Concierge Medicine – My 15th Anniversary

I practiced general internal medicine from June 1979 until November 2003. Immediately after training I became an employed physician of an older internist covering my employer’s patients and building my practice for two years before embarking on my own.

I saw 20 or more patients per day in addition to providing hospital care and visiting patients as they recovered in nursing homes. As managed care made its clout felt by kidnapping our patient’s and trying to sell them back to us at 50 cents on the dollar, I helped form a 44 doctor multi-specialty group with its own lab, imaging center and after hours walk-in center. The hope was that a large group might have some negotiating leverage with insurers allowing us to take more time with our patients for more reasonable fees. They laughed at us.

Three years later, my associate and I went to the bank, took out a big personal loan and started our concierge practice. We did this primarily to be comfortable providing excellent care to patients. The system was broken and no medical leader, insurer, employer or politician was going to fix the broken system.

Year after year as our patient’s survived and grew older and more complicated, private insurers including CMS (Medicare) asked us to see them quicker, in shorter visits, but be more comprehensive. The insurers essentially wanted us to place a square peg in a round hole. Switching to a Concierge practice meant I would be caring for a small group of patient’s well at the cost of finding a new medical home for 2,200 existing patients. Switching to Concierge Medicine was our response to a broken system being pushed in a direction of more money and profits for administrators and insurers at the expense of patients and doctors.

In retrospect, I should have made this change five years sooner. The financial rewards are not very different – caring for a small patient panel that pay a membership fee as compared to an enormous panel of patients. The rewards to the patients’ and the doctor for doing a job well done are priceless.

We increased our visit time to 45 minutes from 10 minutes. We set aside 90 minutes for new patient visits. We made a point of continuing to care for our hospitalized patients while all our colleagues were turning that over to hospital employed physicians with no office practices. We provided same day visits and access to the doctor 24 hours a day, seven day a week with accessibility by phone or email. We had the time to advocate for our patient’s as they weaved their way through a bureaucratic mind numbing health care system that made filling a prescription as difficult as the science of launching a rocket into space.

The results of the change are striking. There are very few emergency admissions to the hospital. Falls and trauma, which are mostly not preventable, replaced heart attacks, strokes and abdominal catastrophes as reasons for hospitalizations. There are many fewer hospitalizations. There are fewer crises because we learn about the problems immediately and see the patient’s quickly. If necessary, we help them get access to specialty services.

We have the time and staff now to battle with insurers and third party administrators to get our patient’s what they need to regain their health and independence. When they need specialty care we get them the best; the people we go to ourselves both locally and nationally. We send them equipped with all the information and questions they need to ask about their health problem.

Concierge Medicine has additionally given us the time to teach future doctors. While this stewardship of the profession and launching of future physicians is immensely satisfying, it also makes us stay current and on top of the latest literature and advances.

I look forward to this coming celebration of my 15th year in concierge medicine. I see Direct Pay Practices developing which deliver concierge services to the masses for lower fees. It is a spin-off of “boutique “medicine” or Concierge Lite” as my advisor calls it. It is an attempt by young physicians to reestablish the doctor patient relationship and deliver care in a broken health system.

I am thankful to my patients, who took a chance and came on this journey with me. I look forward to caring for them for years to come.

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Cannabis & Cannabinoids in the Treatment of Chronic Non-Cancer Pain

My 90 year old patient with spinal stenosis, diffuse osteoarthritis and now polycythemia vera was in for an office visit. He had been to see his hematologist and had been phlebotomized removing a unit of blood to control his overproducing bone marrow. He mentioned that the hematologist had sent him to a medical marijuana clinic run by a pain physician colleague of his.

The patient proudly showed me his marijuana registration license. “It doesn’t work you know. In fact I feel poorly after I take some. I have tried the oils and some edibles but it really doesn’t affect my pain in a positive way.”

Many of my patients now are licensed to receive medical marijuana for chronic pain. It’s a big business here in the state of Florida where senior citizens with chronic aches and pains are always looking for that magical pill to restore their vitality and youthfulness. His experience is unfortunately supported in the medical literature. In the May 25, 2018 issue of Pain magazine which looked at the pain relief of patients with rheumatoid arthritis, fibromyalgia, neuropathic pain and 48 other non-cancer pain conditions. The study was a literature review looking at the 104 studies published on this subject.

The findings were sobering and disappointing. They found that cannabinoids had no appreciable positive impact on pain relief. In addition it didn’t help sleep, there was no positive impression of change and there was no significant impact upon physical or emotional functioning.

I am not an anti-marijuana crusader. I see its positive impact in treating glaucoma. I see the studies citing it is more effective to deliver by smoking it than eating it or taking it in pill form.

The review studies included all forms of administration of cannabis. I just want to make sure that when authorities legalize a substance for use in pain control it is effective and not just profitable snake oil for a strong lobby of well-healed and crafty businesspeople.