Concierge Medicine and the Pandemic

Twenty years ago I practiced internal medicine and geriatrics locally in a traditional medical practice. I cared for 2700 patients seen in 15-minute visits with an annual checkup being given a full 30 minutes. The majority of my patients were over 55 years old and many had already been patients for 10-20 years. The practice office revenue was enhanced by having an in house laboratory, chest x-ray machine, pulmonary function lab and flexible sigmoidoscopy colon cancer surveillance program. If patients needed more time, we allotted more time or, more likely, we just fell behind leaving patients stranded in the waiting room wondering when they would be seen. I had a robust hospital practice made easier by the fact that the hospital was a short walk across the street and most of my hospitalized patients came from being required to cover the emergency room periodically for patients requiring admission but not having a physician.

Much changed quickly in the early 1990’s as we approached the millennium. Insurers managed care programs kidnapped our younger patients by approaching employers and guaranteeing cost savings on health insurance by demanding we provide care at a 25% discount. In addition, mandatory ER call became a nightmare because insurers would only compensate contracted physicians to care for their hospital inpatients.

My very profitable chest x-ray machine became an albatross because that $28 x-ray reimbursement was now accompanied by a fee to dispose of the developing fluid by only a certified chemical disposal firm even though the EPA said there was not enough silver in the waste to require that you do anything other than dump it down the sink. The lab closed too. Congress enacted strict testing and over site rules which made the cost of doing business too expensive and not profitable. That flexible sigmoidoscopy went the way of the Model-T Ford when the medical community enlarged to accommodate board certified gastroenterologists certified to look at the entire colon under anesthesia not just the distal colon and sigmoid.

We tried to overcome increased costs and lost revenue by seeing more patients per day. We banded together as physician owned groups owning imaging centers and common labs but the Center for Medicare Services (CMS), which runs Medicare, and private insurers plus Congressional rules on conflict of interest thwarted those ideas. We attended seminars on becoming a member of an HMO and taking full risk for a patient’s health care and cost.

The message was clear, you could make a great deal of money if you put barriers in front of patients limiting access to care and especially in patient hospital care. The ethics of that model did not sit well with many. So, we started earlier, shortened each visit and worked later and harder. As time wore on, and our loyal patients aged, we realized that we needed to spend MORE TIME with them more frequently.  Not less time!

Spending less time with patients was the primary impetus which prompted my exploration of concierge medicine when I realized I was better off emotionally, ethically and morally caring well for fewer patients. Financially, seeing a smaller panel of patients who paid a membership fee generated similar income to maintaining a large panel of patients in a capitated system or fee for service seeing more people with shorter visits.

I discuss this now because I often wonder how I would be able to care for my large panel of patients today in the midst of this COVID-19 Pandemic.

For the most part I have been able to give my patients the time and availability they need to stay safe from Coronavirus and still keep up with the prevention and surveillance testing they need periodically. The 24/7 phone, email and text message access has allowed me to stay in touch with patients – something that would have been near impossible to do in a practice with 2700 adult patients.

I applaud my colleagues who continued in the traditional practice primary care setting despite the fact that most sold their practices to local hospital systems or large investment groups who placed administrators in the care decision-making process dictating time and number of daily visits, referral patterns and products used in the care of the patients.

As an independent physician, I have been able to continue to provide services and referrals that are the best in the area using doctors and equipment I would see as a patient and proudly refer my parents, my wife and children, beloved friends and family members. I am able to guide patients based on evidence and quality of measures not only what is most cost effective. I have no contract with a health system that requires me to see a certain number of patients per day, per week, per month or face a drop in salary or dismissal. I am proud and fulfilled at the end of the day because I can look in the mirror and know that I tried my best for the patients.

I additionally have the ability to say “no” to a potential new patient that I believe would not benefit from being in my practice for numerous reasons. Providing time to meet potential new patients gives both the patient and physician an opportunity to assess whether developing a professional relationship would be a good fit for both.

During the pandemic these meetings have become tele-health virtual meetings which are far more impersonal and less educational for both the potential patient and the doctor. It is still far better than having an administrator schedule a new patient, with no questions asked, on your schedule with the only criteria being can they pay the price?

Sadly, this horrible SARS 2 Coronavirus pandemic has made concierge internal medicine and family medicine more attractive than less. Having your physician available to discuss prevention, vaccines, testing methods and locations and treatments, if infected, is much easier in these membership practices than in a traditional practice where your phone calls are routed through an automated attendant phone system, reviewed by a non-physician provider and handled usually by a nurse practitioner or physician assistant with only the most serious and complicated situations reaching the physician’s desk.

I predict that more and more patients will seek concierge care in the next few years because patients are getting tired of fighting the bureaucracy and struggling to get the attention of their health care providers when they think they need it.  But don’t blame the providers.  It’s the dysfunctional, inefficient and profit driven corporate system that has created this situation.

