A new kind of doctor’s office charges a monthly fee and doesn’t take insurance – and it could be the future of medicine – TheBreakAway

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Source: BusinessInsider.com
March 19, 2017

Dr. Bryan Hill spent his career working as a pediatrician, teaching at a university, and working at a hospital. But in March 2016, he decided he no longer wanted a boss.

He took some time off, then one day he got a call asking if he’d be up for doing a house call for a woman whose son was sick. He agreed, and by the end of that visit, he realized he wanted to treat patients without dealing with any of the insurance requirements.

Then he learned about a totally different way to run a doctor’s office. It’s called direct primary care, and it works like this: Instead of accepting insurance for routine visits and drugs, these practices charge a monthly membership fee that covers most of what the average patient needs, including visits and drugs at much lower prices.

That sounded good to him. In September, Hill opened his direct-primary-care pediatrics practice, Gold Standard Pediatrics, in South Carolina.

Hill is part of a small but fast-growing movement of pediatricians, family-medicine physicians, and internists who are opting for this different model. It’s happening at a time when high-deductible health plans are on the rise – a survey in September found that 51% of workers had a plan that required them to pay up to $1,000 out of pocket for healthcare until insurance picks up most of the rest.

That means consumers have a clearer picture of how much they’re spending on healthcare and are having to pay more. At the same time, primary-care doctors in the traditional system are feeling the pressure under the typical fee-for-service model in which doctors are incentivized to see more patients for less time to maximize profits.

Direct primary care has the potential to simplify basic doctor visits, allowing a doctor to focus solely on the patient. But there are also concerns about the effect that separating insurance from primary care could have on the rest of the healthcare system – that and doctors often have to accept lower pay in exchange for less stress.

How direct primary care works

Courtesy Lauren Clark

Dustin and Lauren Clark, who operate Black Bag Family Healthcare.

For Brent Long and his family, paying for healthcare is now like paying a cellphone bill. Since they joined Black Bag Family Healthcare in Johnson City, Tennessee, about two years ago, the family has paid about $150 a month to belong to the practice.

Long joined around the time he was shifting his insurance to a high-deductible health plan. There were two reasons he decided to switch and start paying for all six members of his family to get direct primary care: the cost-effectiveness of not having to deal with copays or urgent-care visits, and the fact that it could easily fit his family’s busy lifestyle that doesn’t jibe with spending hours in waiting rooms.

Included in that monthly fee are basic checkups, same-day or next-day appointments, and – a big boon to patients – the ability to obtain medications and lab tests at or near wholesale prices.

Direct primary care also comes with near-constant access to a doctor – talking via FaceTime while the family is on vacation, or taking an emergency trip to the office to get stitches after a bad fall on a Saturday night. Because direct primary care doesn’t take insurance, there are no copays and no costs beyond the monthly fee.

Skye Gould/Business Insider

When Blythe Fortin went in for a recent visit at sparkMD, a direct-primary-care practice in Boise, Idaho, Dr. Julie Gunther spent an hour chatting with her before getting to the results of her blood test, which showed elevated blood-sugar levels.

“She listened when I said I can manage with diet,” rather than starting her on medication, Fortin said.

Fortin, who pays $60 a month for sparkMD, had used a different kind of subscription healthcare called concierge medicine. It has some similarities to direct primary care but often costs thousands per month and still incorporates health insurance. She says she prefers direct primary care because the quality of care she has received is better than concierge medicine, and she likes that it’s available to a wider base of patients.

At the 17 direct-primary-care practices Business Insider spoke with, the percentage of members who still had insurance varied. At some practices, all but a handful had some form of insurance, while at others a little more than half didn’t have insurance.

Courtesy of Dr. Julie Gunther

Dr. Julie Gunther of sparkMD with one of her newest patients.

To describe how coverage functions under direct primary care, doctors use the example of car insurance: You don’t use your car insurance for small transactions like oil changes, but it’s there for you if you get in a car accident. Likewise, health-insurance plans – especially those with high deductibles – can be there if you require healthcare beyond primary care.

For those who have insurance, the choice to pay for both makes financial sense, even if they can’t use it at their doctor’s office.

Fran Ciarlo has coverage through Medicare but decided to pay for sparkMD as well. One of the ways she’s seen an advantage is in prescriptions – like many direct-primary-care practices, sparkMD can provide prescriptions at wholesale prices, adding a 10% fee. On a recent visit, Ciarlo estimated she had saved at least $100 on prescriptions for standard steroids and antibiotics that in total cost her $6.

