Blog

Looking Forward While Glancing Back

 

While I have been looking to 2016 and our business goals for next year, I have to reflect on the past three years. I started this business January 1, 2013, and we opened our doors March 1, 2013. We have impacted many lives since then, and it is hard to believe it has been three years already.

We have helped revolutionize family medicine. We have taken the concierge model and translated it to the middle class. We have offered true 24/7 coverage for our patients, managed everything from upper respiratory infections to congestive heart failure exacerbations over the phone, cared for patients as remote as the Dominican Republic, removed melanomas and squamous cell carcinomas and provided liver-saving phlebotomies for a patient with hemochromatosis.

We have email consultations, phone and Skype visits and regularly text our patients. We send flowers when our patients are in the hospital, and send a sympathy card when we hear of a loss in a family. When ice covers the streets or floodwaters cover our roads, making it impossible to make the drive to the office, we man the cell phone and send prescriptions electronically.  We make house calls to our patients who are unable to get out of their homes, and we provide these services to our members because they believe enough in our practice, in our business, to pay a membership fee.  We supported, testified for and helped pass House Bill 769—the Direct Primary Care bill, which was signed by the governor this summer. Our members realize and understand that they are the ones who keep the lights on, who maintain a nice office for them to come to and who pay the salaries of all of us who care for them.  It seems the most natural way to provide medical care—folks paying a fair price for all we can possibly provide for them.  Free market medicine works!

We have found that the constraints of having a single office are many; and to better care for our patients, we are looking to become more mobile. We think this would be particularly helpful for our small business owners who could use the presence of their physician at the work site, or for our patients who require a face-to-face visit but find transportation to the Lake difficult. This is why one of our goals for 2016 is to have a mobile unit, and we are considering having a scheduled circuit for physical visits. Most of our patients who have to travel an hour or more have been excited to learn that we want to provide this for them. We are not sure whether this is going to be a reality yet, but planning is ongoing.

If we become mobile, and if our membership numbers grow accordingly, we will need more help at the office in Osage Beach. If our membership continues to grow in 2016, we may possibly add a nurse practitioner to our ranks.

Our mission statement, which is displayed proudly over the reception window in our office, is as follows: to break down the barriers that currently exist in the patient-physician relationship, to restore mutual trust, and to provide excellent individualized primary health care.

My staff and I take that mission to heart, and use it as our measuring device in all that we do. The relationships we build need to be open but professional. The trust must be mutual, as I put my license, the entire business and the livelihoods of the staff on the line with every prescription I write and every bit of advice I provide. And, “excellent individualized” medical care is what I was trained to provide, which means that I do not treat statistics, or consider all patients to fall in the width of the bell curve, but embrace the uniqueness of each individual human being.

Our ultimate goals for the coming year are:

  • To break down those barriers that still exist between the patient and the physician
  • To restore mutual trust and provide excellent, individualized care for all our members
  • To provide these services for more and more patients throughout Missouri
  • To continue to think outside the box

Wishing you all that is good and helpful in 2016, and looking forward to serving you better!!

~Jenny Powell MD                                                                                                                                                                     Direct Primary Care Clinics LLC, Osage Beach MO

 

Giving Thanks

The purpose of Thanksgiving is to set aside a specific time to be thankful for the bounty of the harvest. While Thanksgiving, and the holiday season that follows, has evolved into many different things, this is a time of year we focus on giving thanks for our blessings. I am always thankful for my many blessings, but this year I am particularly thankful for my medical practice.

I am thankful for the opportunity to participate in free market medicine. I realize there are places throughout the world this would be impossible. True, free market medicine provides freedom of medical practice for physicians, but it also provides freedom of medical care for patients. It means my patients are not slaves to a system that dictates:

  • Who they may see as a provider
  • Where they must go for their medical care
  • What medical services are available
  • How much it will cost for their care

I am thankful for the opportunity to break down barriers thrown up by insurance companies, hospital systems and governmental agencies between individuals and their physicians.

Are you aware of the walls instituted by hospital systems?

“No, you cannot see your physician today at 2:00 pm.”

“No, you cannot have your physician’s email address or cell phone number.”

“No, you can’t see Dr. Smith; you are assigned to Dr. Jones.”

Your insurance company may dictate what hospital system you may use, what diagnoses they will cover, what testing they will pay for and what treatment—including which medications—they will support. They will tell you not only how much your co-pay will be, but also how much your premium will be; and then, may still tell you they will not cover a procedure or office visit. They may mislead you to believe they will pay for an office visit, but if you did not go through their proper “hoops,” will leave you with the entire bill. And on top of all of this, they will still increase your premiums year after year.

