Dr. Mohammad, Inspire Malibu Monsters & Critics / Dr. Mohammad, Inspire Malibu Michael Phelps Arrested On DUI Charge, What’s Next For The Olympian? October 7, 2014

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*UPDATE
Olympian Michael Phelps has been suspended for six months from USA Swimming-sanctioned competition after his arrest for driving under the influence in Baltimore last week.

In announcing the decision Monday, USA Swimming also said Phelps will be withdrawn from the 2015 FINA World Championships team and that he will forfeit his funding from the national governing board for six months.

“Membership in USA Swimming, and particularly at the National Team level, includes a clear obligation to adhere to our Code of Conduct,” USA Swimming executive director Chuck Wielgus said in a statement. “Should an infraction occur, it is our responsibility to take appropriate action based on the individual case. Michael’s conduct was serious and required significant consequences.”

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Mentally tough and physically well trained, strong and accomplished, Michael Phelps is dealing with the repercussions of a second DUI within a 10 year period, and he has publicly apologized via Twitter and vowed to deal with his issues.

Phelps is the most decorated Olympian of all time with 22 Olympic medals, including 18 gold.  Olympic swimming champion Michael Phelps said Sunday he is “taking some time away” from swimming and will “attend a program that will provide the help I need to better understand myself” after his DUI arrest in Baltimore last week.

phelps tweets

Phelps, 29, registered a .14 percent on a Breathalyzer test after he was stopped on a speeding violation last week, the second time he has been charged with a DUI in Maryland.  Phelps also was charged with DUI in 2004 on the Eastern Shore of Maryland, and he received 18 months’ probation and a $250 fine. Phelps also was required to deliver a presentation on alcohol awareness to students at three high schools.

His second DUI trial is scheduled for Nov. 19.  Previously the USA Swimming governing body suspended Phelps for three months in 2009 after a photo emerged showing Phelps using a marijuana pipe, even though he was never charged.  USA Swimming has not taken any disciplinary action for his second DUI arrest. If he is convicted of the latest charges, he faces up to one year in jail, a $1,000 fine and the loss of his driver’s license for six months.

ESPN reported that his representatives at Octagon say he entered an in-patient program that will keep him from competing at least through mid-November.

A statement from Octagon said Phelps was entering “a comprehensive program that will help him focus on all of his life experiences and identify areas of need for long-term personal growth and development.”

“Michael takes this matter seriously and intends to share his learning experiences with others in the future,” the statement said.

Phelps retired after the 2012 London Olympics, but made a comeback to competition in April and won three gold medals while representing the United States’ team in last month’s Pan Pacific championships.

Phelps, according to ESPN, has already qualified for the worlds, and was not planning to compete in the short course world championships, which will be held in early December in Qatar. The U.S. team for that meet, which includes Phelps rival Ryan Lochte, was announced last week.

Michael Phelps second DUI raises the question if the Olympic champion has more than just a “drinking problem.” Dr. Akikur Mohammad, MD, a board-certified psychiatrist and professor of addiction medicine at University of Southern California’s Keck School of Medicine, suggests that Phelps has all the classic signs of an alcoholic in need of medical treatment.

Dr. Akikur Mohammad is a leading authority on drug addiction and treatment. He is board-certified in psychiatry and addiction medicine, and teaches addiction medicine at USC Keck School of Medicine and is the medical director of the prestigious rehabilitation center Inspire Malibu. He tells Monsters and Critics:

“Being in the public eye is especially hard when you are an Olympian like Michael Phelps. This is a man who has spent his entire life striving for perfection and being better than anyone else in his field. He has also been under a microscope since breaking records at the 2008 Olympics when he was still basically a teenager. Until recently, he was planning on retiring from the sport that gave him so much but decided to come back and compete against much younger and possibly quicker athletes.

“I imagine that trying to be the same Michael Phelps that won so many fans from his early wins and the grueling training with an older body, plus the pressure to succeed has got to be overwhelming. These are the ingredients that can create a very disastrous situation if you already have an alcohol problem, which apparently Phelps does.

