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What is Direct Primary Care?

Since I announced the addition of a Direct Primary Care program to the services offered through Trinity I’ve gotten lots of positive feedback and support.  I’m excited to see the first patients start signing up for the program even though it doesn’t start until January 1st, 2016.

Many people have asked me to provide a short summary of the program and it’s benefits for the average patient.  I could write a lot about why I like this model so much but will try to keep it brief.

The two biggest advantages of this program are the lower cost of providing care and the increased accessibility.  First, with the removal of insurance overhead this office can provide a full range of services at a very low price.  I can only do this by cancelling my contracts with insurance companies to allow a lower than allowable cost.  Most services are inexpensive enough to simply be included in the monthly membership price.  Others can be offered at exceptional discounts.  Second, having more time to counsel over the phone, communicate via email, and spend face to face with each patient allows for more personalized therapies.  I’ve long said that the most valuable thing I have to offer my patients is my focused attention on their concerns bringing to bear my understanding and expertise to their personal, individual situation.  I want to build an office that accentuates those opportunities.

Trinity Medical Associates of Hardin Valley as a Direct Primary Care office will offer the following benefits with membership:

  • Unlimited medically necessary visits in person, over the phone, or via email as appropriate to the situation
  • No per visit copay
  • Direct phone access to me and my office staff during the business day
  • Direct email access to me (
  • Same and next business day appointment availability
  • 24/7 telephone coverage through Trinity Medical Associates on call physician services
  • Longer more focused visits.  The standard visit will be 30 mins in length with physicals lasting one hour.
  • Most in-office testing is included such as rapid strep test and rapid flu test
  • Most routine blood work is included such as Cholesterol testing, Kidney function, Liver function, Thyroid testing, Hgb A1c
  • Most in-office diagnostics are included such as EKG, Audiometry, and Spirometry
  • Yearly influenza vaccination

Membership is $30/month for children up to 22 years of age, $60/month for adults, and $90/month for those 65 years of age and older.  The family plan covers two married adults and all their children at $210/month.  The enrollment fee is waived with sign up prior to January 1st, 2016.  After that the enrollment fee covers the first month of membership with payment.

For those interested in aggressively pursuing better health we’ve added an increased membership level that covers VitalSigns Wellness center membership, VitalMeals enrollment (our email meal planning service), and monthly visits with Nutritional Counseling, Wellness Coaching, or Biblical counseling.  This is designed to give members all the tools necessary to make their health a success story.

I invite everyone with questions to contact me at or Mel Moss, the DPC office coordinator, at  If you already think this is something you’re interested in you can sign up at

Below you’ll find a copy of our flyer.




First Principles: Listen to your patient

At the University of Tennessee Health Science Center in Memphis where I attended medical school I had many excellent teachers.  These teachers spent countless hours at patient bedsides personally instructing me and my classmates using the principles established by Sir William Osler, MD.  In the early 1900’s, Dr. Osler pioneered the teaching method of bringing students to the patient bedside to learn first-hand how to take a patient history, perform a physical exam, and then develop an appropriate diagnosis and treatment plan.  Among Dr. Osler’s many attributes was his adamant belief that good physicians always centered their care on the patient.  His most well known saying is “Listen to your patient, he is telling you the diagnosis” which emphasizes the importance of the patient and their story.

My practice has always tried to take this principle to heart in both patient care and in the way we run the practice.  This has been such a core belief that they are allowing me to embark on a grand adventure that attempts to solve two of the major hurdles I hear my patients tell me they have: the rising cost of routine healthcare and the growing difficulty of routine communication with me as their physician.  I alluded to this in my last post about Trinity’s planned Hardin Valley clinic which I will staff, and Dr. Smith has recently written about it as well in two recent posts: here and here.

The first major hurdle I hear patients have is the rising cost they are having to shoulder to obtain routine primary care.  Unexpected, serious medical problems are known to be expensive (although that is changing too, check out the Surgery Center of Oklahoma) but what many of my patients have wondered is why routine medical care is becoming more expensive.  In fact however, most routine care has become less expensive in the last ten years while the amount that an average patient is responsible for has gone up.  The percentage that patients pay out of pocket has risen even as the cost has come down.

Across the nation, primary care offices are attempting to solve this problem by transitioning to a model of practice called Direct Primary Care.  As high deductible plans become the norm and many remain uninsured, we realize that patients are getting little benefit in cost reduction at a primary care office from having insurance.  At Trinity the allowable (the amount an insurance company reimburses for services) is essentially the same price that someone without insurance pays.  Since each insurance company has a different allowable we’ve made an effort to make our prices as equitable as possible.  We have fought to keep an even playing field for the insured and uninsured alike.  In many venues, the cash price and the insured price are markedly different bolstering the fear we have of a large medical bill.

But what would happen to the cost of care if we simply decided not to utilize insurance for something they aren’t going to pay for anyway?  For instance, if my daughter sees her pediatrician for strep throat my insurance won’t pay any of that visit due to our high deductible.  What would happen to the cost to provide her care if her pediatrician doesn’t have to try to bill or collect from our insurer.  If the doctor doesn’t have to account for the overhead from dealing with insurance then he could charge less for the same care.  In fact, in a Direct Primary Care model the cost to deliver routine medical care without the burden of a bureaucratic overlord becomes so inexpensive as to only cost about $2 a day for most adults.  Imagine being able to have almost all of a typical adult’s primary care medical needs paid for for less than an average cell phone bill.  Children are even less expensive coming in around $1 per day.

