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.

COVID-19 Vaccine Availability

Update January 4, 2021

Last week the Florida Department of Health discussed providing the Moderna vaccine to our office for staff members who wished to receive the vaccine. Our office manager, Judi Stanich, requested enough vaccine to cover the entire practice. We were told we would have a confirmation this morning.

This morning we learned the vaccine isn’t available yet. The vaccine comes in vials of 10 shots. The vials are kept frozen and can remain active in that state or in a refrigerator for 30 days. Once a vaccine vial is opened the entire vial must be used in under six hours or it degrades.

Moderna and the Florida Department of Health require patients to complete legal release forms for the vaccine. They must then be registered into the Florida Shots data bank and a national data bank. That is one of the reasons patients are asked to bring their driver’s license with them.

If you have had a severe allergic reaction to any medication the Pfizer and Moderna mRNA vaccines may not be best for you. If you have ever had to use an Epi Pen or have been treated for anaphylaxis these shots are not for you. The Astra Zeneca Oxford vaccine and the Johnson and Johnson vaccine are thought to be more suitable for those individuals

After receiving your shot, you will need to be observed by medical staff for 15 minutes to look for adverse reactions. You will be given an instructional sheet on how to register with V-SAFE which is a CDC vaccine monitoring app. Every day, at about 2:00 p.m., you will receive a text message with questions about how you feel related to the vaccine.

Medical malpractice insurance companies have not yet formally announced whether physician insurance policies will cover administration of this vaccine in their offices because none have been FDA approved. The Pfizer and Moderna vaccines have received FDA Emergency Utilization Authorization (EUA) which is not the same as approval.

Currently the only avenue to obtaining the vaccine in Palm Beach County is to try and get through on the 561.625.5180 phone number or leave your demographics on an email at CHD50Feedback@Flhealth.gov. Baptist Health System is planning on opening reservations for seniors 65 years of age and older the week of January 11 working with Boca Regional Hospital, Bethesda Hospital and the FAU Schools of Medicine, Nursing and their EMT program. They have not announced how to make a reservation or if they will be using the data from the Palm Beach County Department of Health through the phone number and email address provided above.

I suspect that by the middle of February there will be plenty of vaccine available locally including the Astra Zeneca Oxford product and the Johnson and Johnson products. In the meantime, remain patient and continue to avoid crowds and continue to social distance, wear suitable face masks and keep up the hand hygiene. Please remember that after you complete your vaccinations (two shots for the Pfizer and Moderna Products) we will not know how much immunity the shots will provide and for how long.

We additionally do not know if successfully vaccinated individuals are completely immune or partially immune if they are exposed to the virus. Furthermore, we don’t yet know if you are vaccinated whether you can carry the virus and transmit it to someone else even if you don’t have any symptoms.

Getting the vaccine will not be a reason to resume activities at crowded gyms, crowded bars or go on that cruise ship just yet. The hope is that by the summer 2021 we will have the answers to the many unknowns.

Keep Your Guard Up As The New Year Approaches

As we head into the last work week of the horrendous year 2020, my advice to my patient population is keep your guard up. Most of you have social distanced, worn masks, washed your hands until they are raw and avoided close contact in a social setting with friends and relatives to avoid contracting or transmitting the coronavirus to others.

I have been receiving phone calls for the last several weeks now from patients who have younger family traveling to Florida by commercial airlines or driving by car for the holidays and they ask me about how to stay safe. I applaud them for their common sense and decency after months in virtual isolation and advise them to continue their social distancing, hand hygiene and wearing masks.

If your family members do not have 14 days to self-quarantine from you upon their arrival, and prior to their visit, then there is a risk of contracting the disease from an unknowing asymptomatic carrier. Make sure the visit is outside in a well-ventilated area with at least 10 feet between individuals and you are all wearing up to date functioning face masks. If a meal is involved, make sure not to serve buffet style and don’t share food from each other’s plates.

If your visitors are feeling well and have no symptoms of illness and wish to try the short seven-day quarantine with testing for COVID, I suggest the standard nasopharyngeal or saliva PCR tests sent to a lab because they are more accurate in this situation than the quick tests. The test sites at FAU (they take walk-ins but are closed on Mondays) or the Town Center Parking Lot test site are professional.

In a few weeks, the Ellume home test kit should start to appear in pharmacies and its results even in asymptomatic individuals is remarkably accurate and quick. That test is a game changer.

Many of us have stayed out of restaurants and bars, avoided theaters and shows, postponed travel and worn masks now since late February. The vaccines are beginning to appear in the area and there will be an opportunity over the next few weeks to receive it. I will provide more details when they are made available to me.

Happy New Year to you all. May 2021 be sweet – filled with joy and health.  But please, until we have you vaccinated, stay strong and keep your guard up!

A Light at the End of the Tunnel?

