I suspect someone would have to be fairly cut off from the outside world in order to not have heard that the United States is in the midst of an epidemic of opiate overuse and abuse. No matter which community you live in, we have been affected by what even Donald Trump has now officially designated as a public health emergency.

As I look towards the future and designing the practice that will allow me to best serve our patients, I am constantly considering what are the biggest issues our community is facing and how might we do better to address them? One area that has been quite problematic for us in Monterey County, at least since my arrival here to start residency in July 2015, is lack of affordable access to addictions treatment. Suboxone (a medication used to treat opiate addictions that is used in a manner similar to methadone but without the abuse potential) is offered in multiple clinics locally, but only ONE that I am aware of accepts MediCal for payment and routinely has a waiting list for patients seeking this service. Per the reports of my patients, other clinics are charging cash prices typically around $600 monthly, which most of them find to be financially out of reach. 

As I've been working towards obtaining my own Suboxone prescribing privileges for use at a Federally Qualified Health Center in Santa Cruz, I started considering how this type of treatment might be better incorporated into primary care and a Direct Primary Care practice in particular. Fortunately, someone else has already written an excellent piece about exactly how this can be beneficial and more financially viable for the average patient. 

Rather than charging people on a per-visit basis for the privilege of being forced to show up for added office visits just to receive one's maintenance medication, Direct Primary Care will allow me to prescribe for these patients while also treating the rest of their basic and likely interrelated health care needs. At Proletariat Health, we will choose to focus on the health and overall well being of each patient rather than seeking to nickle and dime people and generate extra revenue by requiring separate visits for each problem due to time constraints. 

Consider that many patients who currently struggle with opioid addictions initially accessed these drugs in an attempt to treat chronic pain. While we can work to stop the cycle by no longer prescribing the drugs of abuse and possibly starting treatment with other agents to control the addiction, how often does the underlying concern that created this situation remain unaddressed? 

The answer is: far too frequently. 

For a low monthly fee with no added charges for additional visits and a totally transparent pricing structure, patients can get their needs met in a more affordable manner than is oftentimes possible even with a comprehensive private insurance policy. Better yet, visits are unhurried because we aren't incentivized by volume or trying to pay the exorbitant overhead costs associated with a typical insurance-based practice. We are free to focus on our patients and their concerns rather than an insurance company's arbitrary metrics about what we should be discussing today.

This is what Proletariat Health is all about and we're thoroughly looking forward to the future. Join us and see what it's like to be part of the health care revolution. 

California Single Payer Bill: Ethical intention, terrible execution

As Republicans in the US Senate are working diligently on the destruction of Obamacare, progressives in California are doggedly pursuing a distinctly opposite approach. The California single payer bill, originally introduced by Senator Ricardo Lara (D-Bell Gardens) in March, aims to expand health insurance coverage to all Californians regardless of income or immigration status. Just as Republicans at the federal level have tried to jam through their healthcare package without debate or adequate analysis of the downstream financial impact to millions of Americans and the healthcare system as a whole, California Democrats are just as eagerly moving along a bill with a projected cost that would be more than double that of the entire annual state budget.



Like most physicians, I would love nothing more than to be able to care for each and every one of my patients without any concern for how the bills will get paid and whether or not a particular test or medication I need to order will be covered by their health plan - if they have one at all. As a student, I learned that the numbers are undeniable: the United States spends far more on health care in every respect than the rest of the developed world and gets far less for it. As I've progressed through my personal training, I've seen countless patients in the unfortunate position of having to make decisions about seeking care for themselves or a family member versus paying for basic needs such as food and rent. From a morality standpoint, I believe deeply that health care is a human right and everyone should have access. So why, given all of this, am I so adamantly opposed to California's latest attempt at a single payer bill?



Well, for starters, I read it.



The Healthy California Act proposes the state establish a universal health insurance program, essentially enhanced MediCal, that would cover every individual residing in the state. This truly universal coverage would replace all private insurance plans as well as existing government programs with the exception of those run through the Veteran's Administration. This means a federal program like Medicare gets wrapped into this new coverage just the same as a high dollar Blue Cross or Kaiser plan paid for by an employer. I reference "enhanced" MediCal because the authors go to great lengths to spell out all of the additional services that must be provided, such as coverage for long-term care, dental, and vision, and even reference certain alternative therapies such as acupuncture. Going even further, the bill requires that patients never be subjected to out-of-pocket expenses such as co-pays, co-insurance, or deductibles. And to make medical providers happy, there is even language specifically referencing that I should always be able to substitute my own reasoning and clinical judgment about caring for individual patients over any guideline or consensus about standard of care.



