Direct Primary Care vs. Insurance Lobby: Score One for Free Market Medicine

On July 2, 2015, Governor Jeremiah “Jay” Nixon signed Missouri House Bill 769 “relating to direct health care services” into law (PDF).

MO HB 769 makes Missouri the twelfth state in the Union to enact such a law recognizing the legitimacy of direct-pay medical practices and defending the model against regulation by the state department of insurance.

The most outspoken opponent of this bill was the insurance lobby. Now, why would that be? The direct health care services model is ideal for those who are uninsured—those who either can’t afford insurance, feel they don’t need it or for those with high deductible health insurance coverage, which is designed to help with burdensome, bankruptcy-causing medical bills. It stands to reason that insurance companies don’t make much, if any, money on these folks. And, if those who are fully insured choose to utilize a direct pay practice for their primary care, it is out of the insured’s own pocket, not at cost to the insurance companies. So, how could this be of any potential concern or harm to the Insurers?

Since there is now a national “law” that states all must have health insurance, one might wonder why an enterprise such as a cash-pay model of primary care is necessary, or at the very least important enough to warrant a state law. How can there be any uninsured patients? If you don’t have insurance, aren’t you now breaking the “law”?

Let’s use an example of a healthy 30-year-old woman. She is single and makes three times the poverty level. She received an exemption this year, because she doesn’t make enough to afford any policies on the exchange. Yet, she also can’t afford any high deductible insurance. So she just hopes life doesn’t deal her a bad hand. Is she a law-breaker? If so, this criminal element is perfect for a direct pay model of medical care. She needs “maintenance” to make sure she doesn’t break down alongside the road, and to keep an eye on anything that might run in her family. Is it reasonable to require her to pay for a product or service solely to compensate for those who receive the subsidies and get the bargains? So much for being affordable for all.

What about the “underinsured? The underinsured are those who have a high-deductible health insurance plan. Some deductibles may be affordable for one, but not for another. Most of these plans pay for very little until the deductible is met for the year. These consumers must pay for primary care and medications out of pocket. The model of direct-pay primary care provides affordable office visits, labs and even some medications for patients. It takes up the slack so the uninsured and underinsured do not have to wait until a problem becomes urgent or emergent, which will inevitably cost more than the original preventative measure or early detection.

So back to the question: why would the insurance lobby be opposed to this bill? Their overwhelming presence was felt at the committee hearings in both the state House and Senate. I believe the answer is a concern for public understanding. The American people have been fed a great lie. Insurance is insurance and nothing more. Insurance cannot get to know you. It cannot hold your hand or give you a hug. It cannot know that because of your anxiety a different type of inhaler would help you more than another. It cannot know that your living situation may preclude therapy effectiveness. It cannot guarantee you a same day office visit. It cannot promise, “If you like your doctor, you can keep your doctor.” Or if you like your nurse, or if you like your receptionist, or if you like your clinic, you can keep any of them. It cannot place sutures in a laceration. It cannot stop bleeding. In other words, it is insurance, but it is NOT care and it is NOT access. You can have the best insurance plan on the planet, but if no one bills it, of what worth is it? If the public were aware of this, that the mandate to have an insurance plan to cover “healthcare” will not make you healthier, or more wealthy or happier, We The People might consider taking a closer look at a the national “law.” We might then find some problems in the “law.” We might start looking back at who supported it and how they benefitted from its passage. We might also find at whose expense the entire system has been shifted.


Summer Sun & Fun: Don’t Forget the ‘Lytes

My husband is a stubborn man. Handsome and smart, but stubborn.

My husband is also a rancher. He works outside from nearly sun up to sun down. He fixes fence, works on equipment, works a fair number of goats and cattle, puts up hay, mows, string-trims—he has even been known to pick blackberries. The last several summers he has experienced episodes where he “just doesn’t feel good.” He will be cold in the air-conditioned house, shiver, have muscle spasms and complain of a headache. Last summer it was particularly bad.

“I drank a bunch of water,” he would tell me.

“When was the last time you urinated?” I asked. Blank look. “How about electrolytes?” I sighed, “Men!”