The COVID-19 Vaccine Is Becoming More Available. Exercise Patience.

COVID-19 vaccine preparations are arriving in South Florida with several hospital systems opening appointments for men and women 65 and older to receive their first injection. Some will receive the Pfizer product, others the Moderna product. If you wish to travel to Dade County go to https://jacksonhealth.org/keeping-you-safe/  and sign up for the vaccine. They are taking appointments.  West Boca Medical Center and Boca Regional Hospital have opened appointments for non-employed medical staff members and their office staffs to receive vaccine with the hint that the week of January 11, 2021 they will start vaccinating community members.  

There is a sense of urgency and panic in the community about not having access to the vaccines. That is unnecessary and raising the stress level inappropriately.

After you receive your first vaccine dose you will still need to avoid crowds, social distance, wear masks and practice impeccable hand washing hygiene because you will not be immune. Twenty-one to 28 days later you will receive your booster shot and it will take about two weeks before we can detect antibodies to COVID-19 if you develop immunity.  You will have peace of mind, but won’t know if the vaccine prevents individuals from catching COVID-19 when exposed completely?  Will they get COVID-19  and have a very mild case because of the vaccine prevention?  Will these people be contagious to others? We do not know the answers to these questions yet.

If you get the vaccine, develop immunity and are exposed to someone with COVID-19, will you possibly transmit the virus to others without you yourself becoming ill?  No one knows the answer to that question yet either.  If everything goes perfectly well, and you develop a protective shield of immunity like a comic book superhero shield or cape, how long will that last?  Nobody knows that answer either.

The point is the vaccine is coming.  Once vaccinated we will still have to behave the same as before until the answers to these questions are known!  Please be patient.

A Perfect Storm Brewing: Flu Season Plus A COVID-19 Resurgence

I was asked by a colleague what I thought influenza seasonal infections coupled with a predicted second wave of COVID-19 would look like locally? Influenza A arrives locally around Thanksgiving and peaks the last two weeks in January and first two weeks in February. I suspect it is fueled by seasonal visitors coming to Florida bringing the disease from their home locales. We see a low level of influenza B year- round in our pediatric population.

A full-page ad appeared in all Florida newspapers today sponsored by every major health system in the state including Baptist, Tenet, HCA, Cleveland Clinic, Broward Health, Jackson, U M Health, Memorial Health and others. It stressed wearing masks, social distancing and frequent hand washing.

If you get sick with mild symptoms, they encourage remote telehealth care. If you have moderate symptoms, they suggest going to their urgent care facilities. For severe symptoms call 911 or go to the ER. At no time did they suggest calling one of their employed physician offices or visiting your private doctor which is all consistent with CDC recommendations. Private independent and employed physicians just don’t have the ventilation systems, sanitizing systems, personal protective equipment or trained staff to see potential COVID patients in their offices. If a patient is positive, or a staff member converts, what is their responsibility to the next patient or to the other tenants of their building? Is a 14-day quarantine in order?

Much depends on unknown factors. How effective will this year’s flu shot be? In my area, the chain pharmacies already received their supply of influenza vaccine and have shamelessly been pushing it on customers since July. Scientific research shows that in senior citizens the flu shot immunity begins to subside 90 days after you receive the shot. Given that, if your pharmacy tech gives you the flu shot in September, then how much immunity will you have by the time the flu arrives around Thanksgiving?

Quick, accurate and inexpensive testing availability for flu and COVID 19 is an important factor as well. We have had a quick influenza test for years requiring a nasopharyngeal swab. A similar test for COVID -19 has just been released by Abbott Labs and received Emergency Utilization Authorization from the FDA. That means Abbot Labs researchers say it works and the FDA takes them at their word. This test, called “a game changer” by many, will be available in October.

When $15 per hour medical assistants start performing the test rapidly, in volume, I hope the accuracy results are similar to Abbots claims. Our health and lives depend on that. At the same time a finger stick blood drop test is heading to market to quickly detect flu and COVID -19 on the same test card. Finnish scientists and Israeli researchers have quick breathalyzer tests coming soon as well. I hope they work and get here soon. I will test everyone at the door as will restaurants, theaters, sports arenas and most businesses.

All of this information really skirts the issue. With no treatment and vaccines available yet, I expect this flu COVID-19 season to be a human health disaster. With no national plan in place and no close coordination with state and local elected and public health officials, I see the fall and winter as a time of continued disease surges and deaths while the political influence on disease treatment supersedes scientific research and public health realities. Without a coordinated program of PPE and medication distribution, coordination of testing availability and results with contact tracing and specific shutdowns of hot spots without challenges related to loss of freedoms the outlook is grim.

Protecting senior facilities without a coordinated program and funding for it will not work for residents or employees. Opening schools and day care without similar precautions, training and funding for materials and tracing will lead to hotspots as well. There are members of the student population such as special needs children who need to return too, in person, learning safely and creatively. Others need to learn remotely or be given a chance to catch up later when safe return to in person learning is possible.

