Primary Care Doctor Explains Real-Life Challenges In New Study’s Recommendations For Men’s Cardiac Health


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?


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.

Original Article

Signature MD

Direct pay: A promising care model with challenges

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.”

Original Article

Signature MD

Is Robert Downey Jr. Right that Drug Addiction is Genetic?

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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.”

Original Article

Dr. A R Mohammad

Inspire Malibu

Back to School for Healthy Habits

Nishi and partners teach students at Sunrise Elementary about their bodies. PHOTO COURTESY KHALILI CENTER

Nishi and partners teach students at Sunrise Elementary about their bodies. PHOTO COURTESY KHALILI CENTER

At Sunrise Elementary School in Boyle Heights, teachers were noticing their students having fried food and a Coke for breakfast, and Flamin’ Hot Cheetos and another Coke for lunch. They knew a change had to be made. This inspired bariatric surgeon Gregg Kai Nishi, M.D., and his partners at the Khalili Center for Bariatric Care in Beverly Hills to volunteer at LAUSD schools to teach kids about obesity awareness and prevention, and how to make healthy lifestyle choices.

“We as a society don’t do much to educate our public about the dangers of overeating or eating fast food and not exercising,” says Nishi. “At first, the kids weren’t familiar with a lot of different types vegetables, and what was healthy for you versus what wasn’t… We explained why [doctors] do the things they do, and what parts of the body can be affected by not eating healthy.”

When Nishi visited Sunrise Elementary School, he would show up in his scrubs and white coat. He role-played with the students, letting them be the doctor so they would be less afraid. He then developed a program to teach the kids to be healthier. The doctors would talk to the students about eating healthy and making healthy choices, and then go outside and exercise with them.

Nishi took some of the practices he uses for adult patients and introduced them to the kids as well. He gave the students at Sunrise Elementary pedometers and helped them set goals for how far they should walk each day. The Khalili Center also sponsors their patients to participate in the LA Marathon 5K, and, with the help of Nishi and the center, many kids are now participating in the event.

Nishi exercising with the kids at Sunrise Elementary. PHOTO COURTESY KHALILI CENTER

Nishi exercising with the kids at Sunrise Elementary. PHOTO COURTESY KHALILI CENTER

The students at Sunrise Elementary were so inspired by what Nishi was teaching them that they began to share their newfound knowledge. Kids would go home and share with their families what they learned about being healthy. Their passion grew strong enough that they were even able to get the taco truck in front of the school to serve fresh fruits and vegetables.

Nishi’s top three healthy lifestyle tips include making healthy food choices, exercising and surrounding yourself with people who do the same thing. All of the technology of today tempts kids to just be at home, but Nishi encourages parents to stress the importance of getting outside. “Don’t just say it, do it together. It is not easy,” Nishi says, “but in order to save ourselves, society and our children, we have to put in a little bit of effort to make a change.”

Original Article

Learn More about the Khalili Center for Bariatric Care

Concierge Medicine Provider MDVIP A Monopoly? Lawsuit Says So

MDVIP Corporate Office Headquarters at 1875 Corporate Boulevard NE in Boca Raton

MDVIP Corporate Office Headquarters at 1875 Corporate Boulevard NE in Boca Raton Melanie Bell

Boca Raton-based MDVIP Inc. is to concierge medicine as Hollywood is to movies.

It is very much the alpha dog in the growing health care niche, which once was the bastion of the rich but is now an available option to many workers through their employer’s insurance plans.

For an upfront annual fee, patients are given specialized attention by physicians with limited patient loads. Services can include house calls, longer appointments and greater access. Some high-end concierge doctors are available 24 hours, seven days a week and will even travel to a vacation location if a patient is ill.

But MDVIP’s competitors say there’s a reason why it dominates the industry, accusing it of creating a monopoly in many regions. An antitrust lawsuit filed against the company claims it has used courts and noncompete agreements with its doctors to bully its way to the top.

Signature MD Inc., a competitor based in Marina Del Rey, Calif., filed an antitrust lawsuit in July against MDVIP in Los Angeles. The lawsuit assigned to U.S. District Judge Dolly M. Gee alleges the company hobbles doctors by making them sign a two-year noncompete agreement.

MDVIP often files lawsuits to enforce the agreements in Palm Beach County, even against nonphysician employees who switch to competitors. The company in January 2013 sued Signature MD and some of its employees asserting theft of trade secrets.

Signature MD described the lawsuit as a “sham” in the antitrust lawsuit.