“While I don’t know Michael Phelps’ medical history, his pattern of criminalized behavior strongly suggests that he is more than just a heavy drinker. Most likely it’s not that he doesn’t want to stop drinking but rather that he can’t. The self-destructive, physiological cravings that an alcoholic experiences can only be managed through medical intervention.

“Alcoholism is a complex chronic disease with a strong genetic component that requires both behavioral and pharmaceutical therapies. While there is a role for 12-step, AA program for some patients, it should never be the exclusive or the focus of treatment. Let’s hope that Michael gets the kind of evidence-based therapy that he needs.”

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Dr. A R Mohammad

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Dr. Mohammad, Inspire Malibu Celebzter / Dr. Mohammad, Inspire Malibu AN EXPERT WEIGHS IN ON MICHAEL PHELPS DUI ARREST AND SUBSEQUENT REHAB STINT: ‘WHILE I DON’T KNOW HIS MEDICAL HISTORY, HIS PATTERN OF CRIMINALIZED BEHAVIOR STRONGLY SUGGESTS THAT HE IS MORE THAN JUST A HEAVY DRINKER’ October 7, 2014

Michael Phelps, the most decorated Olympian of all time, was arrested last week with his second DUI and had decided to enter a six-week rehab treatment program.

But does this mean the swimming champ has a problem?

DrAkikur Mohammad, medical director and founder of Inspire Malibu Treatment Center and the leading authority on drug addiction and treatment, shares with CelebZter his opinion on the situation.

DrAkikur Mohammad says: “Being in the public eye is especially hard when you are an Olympian like Michael Phelps.  This is a man who has spent his entire life striving for perfection and being better than anyone else in his field.  He has also been under a microscope since breaking records at the 2008 Olympics when he was still so very young.  Until recently, he was planning on retiring from the sport that gave him so much but decided to come back and compete against much younger and possibly quicker athletes.

“I imagine that trying to be the same Michael Phelps that won so many fans from his early wins and the grueling training with an older body, plus the pressure to succeed has got to be overwhelming.  These are the ingredients that can create a very disastrous situation if you already have an alcohol problem, which apparently Phelps does.

“While I don’t know Michael Phelps’ medical history, his pattern of criminalized behavior strongly suggests that he is more than just a heavy drinker. Most likely it’s not that he doesn’t want to stop drinking but rather that he can’t. The self-destructive, physiological cravings that an alcoholic experiences can only be managed through medical intervention.

“Alcoholism is a complex chronic disease with a strong genetic component that requires both behavioral and pharmaceutical therapies. While there is a role for 12-step, AA program  for some patients, it should never be the exclusive or the focus of treatment.  Let’s hope that Michael gets the kind of evidence-based therapy that he needs.”

Dr. Akikur Mohammad is a leading authority on drug addiction and treatment. He is board-certified in psychiatry and addiction medicine, and teaches addiction medicine at USC Keck School of Medicine and medical director of Inspire Malibu Treatment Center.

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Dr. A R Mohammad

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Signature MD Monsters & Critics / Signature MD Primary Care Doctor Explains Real-Life Challenges In New Study’s Recommendations For Men’s Cardiac Health September 24, 2014

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new study on cardiac health, whose results were published this week in the Journal of the American College of Cardiology, makes it all seem so simple: Five changes in lifestyle can reduce your chance of heart attacks by 80%.

Sign us up! But with most things in life, the devil is in the details.

The landmark study is considered a serious contribution to understanding how lifestyle affects health because of its size and scope.

More than 20,000 Swedish men who were 45 to 79 years old in 1997 were tracked until 2009 to see how life treated them, given their choices about diet, exercise and smoking. At the time, they had no history of cancer, heart disease, diabetes, high blood pressure or high cholesterol.

The good news is that those who were considered “ultra healthy” by not smoking, drinking moderately, eating a whole food diet, maintaining a proper weight, and exercising daily had a whopping 86% reduced risk of heart attacks. The bad news is only 1% of men qualified as living this ultra-healthy lifestyle.

Why the disconnect between knowing what’s good for you and actually doing it?