Without a plan to assist renters, homeowners, landlords, small business owners, farmers, restaurateurs, etc.; any shutdown for disease will be met with overwhelming resistance. I see a bleak and dangerous health picture developing in the fall/winter creating a perfect influenza/COVID storm.  I hope I am wrong but, if right, the disease surge will overwhelm ERs and hospitals.

Dogs, Cats and Coronavirus

There has been conflicting information on whether our pets can contract and pass on COVID-19 to other pets and humans. Initially, a report out of Wuhan, China noted that a dog tested positive for COVID-19 infection. Additional evaluation of that animal proved the test result was a false positive and the animal was neither ill nor contagious.

Several articles have appeared in newspapers and on TV news shows encouraging individuals to cuddle with their pets for anxiety and stress reduction. Then came the report out of New York City that one of the big cats at the Central Park Zoo tested positive for Coronavirus and was ill. Shortly thereafter, several more of the big cats tested positive.

This week an article was published in the peer reviewed journal called Science. Zhigao Bu, PhD, of Harbin University Veterinary Research Institute of the Chinese Academy of Agricultural Sciences in Harbin , China looked at whether animals could pass the virus through respiratory transmission. The purpose of the study was not initially to determine whether the virus could travel from pets to humans. The real purpose was to find an animal model that they could test new vaccines against COVID-19 on and test medication regimens.

They first looked at ferrets and found that while the virus could replicate in the upper respiratory tract of the animals for three to eight days, it did not make them sick and they were not contagious. They next turned to young cats. They inoculated their nasal passages with the virus and placed these infected kittens next to healthy kittens. They found that the virus was transmitted to the healthy non-inoculated cat with the animals developing the respiratory disease. Necrotic lesions were found in the respiratory tract of these test animals and they were found to transmit the virus by an airborne route.

They next tried the experiment on young beagles. While the virus was detected in the blood of the dogs inoculated with the virus, none of the healthy dogs exposed to them contracted the virus. The inoculated dogs developed antibodies against the disease but none of the beagles became ill. The dogs were felt to be non-contagious. Similar experiments showed that pigs, chickens and ducks did not contract the virus nor were they contagious to their species or humans when inoculated with the virus.

From their research it is probably true that dogs will not contract the disease and transmit it to other dogs or humans. It appears that felines however are susceptible to COVID-19 and may be a reservoir for the disease or a vector of transmission.

Passover and the COVID-19 Pandemic

Passover has never been one of my favorite holidays. As a child with nuclear families still within walking distance the work of changing dishes and silver ware, disposing of the chametz and cooking for 15 or more people made the event not very likeable. The seder’s were long while being conducted in a foreign language (Hebrew).  Even the attraction of having thick sweet red wine as a minor and getting a cash reward for finding the hidden matzo, were not enough to overcome the long tiring nature of the meal and storytelling.

It’s now 2020 and the world is suffering through a plague of its own. The numbers of sick and dying are simply numbing and force you to slow down and remember that each statistic represents a human being. This is someone’s loved one.

With that said my family is following the guidelines of staying home and social distancing. That will mean my grandson, who lives 60 minutes away with my daughter and wonderful son in law, will be having their holiday dinner in their home. They have been distancing for over three weeks now with no trips into the community except to walk the dog and to see her obstetrician.

My daughter lives in the zip code with the most cases in South Florida and she comments constantly that her young affluent neighbors fail to obey most of the restrictions and guidelines announced by the Governor and the Florida Department of Public Health and the CDC. Her sisters in Venice, California and Berkeley Heights, New Jersey will do the same. They are social distancing, staying home sharing their seders’ via Zoom. They will have company with their cousins in Boston, one working in a hospital with the Harvard School of Public Health and Washington, DC at Washington’s Children’s’ Hospital. Their parents from Naperville, Illinois will be in on the computer seder as well. We have no idea how this will turn out but, unlike usual years where I lead the seder service or split it with Uncle Alan, this one will involve assigned roles per Aunt Meryl.

The traditional food will be different as well. The days of me coming home from school and running to my maternal grandmothers’ apartment to see the white fish swimming in her bathtub prior to her making her own gefilte fish are long gone. In recent years, it has been finding the correct Jewish deli that makes its own fresh gefilte fish and chopped liver but even that is on hold due to the coronavirus outbreak.

If there is fish it will come from a jar. Without the chicken to make chicken soup our matzo ball soup will come from a can as well. The matzo will be real. The concord grape Manischewitz wine will be real. The Passover Farfel or a potato nick will be real and there are no dry Passover dessert cakes or macaroons. This year my daughter’ s birthday fell prior to the holiday so we are all spared her complaints that the holiday prevented her from having a “real” birthday cake.

This is not the year for community or restaurant or country club seders. This is the year to stay home, be thankful for your loved one’s health and look forward to better healthier times.