“MDVIP has no legitimate business justification for the restrictive covenant and uses it simply to hinder its competitors from hiring individuals who are experienced in the concierge medicine industry,” according to the lawsuit filed by Duane Morris attorneys Wayne A. Mack in Philadelphia and Cyndie M. Chang in Los Angeles. “Following the expiration of the restrictive covenant, MDVIP continues this anti-competitive conduct by filing lawsuits against its former patient advocates who work for competitors.”

MDVIP has filed a lawsuit in Palm Beach Circuit Court against three former employees, none of whom are doctors. The defendants are a former senior marketing analysts and two former patient advocates who now work for Signature MD. They are accused by MDVIP of improperly obtaining access to the company’s confidential and trade secret information.

Signature MD and two employees in the Palm Beach lawsuit are being defended by Gail McQuilkin, managing partner of Kozyak Tropin & Throckmorton in Coral Gables. She referred questions for comment to Signature MD’s CEO Matthew Jacobson.

Growing industry

Jacobson started Signature MD eight years ago with $300,000, and the company is projecting $27 million in revenue in 2014. He saw an opportunity for concierge medicine with the baby boomer generation getting older and primary care physicians getting squeezed by insurance companies.

“No one was going into primary care because they couldn’t make it any more,” Jacobson said. He estimates Signature MD is 10 percent the size of MDVIP.

He and his attorneys claim MDVIP is using the courts to bully competitors and former employees, and is in effect using the courts to conduct a form of corporate espionage.

“From my observation, the goal of their claims is to bleed us out, to deprive of us of our financial resources and to gather from the questions asked in depositions as much information competitive information and to harass our employees,” Jacobson said.

One lawsuit was filed against a Signature MD employee who worked for about three months in clerical support for MDVIP. The litigation claimed he had stolen trade secrets, Jacobson said.

He said the type of noncompetes MDVIP are forcing employees to sign are akin to what are given to top executives of the company who are duly compensated, not employees who make $40,000 a year.

“I just have never seen anything like this in any other industry,” Jacobson said.

MDVIP’s attorney, Jerome Hoffman of Holland & Knight in Tallahassee, did not return calls for comment by deadline.

MDVIP spokeswoman Nancy Udell said the allegations are completely without merit.

“Signature MD’s antitrust lawsuit against MDVIP in Los Angeles appears primarily to be an attempt to retaliate against the lawsuit MDVIP has brought in Florida against Signature MD for misappropriating MDVIP’s trade secrets,” Udell said in an email.

MDVIP started around 2000 and quickly became an industry leader. Its litigious ways started after it was purchased by Procter & Gamble Co. in 2009 and continued since its sale to equity investor Boston-based Summit Partners LLC in May, Mack said.

Employees targeted

MDVIP’s restrictive covenants prohibit physicians from practicing concierge medicine independently or with another concierge medicine membership program within a 10-mile radius of an existing office or within a 10-mile radius of any MDVIP-affiliated physician.

“They have foreclosed us from certain markets by tying up doctors with long-term contracts, which are in essence evergreen contracts,” Mack said. “We have been unable to sign up doctors or offer consumer choices because of these contracts.”

Mack maintains the contracts are unenforceable because doctors are not direct employees of MDVIP. They pay a royalty or franchise fee per patients for services, such as marketing, patient conversion and clerical support.

“If a doctor signs up with MDVIP, that doctor is stuck,” Mack said.

Patients generally pay $1,500 and $2,000 extra a year for concierge care. They still have co-pays where applicable and must maintain primary care insurance, including Medicare.

The antitrust lawsuit is seeking an injunction ordering the company to cease anti-competitive activities plus treble damages under the California Business and Professions Code.

MDVIP filed a motion to disqualify Duane Morris from representing Signature MD, saying the law firm learned confidential and proprietary trade secrets in previous litigation.

The alleged trade secrets relate to “the strategies and methods by which MDVIP identifies, evaluates and recruits physicians to affiliate with its wellness management program, transitions and supports of their practice in the program and the contractive provisions, including restrictive covenants,” the motion reads.

Gee has scheduled a hearing for Oct. 10. Mack calls the disqualification motion meritless.

Read more:

Signature MD

Direct-Pay Medical Practices Could Diminish Payer Headaches

Most family practice and internal medicine physicians working in private practice today are burdened by ever-shrinking reimbursement rates and a growing list of administrative tasks required by insurance companies. In response, many primary care physicians are exploring alternative practice options, some of which are being encouraged by policy changes embedded in the Affordable Care Act.