My cellphone emitted the shrill sound of the Emergency Broadcast System Saturday evening.  It repeatedly said, “This is an Emergency Message from the Baptist Health System. Please check your email immediately for an emergency message about COVID-19. Please press 1 to confirm receipt of this message.”  Since I was watching my favorite college football team on TV, and they were not doing well, I was in a particularly sour mood, so I ignored the message and sat down and watched the TV.

Almost immediately my home phone rang and when I picked it up, I heard the exact same message.  This time I pressed one and then ran to my iPad and went to my professional email address. There was a message from the Director of Baptist Health Systems and the Chief Medical Officer saying that they had the Pfizer COVID-19 vaccine and they wanted to vaccinate me. I am apparently in Group IA. They explained that the decision to vaccinate was voluntary but if I was interested I should “click here.”  

 I followed the directions and was directed to a calendar with times in fifteen-minute slots.  I selected a day and time that allowed me to drive down to Baptist Hospital on Kendall Drive in Dade County and I received a prompt reply that confirmed my date and time to receive the vaccine.  I was so amazed and surprised by the mechanism of delivering this information that I was sure it was a joke or a scam.  I have two neighbors down the block who are physicians and nurses at Baptist Boca Raton Regional Hospital, so I called them. They had received the same message.

The fact that in this dysfunctional state, run by a government that has maximized the interests of the tourism and business community while minimizing the dangers of the pandemic, could be delivering vaccine to health care workers astounded me.

My team lost the game I was watching Saturday night turning what should have been sheer joy into a mixed bag. Sunday was a glorious day – sunny, warm but not muggy. The local Fire Department sent around Santa Claus on a fire truck with Santa’s elves and helpers.

I walked around the community in complete disbelief watching young families and their children and older family members and friends all closely gathered without masks or social distancing having lawn Christmas parties in advance of Santa arriving.   It was as if there was no pandemic and no warning of the main mechanism of COVID-19 transmission being at family and informal at home gatherings. 

Santa arrived later that day and stayed on his fire truck smiling and waving from a distance while his elves handed out candy canes from a very safe distance from the lawn revelers.  I kept thinking and wondering if Santa would place these apparently carefree individuals on his annual “naughty” or “nice list”?

The vaccine will be a start towards providing some protection against the Sars2- COVID-19 virus. We do not know if it will completely prevent the disease or just modify its complexity and severity.

We do not know:

  1. How long the immune response antibodies to the shot will last and protect the recipient?  
  2. If the recipients can still pick up the virus and transmit it to those without antibodies?
  3. Which of the seven shots in development, and expected to be available by March 2021, are best for adults, seniors, adolescents, children, toddlers and pregnant women? 

We will still have to wear masks, maintain social distance and practice scrupulous handwashing hygiene until we have the answers.  There is, however, a vaccine being administered which is the first light at the end of the tunnel in a painful pandemic plagued year.

Are My Symptoms Due to COVID-19 or the Vaccine?

The Pfizer COVID-19 mRNA vaccine received Emergency Utilization Authorization by the FDA and CDC last week and is being administered to health care workers and seniors in senior facilities as I write. The process began overseas in the United Kingdom last week.

Many of the recipients of the first of two vaccinations are experiencing symptoms as their immune system reacts to the vaccine and hopefully builds antibodies and immunity. They are experiencing fever, fatigue, headaches, chills, myalgias and arthralgias.  Many of these symptoms are identical to the symptom’s individuals infected with COVID-19 experience yet these healthcare workers are expected to take some Tylenol or aspirin and head back to work caring for patients.  How exactly are they expected to distinguish between being infected with “the Rona” virus or just experiencing mild side effects of the vaccine?    

David Kuhar, MD, of the CDC’s COVID-19 Response Healthcare Infection Control Team suggests health care workers need to use their clinical judgement.  They need to assess whether they believe they were exposed to the virus in the previous 14 days?  He emphasized that in clinical trials, these adverse symptoms resolved within 3 days of vaccination and 2 days of the onset of symptoms. If the symptoms last any longer, he believes the healthcare workers need to be evaluated for a COVID-19 infection.  He stressed that the vaccination will not produce a positive COVID-19 antigen test response. It additionally should not produce shortness of breath and loss of taste and smell sensations. 

If you experience those symptoms or have your symptoms for more than two days, then you need to go to a COVID-19 test site and be tested.  The CDC has set up a communication system for those vaccinated called V-safe.  It is an app for your smartphone or tablet that allows you to communicate your symptoms and concerns with the CDC after you receive the vaccine.  When you are vaccinated at a test site, you are provided the information you need to register and participate in this V-safe monitoring program.  The information gathered on this smartphone app will allow the CDC to continue to monitor the safety of the vaccines being administered.

Will I Be Able to Choose My COVID-19 Vaccine?