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We decided to take the question out of the rarefied world of medical research and into the real world of patients by asking Dr. Doug Pitman, M.D., a seasoned family practice doctor, to interpret the findings for us.

Monsters and Critics: From your perspective as primary care physician, what are the most important “take-aways” from this study?

Dr. Doug Pitman, M.D.: Lifestyle choices are just as important as genetics in determining those at risk for heart disease. Identical twin studies confirm the fact that those twins who make preventative lifestyle changes have less heart disease then their identical twins who do not make those changes. These studies apply to both men and women. As the study stated these changes include attaining healthy BMIs with respect to weight, having an active lifestyle exercising 5 days per week, moderate alcohol consumption, no smoking, and a proper diet that lowers saturated fat intakes and avoid simple sugars.

Monsters and Critics: Of the “Big Three” problems identified with middle-aged men in the study — bad diet, lack of exercise and smoking — which is the most serious?

Dr. Doug Pitman, M.D.:I would say that smoking creates the greatest risk for heart disease. I suspect this is especially true in women who have a natural hormonal protection against heart disease based on cholesterol profiles.

Monsters and Critics: As a medical doctor, are you at all surprised that in 2014, medical researchers are telling American middle-aged men that drinking a cocktail each night is good for their health? (Will they next find that buying a fast car is good for your health?!?)

Dr. Doug Pitman, M.D.: It is been known for a long time that red wine with all of its antioxidants has a protective effect on blood vessels. In addition alcohol itself raises the good cholesterol HDL and in moderation — which is the key to consuming alcohol beverages — can play a small role in preventing heart disease along with the other behaviors mentioned in the study. Excessive alcohol plays havoc with virtually every system in the body creating fluctuations in insulin levels, which can lead to elevated triglycerides well known as significant risk for heart disease. In addition, the pure caloric intake from alcohol can lead to weight gain especially if drinking alcohol leads to uncontrolled eating.

Monsters and Critics: What is the challenge of the typical family practice doctor in encouraging their male (and female) patients to adopt a healthier lifestyle?

Dr. Doug Pitman, M.D.: The challenge for doctors is pursuing a healthy lifestyle themselves so patients can learn by example. One study that I can recall indicated that the most important factor in a primary care physician’s influence on patients’ risk for heart disease is not what he says but how he looks. If the physician is fit and practices cardiac prevention himself, patients or more likely to emulate his lifestyle. Overweight physicians who smoke cigarettes – which, by the way, wasn’t uncommon when my father was a physician in the 1950s and 1960s – can preach cardiac wellness until he or she is blue in the face, and they will not inspire their patients or promote compliance to their good advice..

Monsters and Critics:  The study suggests 5 lifestyle changes to dramatically improve men’s cardiac health. If you had to add a 6th, what would it be/?

Dr. Doug Pitman, M.D.: My 6th recommendation is one that I have lived by my entire life. Simply put, it’s stress reduction. Find time during the day to relax your mind away from your work and allow your body to exercise in a comfortable way. Get into a relaxed zone of exercise and your brain will rest. I have always stretched my lunch hours into 90 minute exercise sessions involving jogging, cross-country skiing, biking and more recently walking. What better way to prepare yourself for an afternoon of work? Also, try to take a half-day off per during the work week for some quality relax time. And don’t forget to spend quality time with family and friends.

Doug Pitman, M.D. is a concierge medicine doctor with SignatureMD and the founder ofWhitefish Primary Care in Montana, specializing in premier sports and family medical care.

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Signature MD

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Signature MD Medical Economics / Signature MD Direct pay: A promising care model with challenges September 24, 2014

Physicians say direct pay models offer a viable alternative to health insurance, but require careful planning and outreach

 Fed up with the “hamster wheel” of traditional fee-for-service medicine, many primary care physicians are exploring direct pay models as a way to provide better care for patients and derive more satisfaction from practicing medicine.

READ: How to survive in independent practice

While there is no standard definition for what constitutes a direct pay practice, for the most part they fall into one of three categories. The first is a straight cash model, in which patients simply pay out-of-pocket for a procedure or consultation. Sometimes the practice will give the patient a superbill that the patient can submit to his or her insurance company for reimbursement.