Some doctors are embracing the economic security and reduced administrative burden that comes with employment. Others are selling their practices to hospitals and/or larger groups. And a small but growing number are showing interest in direct- pay practice models that allow doctors to reduce, or in some cases eliminate entirely, the administrative hassles and costs of dealing with insurance.

There are several models in which physicians collect a monthly retainer fee directly from patients instead of relying on fee-for-service reimbursement from third parties. Although the services provided for this charge varies, some of the benefits to physicians in adopting a direct-pay model include:

  • reducing patients panel sizes, often by as much as half,
  • minimizing administrative and staffing costs,
  • increasing the amount of time spent with patients, and
  • potentially increasing incomes

The services covered by the monthly retainer fee vary across practices. Often, however, patients can expect to have all primary care services covered, including care management and care coordination. Typically these include seven-day-a-week, around the clock access to doctors, same-day appointments, office visits of at least 30 minutes, basic tests at no additional charge, and phone and email access to the physician.

Although these models can look different, at their core, experts say, they share the common aim of providing high service levels, and increased access for patients.

Monthly membership models are especially attractive for patients with chronic conditions, but healthy people interested in a higher level of service find these models appealing as well.

Medical Economics spoke with experts to discuss some of the more common direct-pay practice models, along with some of their benefits and drawbacks.

direct pay practice model

Concierge medicine

Concierge medicine practices charge an annual fee that can range from $1,200 to $10,000, depending on the practice.

There are several models that physicians can choose from when transitioning a practice to concierge from traditional fee-for-service.

Full Conversion

One of the main goals in moving to a concierge-style practice is to reduce a practice’s patient panel size to just 300 or 400, rather than several thousand, which is now more typically the case.

Some doctors start with a full conversion of their practice whereby they terminate all patients who choose not to participate and pay the monthly retainer fee.

“It’s a high-risk, low-reward model,” says Matt Jacobson, founder and chief executive officer of  Signature MD, a national concierge medicine provider headquartered in Los
Angeles, California.

Benefits of this approach include reduced physician work hours and the ability to eliminate many of the administrative burdens that come with insurance contracts, but not much increase in income.

Immediate conversion to concierge medicine is also high risk. “What happens if you don’t get the 300 or 400 patients that you need? What if you only get 200?” Jacobson says. “You’re going bankrupt, or you’re working at the urgent care [center] or something else to supplement.”

Hybrid concierge model

In the hybrid concierge model, a physician delivers differing levels of care to two distinct patient groups–those who pay the concierge fee and those who don’t.

“If you pay me $2,000, you’ll have my cell phone number, and you’ll get to the front of the line at the office. If you don’t pay me $2,000 it’s business as usual,” Jacobson says.

Although doctors operating under this model can see a small increase in their income, they increase their clinical hours, Jacobson says.

In addition, there are ethical issues inherent in a two-tiered practice in which some patients pay for a higher level service than others. For example: does the physician spend 30 minutes with a healthy patient who has chosen the concierge model and only a fraction of that time with a patient facing myriad health issues who has chosen not to pay the annual fee?

Market segmentation

Jacobson describes a third model of concierge medicine–a market segmented approach–that he says was developed by SignatureMD. “It’s a high-reward, low-risk model,” he says.

Similar to other approaches, physicians seek to convert roughly 300 patients. The practice then brings on either a junior physician or nurse practitioner. Patients who participate in the concierge model will continue to see their doctor. Those not participating will see the new physician and/or nurse practitioner.

With this approach, Jacobson says, it’s feasible for physicians to more than double their income while reducing their workload by 25%.

According to Garrison Bliss, MD, president of Qliance Medical Group and founder of the second monthly fee practice in the United States, concierge medicine offers physicians many benefits. However, he cautions against a major trap of the model.

“In the concierge world, there’s this fear that if you didn’t do a bunch of exotic testing, and you didn’t have a cool new medicine that you knew about that other people didn’t know about, that it would be hard for people to believe they were getting better care from you,” Bliss says.

Direct primary care model

Bliss envisioned an alternate membership-based approach to routine and preventive care called direct primary care (DPC), which he started in 1997.

“I decided to come up with a healthcare model, rather than a business model. And then, to figure out what the business model would have to look at if we were a monthly fee practice,” Bliss says.

With DPC, the monthly fee for patients is lower than in concierge medicine–often ranging from $50 to $150. The size of the practice is generally larger as a result–600 to 800 patients as compared with 300 to 400 in concierge practices.

