A widening divide: the new schism in healthcare

Although the trend has been there for a while, it's become increasingly apparent to me over the past few weeks that there truly is a schism in the evolution of healthcare in the United States. On the one hand, we have the "big boys" (e.g., large hospital corporations, insurance-backed ventures, etc.) that want to move everything towards greater degrees of automation. If we can ask the super computer Watson to give you a diagnosis, why bother with an actual doctor? Let's attempt to increase utilization of telemedicine at every turn. Farm out increasing amounts of work to support staff with intent to preserve the time of the doctor only for the neediest and most complex of interactions, no time for the mundane day-to-day of typical chronic disease. As someone who grew up with the evolution of the personal computer and feels far more comfortable seeking what I need via my handheld device versus calling an actual office to request an appointment, I'm certainly down with the convenience factor. But that's pretty much where it stops. 

On the other side of this great divide, we have the "little guys." These are the cowboy doctors who continue to bank on the utility of their education, experience, and ability. They are pushing to slim things down, eliminate the excess overhead and meaningless metrics that drive up costs and instead focus on high-touch personalized medicine. Bring the relationship between you and your doctor back to the forefront. Recognize that seeing a patient as nothing more than a series of data points up until she finally visits with you in her moment of highest need is in fact, not a great way to go about providing high quality care. Instead, it allows for greater fragmentation, lesser degrees of trust, and an erosion of the patient-physician relationship. 

The more I find myself looking at evolving trends in healthcare through this lens, the more intrigued I a about which side will ultimately prevail. On the one hand, the industrial complexity of healthcare as big business is certainly where the resources lie to continue investing and frankly, even forcing patients into these models whether we want it or not. Alternately, the cowboys are relying on the extraordinary dissatisfaction patients feel about the idea that they have become just a medical record number, a set of data points in someone's productivity metric, with little attention to how they truly feel after their interactions. 

I know that for my highest need (usually = sickest) patients, I am fearful of how much will be missed as they are forced through systems of fragmented care where the primary care physician's role is increasingly slimmed down rather than expanded to given us greater opportunity to really hear our patients, understand what is important to them, and see what is being missed. 

What will our systems of care look like when this division is complete? And which side do I want to be standing on - as a doctor or as a patient? 

Reclaiming control from the health insurance monopoly

Completing residency is a milestone in the arc of any physician's formal training. I looked towards June 29, 2018 with great anticipation for many years in advance as I knew it would finally signify the return most important thing I had given up for the privilege of my medical education: Freedom.

Yes, I'm aware many of my more senior physician colleagues don't see it this way as they've become trapped in employed positions where the productivity and documentation demands are never ending and becoming dependent on the paycheck, their decisions are still not their own. But given the less traditional path I'll be pursuing for myself, I absolutely do feel free as everything here on out is MY choice, not something mandated of me in order to get through the hoops for licensure and board certification. (The ongoing hurdles to maintain those prizes is another story for a different post.)

One additional far less desirous item I knew was coming down the line along with completion of my residency was the associated loss of my health insurance benefits. Although I didn't consider my plan "great" by any stretch (it was still 80/20 cost-sharing with a moderate deductible and standard co-pays), it would be considered rather plush given how crappy insurance plans have become these days. Knowing that the county had been shelling out nearly $700 each month for insurance I'd hardly utilized had me thinking quite far in advance about whether or not all of this was really necessary. 

Admittedly, I do have opportunities to access health insurance through my employer(s), though I am deliberately choosing to forgo these offers which also come with the attached strings of my working a fixed set of days and hours to "earn" it, which pretty well spits in the face of the ultimate freedom I have been seeking all these years. So I've known for a while I would be sucking it up to cover my own health insurance costs, likely making too much to qualify for any sort of subsidy but not enough for the costs to feel insignificant. 

As of this writing, I'm a healthy 34 year old woman with no major medical conditions and no plans to become pregnant, as well as no one I claim as a dependent and need to provide for beyond myself. First stop to evaluate the damage: Covered California health insurance exchange. As indicated already, I'm over income for MediCal or any subsidized plan which leaves me only with the market rate options for my area. Slim pickings there as the only insurer on the exchange in my area is Blue Shield with plans ranging from Bronze level in the $470/mo range to Platinum plans at $1000/mo with high deductible and 40% cost sharing to no deductible but a much more substantial dent in my bank account each month. Interestingly, after pricing out what these costs could potentially amount to if I had to meet my deductible and out-of-pocket max with the lowest plans, those amounts plus the annual premiums combined would actually be MORE expensive than the top tier plan in the first place, but I guess that just goes to show insurance is really a gamble and how much are you willing to take on? In a healthy year, things might not be too terrible and in a sick year... well, let's hope your savings account was pre-loaded. 

