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.

Why Have Guidelines, Rules & Regulations If No One Adheres to Them & There are NO Consequences?

I live and practice internal medicine and geriatrics in South Florida. We have a substantial elderly population living both independently and in senior facilities. The Sars2 Coronavirus Pandemic has been devastating to this patient population. There are many who became ill and passed away under the loneliest circumstances of in-hospital isolation. There are those who became ill and recovered but have lingering long-term effects. There are those who have avoided infection but are just beaten down by the daily monotony of staying safe, avoiding crowded public places and subsequently forsaking the company of friends and family.

The vaccine rollout in Florida was Helter Skelter and disorganized. It was every man and woman for themselves trying to obtain an appointment to be vaccinated. For the most, part the senior community managed to get the shots.

We were all grateful and buoyed as the summer of 2021 began by the news that we could venture out without masks and start resuming our pre-pandemic lives. The Delta variant and the recent surge in infectious cases, hospitalizations and now mortality put a quick and moribund end to that for most. The disparity between the message coming out of Washington and the CDC and the message delivered by our Governor and State Legislature has made decision making for individuals far more difficult than it should be. The latest conundrum is about the need for booster COVID vaccines or not.

The State of Israel, which exclusively used the Pfizer Vaccine, announced a third shot for those over 50 beginning a few weeks ago. Germany announced it would start such a program in September.

The CDC hinted at a booster program but until a NY Times article appeared on the evening of August 16th there was no official news on the subject beyond the recommendation that immunosuppressed individuals, especially organ transplant patients and cancer patients, under therapy get a third shot. Days before this announcement my patients had begun calling me, texting me, emailing me to tell me that their friends had walked into a Walgreens Pharmacy or Publix Pharmacy, showed them their Medicare ID card and their vaccine card and had been administered a third COVID vaccine shot with no questions asked. This was substantiated by multiple other patients including one couple spending the summer in the mountains of North Carolina.

Is there one set of rules for large chain pharmacies and another set for the rest of the world? What is the point of data and evidence-based recommendations if anyone can just do what they want when they want to?

At this point I will wait to hear the CDC’s recommendations on when to take a third shot and the data they used to explain why. I am thrilled that Pfizer has shown that a third shot is safe with few adverse effects. I am also buoyed by a research paper that showed that those groups who spaced their second shot at longer than the three- or four-week recommendations had a more robust immunologic response.

When my friends call me and ask me to join them on a trip to Publix or Walgreens to get the third shot now, I will hear my late mother’s voice in my brain asking that irritating question, “If all your friends decided to jump off the Empire State Building would you jump too?”

Easing the COVID-19 Restrictions

I read an article written by an infectious disease physician in the state of Georgia. She was quite critical of her Governor Kemp opening the society prior to the state of Georgia meeting the very minimal guidelines for reopening the economy set down by the Trump Administration.  She believes it is a mistake and will be followed in 14-21 days by an increased rate of infection and death.  I next read an article on the CNN website about the reopening of Wuhan, China for business.  Wuhan is a big industrial manufacturing and commerce center of 11 million people who were ground zero for this pandemic.  Businesses are staying closed. Restaurants that could open for takeout are closing because consumers are still afraid and staying home. They fear a second wave of infection and death.

I say this as an introduction to my trip south down to Palmetto Bay, Florida south of Miami in Dade County.  It is a residential community of single-family homes in a reasonably well-to-do and well -educated diverse community.

My daughter and son-in-law moved into that community this past summer. We have not seen them face to face in over six weeks of our self-isolation and stay at home sequestering and miss our 2-year-old grandson desperately.  We had a ton of supplies at our home for them that just never made it south due to the disruption of the pandemic.

My daughter is pregnant and isolated because she too is considered “high risk.”   The trip reminded me of the sci-fi apocalypse series Mad Max Road Warrior. Traffic was light on the Florida Turnpike as I creeped along doing 75 miles per hour in the right-hand lane with SUVs roaring past me at 120+ mph. At certain times, I would see an auto in the left lane doing 80+ mph with the middle and right lanes empty and a faster driver would pull up behind them and tailgate them for miles. It was unclear why they just did not change lanes and safely whiz on by.

When I exited the turnpike for the Palmetto Expressway west the amount of traffic was incredible.  We dodged speeders and creepers and made it to the end on US-1.  The streets south were jammed. As we turned off onto 152nd Avenue, we noticed the young homeowners of Palmetto Bay were all out in their driveways and streets with their children, no masks on and weren’t the social distancing guidelines recommended by Public Health Officials.

Three homes north of my daughter’s home a pool party was in progress with multiple vehicles in the driveway and people of all ages attending.   We dropped off the supplies in my daughter’s driveway, talked for 20 minutes through their impact windows and then headed home.

When I turned into my community and passed our children’s playground, still closed per executive order of the County and Governor, a high school graduation party was in progress.  Multiple vehicles from outside our non-gated community were parked at the park entrance and a large crowd of diverse ages was congregating and celebrating at distances far less than the suggested six feet.

While I am not a registered fortune teller, I do not need a crystal ball or Tarot cards to predict that 14-21 days from now there will be an increase in COVID-19 cases and deaths in Dade, Broward and Palm Beach Counties due to the reopening of the society.  No one seems to care about how highly transmittable this pathogen is and its devastating effects on the older population.

We are approaching off season in Florida. Traditionally the snowbirds or seasonal visitors go home, and the economy is supported by year-round residents most of whom are older Americans. Each newly infected Coronavirus victim, with or without symptoms, will transmit the disease to an average of 5.7 individuals before they know they are ill.

With the rush to open the economy in Florida championed by the Governor, following the President’s lead, if the over 60 crowd is sick or dead, who will financially support the economy this coming off season?