Coronavirus (Covid-19) and the primary care doctor: ‘Creating a better system’ is his goal

Filed Under: Costs, Patients, Providers

Continuing our series of interviews with doctors and other medical personnel in the era of Covid-19: Dr. Jeffrey Gold is a direct primary care doctor -– meaning that his primary care practice runs on a subscription model, where patients pay a set fee monthly for all their primary care. Primary care practices also often arrange low-priced MRI’s, lab tests, medication purchases and the like. Read more about direct primary care (DPC) at Dpcalliance.org. I wanted to get Jeff’s thoughts on the Covid-19 era. Here’s a transcript of our conversation, lightly edited for length and clarity.

 

Jeanne Pinder
Tell me who you are and what you do.

Jeffrey Gold 
My name is Dr. Jeffrey Gold. I am a family physician in Marblehead, Mass. I am a private independent physician in my own practice, doing the direct primary care model, after being employed in the hospital-based system for the first nine years of my career. We have been open for five years and my focus is on delivering high-quality, transparent, affordable care that’s accessible to people from all walks of life ,as well as disrupting the healthcare system for the better.

JP
What has surprised you most about the COVID era? I

J. Gold
think the thing that surprised me the most, but kind of ironically didn’t surprise me the most is the lack of preparedness for something like this to happen. It kind of goes along very similar to the rest of our healthcare system — we have been focused on reactionary care, rather than proactive care. I always say “we don’t really have a health care system, we have a sick care system.”

The system makes more money, the sicker you are. Keeping people healthy and keeping them managed is not sexy or profitable, which is what it should be. So I think unfortunately, it exposed our lack of preparation and lack of prevention. It’s very sad that a country with the amount of money, technology and brilliant people we have — we were so ill prepared to contain this.

Fear, and also wants and needs

JP
What surprised you in your practice and in your personal life?

J. Gold
What really surprised me the most is the fear that people displayed. Regardless of what media outlet you look at, there’s this very heightened public publishing of things before facts are proven and vetted. And I think it instilled a lot of fear in the American public that like I’ve never really witnessed.

The closest thing was probably 9-11. That obviously affected the country, but it really affected the people of New York a lot differently than it did people in the middle of the country.

In my practice? I think people started realizing with healthcare, the difference between a want and a need. Because of fear, people were really realizing that there are a lot of things that you really don’t need to engage the healthcare system for. They’re more wants than actual needs. I think that unfortunately, now that we’re getting closer to opening things back up again, we’ve already noticed that — though I was hoping that would be a more permanent thing — unfortunately, culture is going back to the wanting and demanding things of the system, rather than needing.

JP
So what would be a want versus a need?

J. Gold
There are certain things that I feel, based on my training and years of practice, are urgent versus non-urgent. That view may not be compatible with what the patient feels is urgent or non-urgent.

In the beginning of the pandemic, I think maybe a little rash that you had on your hand for a few months that wasn’t really bothersome — you didn’t care to bring up because of the severity of everything else you were seeing going on, around you. Whereas prior to that, it would have been a call right away that “I need this looked at.”

Obviously, one of the major reasons our system is so expensive and ineffective is because of overuse. A huge part of it is people engaging the system when it’s something that easily could have been handled with some reassurance or some information.

Covid exposed the fractures and weaknesses in the system

JP
What changes have you seen in your practice, or outside of your practice as far as the healthcare system?

J. Gold
I’m hoping that we can find some positive to come out of that. Covid didn’t destroy the system – it was already crumbling underneath it. Covid exposed with a very bright light where the fractures and the weaknesses are in our system, particularly from a primary care perspective.

For me, on a day to day basis in the direct primary care model, probably 5 to 10% of my day-to-day practice changed. Really the only thing we did differently is we didn’t do routine well-child checks and physicals and that type of stuff. But we were still available for, say, stitches on a case-by-case basis. If someone did need to be seen, we would bring them in, making sure that they had a mask on and that we were prepared and all that kind of stuff.

We prevented people from having to go to the emergency room, which was running rampant and overburdened on a good day. You add COVID on top of it, and it’s exponentially multiplied the burden.

We were able to treat a lot of our patients through video, phone, email, stuff that we’ve been doing in the D.P.C. model for 5 to 10 years. very successfully.

It was kind of like a light dawned: not everyone has to come in for a visit so that a claim can get filed with insurance when you take that insurance piece out of primary care.