In the name of subsidies and so-called “insurance plans” provided by the government (federal or state), it is even worse. Medicaid may pay for a medication in July, but no longer cover it in August, even if they had been paying for it for a couple of years. They may send reports to your physician, making veiled threats that the physician should discontinue medication or change it to something else. To frustrate the physician into discontinuing the medication, they may require new “prior authorizations” on medications patients have been on for extended periods without any problems. Of course this will NEVER be a stated reasoning for the means, but it is a roundabout way of achieving the desired end result.

Quality assessment programs, sold to the public and the societies of physicians alike, are designed to control the practice of medicine, to standardize treatment and to force away any individualization of medical care. I am thankful for the free market medicine practice model, because my policy of “kill as few patients as possible” is my quality assessment program.  When it becomes impossible to force physicians into following guidelines instead of using their reasoning power, then the measuring tool for “quality” will become obsolete, and better outcomes (which are often actually the ABSENCE of problems) will become the only measure for true quality of care.

I am thankful for the art of medicine and for those giants upon whose shoulders I stand. I am thankful for patients who seem to understand that all of life is much of an unknown, and that we tread lightly on what we consider “conventional wisdom.” I am thankful for my mentors, for the words of wisdom and the lessons (what to do as well as what NOT to do) I learned second-hand.

I am also extremely thankful for the excellent education I received from kindergarten through residency training. I am also thankful I learned how to study and how to learn on my own. These lessons have enabled me to enjoy a lifetime of learning, while improving my skills, bettering my trade, and thereby bettering the lives of my patients.

I am thankful for free speech, for the ability to write what I’m thinking and publish it for others to read—without fear from the institutions of which I am critical. I am also thankful for a forum whereby folks may choose to read or not read what I publish.

And finally, I am thankful for you—whomever you may be—thanks for reading to the end. Thanks for your attention, and may YOUR blessings be great in number!

~Jenny Powell MD, FAAFP

 

 

Precious Privacy

What a human tendency it is to deny that we have anything “to hide!”  Does this mere sentence cause your self-defensive hairs to rise? It should, because we all have something precious to “hide,” something we take for granted that is the envy of millions around the world.

We all have our privacy to hide.

It concerns me that that with every new, sweeping loss of our privacy no one seems to bat an eye. Oh we might complain a little, or make jokes about it; but, we don’t seem to notice that little by little our precious privacy is being eroded. We have been trained to point to the attacks of 9/11/2001 and declare that if there had been better surveillance, it would not have happened.  “We can’t let it happen again,” is exclaimed.

“In the name of National Security” has become a mantra. Please, do me a favor: find someone who lived in the Soviet Union or Cuba and ask them about National Security.

It concerns me that when we see a vehicle pulled over we make assumptions. They must have been speeding, we think.  When I talk to patients who share their stories of being pulled over and having their medications with them, I cringe.  Then, I print off a copy of KrisAnne Hall’s Fourth Amendment handout http://krisannehall.com/wp-content/uploads/2014/07/fourth-amendment-facts.pdf, which explains the right to privacy guaranteed by the Fourth Amendment.

There are no local, state or federal laws that may supersede the Fourth Amendment! If they do so, they are illegal. A search warrant is required—period.  It will not be difficult to get a search warrant if there is probable cause.  But, I will leave the technical legalities to another day.

My biggest concern is the general lackadaisical attitude toward the privacy of medical records. First, to whom do your medical records belong? By right they should belong to you.

But, I encourage you to try to get a copy of your full records. Go ahead. It will probably cost you, and you’ll have no guarantee what you get includes ALL your records. By requesting a COPY of your records, you are not purging your records, either. You may be told that you have access to your records electronically, but the keeper of the records is careful to control what part of your records you may access. However, your insurance company is not so bridled; they may have full access, and do not require your written permission! Why? Because, you signed a paper signing away all your rights to privacy when it comes to your medical records! Your insurance company, the federal government, other physicians and their office personnel—basically, anyone with whom the record-keeper does business—have access to your records, as long as they sign a business associate contract.

The Health Insurance Portability and Accountability Act (HIPAA) http://www.gpo.gov/fdsys/pkg/PLAW-104publ191/html/PLAW-104publ191.htm really has nothing to do with your privacy, though that is all anyone (including “healthcare providers”) thinks it maintains. The Department of Health and Human Services  (HHS) wants you to think that’s what HIPPA is all about as well. But realize, any law that allows the department of HHS to access your records without your knowledge is not a law about maintaining your privacy.