“We stopped being focused on the issue of getting paid and started being focused on the issue of what do we have to do for people,” Bliss says.

Markets for DPC

DPC is a small but growing movement, says Thomas Charland, chief executive officer of healthcare consultancy for Merchant Medicine, LLC. The two primary markets include individuals who have high-deductible health plans and see the value in paying a low monthly fee for increased access to primary care.

The biggest potential, Charland says, is among employers who have given up on a traditional approach to primary care. Many firms recognize that physicians with large panel sizes don’t have the time to spend with patients and must refer anyone with complications to specialists. That, in turn, is causing costs to skyrocket.

“If it takes off with employers it’s a game changer,” Charland says of DPC.

Building high-deductible insurance products that incorporate this model and that cover the services that direct pay practices don’t is an important step in moving this model forward. And it’s already happening.

“We’re involved in two instances of that in Washington State right now with, I think, more to come,” Bliss says.

Is Direct Pay right for your practice?

Experts offer these considerations when determining whether some form of direct pay model is right for your practice:

It must feel natural.

Physicians most likely to succeed using a direct-pay model are already operating as if they run one. “If you’re not already the guy who is taking the calls late at night, if you’re not the guy who is visiting your patients in the hospital…don’t do it because you will fail,” Jacobson says.

Carefully consider your monthly fee.

“I usually recommend that the doctor map out all of the fixed costs of his or her practice: facility rent and maintenance costs, utilities, equipment leases, staff salary, provider salary,” Bliss says.

Consider the size of your practice.

The next step is to consider how large a practice you want to operate. Once you’ve determined that, Bliss says, “divide the costs by the panel size and you have the annual fee you will have to get to make that work.”

Assess your patient pool.

Ask yourself how many of your patients will actually pay the fee. Jacobson’s firm employs a predictive model that relies on a range of information gleaned from a random sample of the patient population to determine the likelihood of success.

“If you don’t do that, you have absolutely no idea whether you’re going to succeed or not,” he says.

Connect with the community.

Charland says doctors should look for primary group companies operating in their area. In addition, they should become part of a community of practices and/or associations focusing on the type of model that they find most appealing.

Signature MD

Original Article

Top Plastic Surgeon Assesses VMA Celebrity Butts VIDEOS

One of the world’s top authorities on gluteal sculpting and enhancement is plastic surgeon, Dr. Constantino Mendieta, a Miami board certified plastic surgeon, who literally wrote the book on the subject schooling other physicians on what now is unquestionably the focus of women’s figures these days, a far cry from the boobtastic 1970s-1990s where breast implants were ubiquitous and almost a right of passage for many women.


Nicki Minaj in action at the 2014 VMAs

Dr. Mendieta is a frequent contributing expert to Monsters and Critics who shares his opinions on the female form and who can reshape and sculpt buttocks better than anyone. He explained in a past interview that there were four distinct body booty shapes, and the ideal was the “A” frame, the inverted “V” where the waist-to-hop ration was optimal.

Dr. Mendieta said,  ”Though the actual number varies around the world, most in our business agree that a waist-to-hip ratio of 0.7 is a significant indicator of female attractiveness compared to 0.9 for men.  Since the 2000 Grammys when Jennifer Lopez wore the famous low cut back green Versace dress that accentuated her bottom, women have sought to refine and sculpt their backsides and the trend is only increasing.”


As for last night’s 2014 MTV Video Music Awards? “Nicki Minaj’s anticipated ‘Anaconda’ performance really underscored the booty as sexual bait despite her poor backup dancer getting injured in rehearsal by one of the boa constrictors,” said Dr. Mendieta. “She has a really fantastic shape and knows how to work it for her stage show. It’s all about proportions and curves. The new approach does not just focus on the buttock… but the entire panorama. It is about waist, curves, silhouette and the actual shape of the buttock.”


The recipient of this year’s Video Vanguard Award, Beyonce performed a medley of songs from her most recent album with support from husband Jay Z and their adorable daughter Blue Ivy.

“Beyonce was also another great example of a woman whose lower half is strong, shapely and sexy too from good diet, workouts and her constant dancing on tour, a fantastic way to get your booty in great shape if squats and surgery are not for you,” said Dr. Mendieta.

Check out Beyonce at this year’s VMAs.



Heroin in the suburbs: An American epidemic

Heroin needle_Reuters.jpg

A bag of heroin and drug paraphernalia are seen at an abandoned house.REUTERS/Bor Slana

“Here, want a blue?”

