Plum Halo Medical, PLLC

02/10/2022

𝐇𝐨𝐰 𝐦𝐚𝐧𝐲 𝐩𝐚𝐭𝐢𝐞𝐧𝐭𝐬 𝐜𝐚𝐧 𝐚 𝐝𝐨𝐜𝐭𝐨𝐫 𝐬𝐚𝐟𝐞𝐥𝐲 𝐬𝐞𝐞 𝐢𝐧 𝐨𝐧𝐞 𝐝𝐚𝐲?

𝘼𝙨 𝙤𝙪𝙧 𝙝𝙚𝙖𝙡𝙩𝙝𝙘𝙖𝙧𝙚 𝙨𝙮𝙨𝙩𝙚𝙢 𝙘𝙤𝙣𝙩𝙞𝙣𝙪𝙚𝙨 𝙩𝙤 𝙨𝙝𝙞𝙛𝙩 𝙩𝙤𝙬𝙖𝙧𝙙 𝙖 𝙢𝙤𝙧𝙚 "𝙘𝙤𝙧𝙥𝙤𝙧𝙖𝙩𝙚" 𝙖𝙥𝙥𝙧𝙤𝙖𝙘𝙝, 𝙥𝙝𝙮𝙨𝙞𝙘𝙞𝙖𝙣𝙨 𝙖𝙧𝙚 𝙞𝙣𝙘𝙧𝙚𝙖𝙨𝙞𝙣𝙜𝙡𝙮 𝙗𝙚𝙞𝙣𝙜 𝙖𝙨𝙠𝙚𝙙 𝙩𝙤 𝙨𝙚𝙚 𝙢𝙤𝙧𝙚 𝙖𝙣𝙙 𝙢𝙤𝙧𝙚 𝙥𝙖𝙩𝙞𝙚𝙣𝙩𝙨 𝙚𝙖𝙘𝙝 𝙙𝙖𝙮, 𝙤𝙛𝙩𝙚𝙣 𝙖𝙩 𝙩𝙝𝙚 𝙚𝙭𝙥𝙚𝙣𝙨𝙚 𝙤𝙛 𝙩𝙝𝙚 𝙥𝙖𝙩𝙞𝙚𝙣𝙩 𝙚𝙭𝙥𝙚𝙧𝙞𝙚𝙣𝙘𝙚 𝙖𝙣𝙙 𝙥𝙖𝙩𝙞𝙚𝙣𝙩 𝙨𝙖𝙛𝙚𝙩𝙮.

Today’s question is a simple one. How many patients can a physician see in one day and still be thorough? Don’t get me wrong; I’m all for efficiency. But we need to recognize when efforts at efficiency become “medical sloppiness” or, frankly, malpractice.

With healthcare policy and insurance reimbursement what they are today, it’s not uncommon to encounter seeing forty, fifty, and even sixty or more patients a day in the outpatient setting. The truth is, though, no matter how experienced the , no matter how technologically streamlined the practice, one physician can’t maintain medical accuracy at that frenetic a pace. Many physicians like to think they can because they manage to see every on their schedule and do their thing. But, in most instances, good medicine simply can’t be practiced in five to seven minutes.

Sure, there are cases where that is all that’s required. A young, patient, a simple physical, or a stable patient that just needs a refill can usually be handled that quickly. But I often see physicians trying to care for medically complex, older patients on multiple medications in the same fashion. The rationalization is usually that, with enough experience, one can take care of these patients just as quickly. But the issue, then, becomes precisely what constitutes “handling” a patient.

A patient with a complex history always requires more time. Trying to argue otherwise is simply intellectually dishonest. You can’t take a history, no matter how focused, reconcile all current medications looking for undesired interactions or required modifications, review labs, monitor patient progress, look for better therapeutic approaches, address new issues, encourage communication, conduct a thorough physical exam, and spend time on health counseling / preventive care in five to seven minutes. It just can’t be done that quickly with these patients.