Each time you suffer from heat-related illness, it gets progressively worse. My husband KNOWS he needs to replace his electrolytes, drink BEFORE he gets thirsty and has to keep an eye on his urine. But, he gets too busy to really think about it. Time goes by quickly, he’s sweating buckets and is dehydrated and sick before he realizes it.

Don’t be like my husband! If you are going to be working or playing outside, make sure you really DO have both water and something with electrolytes. I love Gatorade. Do you know why? Gatorade was created by a brilliant physician especially for heat-related strenuous activity, like football practice. I love the Gatorade story.

Yes, there are other options to Gatorade, and you may use those as well. Just be sure you have plenty of both water and an electrolyte replacement with you—and be sure to utilize them. Avoid alcohol. It makes the dehydration worse, and replaces the oxygen in your blood stream with something that your organs can’t readily use like they can oxygen. If you are going to drink alcohol, be sure to drink an equal amount of water (i.e.: 12 oz. of beer = 12 oz. of water = repeat). Caffeine, while a mild diuretic (it makes you pee) is not necessarily dehydrating; but, it doesn’t really help either. Avoid soda—do you really want to risk making kidney stones in this situation? Of course you don’t!

Protect yourself from the sun. Yes, you need vitamin D. However, the damage to your skin today can send you to my office years down the road with some nasty skin cancers. Clothing helps some but doesn’t fully protect you. Some clothing comes with Sun Protection Factor (SPF). Light colored clothing helps to reflect the sun; dark colored clothing absorbs the heat from the sun. As far as sun block is concerned, you want either zinc oxide or titanium dioxide present in your sun block. You want protection from both UV-A and UV-B rays, and you want a high enough SPF that you don’t have to be applying it every 15 minutes.

It doesn’t take long to burn without protection. So apply sunscreen and reapply often—even if it says it is waterproof.

Don’t forget to protect your eyes. Apparently damage from sun exposure is accumulative. That is, even small amounts over the years add up, just like the radiation damage from X-rays. This can increase your risk for cataracts or macular degeneration. Per the American Optometric Association, sunglasses should block 99-100% of UV-A and UV-B and screen out 70-90% of light

Don’t forget certain medications can increase your sensitivity to light. Family physicians, like myself, are notorious for prescribing medications and forgetting to tell you that you’ll be more sensitive to the sun with the medication. The list is hefty—everything from some antibiotics to high blood pressure medications to meds for rheumatoid arthritis, diabetes, depression, even Benadryl is on the list. I suggest that you simply assume your medication will cause sun sensitivity, and be sure to protect yourself more than usual. If you generally wear only SPF 15, upgrade to SPF 30 or 45; and, make sure the sunblock contains either zinc oxide, titanium dioxide or both.

Fans may feel good, but they really aren’t much help. If you have an elderly neighbor without air conditioning, a fan is a nice thought but to really provide help, I like the misters that gently cool you down with water. Cool baths, showers, even cool compresses will do a better job to keep the body temperature down.

Know the signs/symptoms of heat exhaustion and heat stroke. Heat cramps may be the first symptom of dehydration, and they will generally be in the major muscles of the body (thigh, leg, abdomen, back, arms). The cramps will generally not occur until after the activity. If you then progress to lightheadedness, sweating, nausea/vomiting, weakness and headache, you’re experiencing heat exhaustion. To prevent this from progressing to heat stroke, the activity must be stopped. The person must be rehydrated and needs to be cooled. Progression to heat stroke (hyperthermia) will manifest with confusion, disorientation, cessation of sweating and coma. This is dangerous and needs to be treated as a medical emergency as it can lead to death. The very young, the very old and animals are most at risk. Don’t be a jerk and think that a little exposure to the hot car won’t hurt.

I’m even a little worried about my turkey hen. She’s a heritage Black Turkey. The other night, she was standing and panting in the shade on the east side of the porch. Panting is not a normal turkey activity. She was fluffed out, holding her wings and feathers away from her body. I should have hosed her down. She wouldn’t have enjoyed it, but it may have been what she needed to cool her.

While we have the capability in our office to run IV fluids, I sure hope we don’t need to do that for any of you this summer. It’s pretty darn hot out there. Don’t make me say I told you so.