How could one little pill, legally prescribed to millions of people, be a dangerous way to have a good time?

Mike Duggan remembers those words. He said yes to a “blue,” a 30 milligram oxycodone. It sent him down a slippery slope that gave way to a bruising tumble. Less than three years later, he was shooting heroin into his veins on a daily basis.

“The idea of heroin terrifies you, but a blue oxycodone doesn’t scare you,” said Duggan, who founded an addiction recovery service called Wicked Sober.

Duggan told Healthline that his addiction began with a prescription for Percocet after a hockey injury in high school. A popular athlete in Arlington, Massachusetts, a Boston suburb, he liked to drink and have a good time on the weekends.

But the Percocet enticed him with a fierceness he did not at first understand. Soon, he was in college, and it seemed like everyone was popping that blue pill for fun. Before he knew it, he could not get enough oxycodone, the drug of choice for painkiller addicts according to research published in the journal Pain.

Heroin was cheaper and easier to get. The other addicts all “sold it to their friends to keep their own habits going, who sold it to their friends, and so on, and so on,” Duggan told Healthline.

‘Unacceptably High’ Rates of Heroin Use

Heroin use among young adults ages 18 to 25 has skyrocketed in recent years. In 2012, 156,000 people tried heroin for the first time, according to the National Institute on Drug Abuse. The agency has called that statistic “unacceptably high.” It has almost doubled since 2006.

Heroin is no longer a drug used primarily by the poor in inner cities. Now it is a cheap high for young, white suburbanites. Many of them became addicted while raiding their parents’ medicine cabinets in high school and selling the pills at school.

Jody* is the mother of a San Fernando Valley, California man named Alex, who has been sober for almost three months. Jody belongs to a group called BILY, or Because I Love You. The network of parents offer support to one another as their children wrestle with heroin addiction and other problems.

Many parents don’t know their children are abusing heroin. They often start by snorting or smoking it, so there are no needle marks.

“For a long time my head was buried in the sand, and I know it was,” Jody told Healthline. She said high school administrators in the Los Angeles suburbs themselves are in denial about the problem of opiate abuse in their schools. It’s brushed under the rug, she said. Nobody wants to talk about it.

Naloxone Brings Users Back from the Dead

Dr. Leonard Paulozzi, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention, told Healthline that more and younger people are dying of heroin overdoses.

He said most of the CDC’s efforts have been focused on the issue of prescription painkiller addiction. “Heroin is a child of that original epidemic,” he said.

Between 2006 and 2010, heroin-related poisoning deaths increased by 45 percent. Earlier this year, U.S. Attorney General Eric Holder, armed with that statistic, urged law enforcement agencies nationwide to train and equip their forces to use the overdose reversal drug naloxone. During an acute overdose, naloxone rapidly blocks opioid receptors in the brain, throwing the user into instant withdrawal.

Naloxone is usually administered intravenously in emergency rooms, but nasal spray versions of the overdose antidote have also been given to community groups working with addicts nationwide. Paulozzi would like to see such a spray become available to the public and for insurers to cover it. Research published in the medical journal BMJ showed that naloxone spray coupled with overdose education significantly reduced overdose death rates.

An auto-injector version of naloxone called Evzio recently came on the market, but it is expensive, Paulozzi said. There is also a shortage of naloxone in the U.S.

Getting Help and, Maybe, a Way Out

Jody’s son Alex* found help at Inspire Malibu Treatment Center. After several previous failed attempts at getting sober, he has almost reached 90 days without using any drugs or alcohol.

Alex has been helped along by another type of drug, Suboxone, a controversial medication used to treat heroin addicts. Dr. A.R. Mohammad was among the first doctors in California to prescribe the drug, a combination of buprenorphine, a partial opioid antagonist, and naloxone, an opioid antagonist.

Between 2002 and 2011, the number of doctors prescribing buprenorphine in Utah increased 67-fold, to 1,088. The number of patients filling those prescriptions increased 444-fold, from 22 in 2002 to 9,763 in 2011, according to the CDC.

The medication treats addiction by acting on the same pleasure receptors in the brain that are stimulated by oxycodone or heroin. However, the medications are safer and generally do not induce the type of behaviors that disrupt a person’s life and render them unable to work.

Buprenorphine, brand name Subutex, can fulfill cravings that occur when a patient stops abusing illegal drugs. But it has the potential to be abused itself. Patients chop it up, snort it, and inject it. It now comes in a film that can be placed under the tongue, however, reducing the potential for abuse, Mohammad said.