I don’t think much of our day-to-day existence really changed. I came to the office, I did telehealth, early on we were doing a lot of Covid education, triaging, that type of stuff. But then people started realizing “Oh, hey, I need stitches I can I can call my doc and get my stitches on there without having to go to an infected emergency room.”

Independent practices are struggling

JP
Do you talk to other non-D.P.C. primary care docs, and what do they say about the Covid era?

J. Gold
I haven’t talked to them directly. But I’ve read a lot of what’s going on in the news, how independent primary care practices have really been struggling to stay open, because of Covid.

I always tell people that in Massachusetts, where I am, most of the primary care practices are owned by the big hospital systems, and most of them operate at a loss anyway. The way they generate revenue is by referring people into the system. But for an independent non-hospital primary care practice, in other areas of the country where they’re more prevalent, it was very hard for them to stay afloat, by not being able to see people in the office and then make a claim with insurance to get paid.

It’s been shown that most of them did apply for assistance to try to stay open. I didn’t really have to worry about that with our business model. I feel for them, because I think they’re all trying to do the right thing, they’re trying to take care of patients. But when the only way you can get paid is by physically seeing a patient in person, and you have a pandemic that’s preventing you from doing that, your business is going to take a hit.

JP
What do you think are going to be long -asting changes for the healthcare system once this is over, however you define over?

J. Gold
I don’t have a crystal ball. I can tell you that my hope is that the innovation and the disruption that we’re trying to bring to the system from a bottom-up approach will be more acceptable to people as they realize — whether it’s employers or families and individuals – that there is a better-cost, more effective way of delivering primary care.

Like I say to people, we’ve been able to stream a movie onto a TV or cell phone for the past, how many years? But yet, it took so long to wake up to realize that we can talk to people through telehealth.

As great as a system as we have in terms of medical research and innovation and all that stuff, especially in the Boston area, our delivery mechanism is in the Stone Age. E.M.R.s are not built to communicate effectively with patients. These portals that they’ve developed over the past five years have been klunky. Can we just send an email?

I’ve always said is that I don’t think technology should ever replace the physician-patient relationship. I think that primary care needs to be based on that rather than a transaction. But you can use the technology to enhance the relationship. I know my patients well enough that if I get a call from them on the weekend, I know their personality — who’s going to be calm and give them some advice over the weekend and check in on Monday, versus who do I need to do a once-over in the office on a Saturday, so that I know that they’re comfortable.

I’m hoping that we can get back to the old days of primary care where you actually had a relationship with your primary care doctor. In the US, it’s said that like 40% of people don’t even have a primary care physician. We need to get back to that. But we also need to use the tools that we have right in our hand and in our pocket to enhance that care and that relationship.

Treating people like people, not cogs in a machine

JP 
The pandemic has been much harder on people of color than on white people. You said something very interesting about direct primary care inner city. Can you talk to me about that?

J. Gold
Just by having a Medicaid card in your wallet doesn’t mean that you are getting good quality care

I think that we have to find better ways of not just saying, “O.K., well, here’s a card, you’re covered,” but making sure that we provide people of lesser means with the support, the care and the help with social determinants of health

If we give people a SNAP card or an EBT card to go buy groceries because they’re low means, we don’t regulate the food that they’re buying to most degrees. And I would argue that that’s even more important for their overall health than anything I’m doing as a primary care doc.

So why can’t people of lesser means or Medicare be given a stipend card like a health savings card, where they can use it for a membership to a practice like mine, or at a community health center or another practice. They can use it for co-pays prescriptions, and whatever they want.

There are so many different ways to do it. But I think the key that we have to get back to is to treat people like people and not cogs in a machine.

So I think that it’s really just treating everyone as a human with individual needs and being able to look at what is their support system, whether it’s financial, social support, family support.

I took an oath to take care of people. And I think that that’s what medicine needs to be about. But I think we can find better ways of supporting doctors and patients to build a better system.

Looking forward

JP
Are there any major changes to the system that you envision going forward balancing Covid care and non-Covid care?

J. Gold
I think there are going to be a lot of unfortunate cases that could have been diagnosed earlier with routine screening, or things that got put off — whether it’s a colonoscopy that got rescheduled and someone had a precancerous polyp growing in there, that would have had a different outcome if it had been picked up earlier. Or mammograms that maybe got pushed off, or people who didn’t have the ability to get answers about preventative care symptoms, that could have been a harbinger of something very concerning – but instead they just said, “Oh, it’s nothing, Covid’s going on. So let’s let it go.”