And for those with high health-insurance costs, it’s occasionally a choice between paying a monthly premium or the monthly membership fee for a direct-primary-care practice. For Rebekah Bennett, paying for direct primary care at sparkMD made more sense for her and her children than opting for insurance through the Affordable Care Act marketplace, since for roughly the same cost, if not less, her family could see their doctor without any copays.

The history of the direct-primary-care movement

Philip Eskew, who has tracked the movement through his website, Direct Primary Care Frontier, said direct primary care began at the end of the 1990s and early 2000s. Around that time, three doctors had the idea to go insurance-free, charging monthly fees instead and freeing up time to enjoy practicing medicine. This way, patients who might not have insurance could have a clear idea of how much going to the doctor would cost.

One of the three founded Qliance, a direct-primary-care system based in Washington state that got its start in 2007. The company was backed by Amazon CEO Jeff Bezos and Dell founder Michael Dell before the company leadership bought it to run it privately, without investor pressure. Qliance now has about 25,000 members visiting a handful of clinics around Puget Sound.

Cofounder Dr. Erika Bliss sees this movement growing in the future from its grass roots, rather than becoming big and national.

“It keeps the resolve and the drive toward independent primary care,” she said, which she described as a critical element. She says she envisions independent practices with maybe 10 to 20 providers at three to five locations being about as big as they’d get.

Getting off the ground

Dr. Matthew Abinante opened his practice in Huntington Beach, California, in September. Since then, he has had two people call his office to find out more about his practice. When he explained the system, he said, the callers thought it had to be a scam.

It’s one of the biggest hurdles doctors face when starting direct primary care – the “too good to be true” factor, the learning curve that comes with the understanding that “No, you won’t be using insurance here.” Even so, Abinante has signed up about 150 patients.

Going into direct primary care often means ditching the reliability of a salary. Because the practice relies on membership fees, the more patients who sign on, the more money that can be made. Practices cap their number of patients at anywhere from 300 to 1,000.

And it’s not exactly cheap to get started. Dr. Vance Lassey, who runs Holton Direct Care in Holton, Kansas, took out a loan to start his practice and spent time renovating a 750-square-foot space he rented from a friend at an industrial park. He picked up a lot of old equipment from a nearby nonprofit hospital and surplus stores. For his in-house pharmacy, Lassey took mismatched cabinets and refinished them so they matched.

Courtesy Dr. Vance Lassey

Dr. Vance Lassey in front of the pharmacy cabinets he built from a mismatched set.

Keeping his costs low helped Lassey break even within four months of opening his practice. Still, he’s not earning as much as he used to when he worked at a hospital and had only five to 10 minutes with a patient – a lot less time than he gets to spend with his patients now.

“I am making a profit, I have more free time, and I can practice properly,” he said. “It’s worth it to me.”

Others, like Dr. M. Chad Williamson in Fort Payne, Alabama, went upscale – he offers his patients a 24-hour gym as part of his practice’s $60 monthly membership fee. Williamson, who opened his practice in August, a few months after finishing his residency, currently has 215 members. He wants to bring that up to between 600 and 1,000 people, ideally.

And it’s not just building the office space – direct-primary-care doctors are also responsible for building referral relationships with other doctors in the area.

What’s holding direct primary care back

While doctors and patients using direct primary care might praise the model – it was hard to get anybody to suggest a group, geographic or otherwise, that they thought wouldn’t benefit from direct primary care – not everyone is sold just yet.

Carolyn Long Engelhard, a public-health expert and professor at the University of Virginia School of Medicine, broke down the main concerns with direct primary care:

It might give the false impression that it’s a kind of insurance, so people might not opt to also get a real insurance plan. But if a patient were to have a health issue outside the scope of primary care, they wouldn’t be protected financially. All the providers Business Insider spoke with said they recommended patients have some form of insurance, and there were many instances where most patients in a practice had insurance or took part in a healthcare sharing plan, a program that functions like insurance in which an amount is sent monthly to people who have medical expenses in the plan.
Because doctors at direct-primary-care practices take on fewer patients than doctors at traditional primary-care practices, it might add to the caseloads of primary-care doctors. There is a shortage of these doctors in the US, partly because many choose to go into specialty medicine. Some doctors, on the other hand, say that they would have considered leaving medicine outright if they hadn’t had the option to do direct primary care. “There are doctor shortages already, so I say, ‘Compared to what?’” Dr. Chad Savage, who runs YourChoice Direct Care in Brighton, Michigan, told Business Insider.
Direct-primary-care physicians could become isolated from other doctors, and because the only person the direct-primary-care doctor has to answer to is the patient, there are fewer insurance regulations in place, potentially putting patients at risk. This is one of the reasons that getting hard data on how direct primary care compares with traditional practices is difficult. But between direct-primary-care networks and the referral relationships doctors build in their communities, there might not be so much isolation from the rest of the system. Dr. Deborah Moore of AmarilloMD in Amarillo, Texas, said she has more time now to do research than she did when she worked at a clinic. “I can do what I really need to be doing,” she said.

Engelhard worries about the direct-primary-care model becoming the norm. Generally, she said, “I do think it has a place in our healthcare system.” Instead, though, she’d like to see more adoption of the “patient-centered medical home,” a model in which primary care is more of a team effort.

Medical organizations have had mixed reactions to the movement as well. The American Academy of Family Physicians supports it, while the American College of Physicians, which represents internal-medicine doctors, has chosen not to take a stance on direct primary care.

There are also logistical hurdles that present challenges. For example, Eskew said that in the eyes of the Internal Revenue Service, having a health savings account is illegal if you’re a member of a direct-primary-care practice. The IRS views the monthly fees as insurance payments, making the person ineligible for an HSA, he said. Patients also can’t use the funds from an HSA, flexible savings account, or Medicare savings account to pay their monthly membership bills.

But politicians have shown support for the business model. Libertarians see direct primary care as a free-market solution to healthcare, and legislation at the state level has gained support from Democrats and Republicans alike. And direct primary care is on the radar of Department of Health and Human Services Secretary Tom Price, who while he was a member of Congress introduced a plan that would allow HSA funds to pay for direct primary care.

“Whoever is in power tries to take credit,” Eskew said. The ACA contains a paragraph about direct primary care that allows for the business model. It’s unclear what would happen to direct primary care under the American Health Care Act, the proposed bill to replace the ACA.

Courtesy of Dr. J. Bryan Hill

Hill with a patient.

Where does direct primary care go from here?

As one of the first pediatricians to go into direct primary care, Hill has had the additional challenge of figuring out how the service works with children. Unlike many direct-primary-care physicians, he offers one-time visits to nonmembers. He said he also spends a lot of time listening to what parents want and sets his prices accordingly, offering discounts to families with three or more kids.

Doctors who are part of the movement tend to be the first in their area to have a direct-primary-care practice, and patients the first of their friends to use direct primary care. But all said they had positive experiences with the model.

“This is a niche, but a niche that makes sense,” Long said.

If direct primary care continues to gain traction, it could lead to new kinds of insurance plans – ones that don’t necessarily factor in primary care. Already, patients with high-deductible healthcare plans are using this. But direct-primary-care doctors also said they’d prefer to recommend catastrophic health insurance plans, which have deductibles as much as $10,000 or $30,000 and aren’t allowed under the ACA.

Even with the growth in the last few years, Bliss said the market is still slow, and a lot of unknowns would come with the AHCA should it become law. And it will be hard to get fully insured employers to use it in the same way self-insured employers and unions have picked it up.

Either way, those in direct primary care are optimistic about the movement’s future.

“In 10 years, we’re going to be an overnight success,” Eskew said jokingly.

‘Horrific incident’: Family speaks out after pet dog killed by ‘cyanide bomb’ | Xtreme Idaho | idahostatejournal.com

By Shelbie Harris sharris@journalnet.com

POCATELLO — As he walked his dog along the ridgeline of the hillside just south of his family’s home on West Buckskin Road, 14-year-old Canyon Mansfield noticed what he thought was a sprinkler head protruding 6 inches from the ground.

Like many curious teenagers would, he bent down and touched the pipe, which erupted with a loud popping noise that knocked Canyon off his feet. A hissing sound ensued and Canyon noticed his clothing and face were covered with an orange, powdery substance. After quickly washing his face and clothes in a nearby patch of snow, he called for his dog, a 3-year-old Lab named Casey.

But Canyon’s best friend didn’t respond.

Within minutes, Casey was dead.