This sounds pretty great, right? Even with the most fancy pants insurance products currently out there, I don't imagine there are too many of us who can say we have insurance coverage like that. So what's not to love? All of my patients should get covered for absolutely everything and I do mean EVERYTHING.



As much as my personal morality says universal coverage is the right thing to do, my professional ethics tell me it is absolutely absurd to continue to prop up our existing woefully broken system with a bottomless pit of cash vis-à-vis the state government. Proponents of the bill argue that money will be saved by cutting out the private insurance industry and negotiating payment for care differently once the state has full authority to do so with all providers. What they fail to recognize is that the insurance industry is behind only one slice of the bloated and wasteful pie that is the US healthcare system. There is an entire mentality affecting how patients seek care and the system provides it that must be shifted in order to make any real gains on health outcomes and cost savings.



Since the implementation of the Patient Protection and Affordable Care Act (PPACA a.k.a. Obamacare), health care services in the United States are increasingly being delivered through very large health care systems. Systems that have become bloated with administrators who contribute absolutely nothing toward actually caring for patients, yet continue to drive up the cost of care and create further incentive to bill as much as possible for every episode and interaction a patient may have. In fact, reviews of quality and cost data in post-PPACA years show that such giant healthcare systems are not only failing miserably when it comes to cost control, but the only bright spot in truly improving outcomes related to both quality and cost come from small physician groups - the exact same groups which are largely being gobbled up by the health care giants in all their perverse incentives to continue their explosive growth. However, the Healthy California Act would serve to only further the decimation of the little guys who are doing it right by forcing patients to be assigned to a "health care coordinator," the responsibilities of which clearly exceed the capacity of your independent primary care physician operating on a shoestring with minimal staff.



Furthermore, as glorious as it would seem on face to know that every service you could ever need or desire will be covered with zero out-of-pocket costs, I have to remain suspicious of the anointed overlords of this proposed system. Anointed is truly an appropriate word as the Act takes literally multiple pages to describe the make-up of the Healthy California board, most of whom will be appointed at the behest of top elected officials to include designated appointees for each the governor, speaker of the Assembly, and president pro tem of the Senate. Those who are behind the crafting and promoting of the bill (largely a very vocal nurses union) have ensured that they will get ample seats at the table. Though as much of a proud union member as I am, I can't say that I'm entirely supportive of the idea that a group responsible for such weighty decisions on the provision of health care for the entire state would ultimately be composed of just as many labor representatives as people who actually have medical degrees.


When I really step back to consider, what are the things that I most detest about my day-to-day in attempting to provide quality care for my patients? Insurance is a hateful burden, but it's far from the only burden nor is it the singular obstacle to my patients universally receiving the care that they need. When I read this bill and consider the energy behind it and the political backlash at anyone who isn't supporting it, I became angry. Should the Health California Act become law, progressives will pat themselves on the back for having finally proven universal coverage is possible in the United States. But what those same supporters aren't talking about is that there is absolutely zero guarantee that California will ever have access to the federal funds that are necessary to make the whole thing work. And should the Centers for Medicare and Medicaid Services (CMS) presently staffed by Trump appointees grant the incredibly broad based waiver to finance the whole thing, this bill offers little to no solutions in the way of future cost containment to make such a program viable for the long-term if said funding doesn't also increase substantially year over year.


I want coverage for my patients and I don't think anyone should have to defer necessary care for worry about whether or not they can personally afford it. But I also want us to be smarter about how we are collectively utilizing health care services in the first place. I don't want to perpetuate the bloat and continue driving care further away from meaningful relationships between patients and care givers into further "systematization" of medicine where individuals become numbers and disease rather than humans with names and stories.


As much as I know that taking a stand against this piece of legislation will likely earn me some dirty words within the advocacy community, my greater obligation remains to be upfront and honest with my patients. Few people would actually request that I deliberately lie to them or sugarcoat a grave prognosis. That is exactly how I perceive the end game of the Healthy California Act which is sucking up all the oxygen in the room and preventing us from moving forward on transforming health care in meaningful ways. Let's devote the same energy to pursuing real reform rather than chasing kudos for passing a half baked plan to get everyone an insurance card that will likely never come to fruition.