I’ve worked in offices where this level of “efficiency” is touted as the future, the result of effectively leveraging new technology. But the truth is, as much as it pains me to say it, it’s just bad medicine. And the argument that a particular practice doesn’t have that many complicated patients is, in most cases, yet another fallacy.

Complicated are not to be confused with medically interesting patients. Many of the most common chronic illnesses that find their way into physicians’ offices are, in fact, not interesting or exciting for seasoned medical professionals. After all, diabetes isn’t exactly extraskeletal myxoid chondrosarcoma or any of the “sexy” hemorrhagic fevers, but that doesn’t mean it isn’t an exquisitely complex illness requiring a thorough clinical approach.

So the average primary care may not have many “medically interesting” patients, but they probably do have many complex patients. I would argue that if any practice has a significant amount of patients over the age of fifty, then seeing more than about twenty-five to thirty patients a day is irresponsible. Seeing three to four patients an hour yields a number somewhere in that range. And while some patients can be “handled” more quickly than others, once you go above that number in one day you’re entering dangerous territory.

If you look at the available data and the current incidence of , heart disease, , , and to name a few, then any practice serving patients over the age of fifty must, by definition, have a good number of complex patients. Although common, none of these illnesses are “simple.” Quick refills, not listening, not asking probing questions, shoddy physical exams, not looking for all possible signs and symptoms of progression, poor or no counseling, and not actively staying ahead of a disease are all poor practice. More importantly, those practices lead to poorer patient outcomes and increased costs in the long run. That is particularly true with this patient population.

The challenge, of course, is that our current system still rewards speed and procedures much more richly than patient interaction and thorough analysis. Although not a new concept, as reimbursement continues to decrease necessarily (Medicare’s pockets aren’t as deep as they used to be) and more patients gain access to the system, addressing the question of “medical speed” will become increasingly important.

Admittedly, the thoughts presented here are only based on anectdotal evidence collected over several years of working with numerous physicians, in multiple settings, and at several different hospitals. However, I do believe there is a trend here. The more “evolved” our healthcare system becomes, the more pressure is placed on physicians to leverage technology and see more patients, the more bad professional habits are being developed. Technology can help increase efficiency, but it can’t yet replace ample time with an interested, compassionate, well-trained physician. Not every patient requires thirty or forty minutes, but if we’re going to be honest, forty or more patients a day is simply ridiculous.

I would challenge all physicians to honestly evaluate how long they spend with complicated patients. More importantly, I’d be interested in knowing how they define a complex patient. And I would question any definition that doesn’t include even the most common chronic illnesses. No matter how “boring” these may be, their intrinsic complexity and impact on public health certainly justify more than a few minutes of diagnostic effort, even with routine follow-up visits.

I would also encourage all patients to expect more from their than a couple of questions and some quick advice in five to seven minutes. If you’re there for a simple cold, then maybe that approach is appropriate. But if you have a chronic and are concerned by some new symptoms or recent changes in your overall , you should expect much more from an office visit.

And finally, I would encourage all policy makers to recognize the valuable role physicians play in our society. We need policies that encourage them to do their jobs properly instead of punishing them for it. Ultimately, though, it’s up to physicians to choose. I hope they are true to their training and show humility in the face of complex, albeit common, . It’s a shame to simply toss all that “medical school stuff” out the window simply because the system is currently what it is.

Luis Collar, M.D.
President and Chief Medical Officer

Plum Halo Medical, PLLC is a direct primary care medical practice serving patients in NY and northern NJ.

