The Business of Medicine Should Not and Can Not Replace Care and Compassion

Compassionate CareWell over a year ago I advised my 80 something year old patient and her children that due to progression of her Parkinson’s disease, and her frail nature, she needed a higher level of assistance and care if she wished to remain in her home.  She was extremely unsteady walking and several courses of physical therapy had not improved the situation. The patient was feisty and would only allow help to come for 4 hours per day despite having a long term care policy that paid for significantly more.  She lost her balance recently, fell and landed on her back. She could not get up or get to a phone or her alert bracelet and was found seven hours later on the floor by her aide arriving for work.  In the Emergency Room x-rays revealed several acute fractures of her vertebrae that accounted for her severe pain with movement and inability to stand, bear weight or walk.

I hustled over to the ER and examined her and called the interventional radiologist to see if he could perform a procedure called a kyphoplasty that would cement the fractures and remove the pain. It was early Friday afternoon and the traditional back specialists were unavailable until the next day.  The radiologist came promptly, was professional and very pleasant explaining that he could do the procedure but because she took a baby aspirin for prevention of stroke, he would not perform it until the aspirin wore off in 5 – 7 days because of fear of excessive bleeding around the spinal cord.  He suggested we send her home with pain medications and round the clock assistance or keep her in the hospital until the aspirin wore off and he felt comfortable performing the procedure.  He was courteous and a credit to any profession. 

Since the patient was in great pain with any movement, I chose to admit her to the hospital while we sorted things out.  I admitted her as an inpatient because she is extremely elderly and frail with medical conditions that led to this injury which an expert had just told me required surgery to fix. She could not walk or transfer to a chair or wheelchair to get food, water or get to the bathroom. She had no arrangements for additional help at home to assist her. She could not, in my professional opinion, go home safely at this point.  

The next day I was making rounds late in the day for me at noon, reviewing the situation with the patient and her son when the physician’s assistant (PA) for the back surgeons, Andy, walked in and introduced himself. They had not seen her Friday evening or Saturday morning and this was their first contact with the patient.  My consult request and phone call had been quite clear. I wanted to know how they viewed the injury and what options did they feel were best to fix the problem. I additionally asked them how their approach would differ, if at all, from the approach of interventional radiology.  I had seen Andy around the facility and said “hello” but never formally met him so it was an introduction for me as well. 

“Hi, my name is Andy, and I work for Doctors Y and Z.  We have a little problem with your insurance.  You have a Medicare Advantage plan and we are not part of that plan. Most of the time, about 95% of the time, we eventually get paid for our services but we need to know how we will get paid for performing a procedure on you to fix your back before we proceed further. In these situations we usually ask the patient to pay the bill up front ($1000 – $1200) and then we submit the charges to your insurance company. If we get reimbursed from the insurance we return the money to you.”  

I took a deep breath and wondered if maybe I was overreacting to the brusque inappropriate presentation to a groggy senior who had been given a narcotic 30 minutes before for pain and was really in no condition to listen to any presentation or sign away informed consent.  I cut Andy off in the middle of a sentence and reminded him that I had requested an opinion. The son, an attorney by trade took up the fight and reminded the PA just how inappropriate his initial remarks were and that in this case money was not a problem but the manner of dealing with an elderly confused patient was.  I played mediator at this point and got the PA to explain that his employers had done several thousand of these procedures and handled many more complications than most interventional radiologists and that their success record spoke for itself.  He outlined a slightly different approach and once we got him talking about the reasons for his invitation onto the case, justified calling his group.

I am all in favor of physicians being paid for their professional services. This could have been handled differently by calling me first and informing me that they had concerns about payment and insurance and letting me address the issues. It could have been handled far gentler by answering the questions asked first and suggesting options and then reviewing the problems with the insurance. Had the gentleman performed a history and or exam rather than rely on the ER PA’s evaluation the day before, he would have seen that the patient was not in a position to comprehend what he was saying or sign for a procedure.  

This is not a criticism of PA’s or Nurse Practitioners. It is a criticism of any practitioner who does not answer the questions asked by the referring physician or question the referring physician about payment before arriving for the consult if they have questions about getting paid for their time and expertise.

The post script is that the son wisely chose to use this group based on their talents and experience and put aside the rude and insensitive communication by the PA. The surgery went well and the patient will go home after spending three nights in the hospital. 