Seeking Simplicity in Healthcare

Today I spent my lunch hour listening to a webinar on the highlights of what physicians need to know to be ready for MACRA (Medicare Access and CHIP Reauthorization Act) implementation, specifically new CMS regulations for the Quality Payment Program (QPP) that physicians accepting Medicare must participate in starting in 2017 in order to not suffer financial penalties. Despite the rather convoluted alphabet soup of acronyms and new regulations, I’ve heard this topic presented by multiple sources over the past few months and am starting to feel I have a fairly good grasp on the content, possibly even well enough to present it to a colleague if necessary. Most would consider this going above-and-beyond for me, if not completely unnecessary, given that I am still completing my residency and working in an environment where I don’t personally have to pay much attention to billing and quality metrics as someone else is doing that part of the job and my not knowing wouldn’t affect my salary or really how I interact with patients one bit.

The problem is, I won’t be in this environment forever. In less than a year and a half, I will graduate and move on into the world where I can prioritize my professional autonomy and would very much like to have my own practice. Unfortunately, to do this requires a tremendous amount of knowledge beyond what has been taught in any of my formal education to become a physician. So sacrificing a peaceful lunch hour to further school myself on the ins-and-outs of avoiding reduced payment for Medicare patients due to my own inadequate reporting is part of the burden I must bear. Unless… I choose to practice differently and refuse to participate entirely.

This whole situation causes me to reflect on a particular moment of reckoning I had back in May 2016. I was giving a presentation at a local elementary school to a group of parents to explain how the state of California had recently expanded Medicaid eligibility to all minors under the age of 19, regardless of immigration status, and how to ensure their children would be properly and promptly enrolled. As is usually the case whenever a physician opens herself up to a broader audience like this, I started getting a lot of questions from those present about their personal family situations. Though rather than focusing on the children which was the initial intent of the presentation, it was regarding themselves or other adult family members who were unable to access our inadequate patchwork of services open to undocumented immigrant adults. I take great pride in understanding the complex interworkings of government programs and have made considerable effort to keep abreast of new developments, something I was doing long before even starting medical school. I happily serve as a reference point for my peers and patients alike. But as I was fielding what seemed like an endless stream of questions that night and watching the defeated looks on the faces of these parents who were clearly overwhelmed by the many steps, entry points, applications, and exceptions to the various programs I was describing for their individual situations, I finally realized just how absolutely crazy this all is.

What good is it for me to be an expert at the ins and outs of the dozen different programs and services, each with their own applications, billing, and reporting requirements, if the systems we’ve created are so completely convoluted that my patients can’t even begin to access them? It was at that moment that I knew for certain that I would need to find a way to practice differently, in a manner that anyone could understand and all could access.

Direct primary care is a beacon of hope in the insurance and billing madness. This model of care is conducted by physicians who rather than billing on a per-visit basis, instead charge a flat monthly rate to receive service at their practice and forego billing insurance entirely. For the physician, this substantially lowers overhead and administrative costs of the practice, providing them with a fixed income stream and allowing more time to participate in actual patient care. Most physicians currently practicing under this model are able to offer visits from 30 minutes to an hour in length (versus the 10 to 15 minutes typical in most traditional offices), have smaller patient panels, and more easily accommodate patients for same-day sick visits. Without the worry about lack of payment for certain services, these physicians are even able to interact with their patients in whatever way makes the most sense, whether that’s discussing symptoms over the phone or through video chat, or possibly even conducting a home visit where warranted. With easier access and more time to spend with your doctor, is it any wonder that these practices have demonstrated significant improvements in patient health outcomes?

What if I told you that on top of providing better care that these practices are even substantially reducing the cost of care? Consider that a typical single office visit to a primary care physician is billed at upwards of $150, excluding any additional tests or procedures. But many of the practices serving in this model are able to charge a flat rate of just $50 monthly for a typical adult, oftentimes providing further discounts for children or families. Frequently, these practices have also negotiated special pricing with labs and imaging centers to obtain tests much nearer to cost than the rates negotiated with typical insurers and even lists of local specialists who have similarly negotiated flat rate reduced fees for patients who will cash pay for services.

For years now, it has been a Republican talking point to bundle high-deductible health plans with health savings accounts as a solution to get patients to become more savvy consumers when it comes to healthcare. As a self-identifying progressive, as a medical student, I used to rail at the idea. It was completely dismissive of the fact that for low-income patients, there was no way on earth they would ever be able to stash away $10,000 to cover the potential deductible for such a plan. Until I realized that this was happening anyway. For my undocumented patients who are without other resources or methods of funding, they are frequently denied service for non-emergent procedures until they can come up with a down payment, often in this exact price range. Furthermore, even on the sliding scale fee schedules charged by our county clinics and community health centers, just 3 or 4 visits could exceed the cost of membership to a direct primary care practice for an entire year. Not to mention, making the decision to pay $150 or $200 to see a doctor when one is acutely ill is often much harder to stomach or even come up with than a planned monthly fee similar to a cell phone or cable bill. A high functioning primary care physician who is given the ability to dedicate ample time and attention to her patients will find that the need to refer to specialists becomes a rarity rather than the norm, no longer a dumping ground for things I simply don’t have time to address in our 15 minutes together.