02/10/2022

𝐇𝐞𝐚𝐥𝐭𝐡 𝐈𝐧𝐬𝐮𝐫𝐚𝐧𝐜𝐞 𝐚𝐧𝐝 𝐇𝐞𝐚𝐥𝐭𝐡 𝐂𝐚𝐫𝐞 𝐚𝐫𝐞 𝐓𝐰𝐨 𝐃𝐢𝐟𝐟𝐞𝐫𝐞𝐧𝐭 𝐓𝐡𝐢𝐧𝐠𝐬

𝙈𝙖𝙣𝙮 𝙥𝙖𝙩𝙞𝙚𝙣𝙩𝙨 𝙖𝙨𝙨𝙪𝙢𝙚 𝙩𝙝𝙖𝙩 𝙢𝙤𝙧𝙚 𝙚𝙭𝙥𝙚𝙣𝙨𝙞𝙫𝙚 𝙝𝙚𝙖𝙡𝙩𝙝 𝙞𝙣𝙨𝙪𝙧𝙖𝙣𝙘𝙚 𝙖𝙪𝙩𝙤𝙢𝙖𝙩𝙞𝙘𝙖𝙡𝙡𝙮 𝙮𝙞𝙚𝙡𝙙𝙨 𝙗𝙚𝙩𝙩𝙚𝙧 𝙝𝙚𝙖𝙡𝙩𝙝 𝙘𝙖𝙧𝙚, 𝙗𝙪𝙩 𝙩𝙝𝙖𝙩 𝙞𝙨𝙣'𝙩 𝙖𝙡𝙬𝙖𝙮𝙨 𝙩𝙧𝙪𝙚.

Whenever a discussion of health care policy is initiated, the importance of health insurance, of extending coverage, takes center stage. The need for insurance quickly becomes an undeniable truth, a universal imperative. And no one ever seems to question this subtle premise before getting more patients fitted with shiny, new policies. This was precisely the case with the Affordable Care Act.

My question, however, is simple. Where is the evidence that insurance plays any role in improving anyone’s health? Why is it assumed that more coverage is always the answer? I would argue it is little more than a myth, one found nowhere else in our collective understanding of insurance.

First, let’s take a look at our experience with insurance in other areas of our lives. In most states, it is mandatory for drivers to carry automobile insurance. To the extent they protect one’s financial interests from being threatened by an uninsured individual, these mandates probably make sense. But car insurance doesn’t reduce the incidence of accidents or extend the life of a vehicle, nor does it cover oil changes, car washes, flat tires, oil leaks, or any other form of maintenance or unfortunate mechanical reality.

Homeowners insurance is another example many of us are familiar with. It, once again, helps protect our financial interests in the event of uncommon occurrences, things like fire, theft, liability to third parties, or, depending on the nature of the policy, natural disasters. But it generally doesn’t cover any maintenance, either. It doesn’t cover dry wall repairs when your kids put a hole in the wall, the price of engineering services when your foundation cracks due to age, or, in most cases, even the removal of mold due to leaky pipes or unsealed windows.

Why, then, do we expect health insurance to function any differently? There is no evidence that simply having health insurance improves patients’ health. Access to health care improves outcomes; the problem is we always assume the best route to greater access is health insurance. We seem to believe coverage for routine medical care, for everything from checkups to preventive care procedures, makes any difference whatsoever in our collective health. It does not; it only appears to because of numerous confounding variables.

What is known, however, is the total amount of money available for health care, generally some large percentage of our GDP. That number is static at any given point in time and cannot be magically increased. In fact, by definition, insurance companies decrease the total amount of capital available for actual medical care. Relegating any aspect of health care to their control necessarily decreases the funds available at the bedside; these companies must extract a profit. That’s how capitalism works. Moreover, by forcing the insurance industry to increase the scope of coverage, patients and physicians give up more control as to the nature, timing, and extent of the routine care that can be provided.

All insurance, even health insurance, should be procured to protect one’s financial interests in the event of unusual or unforeseen events. Engaging it for routine activities, including all but the most costly drug therapies and procedures, serves only to dilute valuable resources and relinquish essential control. Some argue that health care is too expensive for patients to handle without insurance. But the truth is insurance increases costs. It raises physician and hospital administrative overhead and artificially inflates prices in several other ways, not to mention the aforementioned profit reality. More importantly, focusing exclusively on insurance ignores the importance of other factors that actually do affect health.