There is still one obstacle to overcome. The hospital ignored my written order to make her status inpatient and made her status observation which will prevent her from receiving any post-surgery therapy or care which is paid for by her insurance. I will fix that. Keeping the phone number on my phone contact list of the Office of the Inspector General who investigates Medicare irregularities opens doors in situations like this. It does not change the fact however that as practitioners we need to be much more thoughtful when we discuss financial issues before medical issues if we wish to continue to be considered a profession rather than another business.

A Physician’s Call for Help – Rewarded by the Best Payment of All

My wife and I were sitting down to an uncharacteristically late dinner for us Friday at a local eatery when my cell phone rang. Caller ID identified it as Dr David Rosenberg, a family physician practicing concierge medicine about one hour north of my home in Jupiter, Florida.  We had not spoken in months and after some pleasantries and catching up he said, “Steve I just saw a story on the TV News that there is a back to school community fair in Pearl City in your community tomorrow morning and the doctor they had counted on to perform the required school exams for new students had cancelled due to a personal crisis.

Dr. Rosenberg wanted to know if I would join him for a few hours at the Wayne Barton Learning and Community Center and perform the physicals. He told me he had phoned fifty physicians and no one had yet agreed to come. He was prepared to do them himself.  I gave my wife that “duty calls” look and she nodded back approvingly and I told him it would be my pleasure. I agreed to meet him at 10 a.m. at the center.

Wayne Barton is a former City of Boca Raton police officer who is now a community leader and activist. He created a nonprofit agency and, with generous philanthropic support, has built an educational and community center for students from poor homes. He provides year-round learning and tutoring for students and has an annual “Back to School Jam” where new students receive the required school physical plus receive backpacks filled with school supplies that their working parents have great difficulty affording.

Mr. Barton greeted me at the entrance as I walked in and thanked me for coming on short notice. The regular physician who cancelled due to a family crisis has been volunteering for years and is my personal friend, mentor and is my patient. Trying to fill in for him is a tall order and made the experience even more special for me. Dr. Rosenberg, who organized this last minute physician participation, was there as well and with him were two other concierge physicians and a wonderfully warm physician’s assistant.

For the next several hours, with the help of a large dedicated volunteer staff, we saw numerous lovely children with their families. A mother and her high school age daughter and son, who had escaped the ravages of the earthquake in Haiti, were among the first.

A young woman and her two children who had escaped Communism and Castro’s Cuba nine months ago came through my station.  I saw a young man with lead poisoning requiring treatment and follow-up and another lad who wanted permission to play football despite the jaundice in his eyes tipping me off to his history of sickle cell anemia that he had conveniently left off his form.  I was able to stay for three of the four hours and I received the best payment of all – beautiful smiles, blessings from several and a thank you from all.

The degree of appreciation coupled with the level of need leads me to believe it’s time to discuss with Mr. Barton a regular free clinic at the center.

Once last thought, I couldn’t help but notice that the physicians who responded to the call for help were all practicing in a concierge medicine model.

Medicare, if you only knew…

The following guest post was written by Aimee Seidman, M.D., FACP.  Dr. Seidman is an award winning internal medicine physician in Rockville, MD, a suburb of Washington, D.C.

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If I could have a penny for every dollar I saved Medicare, I’d be rich. As a concierge physician, my patients can expect advocacy that stretches from the office to the home, hospital, rehab facility, long term care setting, and to the hospice. When I work with a patient, they can expect me to intervene between the various subspecialty physicians or hospitalists involved in their care, spread out my arms in front of them as if ready to take a bullet for them, and defiantly yell “get your paws off my patient until we hear what the plan is”.

How often are x-rays, ultrasounds, MRI’s, cardiac caths, and yada, yada, yada done in patients with a shortened life expectancy, poor quality of life, or clear living will instructions? How often is patient autonomy ignored in the rush to ‘complete work-ups’? Why do we have to work everything up? We need to stop what we’re doing (and stop the cowboys who are shooting from the hip) and think about the patient’s status and whether or not the proposed intervention is appropriate.

The last time I asked one of my 80-101 year olds how aggressively they wanted their medical treatment to be, they said “no way…leave me the hell alone! When my time comes, it comes. Just make a nice party!“  I shudder to think of the feeding tubes inserted and other interventions done in clear violation of a living will, even if that living will is right there with the patient or family members present.