There are currently four vaccines to prevent COVID-19 in the pipeline. I have been asked numerous times when am I going to have the vaccine in my office and which vaccine should individuals take? This question was addressed by MedPage Today, an online health care periodical on 11/27/2020. The same question was asked of National Institute of Health “chief” Francis Collins, MD, PhD last week at a press briefing. Dr Collins responded there will not be enough vaccine available in December for the whole country and “people who get offered one should feel quite happy about that.” Leana Wen, MD, of George Washington University responded to the same question saying, “Initially there won’t be nearly enough vaccines for hundreds of millions of Americans. We will probably take whatever we are able to get access to.”

If you are a healthcare worker, or in the more vulnerable groups, you are most likely to be offered one of the nRNA vaccines from Pfizer/BioNtech or Moderna because they are further along in completing the FDA required trials and application process for approval. Younger healthier individuals having less priority may get to choose.

Larry Corey, MD, a viral expert at Fred Hutchinson Cancer Institute in Seattle and a leader of the COVID-19 Prevention Network Vaccine Program broke down the numbers at a November 18, 2020 meeting of the American Public Health Association and National Academy of Medicine:

  1. The US Government has contracts for 100 million doses of the Pfizer/BioNTech and Moderna vaccines with production producing the 200 million doses by the spring of 2021. That should cover the highest risk groups including healthcare personnel, nursing home residents, essential workers and the medically vulnerable per the CDC Advisory Committee on Immunization Practices (ACIP) guidelines. The vaccine will be shipped to 50 states, the District of Columbia, 8 territories and five large urban health departments including NYC and Chicago. Who receives it first, and where they receive, it will be decided by the local jurisdictions. This process should take until the end of March 2021 leaving some 200 million Americans waiting for a vaccine. Dr. Corey was clear that “We need other vaccines for the rest of the population.”
  2. In addition to the Moderna and Pfizer/BioNTech mRNA vaccines, there are products from Oxford/AstraZeneca, Janssen/Johnson &Johnson, Merck, Sanofli/Glaxo SmithKline and Novavax. Jay Butler, MD, deputy director for infectious disease at the CDC expects there to be mass vaccinations run by public health agencies and possibly some vaccination programs at community pharmacies. No mention was made of supplying physician offices or clinics.
  3. If there are no major delays, seven different vaccines should be available by the spring of 2021. Naor Bar-Zeev, PhD, of the International Vaccine Access Center at Johns Hopkins University in Baltimore said it is too soon to compare the products because there are no studies comparing them head-to-head. He reminded us that different vaccines might be better suited for different patient populations with pediatric patients, the elderly, the immunocompromised likely to do better with some and not others.

Despite the lack of detail to date, Moncef Slaoui, MD, head of the federal Operation Warp Speed, told CNN that he expects 70% of the US population to be vaccinated by May 2021.

No “Ouch” Band Aids in Our Future

Last week, at the direction of my physician, I had my blood drawn by my staff to monitor some chronic medication issues. My medical assistant, per usual, placed a band aid over the puncture site before I could object.

I went to work and forgot about it. Nine hours later getting into the shower I saw it and painfully yanked it off and with some of my hair. The next morning, that area looked like it had been punched by Mohammed Ali in his prime.

Ironically, I just read a review from an Israeli magazine of a gel or spray-on transparent polymer bandage. It hardens after application and dissolves with an ice pack or cold water. It stays firm and flexible in warm water so you can shower or bathe with it on. You can examine the healing wound through the transparent bandage.

The development of this new bandage took five years and was the idea of Professor Daniel Cohn, an expert on polymers. With a private investor, they started Inteligels and are in the final stages of receiving FDA and European Union approval. The plan is to first market it for chronic conditions to institutions to treat diabetic ulcers, pressure ulcers and conditions where the injury to the wound surrounding tissue causes skin disruption and pain.

A home bandage version is still several years off but is in the development stages. This is promising.

It’s Hard to Believe

I referred my patient to a surgical specialty office last week for a problem that was out of my area of expertise. The doctor’s office is in a building run and managed by our local hospital.

Upon arrival at the office the patient wore an N95 respirator mask, face shield and gloves to protect himself and others from COVID-19. The multilevel parking lot is a short walk to the office from the garage.

The office door to the suite was open and the staff, sitting in a large open reception area, either had no facial covering or a mask around the neck not covering the mouth or nose. It is a multi-physician office, all in the same specialty, so there were several other patients randomly seated in the waiting room.

When the patient approached the desk to sign in the receptionist recognized him by name and said he did not have to sign in with the logbook. The patient asked the receptionist to please cover her face with her mask citing the Palm Beach County ordinance which mandated masks in indoor facilities. She said, “We believe this COVID-19 pandemic is overblown and its really not necessary at this distance.” When he asked to speak to the office supervisor, he was told the same thing.

