Or You Could Pay Cash ...

I heard an interesting interview yesterday on Here and Now with a primary care doctor that has decided to do cash-only care -- no insurance -- for a $50 a month fee. His clinic has a handful of doctors and a nurse -- no billing or accounting staff at all. For that fee you get lab tests, visits to the doctor, even some house calls and after hours care. 

These doctors accept no insurance -- so they don't have to have an army of coders working to fight insurance companies over every dime. For the most part, these small monthly fee provides pretty flexible access to the primary care provider - and avoids unnecessary ED visits. 

They encourage their patients to have a catastrophic or high deductable insurance to cover hospitaliazations and major problems, meanwhile the monthly retainer covers the rest. 

It's a trend happening on the high end and on the lower end of primary care, according to a recent article in Bloomberg/Businessweek.

"Some health policymakers are encouraged by this trend. They think an increase of direct-pay doctors—especially affordable ones—could lead to better health care in the U.S., which has the highest costs and some of the worst outcomes of any wealthy nation. “I think it’s great,” says Kevin Schulman, a professor of medicine and business administration at Duke University. “We’re rediscovering that if we just ask people to pay for services, we could provide them with better value. Primary care is affordable.”

Others worry that the growth of concierge medicine will mean the affluent receive high-quality care while the rest of the country struggles to be seen by fewer and fewer doctors. “It is a step towards a two-tiered health-care system: a system where the rich get first-choice care and the not-so-rich get second-choice care,” says Kathleen Stoll, deputy executive director of Families USA, a health-care consumer advocacy group."

The good news doctors can run a primary care clinic with a lot less overhead and can spend a lot more time with each patient. The bad news is each doctor has to see A LOT fewer patients to get the same income. In fact, MDs may be able to drop their patient list by 80 % and still make the same money, with a higher job satisfaction. 

Which, of course, just points out the problem with our healthcare system. The doctor I heard interviewed made a good analogy with car insurance. We buy car insurance to fix the car when it is broken, we don't expect that insurance to pay for changing the oil and rotating the tires and all the things that keep the car from going in the shop in the first place. So maybe primary care should work the same way. 

Moreover, if this offers a path for primary care doctors to see more patients with fewer administrative headaches, maybe more doctors will train for primary care. 

The interview I heard:New Trend In Health Insurance: Low-Cost Concierge Medicine  http://hereandnow.wbur.org/2012/12/10/concierge-medicine-health-care

Worth reading: Is Concierge Medicine the Future of Healthcare http://www.businessweek.com/articles/2012-11-29/is-concierge-medicine-the-future-of-health-care#p1

The Looming Doctor Shortage: http://www.businessweek.com/articles/2012-09-27/a-looming-u-dot-s-dot-doctor-shortage#r=lr-fst

Fixing Rib Fractures

Did you ever break a rib? 

As trauma nurses, first we look for signs that the rib punctured a lung - which would lead to a pneumothorax. Difficulty breathing after a rib injury may mean that your lung has collapsed and you need a chest tube.

However, difficulty breathing after a rib injury may be just because it hurts like Hell every time you breathe. Our intercostal muscles expand and contract our rib cage every time we inhale or exhale. 

Rib pain leads to shallow breathing. Shallow breathing leads to lung collapse or fluid accumulating in the lower lobes of the lungs, and that leads to pneumonia and other complications. 

We recently had a rib fracture specialist from Dr.John Mayberry Oregon Health Science University come and talk to the staff at our hospital. 

Here are a few of the takeaways:

• It is going to hurt - expect the pain to last for 3 to 4 months and it will take at least 50 days to get back to normal activity. 
• Toradol can help in the initial phase and Lidocaine patches can work too. 
• Incentive Spirometer, Cough and Deep Breathe ... but you already knew that. Respiratory, PT and OT is important to avoid complications. Get them out of bed and keep 'em moving. 
• Physiologic reserve - this drops after the age of 65 and means that you should admit patients with three or more rib fractures. Older than 65 and more than 6 fractured ribs is associated with a higher morbidity and mortality. Of course, with that mechanism, there is also the likelihood of multiple injuries.   

Why don't we internally fixate rib fractures like other broken bones? Mayberry is leading a study group on surgical and outpatient management of rib fractures. According to the OHSU website:

“Historically, physicians have been taught that nothing can be done to fix a rib fracture,” said John Mayberry, M.D., principal investigator of the study and associate professor of surgery in the OHSU School of Medicine. “My colleagues and I have long thought that wasn’t true, but we have yet to prove it. With this study, we hope to identify subsets of people who respond better to surgical repair than nonsurgical therapy, then develop a standard criteria for treatment.” 

Like clavicle fractures, rib fractures are one of those traumatic injuries we've always assumed healed best when left alone. We give patients tons of narcotics and tell them to cough and deep breathe. It takes a long time for these method to work.

  “Based on findings from our previous research, we are convinced that current, traditional nonsurgical management of rib fractures does not facilitate pain relief or a speedy return to normal activity. We believe new strategies, including a minimally invasive surgical method we’ve developed, will alleviate pain and reduce disability for individual participants,” said Mayberry, adding that patients in the United States disabled by acute rib fractures collectively lose approximately 58,000 years of productive work each year.