I believe we scare the daylights out of people by telling them all the horrible things that will happen if they don’t consent to treatment plans. But it’s all defensive medicine. “I’ve got to be able to document that I warned them about this horrible death so I don’t get sued”. I suspect non-intervention, comfort measures, and hospice care are rarely offered to families in a way they can hear it. ER doctors and hospital physicians are just doing their jobs-they want to ‘save lives’ (or at least keep them alive until the next shift) and the primary care doctor is never consulted.

What do people think we do, order mammograms all day? Those of us in concierge medicine who have close relationships with our patients know them and their families well enough to expedite decision-making in a way that is medically and ethically appropriate. The whole point of my concierge practice is to first, do no harm (remember that?), allow my late stage Alzheimers disease patient to have a dignified death, and not spend millions of dollars on unnecessary procedures.

Not only that (I’m almost done), if all primary care physicians and the health care community made a conscious effort to inquire about living wills, explain the subtleties, and respect the choices made, fewer people would use ambulances, go to the ER, stay in the hospital, etc.

The other piece to this is the education of families regarding end of life issues, preparation, ethics, and closure. As it is, families deal with guilt, sadness, confusion, and anger when called upon to make these tough decisions or to respect an established living will. Most of us have seen families reluctant to honor a living will because they can’t bear the thought of letting grandpa starve to death.

If consulted about these decisions ahead of time, much of the combat will not occur. So how much have I saved Medicare by avoiding all this unnecessary stuff? Tens of thousands of patients, times a fortune of money, equals a boatload of bucks.

So, do you want to know ways to fix health care?

1.      Tort reform so docs aren’t so paranoid and aren’t playing “cover-your-butt medicine”;

2.      Docs, shut up and listen to your patients;

3.      Stop insulting the community of doctors who want to practice medicine in a particular model labeling them elitist and focus on things that will work (and by the way, most of us have scholarship patients, indigent patients and perform community service);

4.      A national campaign to educate consumers about the importance of living wills and have discussions over details, including family members in the discussion;

5.      Make it clear to the medical community that honoring a patient’s autonomy in the form of an advance directive is their obligation under the law

6.      Do no harm.

Just listen to me and give me a penny for every dollar I save Medicare, then I’ll really be rich.

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Please note, the opinions expressed in this guest blog post are those of Dr. Aimee Seidman, founder of Rockville Concierge Doctors.

Who Says Concierge Practice Is Unjust For Patients And Doctors Alike?

Medscape Medical Ethics published an article in August 2011 written by Art Caplan, PhD., Professor of Bioethics and Philosophy at the University of Pennsylvania claiming that Concierge Practice Is Unjust For Patients And Doctors alike.  A PDF of the article is attached for your review.  Concierge Practice Unjust For Patients and Doctors Alike by Art Caplan, PhD.

I am in disagreement with Mr. Caplan’s article.  Below is my perspective.

Like the shots fired at Concord and Lexington in 1776, concierge medicine and direct pay practices are the initial shots fired by concerned primary care physicians in the revolution against health care systems which limit access to physicians and destroy the doctor / patient relationship. Concierge medicine arose as a result of government, private insurance, and employer intrusion into the health care field destroying primary care and a physician’s ability to spend the time required with patients to adequately and comprehensively prevent and treat disease.

The only thing that is unjust or unethical about concierge and direct pay practices is that they had to be formed to begin with. They formed after 30 years of:

  1. Primary care doctors lobbying unsuccessfully for adequate compensation for evaluation and management services and for protesting the widening gap between cognitive services and procedural specialty practices.
  2. Going through channels protesting the unfair bureaucratic and administrative burdens placed on primary care practices by Medicare, Medicaid and private insurers.
  3. Warning that the population is aging and their chronic health care problems are far more complex requiring more time with a physician rather than less.
  4. Primary care physicians leaving medical practice for early retirement or for paid jobs with pharmaceutical companies, medical device manufacturers and hospital administrations where hard work and achievement were rewarded without having to deal with system imposed overheads of up to 65 cents on the dollar.
  5. Legislators providing no relief from frivolous lawsuits which makes seeing complex patients in 5-10 minute sessions for “single problem directed visits” a legal liability.
  6. Medical students realizing that the time and financial commitment to the practice of primary care medicine didn’t cover the bills essentially directing them toward more lucrative procedure dominated specialties.

Physicians also left after salaried academic physicians, who never took risk and invested a cent of their own money in building a practice, pontificated and moralized in peer journals supported wholeheartedly by biased pharmaceutical company ads that generating passive income through shared labs and imaging centers was a kickback.

