Archive for July 2016

DPC: Subtracting the Guesswork and Adding Back the Relationship

This week my partner, Jackie Hone, was seeing a new patient who had driven an hour seeking her help in sorting out his health situation. She spent an hour seeking to undo the damage done by miscommunication from multiple encounters in varied medical settings. Her patient had been left confused, upset, and almost ready to give up. He was uninsured and prior to his current problem had been quite healthy and had no primary care physician. But following his recent shoulder surgery he experienced a concerning post-operative symptom, was sent to one ER, transferred to a second hospital, had his diagnosis changed several times, was admitted for a 4-day hospital stay, and was finally discharged still lacking a definite diagnosis, plan, or prognosis. Of course his medical bills are staggering from all of these encounters. He was left pondering, “If medical care costs so much, why is it so poorly delivered?”

Most of us somewhere along the way have had a frustrating medical experience: maybe we received only a fleeting explanation about a procedure, medication, or treatment being recommended. Or perhaps we received a surprisingly huge bill after the dust settled on our medical care. Or we had follow-up questions but couldn’t reach anyone to answer them. Maybe all of these. So, is that just the way it increasingly has to be, or is there a better way?

Having a relationship with a physician who knows us in times of health and sickness is valuable. Likewise having a doctor who can be reached in an emergency is huge. And having a physician’s office that can help us navigate complicated medical tests and specialists to anticipate and manage costs is something for which most can only wish. But maybe these things are not impossible to achieve.

My partner and I believe that a return to direct agreements between doctor and patient is the first step toward providing this experience as the new normal in primary care. I am referring to the medical care model known as Direct Primary Care (DPC). It is so named because patients deal directly with their doctor to form an agreement defining what services and care will be provided for a known and affordable monthly membership fee, rather than billing for services through the middle-man of insurance. One recent joiner to DPC had calculated that his medical cost for primary care would only be about 30% under DPC compared with what he had paid for primary care coverage by insurance the previous year.

Now that Dr. Hone has been practicing a DPC model for the past seven months, we can report that patients in this model are very satisfied with their care, are able to communicate efficiently with our office, and can be seen when needed. Their visits are not so rushed, their wait times have been reduced, and cost is highly affordable due to the reduced overhead from not having to jump through the countless hoops of insurance companies.

The basic fee, not much different than a cell phone contract, covers all basic primary care including normal labs, physicals, maintenance visits and sick visits. Any procedure or lab not included in the membership agreement is offered at a low cost compared to insurance rates, and is discussed in advance with the patient. The lower patient volume in DPC allows more “face time” with patients which translates to better communication all around, the chance to be heard by the doctor and ask questions, and the efficiency of handling more than one complaint at a visit. Because payment is based on a monthly fee, rather than an office visit, communication by phone and email is welcomed rather than discouraged (as it often is in an insurance-based model). Finding the right catastrophic coverage that provides for unforeseen emergencies, imaging, or specialists, is important to complete the picture.

Of course there are still a few folks who have great insurance and may not need Direct Primary Care to help healthcare be affordable and personal. But for many patients we have found that it works wonderfully, saves them time and money, and improves their overall healthcare.

In light of all this Dr. Hone and Trinity Medical are celebrating the Grand Opening of her new office next to Sonic at 1515 E Lamar Alexander Parkway on Thursday, August 11th from 11:00-1:00pm. If you have a few minutes, check it out and find out a bit more about how Direct Primary Care really can be a better way.


Sore Throats – More Complicated Than You May Think

I returned to the exam room with the results of the five minute rapid strep test on an elementary school boy whose mom had brought him in with a complaint of a very sore throat.  “His strep test is negative Mrs. Thompson.”

Well that’s a relief!”

My own thoughts about it were a little more mixed.  Most of the non-strep throat infections are viral so you are left to just letting them run their course.

Pharyngitis is the medical term for infection or inflammation of the throat, generally causing the symptom of a sore throat.  The problem is, someone with a bad sore throat is usually hoping for antibiotics to help them get better.  In fact up to 70% of patients going to a doctor for a sore throat (and there are about 15 million people in the U.S. who see the doctor for a sore throat every year) receive antibiotics.  At the same time, only about 20 to 30 percent of children and just 5 to 15 percent of adults with a sore throat have strep.  Most of the rest have viral infections where antibiotics only contribute to side effects and more resistant infections, while providing no benefit..

So how do we sort out which infections are strep and which are probably viral?  First there are other symptoms that help greatly.  If there is a runny nose or cough with the sore throat it is almost certainly viral and not strep.  A classic strep throat has fever and sore throat without runny nose and congestion, but often with nausea or headache.  Also, age matters: strep is uncommon under 3 years of age, peaks between 4-7 years of age, and becomes less common in adults, though still showing up sporadically.

It has been shown repeatedly that even experienced doctors can’t reliably tell a strep pharyngitis from a viral one just by looking – there is too much cross-over in how they appear.  So a rapid strep test really is needed for accurate diagnosis.  These are up to 90-95% accurate and only take a few minutes.  Recently it has been recommended that the old routine of double-checking a negative rapid strep test with a throat culture be abandoned as it adds cost without any measurable additional benefit.

Here is a question that is not as obvious as it first appears: why do we even want to treat strep throats with antibiotics.  It surprises most people to hear that strep throat will usually clear up in a few days (about 7 days on average) even without antibiotics.  The benefits of the antibiotic (usually penicillin unless a person is allergic to it) are that they:

  • Slightly shorten the course of the infection (by 12-16 hours)
  • Render the person non-infectious more rapidly (usually within 24 hours of starting the antibiotic)
  • May minimally reduce complications such as abscesses of the tonsils or ear infections
  • May possibly help prevent serious other complications of strep pharyngitis. But this is controversial as they have never been proved to prevent the kidney disease called post-strep glomerulonephritis. Likewise many argue that rheumatic fever (a serious complication permanently damaging the heart) doesn’t seem to be caused by the vast majority of the strains of strep currently occurring in the U.S.

So the benefits of antibiotics for treating strep throat are sketchier than they were once thought to be.  And on the other side of the coin, about 10% of those treated with antibiotics get diarrhea, occasionally a serious type caused by C. difficile.  Also 0.24% have a life-threatening allergic reaction. This means that out of 10 million patients treated with antibiotics, as many as 24,000 of them will have fatal or near-fatal allergic reactions.

Most sore throats get better without treatment, even including strep pharyngitis. So the decision to test and treat is a bit more complicated than it was once thought and deserves some individual thought on a case-by-case basis.  As a little side note, that’s why the emergence of telemedicine (where patience are diagnosed and treated by phone) holds as much concern as promise. The tendency to misdiagnose illnesses and misuse prescriptions will only grow with this looser connection between patient and physician.

So who thought something as “simple” as a sore throat would take two articles just to summarize?  But we haven’t even mentioned mono or the non-strep bacterial culprits that can be other serious causes of your sore throat.  More on that next time.