The second major hurdle I hear from patients is the difficulty they have connecting with me when they have a need.  Within Trinity, as we’ve doubled and tripled in size in the last nine years, we expanded our phone room staffing, improved patient’s ability to direct their call, added the patient portal that allows for necessary HIPAA compliant secure direct messaging with the clinical staff, and continued to have 24/7 direct access to the on call physician (740-6436) as many other practices have transitioned to a nurse triage service.  Even still, it can be a challenge to get quick feedback for a patient.  Every patient I have inherently knows that when they call my office there is a 0% chance I will answer the phone.  Wouldn’t it be wonderful if time with your physician in whatever venue seems fitting is valued and encouraged?  Why do only office visits constitute active care?

So what avenues of communication can be utilized if the first major hurdle is overcome by arranging for care outside of insurance?  Virtually any of them.  In many Direct Primary Care practices, patients and their physicians communicate by whatever means they feel are appropriate.  There are no longer restrictions and limitations as the care being provided can be fluid and evolve to fit the need.  Patients often continue to utilize secure messaging through a patient portal but often a direct email to their physician replaces it.  Phone calls to the office change from a phone tree based menu to the nurse (or even physician) having the freedom to answer first.  How much simpler would it be if I could answer my patient’s phone calls directly?

While these changes are bold and drastic, Trinity feels like something needs to be done.  We want to help our patients and continue to listen to their needs; trying to solve these problems as best we can.  So as I embark on the journey of a new satellite clinic in Hardin Valley I will be transitioning to this model of practice.  I’m not sure if I’m the guinea pig or perhaps the tip of the spear but either way I’m stepping out with the support of my colleagues attempting to help our patients.  Trinity Medical Associates of Hardin Valley will be a Direct Primary Care practice while the rest of the physicians at Trinity Medical Associates in Fort Sanders West will continue unchanged in their practice.  We want to innovate and experiment ways to help our patients but aren’t so foolish as to put all our eggs in one basket.  Trinity Medical Associates at Fort Sanders West will remain unchanged in their insurance plans and coverages and staff.  They will continue to provide the high level of primary care our patients deserve.

I’ll be providing the details of my Direct Primary Care office in mailers arriving this week but a short summary of Direct Primary Care principles can be found here.

I know Direct Primary Care solves many problems for patients but it doesn’t solve them all. I think it affords the flexibility to grow into an even better solution as more communities recognize its value.  Trinity has chosen to continue their mission to innovate better healthcare and I’m thankful they are allowing me to build a better healthcare experience in primary care.



Grandma’s cough remedy

Every fall those annoying respiratory infections start getting passed around.  Most are short lived and minor. They don’t require antibiotics or homeopathic medications to resolve. Thankfully, our body will cure itself if given enough time. 

However, there are lots of options to help improve symptoms while the body is clearing the infection. One over-the-counter ‘medicine’ that has long been used for soothing a sore throat or calming a bad cough is honey. In a study of children with a cough that was disrupting their sleep, researchers compared a spoonful of honey, specifically buckwheat honey given its dark color and presumably higher antioxidant content, to dextromethorphan, the leading OTC cough suppressant, and a placebo.  Then they polled the parents on which children slept better. The parents didn’t know which therapy their children had received.

The study showed that the parents reported a better night sleep in the children who had received the honey.  So next time you’re suffering through a bad cold consider how wise your grandmother was in offering you good food as the best medicine.  Remember that children under one year of age should not eat honey.  

Found at my local Food City



Well I know I’m tired, but we do have three young children in diapers and I’m not sleeping well.  It’s probably just normal exhaustion.”

My wife’s explanation certainly made sense, but it was so easy to check a thyroid level that we went ahead anyways.  And low and behold, it showed that besides her “normal exhaustion” she was also hypothyroid (having an underactive thyroid gland).  Once this was treated at least some of her exhaustion eased up.  The rest had to wait until our kids (eventually seven of them) were all sleeping through the night.

So how does hypothyroidism usually show up?  It has many symptoms, most of which are very non-specific.  They include fatigue, dry skin, cold intolerance, constipation, weight gain, hair loss, depression, and menstrual disturbances.

And what causes it?  Worldwide iodine deficiency remains the foremost cause of hypothyroidism.  But in the U.S. where iodine intake is adequate, autoimmune thyroid disease (also called Hashimoto’s disease), is the most common cause of hypothyroidism.  In Hashimoto’s disease one’s own immune system is slowly attacking and knocking out their thyroid gland.

Hashimoto’s disease sometimes also shows up with temporary throat pain, full-out exhaustion or painless thyroid enlargement.  If left untreated long enough (rare in the U.S.), hypothyroidism can eventually lead to myxedema coma where a person exhibits marked fluid retention, slowed mental status and even heart failure.

If you’re one of the legions of folks who are fatigued and perhaps struggling with weight gain, the odds are it won’t turn out to be hypothyroidism.  But then again, it’s easy to check and if it really is hypothyroidism then you have something you can readily treat and improve.  The most commonly recommended blood test is called thyroid stimulating hormone (TSH).  If your thyroid is going low, the TSH will go the other way and be abnormally high.  If that turns out to be the case, thyroid hormone levels and thyroid antibody levels can also be checked to define the type of hypothyroidism.

About the only type of hypothyroidism to still have a normal TSH is something called euthyroid sick syndrome or nonthyroid illness.  In other words, if a person has some other severe illness their thyroid may partially shut down until they begin to recover.  There is some controversy as to how to treat these cases but the main approach is to treat the underlying severe illness which then allows the thyroid to recover on its own.

For being such a small gland, perched like a plump butterfly at the base of the front of the neck, the thyroid exerts an amazing amount of control on the rest of the body.  So if you’re getting symptoms suggesting that your chubby butterfly is getting sluggish, get a blood test.  It’s easy and it may allow you to only have to wrestle with “normal exhaustion.”