If we look at the data accumulating on care from concierge and direct pay practices, we find that despite a sicker patient population these practices generate fewer visits to emergency departments and fewer acute emergent hospitalizations saving the system money.  These practices provide coordinated care for their patients steering them through a complex and confusing health care system riddled with inappropriate advertising and claims and, get the patients to the best people to treat their problems.

Concierge physicians have more time to spend with their patients thus, achieving unheard of levels of retention and patient satisfaction while giving pro bono scholarships to patients who cannot afford their membership fees but were with them prior to their conversion to a retainer model.

After years of being on the conveyor belt of having to see more patients per day, every day, to stay abreast of system generated overhead cost increases and declining payment for services, concierge physicians now have time to teach students, volunteer at health fairs and screenings and participate in the stewardship of what remains of their profession.

If anything is unjust and unethical it is salaried academic non-physicians writing articles about morality and justice about issues they have no hands-on experience practicing. As a primary care physician for 32 years, I feel like a chameleon having to change colors and practice style every few years based on new rules imposed by private insurers, employers and government programs. At no time were these new rules designed to improve the patients’ access to care or total care.  In each case the new rules were designed to save money and do nothing else.

Concierge and direct pay medicine is the first volley in a revolution to take outstanding care of a smaller panel of older sicker patients on a long term basis.  Its proponents have worked hard for decades to change the system through channels. Failure of legislators, government bureaucrats, health insurers, employers and professional associations such as the AMA and the ACP to react and fix the inequities has generated these practices which cost less than a cup of Starbucks grand latte per day to be a patient of and provide comprehensive care and access.

Free Health Screening – A Service to our Community’s Health

Last weekend I had the privilege of supervising University of Miami Miller School of Medicine students at a free public health screening in Pompano Beach, Florida.  The screening was sponsored by the medical school, with the assistance of community leaders, and held in a local public school. The program organization, recruitment of student and faculty volunteers and management of the program was undertaken and implemented by the students. It is one of several programs of this nature undertaken by these students in Dade, Broward and Palm Beach County Florida.

Stations were set up to screen for vital signs, weight, body mass index, glucose and cholesterol. A women’s center with breast exam, cervical pap smears and dexa heel bone density tests was available. There was an ophthalmology station with physicians from Bascom Palmer Eye Institute. A dermatology section was available with fellows from the world class dermatology program at the University of Miami. Pediatric and neurology sections were available as well as mental health screening. The program was enhanced by the participation of the Broward County Health Department and numerous other community organizations.

After the patients rotated through each station they exited at a checkout area manned by students and faculty. The students organized all the data for the patient participants, explained what their exam findings meant and established mechanisms for the patients to receive follow-up care in the Public Health setting.

This was the fifth year I have participated as a voluntary faculty member. I noticed the patients were younger, sicker and presenting with more social and health problems than in previous years. Several times during the screenings, the fire rescue squad was called to transport individuals to the hospital because their initial entry into the health system detected a serious enough condition to require immediate hospitalization. The patients were proud, hard working American citizens of all races, colors and creeds who were devastated by the recession with loss of jobs and health insurance benefits.  For many, this screening was their first trip to the doctor in years. Although well received, this screening was the most rudimentary of safety nets available for this community from the health care field.

Some 225 patients were examined in an eight hour period. I was proud of the students for a job well done. After it was over I went home and took time to read the local newspaper. There was a front page article about how our new governor had just proposed a budget which cuts all funding for primary medical care at Public Health Facilities. I wondered how many of those patients we referred for follow-up to Public Health facilities would now have to wait until next year’s screening program to obtain it?

I wish those Tea Party and righteous cost cutting conservative politicians and our governor had spent the day interviewing, examining and counseling the patients I saw today. I wonder how they would react to a frightened fifteen year old hoping to get a pregnancy test and too poor to afford a store bought test?  I wonder what they would say to a 5th grade teacher who had lost her home to foreclosure and couldn’t afford to pay an ophthalmologist in the private setting to check her glaucoma. I wonder what Governor Scott and the Tea Party would say to a 50 year old former triathlon performer who lost his construction and landscape business during the recession, lost his health insurance, gained forty pounds due to the stress of life and was now unemployed, diabetic and hypertensive with no access to health care?

It’s easy to pontificate about the flaws of health care reform until you sit down with the sickest and most vulnerable and realize they are no different than you and I.

Patient Advocacy – The Decision

My patient received notification of Aetna’s decision of our appeal.  The news was positive.  The appeal was approved.