Under the second, more common form of direct pay, patients pay a monthly fee to be included in a physician’s panel. The fee covers unlimited office visits and 24/7 access to the physician, including via text or e-mail. In most cases it also includes whatever in-office procedures and tests the physician offers, although some practices charge extra for these.

The third form, often referred to as concierge or personalized medicine, also includes a monthly fee, but one that is generally higher than in direct pay practices. In return, the patient receives services such as a comprehensive annual physical exam, and guaranteed no-waiting appointments. Unlike the other two forms of direct pay, many practices that call themselves concierge maintain contracts with insurance companies.

Direct pay practices

Managing the transition

While the vast majority of physicians using direct pay say they are satisfied with it, ensuring a smooth transition to direct pay (or start-up if it’s a new practice) can be challenging.

READ: Why cost gives independent physicians an edge

To start with, not every practice is well-situated for making a successful conversion. It requires a loyal patient base and solid reputation in the community, says Rob Lewis, vice president of physician marketing and operations for SpecialDocs, a consulting firm that helps practices transition to concierge-style medicine. How long a practice has been operating, and how long it’s patients have been with it, are among the first features SpecialDocs looks at when deciding whether to take on a conversion client, he adds.

Primary care physicians

For a typical primary care practice with a patient panel of about 2,000, Lewis says, between 300 and 600 will elect to stay with the practice after it converts to a concierge model.

As with virtually any issue involving the practice of medicine, finances are a significant consideration in the direct pay equation. Cash flow generally is not a problem at first, either because the practice still has contracts with third-party payers or patients have paid fees in advance of the conversion, or both. But getting the fee structure right is another matter.

“You have to do your due diligence and look at how appealing your practice is likely to be in your particular community,” says Harry Izbicki, DO, co-owner of Izbicki Family Medicine, a direct-pay practice in Erie, Pennsylvania. “If you charge too much, you won’t get enough patients to support your business. But if you charge too little, you’re leaving money on the table and maybe working harder than you have to.”

After deciding to transition to some form of direct pay, informing patients–and persuading them to sign up–becomes the next key challenge. The reason is simple: if patients don’t understand direct pay/concierge medicine, or why your practice is going to use it, or the benefits they will derive from it, they won’t stay with you.

The time required to switch to a direct-pay model varies depending on the size of the practice and patient demographics, but generally requires three to six months. Izbicki says it took his practice about four months to complete the transition, “and was really mostly dependent on contractual obligations of notifying each insurer that we were opting out of our contracts,” he says.

Success stories

The number of practices using direct pay is difficult to pin down, in part because some physicians are reluctant to say they do so, says Michael Tetrault, editor-in-chief of the online publications “Concierge Medicine Today” and “The Primary Care Journal.” “There are slightly less than 4,000 physicians who are verifiably, actively practicing concierge medicine or direct primary care across the United States, with probably another 8,000 practicing under the radar,” Tetrault says. That compares to an estimated 500 who were doing so in 2000, he adds. The Direct Primary Care Journal believes that the growth in direct-pay, non-retainer style primary care practices will grow at a rate of roughly 10-15% in the next few years.

Whatever form they take, such practices almost always have smaller patient panels than under the traditional fee-for-service model, allowing physicians to spend more time with each patient and get to know them better. Equally important, it frees practices from the expense and frustrations of dealing with third-party payers.

The experience of Izbicki Family Medicine is typical. After nearly three years of practicing independently, co-owners Jon and Harry Izbicki realized that the traditional fee-for-service reimbursement model wasn’t working for them, either financially or personally.

“We were in the cattle drive of medicine that the insurance companies have most doctors running nowadays,” recalls Jon who, like his brother, is a D.O. “We realized how it was affecting us adversely from a business standpoint and knowing that to keep our doors open we had to see more and more patients, which started cutting into the amount of time we could spend with them.”