Did you know that you do NOT have to sign that you have received the privacy policy of the “healthcare” facility you utilize? Did you know you don’t have to answer any questions you don’t want to answer?  Did you know that HIPAA was the first step in a long line of “laws” designed to create an “interoperable nationwide health information infrastructure?”  (These are official words, not mine.)

Is there anything in that phrase—interoperable nationwide health information infrastructure—that sounds at all reassuring, that it is your privacy they are concerned about preserving? Am I the only one who immediately thinks of George Orwell’s 1984 when I merely read that phrase?

My friends, do you have any notion of what unholy behemoth we have unleashed? It doesn’t eat your soul, but it devours your medical privacy. Plus, with the re-definition of the practice of medicine to “healthcare,” your medical privacy extends to everything you ingest, breathe, wear and to which you expose yourself.  Then, because it is realized that in order to control your health, we have to control your personal habits—there you have the development of an interoperable nationwide health information infrastructure!

Yes, I can hear at least one “friend” cry, “The sky is falling!”

Oh yes my “friend”—it is.

If by sky you mean your freedom, and by falling you mean death.

I just utilized a “healthcare provider” last week.  It is someone with whom I have a real friendship, and this provider likes to have certain things in her medical records; so, I answered some things honestly.  However, there was a lot I wouldn’t answer. It is not pertinent to the issue with which I was seeking care.  I was honest and reported that I do not smoke, unless I am on fire, and that my source of caffeine use is coffee.  The amount? All of it, which is an exaggeration, but it told her what she needed to know.

And no, I did not sign the HIPAA release.

Privacy—an inherent right recognized by our Constitution—has been taken for granted for far too long.  We should never feel we have to give up some of our privacy in exchange for some security.  I am not willing to sacrifice my privacy on the altar of “security”, not for your security, nor for mine. Don’t fall for the “I have nothing to hide” trap. You have something not only to hide, but also to hoard and protect with your life: your right to privacy.

The right of the people to be secure in their persons, houses, papers and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the person or things to be seized. Fourth Amendment, U.S. Constitution.

~JPowell MD

Direct Care Independence

October 1, 2015: Independence Day

 

Atrocities were being committed against everyday citizens. There was no privacy, and property rights were nearly non-existent.

The Boston Massacre was a result of British officers firing into a crowd of citizens. Sam Adams rightly used the event to spark a fire, which eventually lead to a declaration and a long, hard-fought war for independence.  July 4, 1776, will be a day of celebration as long as there is a United States of America to celebrate.

Today, atrocities are being committed against everyday citizens—our patients.

There is little to no privacy regarding medical records, and a patient’s medical records are NOT considered his/her own property. Insurance companies and the government have determined what they finance belongs to them. Physicians are being sent to federal prison, NOT for purposely committing fraud, but because they dictate a technical mistake (that does not change the costs) in their notes on a procedure, and the “system” wants to make an example of them. A new set of “codes,” a language of sorts for the medical community, is being forced upon all of those who bill insurance and government health systems in any way, shape or form.  Physicians are no longer to be referred to as physicians; rather, they are “eligible professionals” along with podiatrists, dieticians, audiologists and advanced practical nurses. If a physician opts to not do business with the Centers for Medicare and Medicaid Services (CMS), the Secretary of CMS shall have the option to decide whether those physicians’ prescriptions will be honored. There is a push, through the Interstate Medical Licensure Compact, to utilize a national licensure as opposed to a state licensure program for physicians, which would punish those who either don’t continue their board certification because it is an expensive “club,” or who anger the national board(s) in any way to render them unable to get a license to practice in ANY state of the Union.  There is a war on doctors; and friends, whether you want to acknowledge it or not, it cannot be good for patients no matter WHO pays the medical bills.

For those of us who:

  • Have dared to go around the “system”
  • Have had enough of getting insurance companies’ approvals for medications or treatments we deem necessary for our patients
  • Have had enough of hospital administrators practically begging us to make more “clicks” on our computer for them
  • Who refuse to have our livelihood tied to the amount of individual patient data collected
  • Who find the presence of insurance carriers, the federal government and middlemen palpable in the once private exam room
  • Who declare our independence from these barriers and are re-establishing the sacred patient/physician relationship

We declare that Thursday, October 1, shall be OUR Independence Day!

That is the day all others must start complying with ICD-10, a copyrighted product of the American Medical Association (AMA). ICD-10 is a coding program that destroys privacy of the patient and sets the physician up to fail. We—the direct-care physicians and medical clinics of America who do not bill insurance of any kind—WE say “ENOUGH!”