And now, we’re also going to be dealing with the aftermath of a disease that we, let’s face it ,really don’t know a lot about. We don’t know what the long term sequelae of this are going to be. How much care people who were infected with Covid and recovered are going to need in addition to the routine stuff.

Only time will tell as to how the system responds. People that have needed elective surgeries that may not be life threatening, but certainly affected quality life — hip replacements, knee replacements — a lot of stuff that yes, it’s elective and can be done on an outpatient basis but had to be put off because we needed ventilators we needed ICU beds and all the stuff. I think we’re going to be in for a pretty tough transition period.

Insurance can hinder, not help

JP
Particularly when you think also not only about that, that issue, but about people who’ve lost their health insurance because they lost their jobs. Growing expectation that hospitals will be raising their rates, because they lost a lot of their elective income. The expectation that insurance companies might be raising their rates too.

J. Gold
I don’t think it’s an expectation. I think it’s a guarantee.

You’re dealing with multi-billion-dollar corporations that have a P.R. and marketing department, they can get out there and say, “we’re going to do good-will and everything Covid-related is going to be free.” Well, here in Massachusetts, the private payers have already announced that the possibility in 2021 is 30 to 40%, increases in premiums. Nothing is free.

So you may not see the money transacted at that point of care when you go get your Covid test or your Covid hospitalization, but it’s all going to be built in because they’re going to have to recoup their losses. And unfortunately, the rule makers in the system set whatever price they want.

I try to break things down simply. There’s a lot of stuff, particularly primary care which 70 to 80% of most people’s care can be delivered in an effective primary care practice. That’s not expensive, and should be routine and preventive and proactive, and is actually very affordable. It should be predictable and not insured.

I’m very concerned about people losing insurance because obviously insurance is a huge important piece of protection against financial loss, if something major happens/ But what I try to educate people on is coverage does not necessarily equate to care. If anything, sometimes people with insurance find there’s more hindrances to getting care than then assistance getting care.

Using insurance for a $12 purchase

Perfect example: I got a prior authorization today from Blue Cross Blue Shield on a 30-day prescription for generic Ambien. If you go on GoodRX, a 90-day supply locally with a coupon is about $12. So I’d like someone to explain to me where the benefit of using insurance for something that costs $12 and me having to waste my time doing paperwork or a phone call to get an approval for something that cost $12. If I had a patient who couldn’t afford it, I would rather give them the $12 myself, then waste time dealing with this nonsense.

People have been made to believe that everything we do in healthcare is expensive. So if you don’t use insurance for it, you’re gonna go broke. Well, the reality and the irony is, sadly, insurance is making people go broke. I mean, premiums now are more than some people’s rent and mortgage, unless you can qualify for subsidies and then you’ll get a plan with $2,000 or $3,000 deductibles.

We had a patient bill insurance for five blood tests, that is out of pocket because of his deductible was not met. The price was $475. In our practice, our negotiated pricing was $46 for the same tests.

Now, again, you get cancer, you have a stroke, you have a heart attack — no one wants to be a consumer, you just want to be protected and get good care. That’s an insurable event.

Getting a non-urgent script for $12 is not an insurable event. But what we’ve done is we’ve used insurance as a form of payment rather than real insurance, and it drives the cost up and it’s made it less accessible to the people who need care the most.

That’s what we’re trying to do make insurance more affordable by insuring the things that really should be insured. A perfect example I use: if you take an average 50-year-old patient with no family history of colon cancer, and no symptoms, and they just go in for a screening colonoscopy, the global price when you clean out all the mess is about $1,200 to $1,500 for the whole colonoscopy, anesthesia or sedation, all that stuff. So if you have a normal colonoscopy, and you have no family history, you’re due every 10 years. So how much sense does it make if you calculate $1,500 dollars monthly over a 10 year period? But that’s covered because it’s preventive.

But yet if they go in and they have three polyps biopsied, it becomes diagnostic, and if they’re on a $2,000 or even $4,000 deductible, they’re actually being exposed to the expensive part. Shouldn’t that be flipped? Like I’d rather pay the $1,500 over 10 years, without involving insurance, than get hit with hit with a bill for $2,000 because I had three polyps biopsied and I find out I have colon cancer, and I’m exposed to two to four grand.

It’s all backwards. We’re not protecting people against the expensive part. I mean, yes, there are out-of-pocket maximums, which is good. But for the average consumer and the average person in America, $15,000 per annum is a lot of dough.