It likely hasn't been lost on anyone reading this blog that earlier this year, the Trump administration relieved us of the Patient Protection and Affordable Care Act's individual mandate which stated that all of us must prove we had insurance meeting a basic set of standards and if not, we would be on the hook for an ever increasing annual penalty to be claimed via the IRS on that year's taxes. So while this move will likely send health insurance premiums further up their exponential curve, it may also be beneficial to someone like me who is willing to stomach a bit more risk. 

Before you go thinking I'm going to totally play with fire and have no coverage for the catastrophic, I am a doctor after all, and extremely aware that none of us are immune to the unpredictable. This is where I tip my hat to the DPC pioneers before me who introduced me to health share ministries. Although this is not a new concept with many of the currently operating health shares having been around for decades, it's becoming a more intriguing option for many as we are all increasingly burdened by the high cost of health insurance premiums. Health share ministries operated by faith-based organizations were exempted under PPACA to continue their operations as is, though with required disclosures that they are NOT health insurance and should not be treated with the same expectations. 

The concept of health sharing is essentially like a cooperative or mutual insurance where individuals who pay in each month understand that their shares will be diverted to others with health care expenses at that time and with the understanding that the same will occur for you in your own time of need. Health shares are certainly more limited in their services and what they seek to cover or consider a qualifying expenses. All of the health shares also promote their religious underpinnings by having members sign statements to abide by principles of healthy living and some even attesting to your own religious convictions. 

Liberty health share is largely regarded as a the "least religious" of the various ministries and generally came with good reviews as far as I have heard among DPC docs nationally. Additionally, they have even recently started an option to reimburse members for part (or potentially even all) of their DPC monthly membership costs which I consider to be a pretty sweet deal overall. The monthly cost to partake in the top tier of Liberty's health sharing arrangement comes out to only $299/mo + a $135 joining fee with a $1000 annual unshared amount (similar to a deductible as an annual wellness visit is exempted from this). Assuming the health share remains viable over the course of the year and continues paying member claims as it has been on their most recent financial reports, total annual costs calculate out to be less than half the potential costs under the standard Blue Shield plans described earlier. 

In reading through the various disclosures and contract documents, it is clear that the services eligible for "sharing" are distinctly limited versus what would be covered (though rarely in full) by the standard commercial plans. This is particularly true in California where we have ever increasing lists of mandatory benefits under state law. But it also made me consider - how much of that SHOULD we as a public be on the hook for covering for other individuals? Have we gone too far in what we determine to be essential medical needs when some things really are just elective or worse yet, have very poor medical evidence to back up their necessity though everyone seems to find procedure XYZ critically important to be available to everyone. One glaring gap is coverage for mental health services. Although this is not something I personally require at present and hope I will not require in the future, I also have to recognize that the vast majority of mental health practitioners don't participate in public or private insurance plans anyway so not having coverage in case a need arises may not even impact my level of access. 

So the conclusion to this now lengthy treatise is that I felt compelled to take the gamble and sign up for a health share. Unfortunately, due to a known defect in my DNA, I have an exclusionary condition that prohibits me from participating in a health share as their guidelines are currently written (despite knowing - as a physician - that this is unlikely to cause my lifetime health expenses to be different than any other healthy young-ish adult). Having now done the math and determined that this would be a good move for me at this point in my life had the eligibility requirements aligned, I would definitely feel more comfortable recommending the same to my own patients in the future.

Given my personal circumstances, I've headed back to the exchange marketplace and will be purchasing an individual Silver level plan from the ONE private insurer still listed for my county. For the remainder of 2018, this will cost me about $560 out-of-pocket monthly, a fee I may seek to have at least partially offset through one of my employers as my work schedule becomes more regular later this year. In the meantime, fingers crossed I won't have to hit the deductible I have yet to set aside funds for. And fingers crossed the premium increases to come for 2019 won't be too gnarly to my carefully plotted budget.