If Suboxone is injected, it will cause uncomfortable withdrawal symptoms that do not occur when it is taken in oral form.

The new oral drugs are preferable to older treatments, such as methadone, Mohammad said, which is less effective and has a high potential for abuse. Another preferred treatment option is Vivitrol, an injectable form of naltrexone, another opioid antagonist.

Suboxone: A Better Drug to Depend On?

Critics of Suboxone contend that a person who takes it is not really sober. But Mohammad, his patients, and their loved ones say it saves lives.

Depending on the duration of opioid abuse, brain damage can be permanent. Mohammad makes no secret of the fact that he has patients who have been on Suboxone for 11 years, but he says there is no other way for them to stay clean.

“There is a deep misconception in society about using drugs,” Mohammad told Healthline. “Addiction is a chronic mental illness. It is a deadly disease and you can die from it.”

Patients do become dependent on Suboxone, he said. “But the difference between heroin and Suboxone is that on heroin, your life is completely screwed,” he said. “With Suboxone, you can have quality of life. What counts is good quality of life.”

Mohammad said patients return to work, become involved with their families again, and no longer meet the criteria for addiction as defined by the Diagnostic and Statistical Manual of Mental Disorders.

It is physically impossible for an addict to get high on Suboxone because of its chemical formulation, Mohammad said. And studies like this one that appeared in the Journal of Substance Abuse Treatment in 2010 show that people rarely abuse it.

Paulozzi called Suboxone “an intervention that’s proven to work. The hard part is making it available to everybody and convincing people to get into a program,” he said. “Most people who have a problem don’t think they need to get help.”

Efforts are under way at the federal and state levels to improve access to Suboxone. Doctor prescribing regulations and insurance coverage of the drug differ state by state.

Suboxone has plenty of opponents, mostly advocates of Alcoholics Anonymous-style 12-step abstinence programs, Mohammad said.

Duggan said Suboxone did not work for him, although he admits that it helps some people. He said Wicked Sober does not turn away those who are on it.

A lasting solution to addiction is “developing fellowship and getting out of one’s self,” Duggan said. “The best way is by helping other people.”

He said Suboxone has definite street value, and some sell it to get the drug of their choice.

Heightened Risk of HIV and Hepatitis C

Overdose isn’t the only danger young heroin addicts face. The issue of young, suburban white adults injecting heroin has been thrust into the spotlight because many of them are now contracting hepatitis C.

Massive outbreaks have occurred in suburban Boston, Wisconsin, Florida, Pennsylvania, and New York. A report produced last year by the Office of HIV/AIDS and Infectious Disease Policy confirmed “Rising rates of hepatitis C infection among young injectors, both male and female, primarily white, found in suburban and rural settings, who started opioid use before transitioning to heroin injection.”

More than half of the 17,000 new hepatitis C infections in the U.S. in 2010 were injection drug users, according to the National Institute of Drug Abuse.

But the risk of contracting an STI occurs apart from injection use, too. Research published last month in the Journal of Substance Abuse and Treatment showed that young adults (more likely to be white and middle class) were putting themselves at risk for HIV as well via unprotected sex with casual partners, often in exchange for drugs.

Alex said he indeed lowered his standards sexually while taking heroin. “It was pretty bad,” he said. “My standard in women went right out the window.”

As for sharing needles, he said he only did it once, during a failed attempt in rehab. “It was a last resort type of deal,” he said.

Getting Treatment Where It’s Needed — Fast

Addicts cannot get clean without significant help.

“To expect someone with a brain illness to manage their own life and do it on their own is an unrealistic expectation,” Duggan said.

Duggan’s work at Wicked Sober involves hooking addicts or their loved ones up with resources as quickly as possible. He does not operate a treatment center. Instead, he networks with a vast directory of resources to fast-track a person into treatment.

“The hard part is making [medications] available to everybody and convincing people to get into a program.”Most people who have a problem don’t think they need to get help.” — Dr. Leonard Paulozzi

You’ve got to strike while the iron is hot, he said, and you’ve got to make sure there is an iron-clad support system when the person is released.

Another problem arises when a parent or friend tries to get help for an addict and reaches out. Usually, a treatment professional says they have to speak directly with the patient if they are an adult.

“If someone says, ‘I do need help and I’m ready right now,’ to a loved one, it can take a day or two to find help,” Duggan said.

He recalled calling several times for help when he was an addict, but being told there was a waiting list or to call the next day. “My solution was to get high,” he said.

*Last names withheld to protect source privacy