I knew in my heart, regardless of the outcome, it was well worth the effort.

Advocacy Makes You Feel Good

I have a 61 year old patient who is the wife of a prominent local physician and has been in my practice for over thirty years.  When she first started developing strange aches and pains as well as abdominal symptoms her evaluation turned up nothing. At that point she was very active; playing ball with her two growing sons and dancing the nights away wearing out dance partner after dance partner at community social functions.

When I could not determine the cause of her ills I asked for help at reputable places including the University of Miami rheumatology division and gastroenterology division. Like so many illnesses, the disease remained a mystery until it was ready to show itself and until technology and progress developed diagnostic tools to allow us to see what is actually there.  With the help of a brilliant local gastroenterologist and rheumatologist, and after a trip to Johns Hopkins Medical Center and the Mayo Clinic, collagenous colitis and Sarcoidosis were documented.  In the interim, local medical doctors and her friends branded this poor woman as “another neurotic spouse of a doctor who liked narcotics.”

She developed a peripheral neuropathy which meant her feet and legs hurt all the time with burning / shooting discomfort exacerbated by walking. She went from dancing the lindy to hobbling with the assistance of her husband and a cane from the bedroom to her kitchen. She would then have to sit down, massage her legs and put on thick cushioned sweat socks to tolerate the foot and leg discomfort.

When her local rheumatologist had lost patience with the frustration of not being able to help her with the off-label use of drugs like gabapentin, lyrica, antidepressants, anti anxiety drugs, anti inflammatory drugs and narcotics; I recommend she be seen by the most acclaimed rheumatologist clinician in the United States.  She consented and went out to Cincinnati.

The consulting physician discussed small fiber neuropathy as the cause of her pain. Fortuitously, an article arrived from the Cleveland Clinic describing the diagnosis and treatment of this disease with intravenous immunoglobulin (IVIG).   I read the article and called the doctors in Cleveland. They were warm, encouraging and helpful. They sent additional information and references, instructed me on how to obtain and transport the skin biopsies required to confirm the diagnosis and, explained the nuances of treatment.

It took several weeks for the biopsy specimen results to confirm the diagnosis.  We decided to try the IVIG and arranged for the daily infusions for five days out of each month only to be turned down for reimbursement by Aetna Insurance Company. The medication costs about $8000 per month. I wrote two appeals for the patient and faxed them off to Aetna, only to be quickly turned down because it was considered “experimental.”

Experimental?   The Cleveland Clinic, the Mayo Clinic and the Weitzman Institute in Israel were using this drug successfully to treat small fiber neuropathy for years. The group in Cleveland had built on previous works in this area and developed an administration regimen and dosing that actually provided relief in 70-80% of cases. Nothing else worked.

Aetna was bound by law to offer another appeal.  A teleconference was scheduled.  I did my homework begging the rheumatologist in Cincinnati to assist me.  He did not.  I asked the local neurologist to help me, but “he was out of town not near a phone.”  Fortunately the care team in Cleveland, along with their lead physician, supplied me with information and data and prepped me like an attorney preps a witness before a trial.  The lead physician offered her time to participate but Aetna would not alter the time of the appeal to accommodate her. I was on my own. Her husband assisted me with preparations and joined the conference on his wife’s behalf.

When I called in to the conference line and gave my password I felt like David facing Goliath.  When I was introduced to their panel of surgeons and lay persons not familiar with the disease I felt encouraged. I decided to slay them with civility, professionalism and data. I painted a personal image of the patient’s life before her illness and now. I wanted the panel to be carrying the image of a human being in their minds and the devastation the disease was causing as they deliberated. I explained that all the conventional treatments and off-label treatments they previously approved, had not worked. I then gave them an educational teaching session from the literature, quoting articles and experts on the subject from around the world. I told them that we now had a rare disease with a treatment that actually worked; quoting soon to be published success stories from around the world – all accumulated and performed at very reputable institutions.

The physicians representing Aetna thanked me for being my patient’s advocate. They told me such participation is rare but it certainly gave them a much clearer picture of the situation and choices. They said a decision will be made within two weeks and we will be informed by mail of their decision.

I hung up the phone feeling very positive. I had taken the time to become an expert on my patient’s illness and fought for their care to the best of my ability. I called my patient and reported what had transpired and informed her that we would have about a two week waiting period for a decision to be made.  Then I sat back and picked up my yellow legal pad and drafted an outline of how I would approach the next appeal when this appeal is denied.