Improving access to education, reducing unemployment, increasing wages and household income by stimulating business and innovation, safeguarding the food supply, limiting environmental hazards, reducing poor health behaviors, and increasing the number of primary care physicians available, to name only a few, would have a greater impact on health and outcomes than more coverage. These are some of the confounding variables that lead us to believe insurance is always the answer. And focusing directly on these true determinants of health status, which can be achieved through better policy or, in some cases, less, does not force patients to relinquish control or artificially drive up the price of health care goods and services. Increased reliance on insurance paradoxically does both.

For the last several decades, we have increasingly relied on insurance (public or private) as an intermediary between patients and doctors. The results have been perpetually increasing health care costs, increased infringement on physicians’ independence, and an ever growing psychological barrier that prevents patients from understanding the true costs of, or seeing the real value in, health care services. We have conditioned patients to believe that a long visit with their physician is worth about twenty dollars. Meanwhile, most Americans recognize and accept that a similar session with any good attorney costs many times that number.

We need to move to a system where health insurance is procured only to protect patients’ financial interests in the event of catastrophic injury or illness, and routine, less expensive health care services are paid for entirely and exclusively by patients. Patients will be better served, having greater control over their health, seeing any doctor they wish, and purchasing competitively priced services from independent physicians free of unnecessary administrative burdens. The transition would, of course, be difficult, but it would be no more difficult than any other transition we attempt.

I tend to believe in people, in the individual. And I think a well-educated, fully employed individual, in consultation with easily accessible, well-trained, independent physicians, will generally make the right choice. In a free society, however, it is their right to make the wrong choice; no insurance policy will change that reality. Unless we limit our reliance on insurance, costs will continue rising, physician reimbursement and therapeutic autonomy will continue declining, and patients’ understanding of, and control over, their own health will continue to wane. Insurance is great if used judiciously, but let’s not continue to assume that more of it is always better; it isn’t.

Luis Collar, M.D.
President and Chief Medical Officer

02/10/2022

𝐁𝐚𝐧𝐬 𝐚𝐧𝐝 𝐌𝐚𝐧𝐝𝐚𝐭𝐞𝐬 𝐑𝐚𝐫𝐞𝐥𝐲 𝐖𝐨𝐫𝐤

𝙒𝙝𝙚𝙣 𝙖 𝙘𝙝𝙧𝙤𝙣𝙞𝙘 𝙞𝙡𝙡𝙣𝙚𝙨𝙨, 𝙤𝙧 𝙥𝙖𝙣𝙙𝙚𝙢𝙞𝙘, 𝙧𝙪𝙣𝙨 𝙧𝙖𝙢𝙥𝙖𝙣𝙩 𝙩𝙝𝙧𝙤𝙪𝙜𝙝 𝙤𝙪𝙧 𝙨𝙤𝙘𝙞𝙚𝙩𝙮, 𝙞𝙩'𝙨 𝙩𝙚𝙢𝙥𝙩𝙞𝙣𝙜 𝙩𝙤 𝙡𝙤𝙤𝙠 𝙩𝙤 𝙩𝙝𝙚 𝙜𝙤𝙫𝙚𝙧𝙣𝙢𝙚𝙣𝙩 𝙛𝙤𝙧 𝙝𝙚𝙡𝙥. 𝙏𝙝𝙚 𝙜𝙤𝙫𝙚𝙧𝙣𝙢𝙚𝙣𝙩 𝙘𝙖𝙣 𝙝𝙚𝙡𝙥 𝙞𝙣 𝙢𝙖𝙣𝙮 𝙬𝙖𝙮𝙨, 𝙗𝙪𝙩 𝙗𝙖𝙣𝙨 𝙖𝙣𝙙 𝙢𝙖𝙣𝙙𝙖𝙩𝙚𝙨 𝙖𝙡𝙢𝙤𝙨𝙩 𝙣𝙚𝙫𝙚𝙧 𝙬𝙤𝙧𝙠.