Although health sharing ministries are clearly not an option for everyone, I appreciate that there was (potentially) another option available to me at this time and I also appreciate the possibility to more freely move in and out of it in the future as one's future needs change. Anyone else out there taken the leap of faith with a health share ministry? Would be interested to hear any and all experiences, good or bad. Please leave a comment below! 

Wellness. When applied to health care workers and more specifically, the need for physicians to strike a better life balance, I am so very sick of hearing this term. It has become so empty and so meaningless. I admit, I even recoil a little at just hearing the word now.

I had a similar experience earlier in my life while working as a domestic violence advocate. The word then was "support" and all the good intent in the world could not restore meaning to the word. I remember one particular discussion with my boss about a statewide advocacy group offering their "support" to local shelter programs during a massive snowstorm. We were outwardly laughing about how absurd this was because the real, tangible sorts of "support" our programs desperately needed - like help shoveling out the snow drifts covering driveways and sidewalks - was not what they meant and never would be. The small things that could have had a big impact and would have meant the world to us, were never going to come.

Years removed from that situation, I cannot help but realize I've found myself back in a similar, if not even more abusive relationship with my employer. Granted, I'm a resident physician and anyone whose ever watched a medical drama on TV is surely aware that residency is a tradition of brutally long hours at emotionally and mentally exhausting labor intended to push competent physicians out at the end. But even if I can forgive the personal process I'm living through, I cannot be blind to what I'm witnessing all around me.

A few weeks ago, I was at a meeting that brought together doctors, physician's assistants, and nurse practitioners who work at the various county health department-run clinics. These meetings happen on a routine basis to give pertinent updates to all of us under one roof. This particular meeting had a different spin than normal, however, as the latter portion of the morning was to be dedicated to the topic of: Wellness.

What ultimately ensued has stuck with me for nearly three weeks now and the more I think about it, the more indignant I feel. This room packed with various highly educated and competent individuals who were dedicating their careers to care for the most underserved in our community, was at a boiling point. It was clear that the System were are all forced to operate within was wearing us ragged and tearing us apart.

Our concerns were voiced to one another. Nearly everyone in agreement, all expressing similar frustrations and angst at our inability to achieve improvement in conditions. We were asked to write out our greatest complaints and suggestions on giant post-it notes hung on the wall. To discuss in open forum thereafter so we could feel heard. The only problem was - the ones who most needed to hear these concerns, were all conspicuously absent.

Despite the reoccurring thoughts about that day I've had over the past few weeks, I had not felt the need to document the experience until now. But now, every experience that re-emphasizes those complaints rings in my head like a warning siren telling me we all need to flee and save ourselves while we still can. While we may still have some ability to save the parts of our humanity and drive to do this work that remain intact.

My best friend contacted me this afternoon to tell me he received a phone call on his way into clinic, a mere two minutes late based on our given start time, to find out where he was an if he was coming in today. My friend is incredibly reliable and timely, particularly for a doctor. So today was an anomaly, to be sure. But the troublesome part is that rather than be met with a question about if he was okay or if anything was wrong given the tardiness is incredibly out of character for him, he was instead met with an accusation. A hard working resident physician, who plays by their rules, always goes the extra mile and accommodates without complaint was not given the benefit of the doubt. Instead, he was treated as troublesome. In this environment where there is always more work to be done than time to do it, there are never any thank yous or recognition for a job well done. There are only shaming lists of ridiculous metrics that mean nothing to my patients and nothing to true quality of care, but seemingly show something about how we're doing to other bureaucrats behind a desk somewhere.

Physicians who are able to live in ways that embody wellness, do not work in these systems. They do not cowtow to meaningless mandates and metrics that do nothing to help our patients. They have found a better way that cuts out the layers of administration and insurance that separate doctor from patient. They refuel their desire to be the physicians they wants to be by taking great care of patients and developing personal relationships where everyone can feel that they truly matter as an individual.

This is what direct primary care is all about. When people tell me that they don't think it is possible in this community or that it is just some far fetched idea that will never work, I often remind myself just how untenable our current system is. Public or private, the setting truly doesn't matter when the drivers are all the same. But to eliminate the unnecessary layers and find the holy grail of incredibly satisfied and well cared for patients with incredibly happy doctors, all for a substantially lower cost?  Proletariat Health will be about getting back to what matters. That's the real revolution.