I couldn’t come up with two grand right away or ten grand right away. So how, how is the average middle-class to lower-middle-class worker in this country supposed to come up with that? But if we could actually make insurance affordable, and protect and have lower prices that are transparent on everything you do before you put your foot in the hospital, and use insurance to cover above and beyond for the unexpected bad stuff, we’d all be better off.

People spending thousands to save a few hundred bucks

JP
Don’t you have a lot of patients who are insured but who don’t use their insurance — they use you for primary care?

J. Gold 
We have patients from all walks of life, we have people on Medicare, I have a handful that are on Medicaid that say, “I don’t want to be treated like a number and I can afford 50 to 75 bucks a month, I’d rather pay you and have a doctor.”

Most of the patients we do have are on a high-deductible plan. About 85% of people in America that are on a high deductible plan never meet their deductible in the year. So they’re literally spending thousands of dollars a year to save a few hundred. They don’t get that money back.

And the rates go up every year, whether you use it or not. So like we have people that are looking at, “hey, if I can go from a silver plan down to a bronze plan and lower my premium a little bit, and maybe up my deductible, I can pay a doctor to get personalized, transparent care, and come close to breaking even from what I was spending before.”

Even better, we have the chance of them getting a big return on their investment. If we prevent one E.R. visit per annum, they’ve probably made their money back.

JP
We talked a lot about primary care. What about the rest of medicine during the time of COVID like, hospitals, surgery?

J. Gold 

I think the changes are going to be significant. Colleagues of mine that are E.R. docs that I know, that didn’t even have the protective equipment to take care of people during this whole thing. These are things that just should not happen in an industrialized nation like this — to tell nurses and respiratory therapists, “Just put a bandana on, that’ll do it.”

It’s not acceptable. So is there going to be a lot of PTSD from some of the hospital workers that have been exposed to the really bad side of this?

When you’re seeing people that in one sentence are speaking full sentences to coding and collapsing, and going into respiratory distress right in front of your eyes, that’s not easy stuff to go see day to day.

I think there’s going to be a lot of doctors, nurses, staff of hospitals and E.R’s. who saw things that no one wants to see. In New York City it literally looked like a third world battlefield. So I think hopefully exposing the public to what these nurses, doctors, janitors, clinical staff and non-clinical staff do day to day to help people — I hope people will have a better appreciation of the rest. These are people who are putting their families and kids at direct risk on a day to day basis. And they’re going home to sleep in the garage so they didn’t get their family sick.

We’ve never had to deal with anything like this.

It’s up to us to make a better system

JP
Is there anything that we haven’t talked about that you think should be on the record here? Parting thoughts?

J. Gold
I think we need to treat each other better and respect each other more. I see so much negativity that it’s just frustrating – what my kids are being exposed to, what we’re all being exposed to. It does eat away at you eventually — you absorb it, and you start becoming negative yourself.

I really hope that we can start focusing on the people who recovered from this after being at the brink of death, on the doctors and nurses and staff that took care of them, and all the positives that happened that just weren’t recorded or reported.

We’re broadcasting riots. What about the people who are trying to make a difference in a positive, peaceful way? So that everybody is treated the same, and so we can eliminate these prejudices that probably all of us have?

I think the key is being aware of it and working at it. I don’t think posting a picture on social media is the cure — I think it’s being individually aware of how we treat people, what our biases are, and how we would want to be treated in return.

I’m a firm believer that it’s really up to us to make a better healthcare system, a better country, a better climate for our kids and grandkids to leave them with something positive, rather than what we’re seeing on a day to day basis. We can all do our small little things as individuals that eventually result in a big change for the better. That is what I hope.

JP
Very inspiring. Thank you.

J. Gold
The one thing that’s constant with humans is that none of us are perfect. I think it’s being aware of what our weaknesses are, what our strengths are, and constantly striving to be a better person. Taking care of your physical and mental health, so that you can help others.

One thing with our healthcare system that really bothers me a lot is people aren’t aware of the physician burnout and nurse burnout — all the regulation, the restriction, that makes it hard to practice independently. If you’re seeing a physician or a nurse who’s not happy, depressed or burnt out, you’re not going to get good care.

It’s having mutual respect for each other. I’m hoping we can get back to that because right now, it doesn’t seem like it’s very common, unfortunately.

It’s up to us to create a better system for ourselves and our future generations.