The benefits to both physicians and patients of such a plan are undeniable. So why isn’t everyone doing it? Because for many of us, it necessarily forces us to exclude some of our patients. Right now, California state law treats a monthly fee charged for health care as a “health plan,” meaning that the doctors taking part in these models open themselves to legal exposure of potentially being treated like an insurance product even though the fees they are charging are to cover services at that practice alone. Furthermore, government and even privately funded health insurance programs will not cover the monthly fee to practices in this model. Traditional Medicare, our federal insurance for the elderly, specifically prohibits payment for this monthly fee for membership-model practices despite the fact that it has proven to be an effective and successful model for patients served by privately administered Medicare Advantage programs.

My patients need simplicity. They need to understand exactly how much things cost and what, precisely, they are getting for the amount they are paying. Physicians need simplicity as well, not a never ending stream of regulations and reporting requirements that do little to improve care and much to limit our time focusing our attention where it would be better served. Even for a policy nerd like myself, this is getting exhausting, and I recognize that my longevity in practice will depend greatly on my ability to simplify things and create a model where my attention can be focused on the health of my patients rather than my ability to understand the latest initiative of a group of bureaucrats who understand little to nothing about medicine. 

The Revolution is Starting

I have been fortunate in my lifetime to have experienced first-hand a few moments of mass resistance that inspired my hope for real change, though none more powerful than today. Yesterday was the Inauguration of President Donald Trump. As ridiculous and improbable as it still sounds, it is a fact that is now real. The resistance showed up that day, by my personal vantage point, matching the strength in numbers of his own supporters. But our presence today exceeded even my lofty expectations for turnout.

The Women’s March in D.C. was initially expecting a turnout of a few hundred thousand. I personally felt like a million was more likely just based on the energy I was seeing online with friends from around the country who are certainly not regular participants in an organized protests before now taking the time and making the investment to show up both in DC and at sister marches in their local communities. However, more recent media reports are suggesting nearly 4 million individuals turned up all around the world. By the absolute gridlock that the city was under, both above and underground, I fully believe it.

Activism has been a big part of my life for a number of years now and on a variety of issues. But the energy I experienced today has inspired me to start thinking about taking my own activism to the next level and even beginning to envision myself as a leader. Tomorrow, I will be attending a training about running for elected office. In the fall of 2015, I had a moment while listening to an interview with Speaker Pelosi, hearing her talk about her work encouraging women to run where I thought that maybe I could and even spent a few months thereafter considering what that would look like. Despite this, it didn’t take long to roll back my confidence, reiterating that I’d much prefer to just direct things from behind the scenes rather than be the public face of anything. There must be someone else better suited for that.

But today, I heard my own voice again. In a sea of people who are fed up, pissed off, and ready for real change toward a more just future. I started to think about my progression through organized medicine over the past few years, specifically recollecting a conversation with one of my mentors shortly before graduating from medical school about how I didn’t feel like I was personally getting much out of the student section anymore, though it seemed to be an expectation that I stay there to help lead. She readily agreed and told me I had already “graduated” from the students and needed to be with the physicians now so I could continue to grow. As I consider the opportunities I have sought out over the intervening two years, I realize so much of it has been built around continuing to seek training and mentorship, but never giving myself credit that perhaps I am already prepared and finally ready to lead.

Over the past few weeks, I have been interacting with people at their professional heights as elected representatives, hospital and health department administrators, and they seem to be universally surprised by my level of knowledge on the subjects about which I am speaking. Perhaps it is time that rather that allowing myself to be satisfied with surpassing their low expectations, that I start exercising that voice and demanding to be heard.

Today, I am inspired by all of those who chose to take a stand possibly for the first time and take part in a movement that says we deserve better. I now stand resolved saying that not only do I believe it too, but I am committing to doing more and to taking the next step that I was previously too afraid of. Outside the Chinatown Metro station, a man handed my friend and I these beautiful artistic prints of Hillary Clinton that I am so excited to hang up at home. Both of us have been avid Hillary supporters and we see this woman as someone whose endless fight and countless contributions have been severely discounted, but still she stands and moves beyond the abuse that comes with the limelight. I can’t help but admire that and consider myself weak for not having been willing to do the same. But today, I commit that this is all about to change. Thank you to the marchers in D.C. and around the world today for giving me that courage because now I know for sure that I am not alone.