 article on Changes in Health Care Spending and Quality for Medicare Beneficiaries Associated with a Commercial ACO Contract. Spending and Quality in ACO

Medical Mojave blogs Medical Mojave  about acute inability to connect with her physician in a moment of medical need.  Fat Head posts a review about a helpful book about cholesterol. Cholesterol Clarity

Dr Howard Brody posts about Overdiagnosis and Overtreatment Hooked: Ethics, Medicine and Pharma, as does Dr Kenny Lin in Common Sense Family Doctor and the above JAMA Overdiagnosis and Overtreatment in Cancer  has an opinion piece on the same topic with a recommendation to the National Cancer Institute.  This issue will be heating up a lot.

Dr Lin also mentions his book in progress, Conservative Medicine and his perspective on the need for passion and outrage in medicine. Common Sense Family Doctor

On Twitter, several chats were in progress including #CHSOCM, #HCLDR, #EOLCHAT

Dr Synonymous post reviewed is about "Direct Primary Care:  You're Worth It" DPC You're Worth Itl
I end with a comment about the upcoming Direct Primary Care National Summit

Direct Primary Care: You're Worth It!

I often advise patients in my Family Medicine office to get a massage.  "Is it covered by my insurance?" they ask.  "No, but you're worth it," is my reply as I point at them with two index fingers.

Healthcare is shifting, "transforming" and becoming way too expensive while also moving ahead on the insensitivity scale.  What happened to "Hi Tech, Hi Touch?"

What happened to your doctor?  Did the Electronic Medical Record (EMR) steal your doctor away from you?  Was your doctor sucked into a billing cartel by a large corporate (possibly even "not for profit") member of the Medical Industrial Complex formerly thought of as a hospital?

If you want your doctor back, get them into Direct Primary Care.  It is a way to refresh your relationship with them while freeing them from onerous mounds of paper work and misguided quality initiatives driven by insurance companies.  Freedom might feel good for your doctor and for you.

Direct Primary Care is not insurance.  It is a way to have direct access to your doctor.  You pay them.*
"You're worth It!"

Your doctor and interested others can learn more at the Direct Primary Care National Summit in St. Louis at the Airport Marriott, October 11-12.

Direct Primary Care National Summit

*Many employers arrange to pay for Direct Primary Care for their employees.  They also should know, "You're Worth It!"

Direct Primary Care Summit: Bending the Cost Curve

Healthcare costs are (shamelessly) way beyond affordable by the average American Family.  How do we move toward financial reality in healthcare?

Direct Primary Care (DPC) is a good start.  It is a business model that allows patients to pay their Family Physician directly.  It allows employers to pay Family Physicians directly.  It saves money.

It may even allow governments to pay Family Physicians directly someday, but both the government and the insurance companies are failing as stewards of healthcare dollars and processes.

Hundreds of Family Physicians, averaging twenty years or more in practice, have now moved into Direct Primary Care practices and more are on the way.  The movement is seeing a crescendo of activity as the transformation of healthcare crushes physician morale and shows no potential for a course correction via an increased primary care workforce.

Direct Primary Care is affordable primary care for most families.  Getting Family Physicians out of insurance plans is a critical element.  Getting health care from someone not employed by "The Beast" (Medical Industrial Complex) is another good idea.

To further advance DPC, a Direct Primary Care Summit for primary care physicians, employers, health care providers, interested medical students and residents is coming to St. Louis October 11-12 at the Airport Marriott.  Speakers such as Garrison Bliss, MD and Dave Chase, leaders in DPC will deliver the nuts and bolts of DPC for both new and veteran DPC fans and practitioners.

 Direct Primary Care Summit

Family Medicine: The Man in the Closet

"My dad used to lock me in the closet for hours at a time.  He would let me out to abuse me.  It was horrible.  I felt so afraid and alone.  I didn't understand sexual abuse at the time, but I knew what he was doing to me was wrong."  A patient told me this story one day when I asked about her childhood.  She had a long list of diagnoses and medications and specialists and hospitalizations.  I wanted to hear the background that delivered such levels of medical interventions.

She continued, "I used to have out of body experiences, flying through the closet door and around the house.  I don't know how it happened, but it was real.  I eventually was able to do it while he was abusing me.  I told my mom about flying around and ended up in the psych ward in the hospital.  They said it was schizophrenia.
I got a lot of pills and hospitalizations.  My sister was abused, too.  She got the schizophrenia, too, and pills and doctors."

"One day when I was locked in the closet, I noticed I didn't feel afraid.  I was calm. There was light in the closet and a man.  I didn't feel nervous about this man.  I decided that he must be Jesus.  He was kind.  I didn't cry anymore.  I even looked forward to being locked in the closet to be with the man..  He seemed to care.  He never harmed me.  He gave me peace."

She asked me to write about the Man in the Closet.