In response, the brothers decided to convert to a direct-pay model. They set monthly fees ranging from $135 for a family to $65 for an individual, which covers all office visits and includes same-day appointments and 24/7 access to the providers. The practice negotiated a direct-purchase agreement with a local provider of lab services, enabling them to provide services such as lipid panels and blood workups for a fraction of the usual cost, often $10 or less.

In addition, because Pennsylvania allows physicians to dispense medications, the practice operates a pharmacy at which patients can get prescription medications for up to 90% less than at commercial pharmacies.

So far, says Harry, direct pay is succeeding. “We have the time to more effectively manage the medical concerns of our patients, without worrying about the number of patients we need to see each day to break even, or whether they have insurance,” he says.

He adds that the practice retained about 15% of its patient panel following the conversion, but “we still have upwards of a thousand patients who have yet to either sign up or tell us they’ve transitioned to a new physician.”

Like most practices converting to direct pay, Izbicki continued to treat all its patients up to the day of conversion, regardless of whether they planned to continue with the practice. Patients who wanted to transfer to another practice were directed to a local hospital and the county medical society for help in finding a new provider.

The ability to spend more time with each patient is often the deciding factor for practices that choose a direct pay model, says Matt Jacobson, founder and chief executive officer of SignatureMD, which helps practices transition from fee-for-service to a concierge-style practice. “The only correlation we can see between any sort of medical practice and better patient outcomes is time. Simply spending more time with patients inherently leads to better results,” he says.

Most of the physicians SignatureMD works with end up with between 350 and 400 patients in their panels, each of whom pays an “amenity fee” averaging  $1,720 annually, Jacobson says. For that they receive guaranteed same- or next business-day appointments and appointments for non-emergency medical issues are guaranteed to start on time.

Jacobson says nearly all his client practices use what he terms a “market segmented” model, under which patients who choose not to use the concierge service remain with the practice and continue to use third-party payers, but are treated by a midlevel rather than the physician. “Those patients often matriculate up to the concierge practice over time as they tend to have a change in health or economic circumstance,” he says.

For Brian Forrest, MD, a major benefit of direct pay has been the ability to provide more access to primary care. Forrest heads Access Healthcare, a family practice in Apex, North Carolina, about 10 miles from the state capital of Raleigh. When he opened his doors in 2002, he says, the county had about 85,000 people without health insurance, and probably ha more today.

To help address that need, he decided he would keep Access’s overhead expenses as low as possible, which also meant not going through insurance companies for payment. As a result, he was able to set a monthly fee of $25 per patient, plus $5 per office visit. For patients who preferred not to join the practice, there was an a la carte pricing schedule with no service costing more than $40.

direct pay chartToday the practice has three providers, with a patient panel of 6,300, of whom 3,300 are active, says Forrest. Membership fees have risen to $40 month. The practice also charges $20 for each office visit. “That covers the variable cost of seeing patients in the office [rather than through telemedicine or e-mail,] says Forrest. It’s the right amount to keep patients from coming more than they should, while not causing them to delay any necessary care.”

Forrest schedules one patient visit per hour, but spends an average of 45 minutes per patient. The remaining quarter-hour is for dealing with walk-ins. “It’s a luxurious pace, and I love it,” he says. His patient panel includes everyone from homeless people to millionaires.

“The homeless people say there’s nothing else they can afford. And we have millionaires who drive two hours away who tell me ‘I can’t pay anyone to get the kind of care I get here.’”

Because Access has used direct pay from the outset, it didn’t have to go through the process of explaining the model to existing patients.  Even so, Forrest says that when patients calling for appointments learned how the practice operated, “initially 80% of the people would just hang up the phone. But now that people have gotten to know us, I’d say 90% of the people who walk in the door understand that we don’t do insurance.”

Among his fastest-growing subset of patients, he adds, are patients covered by Medicare who want to be “off the grid.” “They don’t want to go to a doctor participating in meaningful use who will make their data available to Medicare,” he says.

Prior authorizations

Since most patients at direct-pay practices still have some form of health insurance, physicians are not free of the burden of obtaining prior authorizations for some procedures and medications.