“My little brother is lying in bed crying next to me,” said Canyon’s sister, Madison Mansfield. “He spent yesterday in the emergency room after stumbling upon an unmarked cyanide bomb in the woods directly behind my home. He watched his best friend suffocate as sodium cyanide was deposited in his mouth.”

Canyon was taken to Portneuf Medical Center, where he was treated and released. But he must continue daily follow-up appointments to check toxicity levels.

On Thursday afternoon, Casey joined thousands of other non-targeted animals — both wild and domestic — that have been mistakenly killed by one of the most lethal tools at the disposal of the U.S. Department of Agriculture — spring-loaded metal cylinders that are baited with scent that shoot sodium cyanide powder into the mouth or face of whatever or whoever touches them.

Known as M-44 devices, the Animal and Plant Health Inspection Service (APHIS) division of the USDA deploys these sodium cyanide capsules throughout the West to protect livestock from coyotes, wild dogs, and red and gray foxes.

M-44s are hollow metal tubes 5 to 7 inches long that are driven into the ground, loaded with 0.9 grams of sodium cyanide and coated with the smelliest bait possible.

Though the devices are legal methods of controlling local predators, the legality regarding the manner in which the device that killed Casey was planted remains under investigation.

On Friday, APHIS released the following statement regarding the incident:

“APHIS’ Wildlife Services confirms the unintentional lethal take of a dog in Idaho. As a program made up of individual employees many of whom are pet owners, Wildlife Services understands the close bonds between people and their pets and sincerely regrets such losses. Wildlife Services has removed M-44s in that immediate area. Wildlife Services is completing a thorough review of the circumstances of this incident, and will work to review our operating procedures to determine whether improvements can be made to reduce the likelihood of similar occurrences happening in the future.”

The spokesman for APHIS, R. Andre Bell, said in a Friday statement that “the unintentional lethal take of a dog is a rare occurrence (and Wildlife Services) posts signs and issues other warnings to alert pet owners when wildlife traps or other devices are being used in an area for wildlife damage management.”

The statement also said that M-44 devices are only set at the request of and with permission from property owners or managers, and that this is the first unintentional take of an animal with an M-44 device in Idaho since 2014.

“The USDA’s statement regarding the horrific incident that happened to my family yesterday is both disrespectful and inaccurate,” Madison said. “The USDA intentionally refers to the brutal killing of our dog as a ‘take’ to render his death trivial and insignificant.”

She continued, “They also claim that the killing of an unintended victim is a rare occurrence, but this is entirely untrue. In fact, this issue is nationally recognized due to the lack of selectivity of cyanide bombs, and there have been many reported incidents in which unintended animals and people have been targeted.”

On March 11 near Casper, Wyoming, a national nonprofit advocacy organization called Predator Defense reported that two families out on a hiking trip, including an 8-year-old girl, watched two of their four canine companions die after uncovering unmarked cyanide devices.

When deploying these “cyanide bombs,” applicators must adhere to several guidelines that include requesting permission from the landowners and posting warning signs in both Spanish and English.

However, Canyon said he did not see any posted signs.

“The guy that planted them there said he got consent,” Canyon said. “And he said he put signs up but I would have noticed it because I go up there all the time.”

There were no obvious warning signs, according to Bannock County Sheriff Lorin Nielsen, but as of Friday afternoon, his deputies were still investigating.

“The trapper that set those for the federal government did show up, we were able to interview him and he has disarmed those that are in that area, and hopefully the rest of the county,” Nielsen said.

The identity of the individual who set the cyanide traps could not be confirmed as of Friday afternoon, but Nielsen did confirm the individual is an employee of APHIS.

The Bannock County Sheriff’s Office believes the incident happened on Bureau of Land Management land south of the Mansfield’s property. However, the BLM said Friday the incident did not happen on its land.

“I’ve been sheriff for 20-plus years and I have never heard of these before,” Nielsen said about the cyanide bombs. “It just doesn’t make a whole lot of sense to have a landmine-type device that disperses cyanide gas.”

Cyanide is notoriously known as one of the fastest-acting poisons to ever exist. Yet it’s so uncommon that the Bannock County Sheriff’s deputies, Canyon’s father, Mark, who is a local doctor, and the doctor at the emergency room didn’t immediately know how to handle the situation.