Legislative bodies are moving with unprecedented swiftness to ensure we lead healthier lives. From bans on soda to bans on fast food, from mandates on health insurance coverage to mandates on EMR use, from bans on trans fats to mandates on care delivery models, our governments (federal, state, and local) are supposedly helping us live well. But our current approach to health care is about as scientific as our approach to fashion — skinny jeans, bans, and mandates are in; bell-bottoms, freedom, and individual responsibility are out. Intrusive legislation and false moral imperatives abound despite being little more than blind stabs at improving health, one dim-witted buffoon at a time. But is that what Americans are? Are we all helpless buffoons?

The issue of freedom is a critical one in health care. After all, no individual liberty is more worthy of protection than the right to sovereignty over one’s own mind and body. When we ban something, then, it would be reasonable to assume that the evidence in favor of doing so is clear and irrefutable, that it is immutable. It would also seem logical that anything banned must, by definition, be more detrimental to human health than other things which are not banned. The same is true whenever we, in effect, mandate widespread adoption of a specific health care delivery model, digital technology, or administrative policy. The evidence supporting those mandates should be equally robust, and what is mandated should be decidedly better and more effective than all available alternatives.

The problem is that, in practice, bans and mandates are never applied in this well-reasoned, equitable fashion, and sustained good health will therefore never result from these authoritarian tactics. They generally do little more than limit choice, restrict individual freedom, and codify systemic injustices and inefficiencies that obstruct patient care and prove virtually impossible to reverse. Admittedly, there are indeed rare instances where implementing a ban or mandate is justified. But, too often, they are ineffective, costly, burdensome, and arbitrarily applied.

Mandates that favor particular care delivery models such as PCMHs, for example, are ill advised. A delivery model’s value lies solely in its proven utility to a specific group of patients and physicians. And in any given community, for any given disease, it is the freedom to innovate and creatively address patients’ unique needs that yields improved care and true health gains, gains that develop organically rather than in conference rooms full of bureaucrats far removed from the clinical processes they seek to control.

Another problem is that, in most cases, banning or mandating something is terribly ineffective at changing health behaviors or improving outcomes. Why? Because bans and mandates do nothing to increase someone’s knowledge of how best to sustain or improve health. If you ban one “unhealthy” substance, the food industry will simply develop another that increases flavor, extends shelf life, improves margins, or possesses chemical properties that induce addiction. Ban that new substance and another will arise. Without a primary focus on education, the public will consume each new substance voraciously because bans do nothing to promote real knowledge or a lasting culture of informed choice.

Yet another concern, one that highlights the prominent role of special interests in what should be an impartial process, is the arbitrary nature of what we choose to ban or mandate. For example, if improved health is the goal, should we ban or otherwise legislatively curtail cigarette smoking while simultaneously allowing recreational ma*****na use? Should we ban trans fats while encouraging the widespread use of pharmaceutical drugs that have considerably more toxic effects on the human body? Does it make sense to ban large sodas at fast food restaurants while allowing the sale of jumbo-sized alcoholic beverages, ultra-caffeinated, sugar-packed soft drinks, and unregulated nutritional supplements at local convenience stores?

Similarly, is it wise or just to mandate health insurance coverage without restricting insurance industry profits or outlawing narrow networks? Why do we ban tests that allow individuals to better understand their own genetic composition while simultaneously encouraging mass use of mammography and colonoscopy, even though the data is clear that these tests also carry significant risks and provide no benefit for the majority of those screened? If patient safety, portability of health information, and enhanced inter-provider communication were major goals of the EMR mandate, why spend billions of dollars on software that can’t yet communicate across proprietary platforms?