The physician came into the waiting room to bring the patient back to an exam room wearing a N95 mask. She too said the response to COVID-19 was overblown. The physician practices an outpatient specialty that is highly reimbursed and does not require going to the hospital. I suspect her office sees no COVID-19 patients although in our area, with the high positivity rate, everyone is a potential contagious patient.

If health care providers do not buy into the science of wearing a mask during a pandemic to lessen the transmission of the coronavirus, what hope is there for getting the rest of the public to buy into the idea? We are getting a breather now. The number of patients presenting to ERs with respiratory symptoms are down. Hospital admissions for COVID-19 are down. ICU occupancy is down.

The onslaught of seasonal visitors will soon begin to arrive, bringing with them all the pathogens circulating through their home communities. With them come the tourists from Europe, Canada and Latin America. Our Governor is desperate to restore tourism and the economy.

These out-of-state visitors bring the flu and COVID-19 and; they want to go to the beaches, restaurants, bars, theaters and “party hearty” as vacationers should. With politicians politicizing COVID-19, and now physicians in the community feeling the same way, it looks like a long dark dangerous fall and winter season here in Florida.

Good News on Treatment & Prevention of COVID-19

A study in the New England Journal of Medicine (NEJM) examined the effects of a new vaccine which uses mRNA injections to stimulate an immune antibody response against the coronavirus. The published study looked at two potential dosages while looking at younger patients and those over 65 years old.

Both doses of the injection vaccine produced an antibody response in the younger patients and senior adults. Side effects were minimal – mostly injection site irritation and soreness. Some patients ran low grade fevers and had myalgias. The vaccine is now in a larger Phase 3 trial.

This vaccine and another mRNA product in testing and production both have the drawback of requiring storage at -40 to -80 centigrade which most pharmacies and physician facilities do not routinely provide. It is hoped this vaccine will be available by the end of year 2020. There have been no challenge tests with this vaccine, meaning vaccinated individuals who develop antibodies have not been directly exposed to the coronavirus to see if those levels of immunity are protective.

On the same day of the publication of the NEJM study on the mRNA vaccine, the pharmaceutical company Regeneron released a shareholder report on its Phase1 and 2 IV anti COVID-19 monoclonal antibody. They took antibodies from recovered COVID-19 patients, identified the most important ones and then synthetically created duplicates of two of the more important antibodies in a form that is infused by IV administration. This product blocks the P spike on the coronavirus from working, preventing the coronavirus from attaching to and entering human cells.

They enrolled COVID-19 infected patients with symptoms but not severe enough to require hospitalization. They found that those with a low viral load of the disease developed an immune response with IgG antibodies to COVID-19. Those who had few or no antibodies were overwhelmed by the virus and had high viral loads measured. They found that the Regeneron product worked best in those with a high viral load and few or absent antibodies to COVID-19 virus and more symptoms. These patients cleared the virus quicker with the monoclonal antibody product than non-medicated patients receiving standard care. They had alleviation of symptoms quicker and tolerated the infusion and product well.

In addition to this trial on non-hospitalized patients there is currently an ongoing trial in hospitalized patients in Phase 2 and 3.There is additionally a trial in family members of COVID-19 positive patients to see if the Regeneron monoclonal antibodies can prevent them from acquiring the virus in close household contact.

There is light at the end of the tunnel. We just need to continue to social distance, wear masks in public settings, hand wash frequently and remain patient because these products are very close to release.

Honey Reduces Upper Respiratory Symptoms

The British Medical Journal published a thorough review of the medical literature reviewing the beneficial effects of honey in reducing the intensity and severity of coughs in viral upper respiratory tract infections. The study was performed at Oxford University by Abuelgasm, Albury, Lee and associates. They reviewed fourteen published studies on the subject and then ran that data through their own stringent tests to assure the hypothesis was accurate. We are heading into the fall-winter cold and flu season with cold weather forcing individuals to remain indoors. We can add to this the ongoing Covid-19 respiratory pandemic as a source of coughing. For years now doctors, scientists and public health officials have tried to convince their colleagues and the public that antibiotics do not lessen the course or duration of a viral upper respiratory tract infection. There are dozens of over the counter non- prescription cough preparations sold in pharmacies and groceries. We read regularly about these products causing severe illness, deaths and adverse effects in children and the elderly. Honey solves these issues.

In an online review accompanying the article experts suggest mixing 1.5tablespoons of honey with 6-8 ounces of oolong tea. Let it cool down so it isn’t too hot and it is a great cough suppressant and source of hydration for children one to five years old. The darker the tea the more nutrient rich antioxidants the patient gets from the tea leaves along with caffeine. They suggest later in the day switching to a chamomile tea to avoid all that caffeine. Younger children will benefit from 2-3 servings per day providing hydration plus cough suppression. Adults and older kids can use two tablespoons of honey and consume a larger volume of warm fluids.