The poison works by binding to hemoglobin, the molecule in red blood cells responsible for transporting oxygen throughout the body. It then prevents the cells from using oxygen to make energy molecules. Essentially, cyanide suffocates the victim exposed to it from the inside out.

“Not only is cyanide unethical, the antidote is highly ineffective and can rarely be administered in time to treat it,” Madison said. “My dog suffered as he struggled for breath while my brother stood helplessly nearby. This is not humane, and no animal, dog or coyote should ever be killed in such a gruesome manner.”

APHIS agency records show that more than 3,400 animals have been mistakenly killed by M-44s between 2006 and 2012. These include black bears, bobcats, raccoons, opossums, ravens, ringtails, red fox, gray fox, kit fox, swift fox, turkey vultures and dogs, according to the Sacramento Bee.

At least 18 employees and several members of the public have also been exposed to cyanide over the past 25 years. None died, but many were treated for nausea, blurred vision and other symptoms, the Sacramento Bee reported.

“The placement of these unmarked devices in a residential area without notifying the families and the authorities is grossly negligent,” Madison said. “The individual who placed the bombs is most certainly not ‘highly-trained’ as the USDA claims. If he was, he would have noticed the homes clearly beneath him and this tragedy could have been easily avoided.”

Some of the cyanide devices used to control predator populations are manufactured at Pocatello Supply Depot in Pocatello.

In July 2014, Pocatello Supply Depot transitioned from being a private company and became a fully federalized facility operated exclusively by Wildlife Services, according to documents posted to APHIS’s website.

Canyon’s mother, Theresa Mansfield, said she wants to make the public aware of this situation and doesn’t want to see another pet or child put in danger.

“This is horrific,” Theresa said. “This is like terrorism in my backyard.”

Source: ‘Horrific incident’: Family speaks out after pet dog killed by ‘cyanide bomb’ | Xtreme Idaho | idahostatejournal.com

Happy Eostre – secretsoftheserpent

Source: Happy Eostre – secretsoftheserpent

Eostre(Ostara) is a time to celebrate the vernal equinox. A time when both day and night are equal. A time to celebrate the goddess giving birth. The Holly King is reborn; when Eostre, the Goddess of spring appears in the vines as the ultimate representative of fertility, to present the Eostre egg. It is said that her symbol is a rabbit, an image perceived from the moon and it is the Eostre bunny. It is thought that our Easter celebration comes from Eostre, but she like all goddess come from one special lady in Egypt.

Pagans are right when they say that everything in Christianity was stolen from them, but it was pagan Egypt. What most pagans don’t realize is most of their customs come from Egypt too. If you have followed my work, you know that Egypt was the beginning of it all after the war of the gods. When people left Egypt, whether they were forced out or just left freely, they took all the customs with them. Everything came out of Egypt.

Eostre is a version of Isis. Isis is where we get Easter. In Egyptian Isis is Ast or Est, from which we get Ester or Easter and it refers to the stars or heaven. The hieroglyph for Isis has an egg in it. This is where we get the Easter egg. Isis was a fertility goddess and she was the Queen of Heaven. Where does the easter bunny fit in to all this? Besides being an obvious symbol of fertility the hare was a big symbol in Egypt too. Our ol buddy Osiris, husband of Isis, was sometimes called Un-nefer, and portrayed with the head of a hare. Un-nefer is translated as “the good being” or “beautiful renewl”. The hare in Egypt had to do with Lunar worship, so we are taken back to Thoth once more(See God(s) post). One thing I found very interesting is that Thoth is the god of writing in Egypt. In the Mayan belief it was a hare deity that was the god of writing. The hare in Egypt also had to do with creative energy. If you have read my Magic post, you know sexual and creative energy or the same. That is what the hare is pointing to in certain texts.

Now that you know where this pagan holiday comes from, celebrate Eostre with an abundant array of spring flowers. In the pagan tradition colored eggs, charged as talismans, are given as presents; curative fires are lit at dawn; seeds are planted for new crops, and homes are spring cleaned. Hot cross buns are baked which tells me this pagan celebration is about 2000 years old or is a Pisces custom. Hot crossed buns is purely a Virgo celebration and Virgo is the opposite sign of Pisces. The opposite sign was just as important to the ancients. Baskets are woven to celebrate birds making their nests. On a side note, Eostre(Ostara) is where we get the name for the female hormone oestrogen or estrogen.

Happy Eostre/Isis day!