The only way to truly improve our nation’s health is to unequivocally embrace two concepts: education and freedom. The problem, of course, is that both of these require patience and discipline. Letting education and freedom transform health behavior and care delivery, watching them work their irrefutably effective magic, is no more exciting than observing evolution in real time. But they have an unparalleled ability to improve outcomes while protecting the public’s right to self-determination. Over time, education inevitably impels most individuals to make better health decisions. Some, however, will continue to consume unhealthy foods, forego screening tests, and engage in unhealthy activities. But, as politically incorrect as it may be to say this, it is their right to do so in a free society.

One argument often used to justify bans and mandates, one consistently touted as incontrovertible, is that they prevent those that engage in unhealthy activities from unfairly burdening others with the health care costs they incur. But there is one fatal flaw in that argument. Namely, it is based on the false moral imperative that every citizen is responsible for every other citizen’s health care, that charity and compassion can be effectively legislated. These two highly desirable human qualities are critical to individual self-actualization and societal progress. But attempting to impose them through legislation often has precisely the opposite effect, transferring individual wealth not to fellow citizens in need but to insurance companies, health system administrators, and government bureaucracies.

Laws like EMTALA and PPACA do little to improve real health; they are successful only at redistributing resources in the most inefficient ways possible, providing only the illusion of security and choice. They also treat health care differently than the socioeconomic phenomena truly responsible for health status, things that include food, shelter, employment, and wages. We do not, for instance, guarantee employment, ensure a living wage, subsidize luxury housing, or provide lavish unemployment benefits, nor are food stamps redeemable at the best restaurants. And yet we expect anyone arriving at the ED to receive not only triage and basic care but also expensive imaging studies and procedures, the best available services from multiple specialists, for what are often chronic health problems. Why the lack of consistency and foresight? Why the legislative hypocrisy?

We need to focus on peeling back the layers of legislation and administration, on restraining our penchant for bans and mandates. We must allow physicians to embrace the care delivery models and technologies that best serve their particular patients, not those deemed best by bureaucrats. We need to compensate clinicians for the full scope of their professional services, services that include consistently communicating with and educating patients using all available modalities, not just for writing prescriptions, ordering diagnostic tests, performing procedures, and structuring care to comply with anunnecessarily complex and meaningless collection of codes.

Rather than limiting choice with authoritarian decrees, legislative efforts should focus on health promotion and education, on ensuring price transparency in health care, on demanding clear, accurate ingredient labeling from the food industry, on safeguarding the integrity of the research used by the biopharmaceutical industry to make health claims, on assuring unambiguous, easily accessible disclosures from insurance companies regarding scope of coverage. We also need to grant patients control over how their health care dollars are spent, not continue to transfer that authority to third-party payors or government officials.

In 1755 Benjamin Franklin famously said, “Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety.” And the wisdom imparted therein is every bit as applicable in the realm of health care as it is in our fight against terrorism.

We want to improve health, so we mandate health insurance. We want to prevent disease, so we ban large sodas and trans fats. We want to control health care costs, so we favor one care delivery model above all others. All we accomplish, though, is less access to physicians (due to narrowing networks and greater administrative burden), increased health care expenditures (by increasing uncompensated ED visits and diverting scarce resources toward unproven delivery models), and diminished patient autonomy (with control increasingly transferred to insurance industry and government bureaucrats). We are relinquishing freedoms at an alarming rate and receiving virtually nothing in return.

These affronts to individual liberty, their inability to achieve tangible health gains, merit one final, equally applicable quote, one attributed to Patrick Henry: “Give me liberty, or give me death!” Sadly, if we continue on our current path, we may indeed be forced to choose between the two because, despite all claims to the contrary, the path to wellness does not reside in any legislative document, nor does compassion originate in the halls of Congress. In most cases, the potential for improved health resides exclusively in the minds of well-informed, free individuals, and true compassion can only be born of those same individuals’ hearts. Let’s educate, not mandate, and let’s allow freedom to guide our way, no matter how inconvenient that process may be to those occupying the halls of power.

Luis Collar, M.D.
President and Chief Medical Officer

02/04/2022

02/03/2022