READ: The prior authorization predicament

At the same time, having fewer patients reduces the number and the time spent on them. Apex in North Carolina “has to deal with the same [prior authorization] bureaucracy as everyone else,” says Forrest. When faced with a rejection from an insurance company he will sometimes threaten to tell his local newspaper that the insurer is denying needed coverage to a patient. “Most doctors can’t do that because their contracts with insurance companies prevent them from talking about it [authorization denials],” he says. “I can, and I get everything approved.”

Doug Nunamaker, MD, a physician with Atlas Family Practice in Wichita, Kansas, says many of his patients have high-deductible insurance plans that don’t cover many of the procedures typically requiring prior authorizations, so he does them no more than two or three times a year.

Atlas has about 1600 patients in its panel, which allows its providers to spend at least 30 minutes–and sometimes up to 90 minutes–on each appointment. Nunamaker averages about six patient visits per day. “There’s either quality or quantity, and traditional medicine now is all about the quantity,” he says. “If I can only spend six or seven minutes with a patient, they’re not getting good care.”

Staffing changes

Practices switching to a direct-pay model often find they undergo staffing changes. That’s due in part to the need for higher standards of patient service, particularly among practices using concierge medicine, says Signature MD’s Jacobson “You can’t charge a premium fee without having premium service across the board,” he says.

Jacobson advises clients to identify the staff member who best relates to patients and making him or her the primary point of contact with patients who have signed up for concierge services. “You want the person who treats patients like they’re at the Ritz Carlton focusing on the membership patients,” he says.

Lewis says physicians sometimes will use the conversion process as an opportunity to  dismiss staffers who haven’t been performing well, although those people often wind up leaving of their own accord. On the other hand, “some physicians, if they have a particularly tight-knit staff, will decide to keep everyone initially, and wait for attrition to pare down the staff.”

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Signature MD

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Dr. Mohammad, Inspire Malibu Health.com / Dr. Mohammad, Inspire Malibu Is Robert Downey Jr. Right that Drug Addiction is Genetic? September 17, 2014

Getty Images

A child of an addict or alcoholic is more likely to get hooked.

“Pick a dysfunction and and it’s a family problem,” the Iron Man star told Vanity Fair. It’s not a far-fetched statement. ”Sons of alcoholic fathers are up to nine times as likely to develop drinking problems as the general population,” Dr. Mohammad notes. “Babies of alcoholics adopted into non-drinking homes have almost the same odds of alcoholism as they would if they’d stayed with their birth parents.”

Partying as a teen can set you up for future drug problems.

Robert Downey Jr. has spoken openly about his father (director Robert Downey) introducing him to drugs at an early age, once telling People“When my dad and I would do drugs together, it was like him trying to express his love for me in the only way he knew how.”  Bad idea, say the experts. “Young people (from birth to their college years) have a much higher chance of incurring permanent brain damage from using alcohol or drugs, because their brains are still developing,” Dr. Mohammad explains. Not to mention, partying with the kids sends a powerful message that getting drunk or high is a smart idea.

Nurture also matters–in a surprising way.

Nature and nurture play a role in drug abuse: ”Your environment can trigger the genetic component,” explains Dr. Mohammad. For an alcoholic, simply passing a bar is enough to stimulate the brain receptors that turn on a craving for alcohol. And it can be a lifelong vulnerability. ”Look at Philip Seymour Hoffman,” Dr. Mohammad points out.  ”After 20-plus years of being clean and sober, he reportedly snorted heroin several months before his death, and his addiction returned full-blown.”

These two steps help prevent the problem.

“The vast majority of people who take a drink or even shoot heroin will not become addicts,” says Dr. Mohammad. (Only 10% of the population have a true addiction.) But if you have a family history, it’s key to make lifestyle tweaks. Two smart moves: Avoid friends who party hard and get counseling for any mental health issue that could cause you to ”self medicate” with booze and pills. The encouraging news for the Downeys of the world: the cycle of addition can be broken, stresses Dr. Mohammad says: ”Their fate isn’t sealed.”

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Dr. A R Mohammad

Inspire Malibu

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