  • We are independent from a system that places the physician and the patient together on the “road to serfdom”
  • We do not code our visits
  • We do not have to code our visits, because codes are not helpful to patients; codes are solely a form of forced collaboration with a system that seeks to subjugate us all
  • WE shall proudly flood social media with #iamdirectcare on Thursday, October 1—our Independence Day
  • We will proudly proclaim our freedom before those poor souls who continue to slave away for the “system” https://atlas.md/content/upload/files/ICD10_03.pdf

We shall fly our own flag, and defiantly wait for the inevitable Santa Anna to “come and take it.” They will try, because we fly in the face of their right to command us. Yes, they will try. They will use several methods, and they may succeed. We may fail, but we will fail as free people, not as indentured servants. And we, like our patriotic forefathers, will remain steadfast.  We shall, like them, pledge to each other and to our patients, “our lives, our fortunes and our sacred honor.”

Caring for Your Kidneys

Don’t Tell the Cardiologist, but the Kidney Rules

 

In the first year of medical school, we learned how the human body works. All the anatomy and physiology was focused on the healthy, well-working human body. We learned what goes on at the molecular stage on to the macro-biologic. Second year we learned pathology—disease states, infections, when things even at the molecular stage (or especially at the molecular stage) goes awry. There was some snootiness between professors during the first year, but when the specialists came to speak to us in lectures, this is where it got a bit more heated.

It was a standing joke that the cardiologists (heart doctors) made fun of the nephrologists (kidney doctors), and the nephrologists made fun of the cardiologists.  “All the kidney does is go ‘drip, drip, drip” the cardiologists would laugh.

“All the heart does is pump. How hard is that?” the nephrologists would retort.

Meanwhile, the neurosurgeons (brain surgeons) rolled their eyes (and they knew which cranial nerves controlled the roll!)

The heart IS a pump, albeit an electrical pump. If something goes wrong with the electrical wiring, the heart is in trouble. If the heart muscle is starved of “food” (oxygen) it will die off downstream of where the food supply is halted. If the doors are stiff and creaky and don’t close like they should the pump may back up depending on the severity of the hinge problem. And if the pressure is too high for the pump to pump against, the heart muscle has to work harder. This pump is pretty important because the brain really needs the oxygen that the heart pumps to it.  It is a beautiful design and works great, pumping blood to the brain and the rest of the body about 70 times per minute, 4,200 times per hour, 100,800 times per day. The heart tolerates a lot of abuse, from cigarette smoking to drinking energy drinks to high cholesterol diets.

The kidneys, on the other hand, filter the blood. I liken them to an automatic drip coffeemaker. The water is the blood coming in to be filtered. The brewed coffee in the carafe is like the blood as it exits the kidney. If the filter clogs up, or if the water goes through too slowly, the quality of the coffee is not as divine as it is when the filter works nicely and the water is forced through quickly. But, filtering the blood is not all that the kidneys do; they tightly regulate electrolytes. Sodium, potassium, even glucose are all very tightly regulated.  The kidneys also regulate blood pressure. This is why so many medications for blood pressure work in the kidneys. The kidneys even make hormones that do important things like stimulate the manufacture of blood cells and bring calcium into the bones. They do so much that most people have a pair of them—though you only really need one.

When the kidney(s) don’t work like they should, and it gets so bad that the toxins are not filtered out, a patient is put on dialysis. Kidney dialysis was first discovered by Dr. Willem Kolff and is the process by which one bypasses the diseased kidneys and uses a machine to filter the blood. http://www.nytimes.com/2009/02/13/health/13kolff.html?pagewanted=all&_r=0.

When the kidney(s) fail, and one requires dialysis, unless you qualify for a kidney transplant, you are looking at usually only 5-10 years of surviving on dialysis (though some folks manage to live a lot longer).

Take care of your kidneys! Don’t smoke – remember that smoking affects the blood vessels and contributes to plaque formation in important arteries. Nicotine can also cause contraction of the smooth muscle in the arteries. There is an important artery that runs to the kidneys; so, let’s not put a crimp in that hose.

Drink enough water to stay well hydrated, but not too much.  4-6 glasses (3-4 pints, or 1.5 liters) a day is good. Eat fresh food—avoiding processed foods helps you avoid the sodium (salt) that is used for preserving the food. Keep active—walk, swim, cycle.  Watch your blood pressure.  Every household should have a reliable blood pressure cuff, and know how to use it. Take your home blood pressure cuff into your primary care doctor and have it checked for accuracy.  Then make sure your kidney function (the blood work) is checked periodically. Some people are very susceptible to over the counter arthritis medicines (Non-Steroidal Anti-inflammatories or NSAIDs) such as Ibuprofen and Naproxen. Even if you don’t have high blood pressure, but DO take these medications on a regular basis, your kidney function should be checked to make sure the medications are not having an ill effect on the kidneys. And, try your darnedest to avoid diabetes. Not only diabetes but also the medications for diabetes are exceptionally hard on the kidneys.

So, don’t tell the cardiologist, but the kidneys rule, and the heart would be nowhere without one.

 

Relationship provides better care

Higher Quality Medical Care Comes With Relationship, Not Data Compilation

 

Humans are complex creatures, designed for interaction and the use of ideas and reason to prompt their actions.  A well-established relationship between individuals is essential in the process of communication, which is the basic foundation in any successful interaction.  Therefore, establishing a relationship is important to quality medical care.

What is it you look for in a physician?  Want do you want from your physician?  What kind of return on investment do you seek? What sort of value does having a personal physician have for you?

Ask anyone who is 55 years or greater if they had a physician when growing up.  Unless they lived in a fairly remote area, chances are they will tell you a story of their family “doc,” who “caught” them when they were born, saw them through the childhood diseases and accidents, counseled them as they prepared for college, did their exam and blood work for their marriage.  They will likely remember them with a far-off look in their eye, re-experiencing fondly the antiseptic smell of the office, the creak of the wooden chairs in the waiting room, and the confidence they had that their physician knew all about them.  Ask them, after they tell the story, if they feel they had a higher quality of care than they do today. Ask them to compare and contrast the difference of that relationship with the one they have with their present-day physician(s).

How do their stories compare to YOUR story? Did you have a family physician growing up? Do you have a primary care physician today?  Do you feel there has been a shift of paradigm away from the traditional practice of medicine to an impersonal “healthcare facility?” Unarguably, technology in medicine has greatly increased in recent years, but have human beings changed much as well?  Why has there been such an effort to sterilize the relationship between patients and physicians?  Why have so many barriers been placed between them? Has it been more of a side effect of technology, or has it been purposeful?

Let me ask you more: do you have an attorney? Have you ever needed an attorney, but not had one “on retainer” or in your speed dial? Have you ever found yourself in a situation where you suddenly, urgently, needed an attorney?  Wouldn’t it have been far better to have established a relationship with an attorney well before you needed one emergently? A family attorney would be nice, one who had represented your family for years, who watched you grow up and knew everything about you so that when the need arose you would have someone to turn to. You would know you had someone “in your corner,” an advocate in court. You would also know that anything you revealed to your attorney is confidential.  There are few barriers in the client-attorney relationship.

Why should your relationship with your primary care physician be any less crucial than that with your attorney?  Are the experiences of your mind and body any less sacred than your legal concerns?  Shouldn’t what you discuss with your physician be as confidential as what you discuss with your attorney? Are attorney fees less expensive than physician fees?  Why is there no subsidized exchange to purchase legal insurance?

All these questions are aimed to spark the fire of enquiry.  Think of it this way: you have been programmed to believe that you must have health insurance, and that you must have a physician who bills your insurance, and that that insurance company has the right to all your medical records because, after all, they are paying the bills.  And of course, there has to be insurance oversight, and hospital oversight, and clinic oversight, and physician oversight, because the government is only here to take care of you, to watch over you, to make sure you aren’t harmed in any way by any of these parties. And the result of all this oversight is the achievement of the highest quality of care anyone could have! Or is it? If you KNOW that the insurance company has access to your records, are you more likely to confide your tobacco use or your recreational drug use or your sexual preference or whether you use “protection” to your physician? What difference does it make to the physician? No sense revealing that little problem you had one time with high blood pressure that the insurance company may use to drop you, or increase your rates.  If you have nothing to hide, then why do you care who reads your chart?  But, what if you don’t know whether you have nothing to hide or not? What if there is mining of your records for data of which you are not even aware could be considered suspicious? Are you “non-compliant?”  What does that even MEAN?? Can one have a higher quality of care when there are those kinds of barriers in communication and relationship? Or do you expect quality of care to be higher in a situation of a better, closer relationship?

Good relationships encourage openness and frankness, which helps the physician greatly to better diagnose.  Better diagnoses leads to better treatment plans and better treatment plans lead to higher quality of care.  Physicians who focus on the individual in front of them as opposed to what the insurance company – or the employer, or the Department of Health & Human Services via their “interoperable health information infrastructure” wants documented – will provide better care.

Seek that kind of relationship, seek that kind of primary care physician, and don’t wait until it has become urgent.  Keep that physician and their cell phone on speed dial, keep them on retainer, so when the time comes that is of the essence you don’t find yourself wondering what to do.

And you, the patient, will be happier, and – possibly, hopefully – healthier.